Self-managed medical abortion in India.

On International Safe Abortion Day, September 28th, Marie Stopes International held a public webinar, during which one of its presenters stated that self-managed medical abortion using drugs from pharmacies across India is not legal.

This is important because MSI has been reporting for many years that its operation in India provides at least 40% of all the abortion services it provides globally. In 2018, it reported that Population Health Services India, one of two programmes operated by MSI in India, performed 2.3 million safe abortion and post-abortion care services. PHSI does so largely through the sale of its branded abortions drugs to local pharmacies.

  • Could it be that 40% of all MSI abortions are illegal?

My Body, My Voice.

MSI invited Dr Suchitra Dalvie, Gynaecologist & Coordinator of the Asia Safe Abortion Partnership, to present on the rights-based case for supporting self-management of abortion.

During her presentation Dr Dalvie, when referring to data presented in a Guttmacher and Population Council study, says that the 11.5m medical abortions self-managed by women outside of regulated health facilities, “are safe but not currently legal in India”. These constitute some 73% of all abortions in India at the time of the study, 2015.

You can listen to Dr Dalvie discussing legal status of self-managed abortions, starting from 3:38 in this video clip.

The full video and slides are available online from Marie Stopes International.

Abortion law in India.

  • Abortion law in India has permitted grounds similar to those found in the Abortion Act in Great Britain.

The law governing abortion in India is covered under the Medical Termination of Pregnancy Act 1971 and the Medical Termination of Pregnancy (Amendment) Act 2002. These Acts state that abortion is legal if performed to save the life of a woman, or to preserve her physical or mental health, or in the case of fetal abnormality. Further explanations given in these Acts indicate legal permission in case of rape or to limit the number of children resulting from unintended pregnancies for any married woman. The latter is stated as possibly having an adverse effect on the mental health of the woman, rather than as a socioeconomic issue.

  • The Act stipulates that abortion can only be provided by a registered medical practitioner working in either a national hospital or in an appropriately approved facility.

Out-of-clinic provision of abortion is illegal in India.

The MTP Act and the associated comprehensive abortion care guidelines describe how, where, and by whom, abortion services can legally be provided in India. In both, it is clearly stated, in detail, that abortion is only legal when provided by a registered medical practitioner in an appropriately regulated healthcare facility.

  • It is illegal for medical abortion to be provided to a woman by a pharmacist, out-of-clinic, without a prescription.

You can read more and download copies of the MTP Act here and here.

MTP Amendment Bill, 2020.

In February, the Union Cabinet approved the Medical Termination of Pregnancy (MTP) (Amendment) Bill, 2020 to amend the MTP Act, 1971. It is worth noting that none of the proposed amendments, which aim at making abortion more widely available and accessible, especially for single women, address any change to the current legal restriction on medical abortion out-of-clinic. You can read a concise summary of the MTP Act and the Bill at the PRS Legislative Research website.

Marie Stopes International in India.

Marie Stopes International has two programmes in India, one of which, Population Health Services India, is noted as one of the leading Social Marketing businesses in India. It has a salesforce of 850, who distribute sexual reproductive health products through local pharmacies. In 2018, MSI reported that PHSI provided 2.3 million safe abortion and post abortion care services, representing 47% of MSI’s total global provision (4.8m). In the same report, MSI states that PHSI operates 12 outpatient clinics. It is not possible for all 2.3m abortion services to have been provided in these clinics, that would require each clinic to perform 750 abortions each working day. Therefore, very many of these 2.3m abortion services must have been because of the provision of medical abortion treatments by the PHSI salesforce to local pharmacies and community-based distributors.

In 2015, MSI reported that it provided 3.4m safe abortion and post-abortion care services, that approximately 90% of these were medical abortion and 90% of this medical abortion provision came from the sale of products through social marketing; 80% of all abortion services provided by MSI in 2015 were through the sale of medical abortion treatments to local pharmacies. The report goes on to state that PHSI made the highest contribution to medical abortion delivery across the partnership.

In 2017, MSI reported that it provided 4.1m safe abortion and post-abortion care services. It showed that 90% of these were medical abortion. The same report states that PHSI delivered 1,957,892 self-managed medical abortions through social marketing, an increase of 44% on 2016, which was achieved by strengthening the sales force and deploying enhanced social marketing strategies. In 2017, PHSI were providing just over half of MSI’s global provision of medical abortion, through the sale of medical abortion treatments to local pharmacies and community-based distributors.

Slight decline in 2019.

In 2019, MSI reported a “slight decline” in its safe abortion and post-abortion care services; total abortion services provided were 4.6m, down from 4.8m in 2018.

It says that one of the challenges leading to this decline was, “tightened regulations around medical abortion provision in India”.

The Foundation for Reproductive Health Services India, the sister organisation to PHSI, has conducted a number of studies to assess the availability of medical abortion drugs across India. It reported a shortage of MA drugs in the retail sector and that the non-stocking of MA drugs seemed to be linked with over-regulation by drug control authorities. It stated that about 79% of chemists no longer stock MA drugs to avoid legal issues and excessive documentation requirements. Many chemists mentioned that they are not authorised to stock or sell MA drugs and only hospital pharmacies and/or doctors are allowed to stock and use/sell these drugs. Some said that the provision of MA drugs from their pharmacy is illegal in their state and/or they are banned.

The regulations are clear, medical abortion drugs cannot be sold in pharmacies over-the-counter without a prescription; many women are finding it difficult to obtain a prescription because of the limited number of willing physicians available.

“Where Legal”

On its website, Marie Stopes International says: “The core services we provide are contraception, safe abortion (where abortion is legally permitted) and post-abortion care.”

This same point has been made over recent years in its Financial Statements and Annual Reports.

When defining its Organisational Structure in 2015 it said: “Marie Stopes International is an international non-governmental organisation delivering contraception and safe abortion services (where legal) through static centres, clinical outreach teams and social franchisees in 37 countries globally. [my emphasis]

In 2016, “Marie Stopes International is an international non-governmental organisation delivering contraception and safe abortion services (where legal) through centres, clinical outreach teams, social marketing and social franchisees in 37 countries globally.

2017, “Marie Stopes International is an international non-governmental organisation delivering contraception and safe abortion services (where legal) through centres, clinical outreach teams, social marketing and social franchisees in 37 countries globally.”

2018, “Marie Stopes International is a global organisation providing contraception and safe abortion services (where legal) across 37 countries.

Then in its 2019 report, it simply states: “Marie Stopes International is a global organisation providing high quality, affordable contraception and safe abortion services across 37 countries.”

The phrase ‘where legal’ is nowhere to be found. There is a notable increased emphasis in this 2019 report on the organisation’s “Work to remove policy and clinical restrictions that limit access to contraception, safe abortion, and post-abortion care services, using our position as a partner to governments and a service provider to ‘advocate by doing’.”

MSI is challenging itself to take a more proactive role, along with partners such as IPAS, in lobbying national governments to remove legal restrictions on abortion, whilst it will continue to ‘advocate’ by providing these, often restricted, services.

All data sources used in this article were in the public domain and available online on the day of posting, October 28th, 2020.

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