Abortion

When a woman gets a pregnancy terminated voluntarily from a healthcare provider, it is called induced abortion.

Spontaneous abortion is when the process of abortion starts on its own without any intervention. In common language, this is also known as miscarriage.

Here, in both the situations, an expulsion of the embryo or the foetus before it can survive in the outside world is conducted.

Induced abortion

When abortions are performed by external induction due to several reasons, they are known as induced abortions.

According to the objective behind induced abortion, they are classified into therapeutic and elective induced abortions.

Therapeutic induced abortions

Therapeutic induced abortions are when abortions must be performed by a medical professional to,

Prevent any danger to the life of the mother’s physical health.
Prevent any physical or mental harm to the mother’s physical or mental health
Terminate pregnancies where the child shows characteristics of having very low chances of survival.
Reduce the risk to the mother during multiple pregnancies by selectively terminating the foetus.

Elective Abortion

When abortions are performed according to the will of the mother and in cases, where the mental/physical health of the mother and the child are not in danger, it is termed an elective abortion.

Induced abortion is not appropriate for everyone. Hence, the doctor might suggest that to avoid it, if

The pregnancy has been implanted outside of the uterus (ectopic pregnancy)
The pregnant lady is allergic to mifepristone or misoprostol.
She has a bleeding disorder or consume blood thinners.
She faces severe liver, kidney, or lung disease.
She has an intrauterine device (IUD).
She has been taking corticosteroid drugs for a long time.

Counselling and decision making by the pregnant woman

The pregnant women are the one whose approval stands must prior to an abortion in case of induced abortion.

In this process, proper medical counselling of the procedures involved should be given in prior to the pregnant lady. These counselling sessions should be confidential and carried out by a trained professional.

In case the woman chooses to go forward with the abortion, the risks involved and the legal procedures involved should be explained to the woman. In cases where it is not an emergency, the family members should give time to the woman to make her decision.

Certain case history for abortion

Pressure from family members for an abortion
Pressure from partner for an abortion
Women in abusive relationships
Women living with HIV
Adolescents who have been subjected to pregnancy

It is very important to be sensitive in such cases and make sure that the family members or the close friends or relatives provide support and time to the woman to prepare for the procedure. In the hurry to perform an abortion, sometimes the woman might opt for unsafe practices of abortion and this should be avoided at any cost.

Safe practices of abortion

Manual or electric vacuum aspiration

Here the embryo is vacuumed out of the implanted region in the uterus and is performed by a medical professional. This method is also known as suction aspiration.

Procedure and Recovery

This is not a painful method and it is performed by a medical professional.
Here the embryo is gently suctioned out of the uterus. The foetus and the placenta (if developed) are suctioned out.
The procedure takes about 10-15 minutes.
However, the woman will be kept under observation for about a day to ensure the termination of pregnancy.
There is some amount of cramping felt by the woman because the uterus gets a little contracted during the procedure. The doctor prescribes painkillers and certain antibiotics to prevent the risk of infection due to the procedure.

Side effects

Side effects include bleeding or spotting, abdominal cramps, nausea, sweating dizziness.

Precautions

Sex and heavy exercise or movement are to be avoided at least one week after the procedure. Take some days off from the work to prevent any exhaustion and to ensure proper recovery.

Approximate Cost

Rs 2000/- to Rs 5000/- per procedure

Oral drug Mifepristone (Mifeprex) and Misoprostol (cyclonic)

This is a drug combination prescribed by the OBGYN for pregnancies up to 7 to 9 weeks, to cause termination of pregnancies, wherever required.
These drugs can cause heavy bleeding due to the expulsion of the embryo through the vagina.
The woman might require wearing of the sanitary napkins.

Procedure and Recovery

Mifepristone is given by the doctor to be taken in the clinic itself.
Progesterone is inactivated by the drug preventing the implantation of the embryo.
Misoprostol is to be taken 4 hours after the intake of mifepristone, orally or through the vaginal route after discussing it with the doctor.
The uterus starts contracting and the process of expulsion of the pregnancy tissue begins.
Bleeding and cramping start after 1-4 hours after taking misoprostol.
A sanitary pad is to be worn to prevent any infections which might spread and to control blood flow.
Recovery from the bleeding takes a different amount of time in different women. However, the time can be up to 4 days.
Menstruation should begin a month after the abortion.

