The problem

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A LITTLE over three decades back India de-criminalized abortion, overturning a century-old colonial law that treated the woman who decided not to continue with a pregnancy as a violator of law. Unlike in the West, where efforts to liberalize abortion have been subject to intense religious, moral and ethical debate, the Medical Termination of Pregnancy Act 1971 became law in India without much fanfare.

This was not because Indians are unconcerned about moral/ethical quandaries on whether a foetus should be equated to a living being or ontological debates over the meaning of life, but more because the act was pioneered as part of a population limiting exercise with considerable support from the medical establishment. This is one gender progressive legislation that owes little to the women’s movement, and therein hangs a tale.

Abortion was not only packaged as an integral part of the family planning programme, much of it intrusive and women-centred, given the general insensitivity about women, including their reproductive health, hardly any effort was made to study the impact of the liberalized regimen – whether the techniques were risky, the conditions under which women underwent abortion, and so on. Equally, there was little attention paid to abortion related morbidity and mortality.

For years, it was insufficiently realized that a vast majority, well over ninety per cent, of abortions continued to take place outside the legal framework. Partly this was because of the restrictive definitions of the MTP Act, specifying what provider in which facility is recognized as a legitimate provider of abortion services. The undue focus on public sector providers, never particularly known for either efficiency or sensitivity; the plethora of regulations governing private sector providers, itself with an indifferent record; and turning a blind eye to informal service providers – be they traditional healers or otherwise qualified personnel without a medical degree – implied that most women continued to rely on the services of those outside the pale of the legal framework. Consequently, we had little idea about either the quality/safety of these services or information on what was happening to the women. Evidently, there was little concern as long as family planning targets were being met.

The availability of new medical technologies to detect abnormalities in the foetus dramatically changed both the situation and public concern, more so once it was realized that these tests (amniocentesis, ultrasound) also helped discover the sex of the foetus. Suspicion deepened that, in the guise of testing the health of the foetus, the girl child was being eliminated in the womb. A combination of easy access to abortion facilities and the availability of new medical technologies arguably helped contribute to an alarming increase in sex selective abortions.

India, like the rest of South Asia and China, has long been marked by a son preference. More correctly, a deep-seated bias against women. It comes as no surprise that unlike much of the developed, western world, the sex ratio in the country is dangerously tilted against women. While the sex ratio at birth is nominally in favour of boys, i. e., more boys are born as compared to girls worldwide, in the first year after birth, the girl child has a greater natural propensity to survive. Thus, in situations of gender parity, women should in due course equal or slightly outnumber men.

Ever since India started conducting the decennial census, the sex ratio has been tilted against women, the worst records being reflected in the northwestern states of Punjab and Haryana. Worse, the phenomenon of a declining sex ratio seems to be spreading downwards to Delhi, Rajasthan, Gujarat and Maharashtra, confirming that the status of women, as captured in the sex ratio, has been worsening despite overall improvements in health and nutrition and decline in infant and maternal mortality.

Both demographers and women and health activists trace this trend to an increasing propensity of sex selective abortion. Fortunately, the movement by a large number of activists and health institutions in Maharashtra forced the state government into legislating restrictions on sex determination. The ensuing outcry prompted the central government to legislate the Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 regulating the use of ultrasound and amniocentesis and forbidding providers from revealing the sex of the foetus.

Yet, as the latest 2001 Census makes evident, the incidence of sex-selective abortion has not come down. In over 50 districts of the country, a majority in the northwest and western states, the juvenile (0-6) sex ratio has dipped to alarmingly low levels. And as both surveys and qualitative research make clear, the gender imbalance (and the tendency to practice sex- selective abortion) is more marked in the upper caste/class strata (those with access to land, with a higher educational profile, and so on). Evidently, the rubicon represented by the Narmada has been crossed. As much as region specific cultural factors, increasing materialism in the better-off seems to contribute to a deepening patriarchal bias. It is symptomatic that in the national capital, Delhi, the more affluent South Delhi region reflects a worse gender profile.

This issue of Seminar, drawing primarily on a recently completed national abortion assessment study, both quantitative and qualitative, seeks to explore some questions emerging from this disturbing picture. It is worth noting that studies on abortion are somewhat uncommon in the country. Not just because they are difficult to carry out since such enquiry demands more than technical research skills, but equally because policy-makers, focused as they are on bringing down population growth rates, remain inadequately concerned about the situation as it obtains in the field. Fortunately, by leveraging the global campaigns associated with ICPD Cairo, generating negative publicity about target-based family planning programmes and foregrounding the need for a holistic RCH approach, this study could be conceived and launched.

There are questions related to the working of the MTP and PNDT Acts. In the case of the former, widely criticized as being overly restrictive, it is worth investigating why legally recognized providers account for a minuscule proportion of abortions. What determines the choice of the service provider – the choice of techniques, the conditions of service, the cost, ease of access, concern with confidentiality, sensitivity in dealing with the patient, availability of counselling services, linkages with the population control programme, and so on.

Little is known about the actual decision-making process. Who decides – the woman, the husband, in-laws? How does the birth order affect the decision about abortion? If the first or second child is a girl, does the pressure to undergo a sex-determination test and subsequent abortion become greater? Has this pressure increased as a result of a wider acceptance of a small family norm? We need to keep in mind the social demographic implications of enforcing a one child norm in China.

Clearly, there is need to revisit, possibly radically revise, both the MTP and PNDT Acts. The obsessive bias in favour of public sector providers too needs to be addressed, more so since many of the PHCs are ill-equipped to offer safe abortion services. Also their record in maintaining confidentiality, in dealing sensitively with the patient, offering post-abortion counselling and so on, remains poor. Equally, we need to rigorously study the many traditional informal service providers and research the herbal medicines used to induce abortion. Are we, as is often alleged, far too much in the thrall of the modern pharmaceutical industry, privileging one set of providers, techniques, medicines and instrumentation, thereby constraining access and increasing costs?

So too with the PNDT Act. The current mode of functioning has better worked to drive the services underground, thereby criminalizing them and increasing costs and reducing the power of those in need of services. Will making the provisions of the act even more stringent help? The Supreme Court, responding to a PIL on the subject, delivered its final judgement on 10 September 2003, placing the onus of rigorously implementing the revised PNDT Act on the state governments. Equally, there is the old and unsettled debate regarding choice – if the woman is free to determine whether or not to continue with/terminate her pregnancy, why is her freedom in choosing the composition of her family restricted?

These are difficult questions which only more (and better) research and public debate can settle. Meanwhile, our society has to contend with the serious problem of the missing girls. Reportedly, regions with a serious shortage of marriageable girls have begun a practice of importing/buying brides from other regions. Possibly in the long run this may contribute to national integration! Meanwhile, it is criminal to turn a blind eye to the systematic elimination of the girl child in our society.