Although India’s Supreme Court issued a landmark decision granting all women the right to an abortion up to 24 weeks of pregnancy in late September, many obstacles stand in the way of women getting abortions – including the conservative attitudes of health workers towards unmarried women.

The Supreme Court decision erased the difference between married women and unmarried women, which had been enshrined in a 2021 amendment of India’s Medical Termination of Pregnancy (MTP) Act, passed in 1971.

Under the 1971 law, abortion was technically allowed for all women up until 20 weeks – although in fact multiple cultural and practical obstacles existed for unmarried women.

The 2021 amendment expanded abortion rights for certain categories of women, such as survivors of rape and incest, allowing them to obtain abortions until 24 weeks.  It also allowed married women to terminate their pregnancies up to 24 weeks under certain circumstances, such as failure of contraception – but did not allow unmarried pregnant women the same right.

Expansion of abortion rights aims to reduce deaths from botched procedures

The expansion of abortion access is aimed at protecting women’s health, as eight women a day are estimated to die in India as a result of botched abortions, according to the United Nations Population Fund, UNFPA. 

Over a quarter (27%) of all the abortions in India are performed by women themselves in their homes, according to National Family Health Survey (NFHS) – 5.  Around 16% of women who had abortions reported complications, and 90% of these needed medical treatment.  

But while the ruling has been praised as a milestone for India and South East Asia, with respect to reproductive health rights, activists in India say that the situation on the ground remains unchanged in many respects.  Women seeking access to abortion continue to face social stigmas and prejudices that are far from the liberal attitudes reflected in the court decision.   

Judgemental health workers

Ground-breaking research conducted by the progressive Indian YP Foundation, has identified a range of barriers – from high costs of the procedure to judgemental health care workers. 

Many teenagers seeking abortion in India today contend with laws criminalising consensual sex, judgment & shaming by caregivers & pressure to make false rape complaints to break up interfaith & intercaste couples @Saumya_Kalia reports. 1/2https://t.co/cjYnnCL0uf

— Article 14 (@Article14live) November 21, 2022

Service providers’ impose value judgements on premarital sex, as well as abortion, the research found, with some providers insisting that unmarried women obtain their parents’ consent for the procedure. 

The research fellows, who posed as patients at health facilities and conducted surveys amongst young people and in seven Indian states, also found confidentiality breaches in government facilities, caste prejudice and gender disparity in treatment, with those women who were accompanied by male partners getting a much better reception.  Finally there are the arbitrary costs of abortion in public clinics, as well as providers’ reference to  expensive private facilities even when lower-cost alternatives exist.

Anecdotally, as well, the stories mount up, as well.

One tweet by an Indian doctor stating that it was important for her to ask patients if they were married as this determined how she would treat them, opened a floodgate of responses from angry social media users, many of whom had bad experiences with doctors, especially gynaecologists. 

All these lovely 'woke' women tweeting about being offended by the question, "are you married," asked by their ObGyn, let me tell you something as a doctor. Martial status is imperative in the diagnosis and treatment of a patient, especially in OBG. (1/n)

— dr_vee (@dr_vee95) June 28, 2022

There have been a number of reports of gynaecologists, even in India’s urban centres, refusing to perform a vaginal examination on an adult patient without the consent of their parent or partner.  

Years ago, Akshita* remembers visiting her gynaecologist in Hyderabad after she missed a period. “I was suspecting polycystic ovarian disorder (PCOD) and requested a diagnosis. I made it clear to the doctor that I was not sexually active,” she told Health Policy Watch. However, her doctor refused to believe her and then went on to suggest a diet plan without diagnosing her condition. The experience traumatised the 22-year-old Hyderabad-based young professional, who avoided going to a doctor for a long time after. 

“When I have gone for smaller, simpler things, they have traumatised me so thoroughly. I cannot imagine what it would be like to approach one for something like a birth control or abortion, which they would definitely be much more judgemental about and would straight up deny access to these services.” 

Informal networks pushing back on stigmas and prejudice

The petition that pushed the Indian top court to issue its milestone pro-choice verdict in September was filed filed by a 25-year-old unmarried woman who was 22 weeks’ pregnant.  

In her petition, she said that her partner refused to marry her and she didn’t want to have the baby out of wedlock due to societal stigma. She also asserted that she could not afford to raise a child as she was unemployed and did not come from a wealthy family. 

In the southern Indian state of Tamil Nadu, Chennai activist Archanaa Sekar works with an informal network of women in the city who have been instrumental in helping such women to get abortions from non-judgemental gynaecologists.   Her group also has organised with local government actors and pharmacies to ensure that emergency contraceptive pills (ECPs), which are not normally stocked, may be made available. 

While acknowledging that the September Supreme Court decision was groundbreaking, she added that it will still take a long time for new legal thinking to filter into health workers’ responses, and broader societal values. Meanwhile, advocacy and women’s support networks will play a critical role in expanding women’s access, little by little, on the ground. 

#IMPORTANT #UPDATE: #ECP’s in #TAMILNADU
The Director of the Drugs Control Dept. will direct pharmacies to make emergency contraceptive pills available for OVER THE COUNTER purchase. The Dept. will clarify to all pharmacies that ECP’s are LEGAL/NOT BANNED, must be stocked & sold

— Archanaa Seker (@Archytypes) November 13, 2020

“As a doctor, one is in a position of power of allowing a person access to abortion. Unfortunately, we are still not in a place where a professional comes into the table just as a professional. They bring their baggage and prejudices with them,” said Sekar, in an interview with Health Policy Watch.

“With respect to abortion, there is a cultural, moral understanding that killing anything seems wrong and therefore you think abortion is illegal,” she said.  “So, for you to come around to the fact that abortion is legal, it takes a while. In all of this, in case of something like pregnancies you are losing precious time.”

“Unlike environmental laws where it is easy to expose people flouting the law, in cases of abortion it is difficult to speak out against someone who goes against the law and denies abortion,” Seker explained. 

“To a layperson it doesn’t matter whether the law exists or not. Because the law is not going to protect them,” she added. “People need to know their rights. If we are doing any kind of rights education, are we including a module also on laws such as the MTP Act and the Mental Healthcare Act?” 

Deeper issue remains attitudes towards sexuality

But even deeper attitudes towards sex and sexuality, which remain taboo topics in much of Indian society, also come into play in the abortion access landscape, she says.

Sex education continues to be banned in states like Gujarat, Karnataka and Maharashtra, for example.  And even when sex education is included in the curriculum, students are taught to abstain. Most adolescents in India are not aware of contraception or how to use it, which leads to unsafe sex and unwanted pregnancies, she noted. 

“Until we take the shame out of sex, we are not going to take the stigma out of contraception or abortion access.” 

The Rosa Luxemburg Foundation provided support for this article.

Image Credits: Srimathi Jayaprakash/ Unsplash, The White Ribbon Alliance/Flickr, Trinity Care Foundation/Flickr.