This method is not performed in women who show signs of ectopic pregnancy, in women who are allergic to either drug, women with bleeding disorders or severe liver/kidney/lung diseases, women who have been taking corticosteroids and women with intrauterine devices (IUDs).

Side Effects

Side Effects of the drug include nausea, vomiting, dizziness, tiredness, diarrhoea, sweating, the passage of small blood clots, headaches.

Approximate Cost

Rs 300/- to Rs 500/- at pharmacies

Oral drug Methotrexate and Misoprostol

This method is also used for abortion.
Methotrexate is also used for cancer treatment and it works by preventing the cells of the embryo from multiplying.
When administered alone, the process of expulsion of the embryo takes longer than the method of combination of the two drugs.
These drugs can cause heavy bleeding due to the expulsion of the embryo through the vagina.
The woman might require wearing of the sanitary napkins.

Procedure and Recovery

Methotrexate is given by the doctor in the clinic, which can be taken as an oral pill.
Take misoprostol orally 4 to 6 hours later
The abortion starts within 1-12 hours and bleeding are heavy for 4-8 hours
Wear a sanitary napkin to control the bleeding and to avoid the risks associated with infections
Take a break from work for a few days because there will be discomfort for about a week. Some people even take months to recover.
Menstruation will begin after one to two months after the abortion.

Side effects

Include vomiting, fever, nausea, chills, dizziness, headache.

Approximate Cost

Rs 300/- to Rs 500/- at pharmacies

Dilation and Evacuation (D&E)

This is a procedure which is performed like vacuum aspiration.

D&E is recommended for patients who have been over 14th week of pregnancy.

Procedure and Recovery

This process takes two days because the pregnancy tissue is considerably larger than its size on the first trimester.
On the first day, the doctor dilates your cervix tissue to assist the expulsion of the pregnancy tissue.
On the second day, forceps are used to remove the foetus and the placenta.
Anaesthesia might be required for the procedure as it can be painful.
After this, a tube is used to suction out the uterus.
A scoop like an instrument called a curette is used to scrape out the uterine lining.
Recovery takes up to a few weeks and a few days off from the work is recommended for a steadier recovery.
The patient is supposed to avoid sexual intercourse and heavy exercise for about 2 weeks.
Menstruation will begin about 4 to 8 weeks after the procedure.

Side effects

Side effects of this procedure include bleeding, abdominal cramping, nausea and dizziness.

Approximate Cost

Rs 2000/- to Rs 5000/- per procedure

Induction Abortion

This method of abortion is not frequently performed. Induction abortion is performed after the 24th week of pregnancy.

Procedure and Recovery

This method of abortion is performed by a doctor in a hospital.
Medication which induces labour is given to the woman.
The uterus begins to contract and the pregnancy tissue begins to get released
Suction or curette is used to scoop out any pregnancy tissue remaining in the uterine lining.
Sedatives are given in some cases to minimise the pain associated with the process.
This process takes a few hours to complete and sometimes, it takes a whole day. The recovery will be smooth if the woman takes a few weeks off from the work to assist the process of recovery. Sexual intercourse and exercise or heavy exertion are to be avoided for about 2 to 6 weeks after the procedure. Menstruation begins about a month or two after the procedure.

Side effects

Side effects of the procedure include abdominal pain, bleeding, nausea, vomiting, diarrhoea, chills, headache.

Approximate Cost

Rs 5000/- and higher up to Rs 20,000/- depending on the other diagnostic procedures required.

Side effects and Complications post abortion

Common side effects, post abortion

Abdominal cramps
Light vaginal bleeding
Nausea and vomiting
Sore breasts
Fatigue

Alarming side effects, post abortion

Fever and/or Chills
Excessively heavy bleeding
Strong-smelling vaginal discharge
Severe abdominal pain

Complication post abortion

Infection
Incomplete or failed abortion

Infection post abortion

While both certified medicinal and surgical abortions are generally considered to be safe, they can sometimes result in serious complications.

