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Making Legal Abortion Accessible in India
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When Kiran Kumbhar (name changed for safety reasons) was pregnant with her first child, she experienced severe complications that almost took her life. And the debilitating symptoms have continued in the years since: weakness and dizziness, weight gain, and delays of as long as six months between periods. For years she tried to ignore the health ailments, but things got so bad that she eventually sought medical care. She was diagnosed with hypothyroidism, which limits the secretion of necessary hormones that control how a body uses energy, and polycystic ovarian disease (PCOD), in which enlarged ovaries secrete hormones that cause health issues.
Then, 15 years after giving birth to her son, she found herself pregnant again. She faced insults and name-calling daily because of her age and the long gap since her first baby. Both are considered shameful by those who carry conservative beliefs in India.
Kumbhar, 34, tried ignoring the criticism, but even her brother abused her verbally. “Is this even an age to get pregnant?” he asked her. Meanwhile, a few neighbors offered empty congratulations, saying they hoped she’d give birth to a boy, highlighting the social disdain toward female children.
“For me, pregnancy was a big thing,” Kumbhar says, recalling the difficulty of her first. “It made me happy for a while, but I had mixed feelings later. I was confused between childbirth and getting an abortion.”
Many people in her position in India have very few options. Abortion is legal, per India’s Medical Termination of Pregnancy Act of 1971, but that doesn’t mean it’s accessible. Government records show that for the more than 370 million women of childbearing age in the country, India just has 10,782 public health facilities that provide abortion up to 12 weeks, and merely 4,213 public health facilities that can abort up to 20 weeks.
As a result, unsafe abortion remains India’s third leading cause of maternal mortality, with eight women dying every day. Approximately 800,000 unsafe abortions are carried out in India annually, and most of these are provided to people from marginalized communities.
Stressed and unsure where to turn, Kumbhar contacted community health care worker Maya Patil, a resident of Kutwad village in Western India’s Maharashtra state. Patil took Kumbhar to a doctor who explained that there could be a potential risk to both the mother and her unborn child. During pregnancy, fetal blood cells can cross into the mother’s blood system. If the mother and fetus have different Rhesus (Rh) factors, for example the mother has Rh-negative blood and the fetus has Rh-positive blood, then the mother’s immune system sees the fetus’s cells as enemy cells, and responds by producing antibodies. This was the case in Kumbhar’s first pregnancy. There is an intervention called the Rhesus injection, which, if given after a childbirth, can slow or prevent that immune response in a subsequent birth. But since she didn’t receive the injection after her first childbirth, there was a good chance she could experience an even faster immune response to the fetal cells this time around. When these antibodies cross the placenta and enter the blood of the developing fetus, they can lead to permanent nerve damage or even death. Hypothyroidism further complicated the health risks of pregnancy for Kumbhar, who was already experiencing anemia, muscle pain, hypertension, and weakness due to the condition.
But there is a widespread societal belief in India that an abortion is sinful and equivalent to killing someone. Kumbhar’s husband and neighbors—the same neighbors who were criticizing her for being pregnant—now pressured her not to abort. It took Patil multiple visits to explain to Kumbhar and her husband about the risks involved and why abortion was the only safe option. She spent several hours counseling the couple, ensuring them that she had their best interests in mind and that her recommendations were based on medical science, not societal pressures.
Finally, Kumbhar made a firm decision to end the pregnancy. The local community doctor referred her to the district hospital 50 kilometers away, which she visited multiple times in search of treatment. Each time she went, the doctors would shun her when she tried to talk to them, and ask her to visit some other day. “None was serious,” she says. After four such visits, collectively traveling more than 400 kilometers via a series of public buses despite her severe physical weakness, Kumbhar lost her calm. She asked Patil if she should reconsider her decision.
Working hard to get Kumbhar the treatment she needed, Patil dialed a few doctors and the administrative staff and found that the district hospital was oversaturated and understaffed. A 2020-21 government report points out that India has only 25% of the obstetricians and gynecologists they need to keep up with the existing patient load. Patil pleaded with the doctors and was able to get Kumbhar a timely abortion.
But the public health care facility’s limited resources and old equipment led to yet another brush with death. “The medical devices malfunctioned,” Kumbhar remembers, teary-eyed, “and I was in the hospital for nine days.” Kumbhar recovered but calls it one of the worst phases of her life. Had it not been for Patil’s consistent support, Kumbhar says she wouldn’t have survived. “The trauma was just unbearable.”
