In Conversation With Debanjana Choudhuri, Gender And Climate Justice Specialist.

Why is there a need to include abortion in telemedicine guidelines?

In India majority of abortions (81%) are carried out using MA drugs. However, India’s telemedicine guidelines do not include abortion. We need to consider key aspects on incorporating MA under telemedicine; first and foremost, it will help in bringing in legality to users, second, it will exponentially expand access, particularly in resource impoverished areas. Overall if we see, there has been a paradigm shift in the world order since the pandemic; the new normal has translated into this vast digital maze, which has made services and products accessibility more congruous with shrinking mobility. Internet penetration has substantially increased in the last decade, (with 560 million internet subscribers in 2018ii) and so has the usability, more so during the pandemic. While the lockdowns divided the world into essential & non-essential goods and services, many of the health services also took a huge hit due to this preferential dictum. Access to Medical Abortion was proclaimed as an essential service during the lockdown in March 2020, however, not including it within the telemedicine umbrella in such changing times, is equivalent to limiting options and causing hurdles. Even the updated operational guidance from the WHO for maintaining essential health services in the COVID-19 context recommends minimizing facility visits and provider-client contacts through the use of telemedicine for abortion. This are clear indications on where we are headed in terms of adapting technology and mainstreaming telemedicine particularly for MA.

What are the challenges faced by women and girls during the process of seeking telemedicine?

One of the biggest challenges that individuals could face while seeking telemedicine is the know-how & technicality about the system, authenticity of the service, doubts about privacy and confidentiality, genuineness of the intervention, quality of the services. According to me, these are initial hiccups and bumps on the road, which can be mitigated once telemedicine becomes mainstream and ubiquitous particularly for MA. Right now, these doubts or inhibitions are both necessary and expected. And these doubts itself would play a key role in taking a client-centered approach, for service delivery experts, and also help in leveraging technology for better user-experience, through practical experiments.

What did contraception and safe abortion services in India look like before COVID-19?

With population explosion during the onset of the neo-liberal era, contraception assumed a huge importance, with the objective to curb the surging population. Along with it, a progressive act of Medical Termination of Pregnancy (1971) also came into being, legalizing abortion in India. During this shifting landscape, women were seen as a medium to alleviate this problem by using various tools, and not as an empowerment mechanism, or furthering the cause of sexual and reproductive rights. However, almost 50 years down the line, access to safe abortion services continues to be poor, especially in rural areas, due to unequal distribution of abortion facilities and providers, bottlenecks related to service provision. For example, a study of licensed facilities across all 33 districts of Rajasthan in 2009-10 revealed that there were 0.85 certified abortion facilities per 100,000 populations in rural blocks as compared to 3.65 in urban blocks iii. In another study on “Availability of Medical Abortion Drugs” across 4 Indian states conducted by Pratigya Campaign found that there was an overwhelming shortage of MA drugs in two of the four states surveyed. The main reason for the shortage was legal barriers, excessive documentation, and paperwork. Therefore, to sum it up while legally we are progressing, in terms of logistics, some of the structures and processes are obsolete and needs an overhaul. Along with that, these policies should work in conjunction with sexual and reproductive health and rights, prioritizing the autonomy of a woman over their body.

What is your recommendation to improve access to safe abortion telemedicine and overall well-being and health?

My recommendation would be to kick-start the process of incorporating MA within telemedicine at the earliest. Given the emerging need of the service and the discrepancies created by the pandemic, it should not be viewed as a contingency action plan or even a relief measure to the pandemic. Rather it should be mainstreamed, and that would require a substantial R&D, technical, inter-sectoral collaboration, and a synchronized effort across the board to upscale the accessibility through acceptance. We need to understand that telemedicine is the future and can bring out systemic change in the realm of Sexual Reproductive Health and Rights (SRHR).

Please shed some light on how COVID-19 impacted on contraception and safe abortion services.

Of the estimated 15.6 million abortions that happen in India annually, 73% are through medical abortion (MA) drugs accessed outside of facilities, 16% in private health facilities, 6% in public health facilities, and 5% through traditional unsafe methods*. COVID-19 and the lockdown has had an unprecedented impact on women’s ability to access abortion primarily because - 

• Public health facilities were repurposed as COVID-19 treatment centers 

• Redeployment of facility staff from regular duties to COVID-19 care 

• Closure of private health facilities due to provider unavailability and lack of protective gear

 • Suspension of transport facilities restricting mobility of women to access facilities or chemist outlets

 • Disruption in supply chain of MA drugs at both chemist outlets and facilities. In India, perceived availability of abortion services from a clinic decreased from 61% to 44%. According to a survey by MSI, 13% of respondents in India reported a need for abortion services during the pandemic. The need for contraceptive services and domestic abuse services is also high in India, with over 1 in 3 women (35%) reporting a need for contraceptive advice, service, or products. Almost a third of women in India (31%) who were seeking a contraceptive service or product were unable to leave home to attend the service due to fear of COVID-19 infection.

Overall, the pandemic took us few decades back, in terms of accessibility and progress, and therefore there is a need to urgently respond to it in a much more composite and versatile manner, such like telemedicine.