One of the most common complications is infection. This can be caused by incomplete abortion or exposure to bacteria vaginally, such as by having sex too soon post abortion. One can reduce the risk of infection by waiting to have sex and using pads instead of tampons.

Symptoms of infections post abortion

Strong-smelling vaginal discharge
Fever
Severe pelvic pain

Untreated infections can result in pelvic inflammatory disease, so consulting the doctor for further treatment upon symptoms are advised.

Incomplete or failed abortion

Incomplete or failed abortion, in which the foetus is still viable or was not fully evacuated from the womb.

This can cause serious medical complications such as, uterine perforation and septic shock.

Uterine perforation, which has symptoms of severe abdominal pain, bleeding, and fever.
Septic shock, which has symptoms that include fever, chills, abdominal pain, and low blood pressure.

Unsafe Abortion

There are many ways that some unethical medical professionals or non-professional who claim to perform an abortion for women who do not have access the safe methods of abortion due to multiple reasons. These types of abortions are unsafe.

Unsafe abortion is the third largest cause of maternal mortality leading to death of 10 women each day and thousands more facing morbidities.

Common reasons to opt for these unsafe abortions

Restrictive laws in the regions where they live.
Poor availability of medical services.
The very high cost of legitimate medical services.
Stigma existing in society associated with abortion.
Misleading information provided by third party authorities.
Improper training of some medical professionals.
Medically unnecessary tests which delay the care by legitimate healthcare provider.
Refusal by the woman to visit healthcare facilities for an abortion.

Some means of unsafe abortions

Ingestion of caustic substances like phenyl or any other substance with hopes to terminate the pregnancy. Usage of methods such as insertion of foreign bodies into the woman’s uterus by an untrained professional
Traditional concoctions, Outdated methods like sharp curettage being used by medical professionals.

The complications of unsafe abortion

Incomplete abortion: failure to remove the foetus/embryo and other pregnancy tissue from the uterus
Haemorrhage: Heavy bleeding
Infections: contacted during the procedure due to the use of unsterilized equipment or after the procedure due to improper post-procedural care.
Damage to internal organs: Occurs due to inserting objects like sticks, needles, knives, glass into the vagina or the anus with the hope of conducting an abortion.

Signs and symptoms of Unsafe Abortion

Abnormal vaginal bleeding.
Abdominal and pelvic pain which becomes unbearable
Signs of infection
Shock- the collapse of the circulatory system characterised by profuse sweating, inability to breathe and in some cases, sudden death.

In case the abovementioned signs and symptoms are observed, the woman must be rushed to a nearby health facility immediately.

Post Abortion care

The family members and partner should discuss with the doctor about clear indications on the guidelines which include the risks associated with the procedure and explain these guidelines to the pregnant woman.

The guidelines include

Abstain from penetrative sexual intercourse until bleeding stops.
Fertility will return after 2 weeks of abortion or before so emergency and other methods of contraception should be prepared.
Visit the nearest hospital if pelvic pain increases, fever occurs and heavy bleeding occurs.
The contact number and details of the doctor should be provided to the woman, which should be collected by the family members and partners.
In cases of surgical abortion due to rape or other forms of mental and physical trauma, assisted therapeutic help needs to be arranged with a therapist after the woman recovers from the procedure.
Family members should not shy away from taking the woman to the doctor for follow-up visits after any kind of abortion.
In the case of surgical abortion, the family members must take the woman to the doctor after 2 weeks of the procedure for a follow-up visit.

Post abortion Care

Use heating pads, which can ease cramps.
Stay hydrated, especially if experiencing vomiting or diarrhoea.
Have a support system in place, as some women experience emotional changes from the drastic hormone shift.
If possible, plan on staying in for a day or two, so that you can rest and recover in the comfort of your own home.
Take medication like ibuprofen to lessen cramps and pain.
Massage your abdomen at the site of the cramps.
Wear a tight-fitting bra to relieve breast tenderness.

