India’s Inverted Abortion Politics
3 Aug.2015 The New York Times
Manil Suri
IN America, many state governments have tried to curb abortion by placing severe restrictions on providers and clinics, purportedly for women’s protection, despite opposition from the American Medical Association and other groups. If the limits are allowed to stand, self-induced abortions are expected to rise, leading to an escalation of health dangers to women, particularly those who can’t afford to travel for help.
In India, a curious inversion of this story is playing out: The government is trying to reduce the qualifications required of providers so that poor women will have easier access to abortions, while doctors are the ones opposing this relaxation of rules.
Abortion is allowed in India under relatively liberal conditions — for example, contraception failure. Although its legal status is uncontroversial, the topic itself, like all sexual matters, is nevertheless taboo in the religiously conservative country. Women must often deal with unwanted pregnancy in secret, a problem compounded by unmet contraception needs and widespread gender subjugation.
The lack of adequate medical facilities in rural areas and urban slums forces many women to try to terminate pregnancies themselves, or to seek the services of quacks and untrained midwives. Ipas, an international abortion care organization, estimates that about five million abortions were carried out in India in 2013, with more than half of them unsafe. On average, an Indian woman dies every two hours from such procedures, and perhaps a hundred times as many are left with temporary or lifelong disabilities.
Last October, the Indian government proposed an amendment that would, among other things, allow abortions to be performed by specially trained registered nurses and licensed practitioners of traditional and alternative medicine systems like ayurveda, unani, siddha and homeopathy (which, along with yoga and naturopathy, are so widespread in India that they have their own federal department, known by the acronym Ayush).
Several developing countries have already been safely employing these extended cadres, including India’s neighbors Nepal and Bangladesh (where abortion is called “menstrual regulation,” to sidestep controversy). Feasibility trials in India demonstrated that nurses and ayurvedic doctors performed first-trimester abortions as effectively as doctors.
Although women’s groups hailed the proposal, the Indian Medical Association undertook a vigorous campaign against it, characterizing the feasibility studies as medical malpractice. The Federation of Obstetric and Gynecological Societies of India, which participated in both the amendment process and the design and authorship of one of the feasibility studies, soon repudiated its own policy statement and now likewise opposes the proposal.
The primary reason advanced for this opposition — concern for women’s health — is just as specious in India as it is in America. Doctors are aware that abortion drug kits, like most prescription medicines in India, are available without authorization, and that their rampant self-administration is the cause of a large numbers of injuries and deaths. Midlevel practitioners could easily be trained to verify that a gestation is in the recommended early stage, ensure the drug protocol is correctly followed and contact a supervisor in case of complications. Underprivileged women would find female nurses less intimidating to approach than doctors, who are predominantly male. By increasing access and introducing a layer of safety in current practice, the amendment would help bring down India’s childbirth mortality toll, the highest in the world.
Another objection is that given the pressure on Indian women to bear sons, the rule would promote more abortions of female fetuses. However, most gender determination (and resulting abortion) occurs during the second trimester, while the amendment expands the provider pool only for the first trimester.
But the real root of the tension is the government’s promotion of alternative medicine as a medically equivalent but cheaper alternative to allopathic (modern) medicine. Last year, the department of Ayush was elevated to the status of a ministry. Its head, Shripad Naik, claims the British “suppressed Indian medicine and tried to foist allopathy on us.” Not surprisingly, allopathic doctors, already chafing at past proposals to allow Ayush doctors to practice modern medicine, have drawn the line at this amendment.
There are legitimate concerns against giving equal status to Ayush and allopathic medicine. Although Ayush treatments can be effective in managing chronic conditions, very few are backed by scientifically rigorous evidence. Some aspects amount to clear quackery: For instance, the claim that yoga cures homosexuality, or the medication of adolescents who have wet dreams (which indicate “pulse imbalance” in the siddha system).
Nevertheless, Ayush doctors provide invaluable services in rural and impoverished urban areas, where allopathic doctors are reluctant to practice. A long-term government goal, consistent with recommendations from the World Health Organization, is to integrate the two systems. This presents ethical and logistical challenges, so progress can be expected to be slow and marked by bouts of friction.
It is unfortunate that the abortion amendment, with its limited scope and clear potential to save lives, is caught up in these larger turf wars. The government has scaled back its proposal to include only drug-induced procedures, a compromise allopathic doctors should accept. They should take heed, even if American legislators haven’t, of the fact that playing politics with health issues hurts the poorest segments of society the most.
