Nurses & Midwives Can Make Abortions Safer in India

In India, abortion under certain conditions has been legal for almost five decades. You would imagine that further legalising abortion would make it safer and more accessible for all. However, this has not been the case.

Abortion is a complicated subject within Indian society. It can be challenging for people to seek safe abortion services due to service providers’ personal beliefs, societal stigma, and lack of knowledge. But even for those able to overcome these challenges, safe and affordable abortion remains elusive.

Part of the problem is that Indian public healthcare systems face an acute shortage of staff and infrastructure in all corners of the country.

Hospitals with advanced facilities are generally present at district level. However, remote rural areas with limited connectivity are more likely to rely on Primary Health Centres (PHCs). The government-ordained one-doctor-minimum at all PHCs remains unmet in most regions.

Without doctors, people run the risk of unsafe or precarious abortions by self-treating or consulting untrained providers. When they do seek allopathic medicine, it is often through pharmacies where shopkeepers give medicines without proper guidance. 

Appointing enough trained doctors to PHCs and clinics is a protracted process. However, there are other ways to mitigate the incidence of unsafe abortions. One is to employ nurses and Auxillary Nurse Midwives (ANMs) to administer safe abortion services in remote places. These trained practitioners can task-share in areas where supply falls short of demand. The World Health Organisation (WHO) deems this an “increasingly important public health strategy”.

Data shows that 87% of all abortions happen within the first twelve weeks of pregnancy (first trimester). A first trimester abortion generally requires a ‘Medical Abortion’, rather than an invasive procedure. This involves the pregnant person taking a combination of two drugs in the form of tablets and monitoring consequent bleeding. The process can be easily managed by most people at home and does not necessarily require a health facility. If, in rare cases, emergency services are required, these can be accessed at some 24/7 PHCs and/or Community Health Centres (CHCs).  

Nurses form the biggest healthcare providers’ workforce and are involved in all reproductive healthcare service provisions.

This includes independently managing normal deliveries, assisting C-sections and even surgical abortions. ANMs are trained to provide maternal and child health and family planning related resources to the community at the grassroots level. They also give vaccinations to newborns and nutritional advice to new mothers.

Therefore, adding Medical Abortion assistance to ANMs’ vocation is not a stretch. In fact, it is beneficial to include abortions in the larger ethos of reproductive healthcare. Not only will it make abortion more accessible in remote areas, it will play a critical role in normalising it. Safe abortion advocates have identified the significance of making abortion-related information just as readily available as labour and childcare information.

Providing a holistic basket of choice to a pregnant person ensures that they possess the agency to make informed choices about their own life.

For abortion to be recognised as a valid choice during pregnancy, it is imperative to ensure a certain quality of care. As health workers from within the community, ANMs are more approachable and readily available. Similarly, in poorly-staffed health facilities in rural parts of the country, nurses are often the first point of contact with patients – including abortion seekers. They can provide the necessary patient-centred care that makes abortions more comfortable.

Amendments to the Medical Termination of Pregnancy (MTP) Act of 1971, which initially legalised abortion in India, are currently pending discussion in the upper house of the Indian Parliament. The proposed changes aim to improve access by increasing the gestational limit for legal abortions. Several important aspects are missed out of the proposed amendments, though. There is no mention of expanding the provider base, for instance. 

We think this is a critical time to consider the abortion provider base, since the Indian Government is currently setting up a pilot curriculum for specialised nursing courses in midwifery. Nepal, a neighbouring country with a similar socio-economic context and comparable health infrastructure, has already authorised training programmes for nurses on providing abortion services. Nurses who have received this training are now successfully managing abortions. We asked one nurse about contributing to comprehensive abortion care. She highlighted the myriad ways in which nurses can improve services:

“Nurses should be trained and legalized to provide abortion services just like doctors. [They come in contact] with the clients and patients more, patients feel more comfortable with them. [Health] emergencies are the results of inaccess, lack of awareness, societal stigma and poverty. Who would be better than a provider nurse of a local place to fill those gaps? Health education and timely safe abortion provision can prevent the situation getting worse, it can prevent health deterioration.”

Nurses and midwives around the globe help create a care-centered health system that affirms a rights-based approach to healthcare.

It is only natural, then, to place them at the forefront of task-sharing for sexual and reproductive care that encompasses safe abortions. On this World Health Day, WHO commemorate the International Year of the Nurse and Midwife by highlighting the indispensable contribution of nurses and midwives to health systems worldwide. In that spirit, we hope to recognise their efforts by advocating for their inclusion in rights-affirming abortion service delivery. We believe that this will benefit society in significant ways. 