FEMALE FOETICIDE

Female foeticide is defined as the illegal abortion of the, particularly female foetus.

The practice of determining the sex of a girl child through misuse of diagnostic methods is what leads to female foeticide.

The frequency of female foeticide in India is increasing day by day. To curb these cases, the government of India constantly works on the legal process of by-laws concerning female foeticide.

The reasons why female foeticide is so common in India is because:

Gender biased access to resources like education, job and much more.
Cultural practices like Dowry system
Inadequate sanitary risks are higher in a female.
Assumption of greater social and financial security in case of a boy child.
The immense pressure to bear boy child to inherit their assets in all forms, as they believe a female is meant to belong to in-laws in mere future of their birth.
Assumption of having to incur the higher expense of raising a girl child who will rather be a burden until and during the wedding ceremony.

Due to the rising cases of female foeticide, the government of India has come up with regulations to curb cases of female foeticide with regulations that state:

Misuse of diagnostic ultrasound machines and other diagnostic procedure will result in the seizure of the equipment.
Sealing of any unregistered centres performing sex determination, while the law clearly states that prenatal sex determination is an illegal practice.
All sex selection advertisements and sex determination advertisements shall be blocked.
Dowry is absolutely banned in India since 1961 under the Dowry Prevention Act.

Several other steps like raising awareness in areas with low sex ratios and the passing of the Equal Remuneration Act which prevents the monetary discrimination between males and females in the workforce ensure that all the issues which cause female foeticide are being attended to.

Legal aspects of Pregnancy

Not hiring, firing or demoting are some of the general practices followed by many firms when it is with respect to a pregnant woman. As long as the pregnant women can perform her duties and do justice to her post in any organisation following any of the above practices or discrimination stands illegal in the eyes of the Indian Law.

The Maternity Benefit Act

The Maternity (Amendment) Bill 2017, an amendment to the Maternity Benefit Act, 1961, was passed in Rajya Sabha on August 11, 2016, in Lok Sabha on March 09, 2017 and received an assent from President of India on March 27, 2017.

Applicability

The Act is applicable to all establishments which include factories, mines, plantations, Government establishments, shops and establishments under the relevant applicable legislation, or any other establishment as may be notified by the Central Government.

Eligibility

As per the Act, to be eligible for maternity benefit, a woman must have been working as an employee in an establishment for a period of at least 80 days within the past 12 months. Payment during the leave period is based on the average daily wage for the period of actual absence.

The Maternity Benefit Amendment Act makes it mandatory for employers to educate women about the maternity benefits available to them at the time of their appointment.

Also, keeping the amendments in mind, a pregnant lady cannot be fired from job. However, companies can fire her for non-performance impact due to her pregnancy.

Key amendments by the government of India for a Pregnant Women in India

1. Increased Paid Maternity Leave
2. Maternity leave for adoptive and commissioning mothers
3. Work from Home option
4. Crèche facility

Increased Paid Maternity Leave

The Maternity Benefit Amendment Act has increased the duration of paid maternity leave available for women employees from the existing 12 weeks to 26 weeks. Under the Maternity Benefit Amendment Act, this benefit could be availed by the pregnant women for a period extending up to a maximum of 12 weeks before the expected delivery date and the remaining time can be availed after childbirth. For women who are having 2 or more surviving children, the duration of paid maternity leave shall be 12 weeks (i.e. 6 weeks before and 6 weeks after expected date of delivery).

Maternity leave for adoptive and commissioning mothers

Maternity leave of 12 weeks to be available to mothers adopting a child below the age of three months from the date of adoption as well as to the “commissioning mothers”. The commissioning mother has been defined as biological mother who uses her egg to create an embryo planted in any other woman.

Work from Home option

The Maternity Benefit Amendment Act has also introduced an enabling provision relating to "work from home" for women, which may be exercised after the expiry of the 26 weeks' leave period. Depending upon the nature of work, women employees may be able to avail this benefit on terms that are mutually agreed with the employer.