3 Aug.2015 The New York Times
Manil Suri
IN America, many state governments have tried to curb abortion by placing severe restrictions on providers and clinics, purportedly for women’s protection, despite opposition from the American Medical Association and other groups. If the limits are allowed to stand, self-induced abortions are expected to rise, leading to an escalation of health dangers to women, particularly those who can’t afford to travel for help.
In India, a curious inversion of this story is playing out: The government is trying to reduce the qualifications required of providers so that poor women will have easier access to abortions, while doctors are the ones opposing this relaxation of rules.
Abortion is allowed in India under relatively liberal conditions — for example, contraception failure. Although its legal status is uncontroversial, the topic itself, like all sexual matters, is nevertheless taboo in the religiously conservative country. Women must often deal with unwanted pregnancy in secret, a problem compounded by unmet contraception needs and widespread gender subjugation.
The lack of adequate medical facilities in rural areas and urban slums forces many women to try to terminate pregnancies themselves, or to seek the services of quacks and untrained midwives. Ipas, an international abortion care organization, estimates that about five million abortions were carried out in India in 2013, with more than half of them unsafe. On average, an Indian woman dies every two hours from such procedures, and perhaps a hundred times as many are left with temporary or lifelong disabilities.
Last October, the Indian government proposed an amendment that would, among other things, allow abortions to be performed by specially trained registered nurses and licensed practitioners of traditional and alternative medicine systems like ayurveda, unani, siddha and homeopathy (which, along with yoga and naturopathy, are so widespread in India that they have their own federal department, known by the acronym Ayush).
Several developing countries have already been safely employing these extended cadres, including India’s neighbors Nepal and Bangladesh (where abortion is called “menstrual regulation,” to sidestep controversy). Feasibility trials in India demonstrated that nurses and ayurvedic doctors performed first-trimester abortions as effectively as doctors.
Although women’s groups hailed the proposal, the Indian Medical Association undertook a vigorous campaign against it, characterizing the feasibility studies as medical malpractice. The Federation of Obstetric and Gynecological Societies of India, which participated in both the amendment process and the design and authorship of one of the feasibility studies, soon repudiated its own policy statement and now likewise opposes the proposal.
The primary reason advanced for this opposition — concern for women’s health — is just as specious in India as it is in America. Doctors are aware that abortion drug kits, like most prescription medicines in India, are available without authorization, and that their rampant self-administration is the cause of a large numbers of injuries and deaths. Midlevel practitioners could easily be trained to verify that a gestation is in the recommended early stage, ensure the drug protocol is correctly followed and contact a supervisor in case of complications. Underprivileged women would find female nurses less intimidating to approach than doctors, who are predominantly male. By increasing access and introducing a layer of safety in current practice, the amendment would help bring down India’s childbirth mortality toll, the highest in the world.
Another objection is that given the pressure on Indian women to bear sons, the rule would promote more abortions of female fetuses. However, most gender determination (and resulting abortion) occurs during the second trimester, while the amendment expands the provider pool only for the first trimester.
But the real root of the tension is the government’s promotion of alternative medicine as a medically equivalent but cheaper alternative to allopathic (modern) medicine. Last year, the department of Ayush was elevated to the status of a ministry. Its head, Shripad Naik, claims the British “suppressed Indian medicine and tried to foist allopathy on us.” Not surprisingly, allopathic doctors, already chafing at past proposals to allow Ayush doctors to practice modern medicine, have drawn the line at this amendment.
There are legitimate concerns against giving equal status to Ayush and allopathic medicine. Although Ayush treatments can be effective in managing chronic conditions, very few are backed by scientifically rigorous evidence. Some aspects amount to clear quackery: For instance, the claim that yoga cures homosexuality, or the medication of adolescents who have wet dreams (which indicate “pulse imbalance” in the siddha system).
Nevertheless, Ayush doctors provide invaluable services in rural and impoverished urban areas, where allopathic doctors are reluctant to practice. A long-term government goal, consistent with recommendations from the World Health Organization, is to integrate the two systems. This presents ethical and logistical challenges, so progress can be expected to be slow and marked by bouts of friction.
It is unfortunate that the abortion amendment, with its limited scope and clear potential to save lives, is caught up in these larger turf wars. The government has scaled back its proposal to include only drug-induced procedures, a compromise allopathic doctors should accept. They should take heed, even if American legislators haven’t, of the fact that playing politics with health issues hurts the poorest segments of society the most.
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