The YP Foundation is a youth run and led organisation that supports and develops youth leadership to advance rights of young women, girls and other marginalised youth. It strives to make access to sexual and reproductive health and rights easier for young people, including the right to safe abortion. The YP Foundation is a Safe Abortion Action Fund grantee partner.

Put Aside Your Stethoscope & Listen to Women’s Pain

It was sudden, debilitating pain that would come out of the blue. It just kept getting worse. Eventually, I ended up in hospital.

The emergency room doctor sent me home with no leads on the cause of my pain. He told me to follow up with my primary care physician, and so I made an appointment.

As I sat in my lovely exam gown waiting, my mind went to dark places about what this pain could possibly be. “I really hope the doctor will have some thoughts on this,” I thought. “I hope he’ll be able to reassure me somehow.”

He didn’t. Instead, he asked me two questions and mumbled something while scribbling on his prescription pad. He shoved the paper in my face and told me to pick it up at the pharmacy.

Before I had time to decipher the handwriting, he was gone. Securing the back of my gown with one hand, I jumped off the exam table and chased him down the hallway.

I don’t embarrass easily, so I didn’t care that I was running around in a paper-thin gown while other patients gave me the side eye.

“I’m not done, I have questions” I said. Visibly annoyed, he followed me back into the exam room.

I hopped back onto the table while still holding my gown closed, impressed with my own acrobatic abilities. But I was even more impressed with my boldness. Where had it come from?

I was taught that doctors are powerful and mighty. They shouldn’t be questioned, only readily and blindly trusted.

Yet, here I was, demanding he take the time to answer my questions.

“What are the side effects?” I asked.
He smirked.
“There are very few. This is a very common medication for stomach upset.”
“Stomach upset? I’m having sharp pains. And they’re not going away.”
“You’ll be fine. Just take the medication as prescribed.”
“But what do you think is causing it?”
“Take the medicine and if it doesn’t work, call us.”
“Do you need to do any tests?”

“Tests?” he said. “We don’t need to do any tests. It’s probably just gas.”

This was useless. I’ve made plenty of excuses for doctors like him before: he’s busy, he’s stressed, maybe it’s the nature of the job.

The truth was, he just didn’t care.

At home, I began to read the little pamphlet inside the box of medication. Did it really state that caution should be taken with Asian patients due to higher risk of side effects?

But…I’m Asian?

I made an appointment with a new doctor. A woman. By now, the pain was worse and more frequent. I had done some research on my symptoms and was starting to think it it lined up with some form of dietary sensitivity. There was a pretty clear pattern and I’d been taking detailed notes.

The doctor was an older woman with a commanding presence. “She’ll listen,” I thought. “She’s a woman.”

Instead, she dismissed everything I shared and everything I asked. She attributed the skin breakouts around my elbows to a type of spider bite.

“So you think it’s a coincidence that I have these breakouts every time I eat bread?” I asked. She actually rolled her eyes. Finally, she agreed to test for celiac disease, saying it was nearly impossible that I had it.

The test was negative. I started to feel like a hypochondriac. Was I making these symptoms up?

I reminded myself that dismissal of symptoms are a reality of health care for women, and that I’d have to fight to be listened to.

In my appointment with a third doctor, she shook my hand warmly. But she scrunched up her eyebrows as I explained my symptoms and gluten theory. “Here it comes,” I thought. “She’s going to tell me I’m imagining this.”

The doctor scooted closer to me and said, “You know, there is a test for celiac disease but not gluten sensitivity. It sounds possible that your body is reacting negatively.” She paused, and then said, “My goodness, it must’ve been frustrating dealing with this.”

My mouth dropped open. She went on to share next steps and review possible treatment options. She even asked me about my thoughts on my symptoms. I walked out feeling informed and validated.

Listening is one of the most healing forms of medicine.

To know we’re not alone is a powerful form of treatment. Hear us. Believe us. Put aside your stethoscopes for a moment and listen with your hearts.

It’s Time to Confront Sexism in Medicine

I was told often at school that I was “very good at maths…for a girl.”

It’s been a long time since then. I believe that gender stereotypes in science and maths are a little less rife today. We cannot afford to become complacent though, as unconscious biases still exist.

Now, in my work as a doctor, antiquated comments crop up regularly.  Patients will mistake female doctors, residents and students for nurses. This happens regardless of how a female doctor introduces herself. The idea that a woman could only possibly be a nurse is clear evidence of the sexism that pervades society.

