India Needs More Abortion Providers. Let the MTP Bill Enable Them.
One of the more contentious provisions of the amendments to the Medical Termination of Pregnancy Act (1971) proposed in the MTP Bill 2014 and currently still awaiting cabinet approval is expanding the ‘abortion provider base’ to include nurses and AYUSH practitioners. (Currently only physicians with at least an MBBS degree and requisite training are legally allowed to provide abortion in India.) In a society where stories about harm from ‘jhola-chhap’ doctors abound, an opposition to such a proposal is understandably instinctive. However, it is worth revisiting some of our biases with respect to the abilities of nurses and non-MBBS doctors, especially considering the current, acute shortage of MBBS physicians and the lack of safe and quality healthcare in rural areas.
Abortion services are part of basic healthcare services for women: every day in India more than 18,000 women access these services, including from illegal providers. Unfortunately, more than half of all abortions in India are unsafe, leading to 10 deaths each day. Out of the many causes of maternal mortality, unsafe abortion is the only one that is entirely preventable. In other words, one woman dies almost every couple of hours in India because we have failed to institute an overarching system of legal, trustworthy, and safe abortion services. The World Health Organization recommends that “safe abortion services should be readily available and affordable to all women [and] be available at primary-care level, with referral systems in place for all required higher-level care.” The radical proposals of the MTP Bill 2014 need to be seen in this context; there is an urgent need to make safe abortion more accessible for women in India.
One way to do that is to expand the number of trained abortion practitioners. Women in India undergo unsafe abortions for several reasons, but a major factor is the unavailability of safe and legal abortion services in most non-urban regions and a general shortage of trained MBBS or ObGyn abortion providers. Non-physicians providing abortion services, especially medical (pharmacological) abortion, is a common policy in many countries. For example, nurse practitioners and physician assistants have been permitted to provide first-trimester abortions in Vietnam since 1945 and in South Africa since 1997; in France and Great Britain, medical abortion is largely supervised by nurses; and physician assistants have been permitted to carry out early abortions in the states of Montana and Vermont in USA since 1975. Experts believe that the policy in many countries of keeping abortion services in the jurisdiction of physicians only “has not kept up with technical innovation and is not only out-of-date but makes it more difficult for countries to provide highly accessible, quality abortion services at low cost.”
One can’t help but wonder if apathy and disdain for women are playing a role in the delay of the passage of India’s MTP Bill.
It would be, of course, an undertaking to ensure the proper training of a new cohort of abortion providers so that the goal of safety can be met. But evidence for the effectiveness and safety of such task-shifting — a process wherein “specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications” — abounds in India. For example, in the two decades-old home-based newborn and child care model developed by Rani and Abhay Bang in Gadchiroli, several tasks traditionally performed only by pediatricians and obstetricians are now being safely carried out by rigorously trained community health workers. With respect to abortion, a 2011 study in northern India showed that manual vacuum aspiration — a WHO-recommended procedure for surgical abortion — can be carried out with the same safety and effectiveness by nurses as by physicians after study coordinators trained 10 nurses following the GoI-prescribed training regimen for MBBS physicians, and compared their performance to 10 similarly trained MBBS physicians. Researchers associated with this study also looked at the feasibility of training Ayurvedic physicians in abortion services, and came up with similarly positive results.
In light of this growing evidence of the safety and positive public health effects of task-shifting abortion services, it is unfortunate that the Indian Medical Association (IMA) has been vehemently opposing the draft bill’s proposals to train nurses and AYUSH practitioners. The IMA’s argument that abortion can safely be performed only by ObGyns or trained MBBS doctors completely disregards the evidence from India and abroad for successful task-shifting, making its intentions suspect. (The IMA is the official body of India’s allopathic doctors, though in the past it has been criticised for preferring to protect the business interests of elite doctors and not the health and welfare of the public.)
The draft bill does not, in its current format, propose any specific methods to implement the envisaged task-shifting. Some experts are thus rightly concerned whether the government machinery itself can implement quality training in an accountable and non-corrupt manner, and this is perhaps a more valid criticism of the bill than questioning the inclusion of nurses and AYUSH practitioners into the ranks of abortion service providers. Yet, this vagueness also leaves the potential for flexibility in the kind of procedures that could ultimately be permitted for nurses and AYUSH practitioners and in the type of settings in which those could be provided once the bill becomes law. A Health Ministry official was recently reported as saying it will primarily be medical (pharmacological) abortions that will be expanded while “surgical abortions will continue to be done by registered physicians.” It would thus be prudent for the IMA and civil society advocates, rather than stand in the way of task-shifting entirely, to be vigilant and ensure training programs do not end up churning out (like many medical colleges in India now) poorly skilled healthcare providers.
Despite well-intentioned and rationally argued provisions, it is unfortunate that such progressive legislation (the bill also eliminates the need for a medical opinion or any mandatory justifications from the woman for getting an abortion within 12 weeks) has been in a state of limbo for three years. Recently, two legal experts lamented how the bill is “being passed back and forth without any effective action”, and that it “still also needs cabinet approval, after which the Bill will be tabled in Parliament.” Many experts believe that the underlying causes for the huge number of unsafe abortions in the world are apathy and disdain for women. One can’t help but wonder if apathy and disdain for women are playing a role in the delay of the passage of India’s MTP Bill, too.
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