Crèche facility

The Maternity Benefit Amendment Act makes crèche facility mandatory for every establishment employing 50 or more employees. Women employees would be permitted to visit the crèche 4 times during the day (including rest intervals).

The pre-natal Sex Determination

Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 is an Act of the Parliament of India enacted to stop female foeticides and arrest the declining sex ratio in India.

The act banned prenatal sex determination. Every genetic counselling centre, genetic laboratory or genetic clinic engaged in counselling or conducting pre-natal diagnostics techniques, like in vitro fertilisation (IVF) with the potential of sex selection (Preimplantation genetic diagnosis) before and after conception comes under preview of the PCPNDT Act and are banned.
Sex selection is any act of identifying the sex of the foetus and elimination of the foetus if it is of the unwanted sex is illegal in India.
The Act mandates compulsory registration of all diagnostic laboratories, all genetic counselling centres, genetic laboratories, genetic clinics and ultrasound clinics.
Offences under this act include conducting or helping in the conduct of prenatal diagnostic technique in the unregistered units, sex selection on a man or woman, conducting PND test for any purpose other than the one mentioned in the act, sale, distribution, supply, renting etc. of any ultra sound machine or any other equipment capable of detecting sex of the foetus.
This act is an attempt to ensure gender equality from birth and also stopping female foeticide by certain families who traditionally consider a girl child to be a burden and unwanted and prefer the birth of male child only.

Main provisions in the act

The Act provides for the prohibition of sex selection, before or after conception.
It regulates the use of pre-natal diagnostic techniques, like ultrasound and amniocentesis by allowing them their use only to detect :

1. genetic abnormalities
2. metabolic disorders
3. chromosomal abnormalities
4. certain congenital malformations
5. haemoglobinopathies
6. sex linked disorders.

No laboratory or centre or clinic will conduct any test including ultrasonography for the purpose of determining the sex of the foetus.
No person, including the one who is conducting the procedure as per the law, will communicate the sex of the foetus to the pregnant woman or her relatives by words, signs or any other method.
Any person who puts an advertisement for pre-natal and pre-conception sex determination facilities in the form of a notice, circular, label, wrapper or any document, or advertises through interior or other media in electronic or print form or engages in any visible representation made by means of hoarding, wall painting, signal, light, sound, smoke or gas, can be imprisoned for up to three years and fined Rs. 10,000.

However, Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 (PNDT), was amended in 2003 to The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition Of Sex Selection) Act (PCPNDT Act) to improve the regulation of the technology used in sex selection.

The Laws of Abortion in India

Abortion in India is legal in certain circumstances. It can be performed on various grounds until 20 weeks of pregnancy. In exceptional cases, a court may allow a termination after 24 weeks.

The Medical Termination of Pregnancy (MTP) Act, 1971 provides the legal framework for making CAC services available in India.

Termination of pregnancy is permitted for a broad range of conditions up to 20 weeks of gestation as detailed below:

When continuation of pregnancy is a risk to the life of a pregnant woman or could cause grave injury to her physical or mental health.
When there is substantial risk that the child would be seriously handicapped due to physical or mental abnormalities, if born or dead.
When pregnancy is caused due to rape (presumed to cause grave injury to the mental health of the woman).
When pregnancy is caused due to failure of contraceptives used by a married woman or her husband (presumed to constitute grave injury to mental health of the woman).

The MTP Act specifies

Who can terminate a pregnancy?
Till when a pregnancy can be terminated?
Where can a pregnancy be terminated?

The MTP Rules and Regulations, 2003 detail training and certification requirements for a provider and facility; and provide reporting and documentation requirements for safe and legal termination of pregnancy.

Who can terminate a pregnancy?

As per the MTP Act, pregnancy can be terminated only by a registered medical practitioner (RMP) who meets the following requirements:

Has a recognized medical qualification under the Indian Medical Council Act.
Whose name is entered in the State Medical Register.
Who has such experience or training in gynaecology and obstetrics as per the MTP Rules.

If any of the conditions are violated, the punishment includes imprisonment for about 2 to 7 years.