Unpacking the rise of self-managed abortions in India

In India, women are increasingly turning to self-managed medical abortions. This is a change that reflects a demand for care that is convenient, private, and provides control. While this demand indicates expanding agency, it also highlights gaps within the healthcare system that leave women with very few options. The problem here, is that while the abortion drugs are clinically safe, a lack of multiple factors: proper information, trusted providers or pharmacists, and confidential services puts women at risk of unsupervised self-management.

Supervised vs. unsupervised abortions

It is important in this scenario, to differentiate between safe and supervised self-managed abortions and unsupervised ones. The World Health Organization states that self-managed, supervised medical abortions with mifepristone and misoprostol are safe and effective in early pregnancy. In India, where medical abortion is permitted under the Medical Termination of Pregnancy (MTP) Act, abortion drugs are legal and regulated. The Drugs Controller General of India approved a combipack in 2008, for termination of pregnancy up to 9 weeks. With a prescription from a certified registered medical practitioner, these medicines can be accessed from pharmacies.

Data from the National Family Healy Survey-5 highlights the growing reliance on medication-based abortions in India, accounting for an estimated 67.5% of all abortions in India (by method). The data also suggest that a considerable proportion of these abortions are self-managed at a reported 21.6% in urban areas and 30% in rural areas.

Barriers to safe care

Women turn to unsupervised self-management because the formal system can be difficult to access. In a society where stigma is prevalent, privacy and autonomy become important. The fear of judgment, denial of services, or breach of confidentiality keeps vulnerable women, survivors and the youth away from clinics. Adding to this, is the lack of certified abortion facilities in urban areas, owing to which, pharmacies are as seen as more accessible and cost-effective.

To add to this problem, women are often denied services based on marital status. They are often asked for consent of partner and/or parents or judged morally by healthcare providers. Also, misinformation and confusion among healthcare providers regarding the PCPNDT Act and the POCSO Act have led to over-caution, resulting in delays or denial of services to women. Unsupervised self-management then becomes the only option at times, because the formal system is difficult to access and hostile.

Making self-management safe

Proper information and follow-up care make self-managed abortions safe. Taking the correct dose is essential for success and to reduce any risk of complications. Incomplete or incorrect information, or consulting unreliable sources in times of need, results in the use of abortion drugs beyond the recommended pregnancy period and increases risks. Unsupervised self-managed abortion can result in serious health complications. These may include incomplete abortion necessitating to surgical intervention, excessive or prolonged bleeding resulting in anaemia or requiring emergency hospitalisation, and undetected ectopic pregnancies which can be life-threatening if a rupture occurs. There are other risks involved too. Delaying care can lead to infections. Using the wrong pills or method can mean the pregnancy continues. Dealing with complications alone, in secret, can take a serious emotional toll.

To ensure safe, accessible and stigma-free abortion care, and to avoid preventable complications, reforms are the need of the hour. Changes in policies and regulations are necessary to simplify the distribution of self-managed abortion drugs and to reduce fear among providers by aligning drug regulations with the abortion law.

Abortions are part of reproductive healthcare and should be treated as such. Essential care should be available at local health centres at all times. Just as important is the need for supportive training of healthcare providers in order to address personal biases as well as a better understanding of reproductive laws. Community-level dialogues can normalise abortion as essential healthcare and a fundamental right. When this shift happens at a healthcare and community level, women are far more likely to be met with empathy and respect when they seek care.

The rise of self-managed or medical abortions indicates gaps in the ability of the health system to provide dignified care, while also pointing to women’s need for convenience, privacy, and autonomy over reproductive decisions. Our response cannot be to resist this shift, what we need to do is strengthen and adapt our laws and health systems to support it.

(Dr. Abbha Dhuriya is director – clinical services, FRHS India and member, Pratigya Campaign. abbha.dhuriya@frhsi.org.in)