Accessiblity of Care
To make abortion accessible, health care workers like Patil spend countless hours working well beyond their duties. Patil is an Accredited Social Health Activist (ASHA), and is responsible for bringing health care to rural areas. There are approximately 1 million accredited social health activists in India—one assigned for every 1,000 people in India’s villages. They perform more than 70 different healthcare-related tasks, including distributing medicines for common ailments, handling pre- and postnatal care, ensuring universal immunization, and much more.
Many ASHAs across India are risking their lives to make abortion accessible.
As with Kumbhar, ASHAs like Patil talk to the doctors on behalf of patients, explaining their situations and advocating for their care. Several times, Patil has faced abuse for this, from both doctors and community members. And in some cases she’s had to reach out to ASHAs from different states in India for support. But she keeps going until the needed care is provided. She has helped many people, including minors and single women—several of whom were victims of sexual abuse and incest—access abortion safely.
Patil recalls a case five years ago where an unmarried woman got pregnant. When the woman sought an abortion, multiple public doctors asked intrusive questions and denied her abortion without giving a reason. After three months of failed attempts, Patil got involved. She talked to the doctors on the patient’s behalf and explained the urgency of the situation. When Patil refused to answer the doctors’ inappropriate questions about the patient’s personal life, she was yelled at and verbally abused. In this case, she had to call a senior public health care official in order to get the patient the care she needed.
The task doesn’t end there, though. Often ASHAs spend months counseling people who face scathing remarks from their families before or after an abortion. ASHAs even take patients to psychologists for therapy. This is significant, especially because for the population of 833 million people currently living in India’s villages, there are just 764 district hospitals and 1,224 subdistrict hospitals with clinical psychologists and psychiatrists.
A 2017 World Health Organization report found that India has less than 7 psychiatrists for every 10 million people.
Accredited social health activist Netradipa Patil, from Maharashtra’s Shirol region, says, “In cases of rape, the district hospitals first ask us to get a police case registered and bring several documents before aborting—despite an emergency. It’s not easy to get a case registered, and the district hospital staff first asks several uncomfortable questions intruding on privacy and then ask the victims to revisit later.” In such cases, she has observed that the victims are forced to reach out to quacks and faith healers, often risking their lives, to end their pregnancies in a timely manner. In other cases, Netradipa Patil says the paperwork and red tape require so much time that the pregnant people end up giving birth.
“Yes, we are given reproductive rights, but it’s not easy to avail of them,” she says. “Abortion is legal in India, but the process is the punishment.”
How Abuse and Stigmatization Are Leading to Unsafe Abortions
“Many public doctors abuse and insult abortion-seeking women to such an extent that they are forced to use unsafe abortion methods,” says Maya Patil. She recalls an incident two years ago where a doctor berated a pregnant woman, saying, “How many children do you want? Are you going to give birth to a dozen more?”
In the face of such ill-treatment, many pregnant people tell ASHA workers that they are ready to suffer in silence rather than visit the government doctors, Patil says.
One among them is Archana Kamble (name changed for safety reasons), 30, who refused to visit a doctor to get an abortion. “I just took a few emergency contraceptive pills,” she says. But afterward, the bleeding and heavy cramps didn’t stop, even after 17 days. Kamble then reached out to her safest point of contact, Maya Patil, who encouraged her to consult a doctor.
However, fearing the insults, Kamble refused to go to the doctor and continued working, lifting heavy farm loads for another 13 days. “It was almost a month, and my bleeding wouldn’t stop,” Kamble says.
Eventually, dizziness and fainting forced her to reach out for medical help; Patil accompanied her. However, just as Kamble feared, the doctor she visited yelled at her for attempting to terminate the pregnancy on her own. “Instead of helping the patient, the doctor kept shouting at us,” Patil says. “He just wouldn’t stop, and kept asking several questions, making her extremely uncomfortable.”
Patil pushed back until the doctor agreed to do a sonogram. “It was an incomplete abortion with the fetus and pregnancy tissue still present,” the doctor said, and referred Kamble to the district hospital.
But Kamble already felt traumatized by the doctor’s comments, so she was reluctant to go. Patil counseled her and explained how urgent it was for her to get surgery to remove the fetal tissue. She agreed, and the surgery was ultimately successful.
With Patil’s help, Kamble then also got the tubectomy she wanted. “Even this was extremely challenging as the community women kept asking me to try for another child, meaning a boy,” Kamble says.
