After the onset of the COVID-19 pandemic, most countries have diverted their often inadequate public health infrastructure to combating the novel coronavirus. However, beneath the surface, a global human rights crisis looms large in the form of an unprecedented threat to reproductive rights. The UN Population Fund has warned that the pandemic has “severely disrupted access to life-saving sexual and reproductive health services”; Human Rights Watch has flagged the impact that the ongoing crisis could have on abortion access and maternal care. To mitigate this threat, WHO has urged governments to treat abortion as an essential healthcare service.
In countries with no legal impediments to abortion, the threat manifests in the form of shortage of contraceptives and medicines, strained medical facilities and dwindling personal incomes. In countries like the US, where abortion is a contested issue, several states have attempted on the anti-choice side of the abortion debate to restrict abortion access in the shadow of the pandemic by declaring it a non-essential medical procedure.
The Guttmacher Institute recently estimated that even a “10% proportional decline in use of contraceptive methods in low-and middle-income countries due to reduced access would result in an additional 49 million women with unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year”. Experience with previous epidemics, such as those of the MERS-CoV, SARS and Ebola viruses, provide enough evidence of the negative outcomes for sexual and reproductive health during such crises, and ought to serve as a warning for governments.
In India, the nationwide lockdown to flatten the COVID-19 curve has been followed by reports of increasing domestic violence, mirroring the global trend, and which UN Women has called a “shadow pandemic”. This places women at an increased risk of unwanted pregnancies with fewer means to assert their bodily autonomy. There is a pre-existing issue with contraception access, especially in rural areas, which could become aggravated as public health workers responsible for distributing contraceptives are engaged with COVID-19 issues. Further, disruptions in pharmaceutical supply chains are likely to impact the availability of contraceptive methods and medical abortion drugs.
A public health crisis of this scale renders invisible the rights of those already at the margins. Reports have begun to emerge of women struggling to access abortion services during the lockdown even though the health ministry has classified abortion as an essential service. Even otherwise, India has a poor record in sexual and reproductive health services.
In 2017, the Comptroller and Auditor General of India’s performance audit report on reproductive and child health under the National Rural Health Mission flagged several issues with physical infrastructure, equipment and medicines, human resources, and provision of safe abortion services. Despite the relatively liberal medical termination of pregnancy laws, women face barriers in abortion access. The recent amendments to the Medical Termination of Pregnancy Act 1971 were meant to remedy some longstanding lacunae in the law, but the pandemic threatens to undo all progress on this front.
Abortion and maternal care are time-sensitive interventions. Recognising this, a PIL was filed in the Delhi High Court for directions to the Centre to ensure access to medical services for pregnant women. As a relief measure, the high court directed the Delhi government to ensure a helpline service is made available for pregnant women and is publicised through newspapers and the social media.
Even after the lockdown lifts, normalcy may not immediately return, with physical distancing norms, movement restrictions, increased burden on public health systems, and supply chain issues expected to continue. Hence, ensuring sexual and reproductive health must be an integral part of the government’s immediate response strategy. Relegating it as a problem for another day could have cascading effects not only on reproductive health but also on female well-being and empowerment. It could cause immeasurable damage to the progress that India has made in meeting the sustainable development goal of gender equality. Reproductive rights are inalienable and have legitimate demands on public resources even during, and especially during a crisis.
Some potential interventions
* Drawing from the helpline intervention model set up by the National Commission for Women for domestic violence cases, and as directed by the Delhi High Court for pregnant women, nationwide helpline services to ensure abortion access must be extended.
* Adequate supply of contraceptives and medical abortion drugs should be ensured. Interestingly, family planning kits have been home delivered in UP’s Ballia district amidst concerns of a population boom. State governments could consider the possibility of adding family planning kits to the distribution of other essential ration supplies.
* To tide over the acute shortage of obstetricians and gynaecologists, nurses and AYUSH doctors may, as an interim measure, be used to expand the provider base in first trimester medical abortion.
* Currently, the Telemedicine Practice Guidelines issued by the Indian Council of Medical Research don’t mention reproductive health services. Taking a cue from other countries, the use of telemedicine can be explored to improve access to medical abortion services. France has extended the time limit for at home medical abortion to nine weeks using medicines which can be prescribed over phone or by video consultation by doctors or midwives. Even UK and Germany have attempted to use telemedicine to address the abortion needs of women.
The government must widely publicise the fact that abortion services are essential health services, so the women who need them are not turned away from health facilities.
From a long-term strategy perspective, capacity-building to ensure uninterrupted delivery of sexual and reproductive health services must be built into the epidemics and disaster management policies. There are several important lessons for policy makers to learn from the pandemic, one being that gender concerns tend to become unseen at such times, but neglecting them can pose catastrophic consequences for millions of vulnerable women.
Rupavardhini B.R. is a civil servant and Vrinda Agarwal is a lawyer and legal journalist. The views expressed here are the authors’ own.