Abortion In India Is Legal Yet Women Are Still Dying
One day in the summer of 2013, 25-year-old Seteng Horo found herself on a bus to the nearest public hospital, about four hours away from her remote village in the eastern Indian state of Jharkhand. It's not a trip she can afford to take often — buses are infrequent, the journey is long and the cost of about a dollar roundtrip is not insignificant. But she had no choice. She was running a temperature and had been bleeding for days. The reason: an unsafe abortion performed by a village midwife.
Horo's story is not uncommon in India. An estimated two-thirds of abortions performed are unsafe, done illegally at home or by quacks and midwives, and the annual death toll is about 4,600. Many women end up with life-long health problems. And women in rural India are disproportionately affected.
And yet, abortion has been legal in India since 1971.
"That's the irony of the situation," says Vinoj Manning, the director of the India office of IPAS, an international nonprofit organization that works to increase access to safe abortions.
Seteng Horo with her son Abhishek, 4, in their two-room mud hut. Seteng is married to Kunwar. The couple has two children. Their daughter is 6.
The Indian public health system has failed to provide any abortion services to poor women in rural areas, he says. "All good [health] care is concentrated in urban centers" — and is not affordable by India's poor.
When Seteng Horo, a mother of two, became pregnant last year, she and her husband decided to terminate her pregnancy. "I don't want more kids," she says. "My husband doesn't either." Raising two children was expensive enough, she says.
But they had few options for an abortion. Her village, Serotoli, doesn't even have a public health clinic or hospital, and they are too poor to afford private health care. Besides, Horo had no idea that abortion is legal and that she should only undergo the procedure at a facility certified by the government.
Horo first went to what is known in these parts as a jhola wala doctor, a doctor with a bag. They're men who travel from village to village with a bagful of medicines. But they aren't qualified doctors. Some are trained in alternative medicine but have little or no understanding of modern medical science. Others have no medical training at all. They are basically quacks.
The jhola wala doctor gave her an expensive pill that didn't work. Then, she went to a daai, an elderly woman in her village who serves as both a midwife and traditional healer, especially for women's reproductive health. A daai is an important figure in India's villages, at once a medicine woman and a confidante and adviser on matters of reproductive health.
Abortion, like all matters related to sex, is a taboo. "Anything about sex and sexuality is stigmatized," says Manning. "We don't even talk about it in our own homes. And when it comes to abortion, it is even more stigmatized" — because a woman's primary role is still seen as a child bearer. This creates a culture of silence around the topic, he says. And women prefer to go to a daai knowing she will keep the abortion confidential.
Sonpati, 55, a midwife in Salihatu Village, uses warm herbs and sand to massage the belly — her method of carrying out an abortion and also treating abdominal pain.
Horo's daai gave her an abdominal massage, a commonly used abortion practice in the region. The massage, usually done with hot oil and plant leaves is intended to destroy the fetus. "At first I thought it worked," says Horo. Days later, she was feverish and bleeding profusely. It was only then that she decided to take the 60-mile bus ride to the nearest public hospital. But like most public hospitals and health clinics in rural India, this one did not have a doctor trained to perform an abortion.
The hospital referred her to a small clinic nearby, in Khunti, run by the Family Planning Association of India (FPAI), a nonprofit organization that provides reproductive health services at little or no cost to the poor.
As more people have learned about the clinic in the four years since it opened, Dr. Mahesh has seen the number of patients grow. The clinic currently performs an average of 50 abortions every month, she says. "They come from very far-flung areas," she says. There are two other clinics elsewhere in Jharkhand and others around the country. But they probably don't reach as many women as they should, says the doctor.
The government of India recognizes the problem and is trying to solve it. This year, it took steps to train more providers in government hospitals. It also launched a media campaign to raise people's awareness.
In addition, the government is trying to amend the law so that trained nurses can perform abortions, and not just certified doctors. This will increase access to safe abortion, especially in poor and rural communities.
Seteng Horo and her son, Abishiek, walk toward her husband, Kunwar, who's working in the fields.
"What they're trying to do is move abortion from informal backstreet culture to a mainstream one, and to bring abortion closer to communities," says Manning. As for changing the culture of silence around abortion, "that's will probably take a long time to address," he says.
Those practitioners have another role to play. When I met Horo earlier this year at the clinic in Khunti, she had come for a second abortion. "I'll come here again and again if I have to," she said.
But she may no longer need to contemplate ending an unwanted pregnancy. Until she came to the clinic, Horo had no easy way to obtain birth control pills. Now she relies on the clinic for birth control and recently got a contraceptive injection.
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Transcript
RACHEL MARTIN, HOST:
India was one of the first countries to legalize abortion. That was in 1971. Making abortions legal in India and providing them in government-regulated clinics has decreased the risk to women seeking abortions. But in much of the country, women don't have access to those clinics.
ROBERT SIEGEL, HOST:
As a result, the country has one of the highest rates of death due to unsafe abortions. It's estimated that every two hours a woman dies from abortion-related complications. And for every woman who dies, 20 more develop lifelong health problems.
MARTIN: As we continue our series on abortion, reporter Rhitu Chatterjee sends us this story about the realities women face in India.
RHITU CHATTERJEE, BYLINE: Seteng Horo is a small, gaunt woman, 35 years old and a mother of two children.
SETENG HORO: (Through translator) I don't want more kids. My husband doesn't want them either.
CHATTERJEE: Horo lives in a remote village in the eastern Indian state of Jharkhand. And like most people here, she and her husband are among India's poorest citizens.