She isn’t an exception. As per India’s National Family Health Survey, 2019-21, more than 25% of abortions were performed by women themselves at home. Just 20% of abortions took place in public health care facilities, while 53% took place in private hospitals, which are mostly located in urban areas.
Solving Problems Before They Happen
In 2008, accredited social health activist Suraiyya Terdale from Maharashtra’s Ganeshwadi village got pregnant. “I didn’t want another child, but my brother told me he would adopt,” she says. However, in the third month, he denied having made such an agreement. After that, her sister-in-law said the same thing, and rejected the idea of an adoption. “By now, I was into depression,” Terdale says.
In her sixth month of pregnancy, Terdale accidentally fell from a height while cleaning the house, causing severe injuries to the fetus and ongoing bleeding. She went to a doctor who warned of the risks of continuing the pregnancy, which they said could even take her life.
Terdale had no idea about India’s abortion laws or if any doctor provided such services nearby. So she reached out to a local doctor who, with the help of another doctor, performed a surgical abortion without proper medical equipment or care in place. “I still remember how unsafe it was. I can never forget that moment,” she shares.
From that instant, Terdale, who wasn’t able to complete her education beyond grade 10 due to financial constraints and patriarchal attitudes, decided to save lives by making abortion accessible. She studied to become an accredited social health activist in 2010 and went on to complete a nursing and midwifery course.
Since then, she has worked to make her community aware of pregnancy and abortion laws. However, sometimes she runs into challenges that arise from the policy itself. For instance, pregnant women with multiple daughters often have a hard time getting an abortion. “In several cases, an investigation is done whether she has undergone a sex determination test,” Terdale says.
The preference for male children was leading to a decline in India’s sex ratio. In 1981, for every 1,000 boys, only 934 girls were born. By 1991 that ratio was 1,000 to 927. To stop this, the Pre-Conception and Pre-Natal Diagnostic Techniques Act of 1994 was enacted, which made prenatal sex-detection tests a criminal offense.
“But, this also made it extremely difficult for women to access safe abortion,” Terdale says. For instance, women like Kamble, who have two daughters, are often on the radar of public health care authorities when they seek an abortion. “Many doctors fear they will later be arrested for aborting a female child, and so they deny an abortion,” Terdale says.
During such times, ASHAs talk to the health care authorities and ensure a safe abortion. Terdale’s work brings hope, especially in these times when reproductive rights are under threat globally.
“I always ensure that an abortion is done in less than six weeks. The sex of the baby can be determined after 12 weeks of pregnancy, and since they get an abortion before that, there’s no reason they are denied an abortion,” she says.
However, Terdale’s work isn’t easy. She has been the subject of scorn from several medical officers and community members for helping marginalized women. During such challenging times, she thinks back to what made her do this work in the first place: She never wants anyone to go through what she had to go through. With her tremendous work traveling to villages on foot, Terdale has helped more than a hundred women access safe abortion. “If my work saves even one woman, I will happily believe that I have done something in life,” she says.
Despite their life-saving work, accredited social health activists, first instituted in 2006, aren’t considered full-time workers and therefore remain overworked and underpaid. They are compensated with an honorarium and performance-based incentives, meaning they are paid a small fee for each task completed. In Maharashtra, they average $45 to $60 a month—far less than the state’s average of approximately $215—and payments are often delayed.
Many of these health activists have aimed to address these strenuous working conditions by unionizing. There are now a number of ASHA unions across the country. Others like Terdale are silently making abortions accessible.
“While abortion is legal in India, there’s still a long way to make it accessible,” says Netradipa Patil, who has been fighting the system to bring change. She has written letters to the health ministry and meets with senior health care authorities to raise the issue of access to legal abortion.
Maya Patil, too, talks about why she keeps going despite the risks: “Today, whenever we meet the women and girls we helped, they smile. That smile inspires us to bring more smiles.”
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Sanket Jain
is an independent journalist and documentary photographer based in Western India's Maharashtra state. He is a senior People's Archive of Rural India and an Earth Journalism Network fellow. His work has appeared in more than 30 publications. As part of his long-term project, Sanket is documenting vanishing livelihoods and dying art forms from India's remote villages. He is also the co-founder of Insight Walk, a nonprofit that offers teaching fellowships to rural community women. These women work to ensure every child in their village has access to contextual education of their choice. At Insight Walk, every student designs their own syllabus. You can follow him on Instagram @snkt_jain (https://www.instagram.com/snkt_jain/)
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