In spite of the steadily increasing proportion of women in medicine, the culture of medicine has not caught up. It’s well-documented that women are vastly underrepresented in leadership positions, such as full professors and department heads.

Stereotyping also exists within specialty programs. Many assume that the nature of the work demands detachment from emotions and an ability to withstand long hours and grueling procedures. To be tough, resilient and to soldier on have traditionally been thought of as male traits.

Even though the number of women taking up surgery has significantly risen in recent years, surgery is still very much a male-dominated field.

Sexism in medicine is deeply ingrained.

It is difficult for most young doctors to gain visibility and recognition. The situation is even more complex if you’re a young woman. Misogynist jokes and remarks about physical appearance or potential are obstacles that many have to deal with.

One challenge I have frequently faced is assumed incompetence. As a woman, I have had to fight for people to take me seriously. I hear doubts like ‘Can she provide medical care or take critical decisions when required?’ Often, a patient asks to see ‘the real doctor’. Translation? The male doctor.

There is no easy fix. On one side, you should not let any of the gender stereotypes thrown at you affect you. But neither can you ignore the bias.

The #MeToo movement has shined a light on the many places in our society where insidious or obvious sexism have long gone unremarked.

Medicine is no exception. There have been moments when I have been interrupted by an irrelevant comment and I have had to listen to sexist jokes. I have had to work hard to be heard and recognized. I’ve had to go the extra mile to earn the trust of patients, and even to identify with the scientific community.

I am learning that the most important thing is never to lose confidence. I try to stay focused on what’s important: doing great medicine.

What the medical profession needs is a drastic culture shift.

Sexist comments and inappropriate behavior in the medical field are evidence of a much larger problem. They show the insidious misogyny in our culture.

Doctors do not exist in a bubble. We are, to a large extent, products of our society. This includes people who make sexist jokes or commit sexual harassment. It also includes people who laugh along or accept sexism as normal. A shift this great requires courage and concerted efforts.

As one of the underrepresented populations in STEM, I believe I am making a difference simply by existing. I believe that it is really important to #balanceforbetter. We must put forward diverse, inclusive visions of the kind of future we would like medicine to create.

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Health Care Workers Matter for Gender Based Violence

It was 10:30 pm on a Monday night.

After a long day at work, I was preparing to go to bed. I usually read before I go to sleep and I’d been trying to finish one book for ages but other things kept coming up. I hoped and prayed tonight would be the night, but the universe had other plans – as always.

My cell phone beeped: “Doctor, it’s an emergency.’’ 

I flung myself out of the bed and tried to reach the hospital as quickly as I could. The patient was a married 27-year-old woman who had sustained major injuries after accidentally burning herself while cooking.

“60 percentage burn,” I deduced, after taking the patient’s history and a physical assessment. But somewhere inside, I knew this wasn’t an accident and I felt sure there was more to the story.

I started with the patient’s family members. Unsurprisingly, upon enquiry they maintained their stance and kept trying to convince me that their daughter-in-law burned herself while preparing the meal for the family. I decided to talk in confidence with the victim, but she was hesitant to break her silence too.

One day, over the course of providing her with routine care, the woman broke down into tears and alleged that her in-laws had set her on fire for dowry.

In a country like Nepal, speaking out about gender-based violence (GBV) is exceptionally difficult because of the shame, stigma and pressure from families and communities preventing victims from reporting abuse and seeking appropriate services.

Victims are often afraid of disclosing or reporting violence because of the consequences they fear will follow.

In turn, silence can aggravate the situation for survivors, leaving them with prolonged mental and physical suffering.

Nepal has a very high incidence of gender-based violence. And while everyone – regardless of gender – can be affected, women remain the main victims. It is difficult to understand the gravity of GBV in Nepal as many of these cases go unreported due to the silence maintained by victims and perpetrators.

GBV remains one of the most rigorous challenges to women’s health and well-being. It can take many different forms, like physical, sexual, emotional or psychological. The causes of gender based violence are multi-dimensional, and include social, political, economic, cultural and religious factors.

Dealing with survivors of GBV can be a very challenging and sensitive task; starting from acknowledging and identifying the violence to asking relevant questions, without being too intrusive or judgmental at all.

Like me, a wide range of health professionals are likely to come into contact with individuals who have experienced GBV. Health workers are in a unique position to help and heal the survivors of GBV, provided they have the knowledge to recognize the signs. Most of the time, health professionals are likely to be the first point of contact for GBV victims.

But are we, as health workers, equipped with the necessary skills to deal with GBV?

