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.