"My idea of how choice should have developed was not a privacy notion, not a doctor's right notion, but a woman's right to control her own destiny, to be able to make choices without a Big Brother state telling her what she can and cannot do --- Justice Ruth Bader Ginsburg, Supreme Court of the USA
At Ernakulam General Hospital, Swati (name changed) waited for her turn at the gynaecology outpatient (OP) department. With promising career prospects awaiting her in Bengaluru, she and her partner had decided to terminate a seven-week pregnancy. They had been to three major hospitals and two clinics in Kochi but found that the procedure costs in the private sector were unreasonably high and exploitative.
As she was humiliated and harassed in that OP room by two trained doctors, she got a reality check on how bodily autonomy and reproductive rights guaranteed by law and the Supreme Court remain a myth in Kerala.
"From the moment my OP sheet was reviewed, I was subjected to hostile, judgmental and humiliating behaviour related to my request for medical termination of pregnancy (MTP). One senior doctor present in the consulting room slammed my OP sheet on the table and asked condescendingly why I came to a govt hospital after undergoing a scan at a private hospital. "Her colleague asked why was I making them commit kolapathakam (murder)?" Swati said.
Swati's is not an isolated ordeal. Accessing MTP procedures at govt facilities is getting increasingly difficult across Kerala. Most doctors in the private sector are either reluctant or charge heavily for the procedure or even for prescribing medicine at an early phase.
The lack of access to MTP in the state should be seen against the backdrop of unintended pregnancies being brought to term and children being abandoned, neglected or killed.
Swati tried to reason further with the doctor citing the early stage of her pregnancy, but the latter kept morally equating the procedure with murder.
"Both doctors responded with laughter and further patronising behaviour. I was asked how this "mistake" happened and if they were supposed to pay for my mistake?" Swati said. A blood test was prescribed, and she was asked to return with a "female bystander."
"Due to the humiliation, I sought care elsewhere, bearing significant personal financial burden," she said.
"Calling a lawful procedure under the MTP Act "murder," pressuring the patient and imposing non-statutory conditions breach the Act's intent and provisions. Mocking, moralising and blaming a patient violates the national medical commission's code of ethics. Questioning her use of a govt hospital constitutes harassment and discrimination in public healthcare," the woman wrote in a complaint to the hospital superintendent. She is yet to receive a response.
The couple said they first went to a major private hospital in Kochi, which refused to do the procedure while another hospital demanded Rs 70,000, claiming that it had to be an in-patient process.
"A third major hospital also denied MTP outright," said Swati's partner. They next approached a clinic in Edappally, where conversation turned more eerie.
"The doctor there was too insensitive. She said they refused to carry out the procedure even when rape victims seek MTP. I was shocked to hear such a statement. Still, she kept asking what she would get out of it. She said that they were anyway doing a bad thing and at least needed money," she said.
The couple was asked to pay Rs 25,000 just to prescribe medicines and Rs 45,000 for a hospital procedure. They opted for a hospital in Tripunithura but ended up paying Rs 17,000 for medicine-based MTP and necessary tests.
Sex Education Kerala Foundation founder Dr Edwin Peter says that planned parenthood, as opposed to leaving it to chance, is still not common here.
"When you switch to a value system where pregnancy is an individual's choice and is a serious planned decision, then you become aware that you also have the right to not accept an accidental pregnancy. However, many don't understand it that way, due to social, religious or varying value systems," said Dr Peter.
He says that the medical profession should not impose moral values on a patient though doctors have the duty to protect life. It often leads to ethical dilemmas.
"Religious or social moral values consider a foetus as a life form soon after pregnancy. However, human rights conventions have highlighted the impracticality of assigning human rights to cell structures before birth. What MTP does is terminate the pregnancy, basically withdrawing the support given to the cell group called a foetus from the maternal body. That process cannot be considered as a human rights violation," said Dr Peter.
He said it was childish to place the human rights of cell groups above that of a female-bodied, full-fledged person.
"Our doctors are stuck in such matters. In India, doctors have the right to choose patients unless it is a life-threatening situation. Doctors in govt hospitals, unlike in the private sector, are legally bound to provide the services that the govt intends to provide. Denying them is a serious rights issue. Behaving without considering that obligation is an injustice to their profession," said Dr Peter.
Payyannur-based gynaecologist Dr Praveen Gopinath said MTP has become a procedure done in the shadows.
"Indian law is very favourable for MTP. However, procedures and paperwork were increased to prevent female foeticide. Subsequently, the number of doctors who provide the service came down drastically, facilitating a situation to overcharge," said Dr Gopinath.
He said the added paperwork requirements and procedures have neither reduced female foeticide nor improved the male-to-female ratio.
"Creating difficulty for patients and making the situation favourable for exploiters are the only results. Only social awareness can reduce female foeticide. When it becomes difficult to do it legally, it facilitates those who do it illegally," said Dr Gopinath.
Dr Peter adds that in majority of cases in Kerala, most women recognize pregnancy when periods get delayed. "In first-trimester (six-to-eight weeks) pregnancies, if it is a pregnancy without any complications, MTP is possible through medicines. In most cases, only basic investigations, like an ultrasound sonography to confirm that the pregnancy is intrauterine, and preliminary blood investigations are done. It is an OP procedure where the cost of these basic investigations is levied and the medication is prescribed," he said.
Dr Peter said that in many cases, those seeking services are exploited. "The most exploited are unmarried persons, either through higher charges for investigations or by being forced to take high-cost ward admissions to increase the total bill. There are several private hospitals who exploit the helplessness of the people," he said.
Author and rights activist Dr Jayasree A K says that society has largely turned against MTP. She noted that in the 1980s, such stigma was not associated with the procedure.
"Unlike in the past, of late, especially in the aftermath of the widespread campaigning by the global pro-life movement, MTP is considered a sin in Kerala," Dr Jayasree said.
"I remember the amount of backlash on social media when the women & child development department made a post on MTP being a necessary service. The comments were that it shouldn't be done at all," she said.
So, doctors too will not take the risk, Dr Jayasree said. "When it's something that society doesn't accept, the risk increases. More so at a time when there have been frequent conflicts between the public and medical practitioners on various issues," she said.
Dr Jayasree said to gain access to a right, there should be pressure from the public. "Are any organizations raising this issue? No civil society organization or women's organization is demanding it openly," she said.
Dr Peter said it is high time the govt took an initiative to set up MTP-specific clinics.
"At least one MTP clinic with doctors willing to provide the service should be started in every district. They can at least provide medicine-based MTPs," he said.
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