HORO: (Through translator) Raising two kids is difficult enough.
CHATTERJEE: That's why she traveled 60 miles on a bus through forests and farmland to come to this clinic for an abortion. The clinic is a reproductive health clinic run by a nonprofit called the Family Planning Association of India. Located in a tiny town called Khunti, it's the only place where people from nearby villages can get a safe and legal abortion.
HORO: (Speaking foreign language).
CHATTERJEE: After her abortion, Horo talks to the clinic's physician and agrees to return the following week for a contraceptive injection. It's a long way to come, she says, but she doesn't mind an occasional trip for the services. But a year ago, Horo didn't know she had this option. When she got pregnant last May and decided to terminate that pregnancy, she didn't know of any clinic where she could get the job done. Her village doesn't have a health facility, so she did what most women here do under the circumstances.
HORO: (Through translator) I went to the dai for an abortion.
CHATTERJEE: A dai is usually an older woman with experience delivering babies. She acts as both the village midwife and a traditional healer specializing in women's health. And unlike an American midwife, a dai also does abortions using roots or herbs or like the dai Horo went to, aggressive abdominal massages with leaves and hot oils.
HORO: (Through translator) At first I felt fine. But then I had a lot of difficulties.
CHATTERJEE: Horo said she bled for days and developed a fever. She was distressed enough to travel the 60 miles to come to this town of Khunti, the nearest place with a public hospital. But the doctors at the local hospital realized that she had had an incomplete abortion and they sent her here.
The doctor at this clinic operated on her right away and completed the abortion. But Horo is lucky, because most women in the region don't make it to a clinic or a hospital in time. Sushanti Tuti is a social worker with the non-profit that runs the clinic. Tuti's work is actually outside, in nearby villages like this one called Maranghadda, where she meets regularly with local women to educate them about reproductive health and safe abortion practices. Despite her efforts, she says women in these villages still go to dais and local medicine men, who are outright quacks.
SUSHANTI TUTI: (Through translator) Many women have died. And many have also lost their ability to conceive.
CHATTERJEE: She tells me about a young woman in a village about 12 miles from here.
TUTI: (Through translator) It's a village right in the middle of thick forests.
CHATTERJEE: When she met her, the woman was at an advanced stage in her pregnancy and looking to get an abortion. Weeks later during a visit to the woman's village, Tuti learned that she had died.
TUTI: (Through translator) She had gone to a dai who had given her some herbs. She did whatever the dai asked her to do. But then she died.
CHATTERJEE: The state of Jharkhand has one of the highest rates of unsafe abortions in the country. But the story is similar in many parts of rural India.
VINOJ MANNING: That's the irony of the situation.
CHATTERJEE: Vinoj Manning directs the India office of Ipas, an international non-profit that works on improving access to safe abortions.
MANNING: Forty years of legal abortion - medical advancement has gone high. But still, out of the 6 to 7 million abortions that happened in the country, half of them or more are backstreet abortions.
CHATTERJEE: By backstreet abortions, he means those attempted at home, or done by quacks and dais. Manning says when these abortions fail, women often go from one unsafe provider to another before they finally reach a clinic or a hospital.
MANNING: So what happens for pregnancy termination at around 8 weeks? In the worst cases - goes up to 20 weeks of continuous bleeding and morbidity.
CHATTERJEE: He says absence of public health facilities at the village level is one of the main reasons behind this situation, as are poverty and lack of education. When women don't know that abortion is legal and when they're too poor to get private health care, they have few options. But there's another reason behind India's abortion woes, Manning says - a deeper, cultural reason.
MANNING: Anything about sex and sexuality is stigmatized. We don't even talk about it within our homes. And when it comes to abortion, it is even more stigmatized.
CHATTERJEE: Now, abortion is not a political issue in India like it is in the United States. But in rural areas it is considered wrong because a woman's main role is still seen as a child bearer. As a result, women are discrete and secretive about getting an abortion. That's what Manning and his colleagues found in a recent study they did involving nearly 400 women who had been treated for complications from unsafe abortions.
MANNING: They just didn’t want to talk about it. They hoped that could resolve the - what they considered a problem at home, without people knowing about it, without families knowing about it.
CHATTERJEE: This culture of silence and secrecy also prevents people from openly discussing the issue.
SIMMI MAHESH: Speaking about abortion was a sin.
CHATTERJEE: That’s Dr. Simmi Mahesh, the physician at the reproductive health clinic in Khunti, Jharkhand. She says that’s why her organization, the Family Planning Association of India has been running education programs in nearby villages.
MAHESH: We used to tell in our programs, no, we are not promoting abortions. We are promoting safe abortions. If a woman wants to go for an abortion, she should go to a safe, certified place by a certified doctor.
(SOUNDBITE OF CHILDREN)
CHATTERJEE: The growing number of patients at this clinic is evidence that the message is starting to spread, not just in this area but also in other parts of the state.
(SOUNDBITE OF CHILDREN)
CHATTERJEE: Twenty-eight-year-old Rina Devi lives in another part of Jharkhand. She’s the mother of two daughters, both delivered by a dai. But another experience with a dai led to complications, then surgery to have her uterus removed. That’s why she doesn’t want her daughters to go to a dai when they grow up.
RINA DEVI: (Through translator) Now we know we shouldn't depend so much on dais. We should only consult with a good doctor.
CHATTERJEE: And she doesn't mind that a good doctor is a 45-mile bus ride away. For NPR News, I'm Rhitu Chatterjee, Jharkhand, India. Transcript provided by NPR, Copyright NPR.
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