While staff and facilities play a key role in health delivery systems for GBV victims, their efforts will have limited impact unless there are specific policies on the issue of GBV to guide the integration of the response to GBV into health care.

One important approach is to specify the role of health care professionals, and to provide guidance and tools. For instance, the World Health Organization has developed guidelines for in-service training of health care providers on intimate partner and sexual violence against women, specifically. The guidelines are based on systematic reviews of evidence, and cover:

• identification and clinical care for intimate partner violence
• clinical care for sexual assault
• training relating to intimate partner violence and sexual assault against women
• policy and programmatic approaches to delivering services
• mandatory reporting of intimate partner violence

The guidelines aim to raise awareness of violence against women among health-care providers and policy-makers, so that they better understand the need for an appropriate health-sector response. They provide standards that can form the basis for national guidelines, and for integrating these issues into health-care provider education.

Sensitizing staff and building their skills on how to recognize and respond to GBV is crucial. Ensuring that services follow human rights-based and gender specific approaches, and are guided at all times by the preferences, rights and dignity of the victim, is important.

Providing adequate infrastructure to ensure the patient’s privacy, safety and confidentiality is also essential. This can be done by providing a private room for consultations, requiring that consultations are held without presence of a partner, putting in place a system for keeping records confidential or giving instructions to staff on explaining legal limits of confidentiality, if any.

Not only are health workers the ones to fix a fracture or heal a burn injury, they can also play the role of advocate by speaking up against injustice in the course of providing routine care.

Health professionals can also assist victims by making them aware of the counselling and legal services available, which is often a part of the recovery process. Gaining the trust of victims is important in this scenario. Community health care workers and midwives, who are often the most trusted members of societies, can use their power to reach women and vulnerable groups to encourage them to break their silence, and to make informed decisions about their bodies and lives.

The role of health professionals goes beyond simply treating and healing a survivor of gender bases violence – we can empower them, too.

Knowledge and Perception about Family Planning by Women in Uganda

Blog post by Sylvester Nnyombi, Content Guru, Reach A Hand, Uganda

Phoebe Nabaweesa* was 22 years when she decided to try a family planning option mid last year. She zeroed in on the injection primarily because she had observed its impact on her best friend for quite some time. Most of which was positive- at least as far as she was concerned.

Phoebe’s friend had a good appetite, gained weight and was having sex without getting pregnant. Phoebe went to a clinic in Konge, one of the suburbs of Kampala, with a preset mind to receive the injection. Parting with 4,000UGX (Approx. $1) she received it, and that’s when all hell broke loose.

“I had a constant flow of blood from the time I got the injection. It was like having my period every day for three months!” the 23-year old factory worker in Konge narrates.

Having seen the blood flow for a month, she returned to the health facility, this time seeking medical attention. The attendants tactfully told her that the body needed time to get used to the hormones injected in it. Unfortunately, this was to span over 3 months. She also suffered constant illness over the next month after the injection-prescribed time had elapsed.

“When I saw my friend having the injection work for her, I believed it would work for me too, so I didn’t bother seeking advice from a health worker” she added.

That was her most painful miscalculation. Her biggest regret. Choosing a family planning method without the advice of a medical practitioner is not only improper, but also risky, heralding several complications to the body that may be fatal at worst.

The importance of involving a health personnel when choosing a family planning method is very cardinal to its effectiveness, and the story of Juliette Nawungu* is just another of the many testimonies that go a long way in demonstrating that  fact. Across the hill from Phoebe’s work station, Juliette, then 21, decided to opt for family planning after having her second child.

“I went to a Marie Stopes clinic and after the health worker had taken me through the very many available options, we agreed that the implant was the best for me” she said.

The method cost her 50,000 UGX ( about 13 US$) and it was carefully inserted by the medical staff at the facility. Lodged in her arm, it would last 3 years. It was removed  last week at the #Voices4Health community outreach in Kansanga. She is now 24 years, and is proud of the decision she made.

Dennis Sessanga, the Marketing and Public Relations Officer at Marie Stopes Uganda further re-echoes the importance of involving a doctor or midwife when choosing a family planning method.

“Our bodies are not the same. How one may react to one family planning method is not the same way another would react to the same option. Discussing with an expert helps you to identify which one would work best for you, so you don’t regret the decision” he explained.

Phoebe has since stopped using family planning because she deems the time right to have a child. She however says that if she ever chooses to take another go, she would go to the health worker first, having taken lessons from the #Voices4Health outreach. The health personnel’s advice is the most important part in choosing an option, endeavor not to miss this step.

*All names with asterisks have been changed to enhance the privacy of the women interviewed.