Marking 49 years of the inception of the Medical Termination of Pregnancy (MTP) Act in 1971, a new study out on August 10, 2020 evaluated the availability of Medical Abortion (MA) drugs in six Indian states to understand the awareness levels and perceptions of the chemists stocking and selling MA pills.
Despite the passage of the MTP (Amendment) Bill in March 2020 that extended the upper limit for permitting abortion to 24 weeks from 20 weeks, the non-availability of MA drugs, which are approved for use up to nine weeks of pregnancy in India, is seen to be “threatening” to women’s access to safe abortion and proper reproductive healthcare.
According to the quantitative cross-sectional study conducted between January and March 2020 by Foundation for Reproductive Health Services India (FRHSI), among 1,500 retail chemists in six states, there is an “overwhelming shortage (of MA drugs) in five states surveyed with abysmal stocking in Madhya Pradesh (6.5 per cent), Punjab (1.0 per cent), Tamil Nadu (2.0 per cent), Haryana (2.0 per cent), and New Delhi (34.0 per cent). The only state that seems to be better is Assam with 69.6 per cent.
These MA combipacks are a single pack containing both the drugs — 1,200 mg tablet Mifepristone and 4,200 mcg of Misoprostol — for terminating a pregnancy up to nine weeks gestation. Since the the maximum retail price is fixed by the National Pharmaceutical Pricing Authority, the MA drugs are affordable.
However, as per the study, the non-stocking of MA drugs seems to be linked with over-regulation by drug control authorities. It stated that about 79 per cent of chemists no longer stock MA drugs to avoid legal issues and excessive documentation requirements. The study noted how 54.8 per cent of chemists also reported MA drugs are over-regulated as compared to other schedule H drugs (prescription drugs which cannot be purchased over the counter without the prescription of a qualified doctor).
Interestingly, even in Assam, that has the highest stocking percentage, 58 per cent chemists reported over-regulation of MA drugs. State-wise regulatory/legal barriers continue to be the major reason for not stocking MA drugs, with 63 per cent chemists in Haryana, 40 per cent in Madhya Pradesh, 74 per cent in Punjab and 79 per cent in Tamil Nadu reporting so. “In the last quarter of 2018, we had done a similar study in the states of Bihar, Maharashtra, Rajasthan and Uttar Pradesh. Since most of the states studied were in north and western part of the country, we opted to include Assam and Tamil Nadu,” said V S Chandrashekar, chief executive officer, FRHS India and CAG member, Pratigya Campaign for Gender Equality and Safe Abortion.
In a 2015-Guttmacher Institute study ‘The incidence of abortion and unintended pregnancy in India’, it was estimated that 81 per cent of all abortion in the country were done using MA drugs. It indicated that if MA drugs are non-available with chemists, one can assume that access to MA — ‘a safe and effective method to terminate a pregnancy is no longer an option for many women’.
It was inferred how access and choice of safe abortion care could likely force many to seek unsafe abortion services, risking their health and lives. “I must mention here that abortion in India is still not a women’s right, it is a conditional right, and she can access it if the provider is of the opinion that she meets the conditions mentioned in the MTP Act. Sadly, the proposed MTP (Amendment) Bill 2020 does not change this situation. To begin the process of making the MTP Bill a rights-based legislation, we would recommend that at least first trimester abortion (up to 12 weeks gestation) should be available on request and not dependent on a provider’s opinion,” Chandrashekhar told indianexpress.com in an email interview.
Chandrashekhar apprised that as per government records, there are 25,931 health facilities in the public sector which provide abortion services. “However, annually only around 7,00,000 abortions or 4.5 per cent of the 1,56,00,000 estimated abortions in the country are provided in public sector, the rest is provided by private sector. When read in the context of how “about half of the pregnancies in the country were unintended” as per a 2015-Lancet Global Health study, access to safe abortion needs to be prioritised, he said.
“Only 43 per cent of all pregnancies in India are planned. Unplanned pregnancies and unintended births can be devastating and life changing for women and families. Apart from the health and economic impact, it prevents women living their lives to the full potential. It infringes their right to life and liberty. Unfortunately interests of women do not receive the required attention from policy makers and public at large. This needs to change,” he said.
It was in 2019 that included MA drugs in its Core List of Essential Medicines, removing an earlier advisory that required medical supervision while taking the drugs. Interestingly, as per the study, around 82.3 per cent chemists in the six states said they never sold MA drugs without prescription. Around 10 per cent said they would not sell MA drugs to unmarried woman, and would refuse to attend request if the unmarried woman is below 18 years of age. Only 3.5 per cent chemists in Delhi said they would provide MA drugs to such women.
Quashing the perception how easy availability of MA drugs could lead women to pop pills that may be harmful for them, the study noted how 93 per cent of clients appear to have had the desired outcome with the MA drugs, and chemists reported that 77 per cent of their clients came with a prescription. Chandrashekhar mentioned that if MA drugs are not available then the “only option women will have is surgical abortions”, which can be done only in a facility, which again exposes them to unsafe abortion risk.
While some of the amendments in the MTP Amendment Bill 2020 like – failure of contraceptive used by women or her partner is a ground for seeking abortion (it was previously restricted only to married women); opinion of one doctor for 12-20 weeks instead of two doctors; removing upper gestation limit for fetal anomalies and extending the upper gestation limit from 20 to 24 weeks for ‘certain categories of women’ are welcome, the amendments have not gone far enough to make access to safe abortions a reality for women, said Chandrashekhar, and urged the Ministry of Health and Family Welfare to clarify that MA drugs cannot be used for sex selective termination of pregnancy.
According to Chandrashekhar, since MA drugs are only approved for use up to nine weeks gestation and sex determination through the most common and affordable method of sonography can only detect the fetus at 13-14 weeks gestation, so sex-selective abortions can’t increase due to availability of MA drugs which 35.5 per cent of chemists/respondents in Tamil Nadu reported.