Question Of Who And How

• MTPs performed annually 7 million
• Deaths caused by MTPs 5,800

Source: Ipas Development Foundation.

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A final decision is still awaited, but the proposal is fraught in controversy. The Union health ministry under the new BJP-led government wants to allow nurses, midwives and practitioners of ayurveda, unani, siddha and homoeopathic medicine (Ayush) to perform abortions using both medical and surgical methods. This means medics with little or no training in modern surgical practice will be performing operations that could involve life-endangering situations. Many in the medical fraternity are alarmed; they take consolation only in the fact that the ministry has elicited people’s views on its website.

India has an embarrassing maternal mortality record. Every two hours, a woman dies in an abortion performed unsafely or unscientifically. That makes for one-tenth of all expecting mothers. Medical infrastructure is poor and sanitisation of operation rooms at government and midsize private hospitals treacherous. Conditions are worse in rural areas. Last fortnight, in Bilaspur, Chhattisgarh, a dozen women died after undergoing tubectomies at a free sterilisation camp. One of those performing at the camp, organised by the state government, was an award-winning surgeon.

Opinion is divided. Among modern allopaths there are some who believe it’s better to allow indigenous practitioners to conduct abortions than leave it to quacks. They say medical termination of pregnancy (MTP) is simple enough for a nurse or compounder to master with some training. Ayush practitioners, naturally, are happy. “What’s the fuss about?” says Dr D.C. Katoch, an ayurv­eda advisor to the ministry. “Didn’t we have surgery in ancient times? Aren’t people aware of Sushruta, the first surgeon?”

But Dr Narendra Saini, general secretary of the Indian Medical Association (IMA), is unimpressed. He says he has discussed the issue with at least 200 gynaecologists and each had an account of having to intervene after an abortion botched by non-allopaths. In one case, the uterus had ruptured and the quack had kept tugging at the protruding intestine, taking it for some worm.

“We are shocked and appalled. We’ll put a strong fight,” says Dr Sharda Jain, secretary general of the Delhi Gynae­cologists Forum. Many gynaecologists had written to Dr Harsh Vardhan, the health minister before the reshuffle, demanding the withdrawal of the proposed amendments to the MTP Act that will allow Ayush practitioners to perform abortions. Says Dr Anil Goyal of the IMA, “MTP is a highly complex, blind procedure. Misjudgements can occur even in expert hands. Out of 500 medical negligence cases before the Delhi Medical Council, some 50 are of abortions.” Quite often, abortions botched by traditional midwives go unreported because the patient has strong community-based ties with the midwife, says Dr Nikhil Datar, a Mumbai-based gynaecologist. And Dr Hitesh Bhatt, who heads the ethics committee of the Federation of Obstet­ricians and Gynaecologists Society of India (FOGSI), says that though it may be notionally claimed that ayurveda, homo­eopathy and MBBS students undergo the same training except in pharmacology, the theoretical foundations of the three systems are completely different and therefore approaches to diagnosis will be completely at variance too.

These experts say homoeopaths and ayurvedic practitioners are unequipped to handle likely complications, such as excessive bleeding, perforation, infection, bowel injury or urinary fistula, nor will they be able to minister to underlying conditions such as heart disease or hypertension. They wouldn’t recognise ectopic pregancies either, in which the embryo is not in the uterus and hence an abortion pill won’t work. Introducing “cross-pathy practice”, they say, is a systemic invitation to quackery.

The health ministry’s department of Ayush, however, is perplexed by this opposition. Echoing Dina Nath Batra and Prime Minister Narendra Modi, Dr Kat­och says, “Sushruta, the first surgeon, was an ayurveda practitioner. Ganesha’s head was replaced with an elephant’s at a time MBBS doctors did not exist. Once trained, ayurveda doctors can perform abortions as efficiently as MBBS doctors. Surgery is a skill that can be learnt just the way people adapt to technology.”

Those in favour of the proposal also cite the WHO’s safe abortion guidelines, which say that training and enabling midwives to perform safe abortions will benefit large numbers of people in remote parts of the country. “Nearly 50 per cent of abortions are performed at home or by untrained practitioners. Over 5,800 women die each year due to unsafe abortions. This amendment will, in fact, bring back-of-the-street practitioners into the legal fold, train them, and help monitor their services. This is only a draft bill. The rules will ensure that the role of non-allopathic practitioners is restricted and regulated adequately,” says Vinoj Manning, executive director, Ipas Development Foundation, an international NGO working to ensure safe abortions. Even this stance requires a nuanced view, says Nozer Sheriar, secretary general of FOGSI. He agrees that substantive training, and more important, formulation of rules defining and limiting the role of non-allopaths performing abortions, could help millions of women in rural India—but, he says, that can happen only if there’s a progressive motive driving the formulation of rules.

There are fears that the amendments could lead to a spike in female foeticide, encourage abortion and discourage cont­ra­ception. The draft bill also goes against two rulings of the Supreme Court which strictly prohibit cross-pathy practice. In the Poonam Verma vs Ashwin Patel judgement, the court observed: “A person who does not have knowledge of a particular system of medicine but practises in that system is a quack and a mere pretender to medical knowledge or skill, or to put it differently, a charlatan.” And the Dr Mukhtiar Chand vs State of Punjab judgement checks non-allopaths from prescribing allopathic drugs.

Questions are also being raised about a strong ayurveda lobby at work, influencing a saffron government inclined to promoting Indian indigenous systems. It was for the first time that this year the Union government took ownership of the World Ayurveda Conference held in Delhi from November 6-9. For years, it had been held with minimal government involvement. “This government is interested in Indian traditional wisdom and knowledge that will help our country gain a unique position,” says Jaya Kumar, secretary general of Vijnana Bharati, whose brainchild the wac is.

On another proposed amendment to the MTP Act, however, there seems to be greater consensus: raising the ceiling on abortions from 20 to 24 weeks’ pregnancy. The amendment is being seen as progressive. “Often, cardiac and other abnormalities are detected in the foetus only after 20 weeks in the womb. In such situations, before 20 weeks of pregnancy, the woman, her gynaecologist and other doctors cannot decide on whether or not to carry out an abortion,” says Dr Datar, whose PIL in the Supreme Court is one of the triggers for the amendment.

So, how can a government that is taking a progressive decision like this simultaneously push an amendment that, given India’s poor enforcement of rules, opens the doors to quacks, ill-trained medics and quasi-medics performing abortions? It’s a question the new health minister, J.P. Nadda, might ponder over even as he badgers a certain former CVO of AIIMS.

By Pavithra S. Rangan in Delhi