Access to Safe Abortion in South Asia during COVID 19: A Crisis or an Opportunity

Dr. Shilpa Shroff

Director of Advocacy, International Campaign for Women’s Right to Safe Abortion

The COVID 19 pandemic saw the access to sexual and reproductive healthcare services shrinking, particularly access to safe abortion services, as there sources were redirected towards COVID-related responses. In South- Asia, many countries went into a complete lockdown from March 2020, and access to safe abortion became further difficult. As per WHO, worldwide 190 million women want to avoid pregnancy and over half of all unintended pregnancies end in abortion, making it essential for women to have access to safe abortion.  The nationwide lockdowns and closed borders, restricted mobility, disrupted the supply of medical abortion pills, and made it difficult to access health care facilities and pharmacies.  To add to that, existing social stigma that surrounds abortion, lack of awareness about available services, privacy for a woman living in big family settings, made it further difficult for woman to access safe abortion.

The extent of impact on these services in the region is evident from individual country situations and experiences. In Afghanistan, abortion is highly restricted by law. The Afghan Family Guidance Association (AFGA) was the only Post Abortion Care (PAC) service provider operating during this lockdown period. They observed huge decline in PAC services, their clients reduced by 80%, and there was a dip of 58% in uptake of contraceptive services. [1]

In India, though the government declared safe abortion an essential health service on April 14, access to the services was not a simple task. Most of the health care facilities were redirected towards COVID treatment and the Private facilities were shutdown. The Medical Termination of Pregnancy Act does not permit telemedicine or self managed abortion.  Additionally, the Medical Abortion Pills are registered as schedule-H drug, making it tough for woman to procure them without a Gynaecologist’s prescription. A report by the IPAS Development Foundation estimated that access to 1.85 million abortions was compromised during the period from March to June 2020.  Another report by the Foundation for Reproductive Health Services, India estimated that the pandemic could lead to 834,042 unsafe abortions and 1,743 additional maternal deaths.[2]

Nepal is known for its progressive law that facilitates life-saving decisions for many women and girls in need of abortion service. However, during lockdown, even women in the country faced difficulty in accessing services due to restricted mobility. There are anecdotal evidences  that women from Nepal access the second-trimester abortion services from India and women from Bhutan, Sri Lanka & Maldives, where abortion services are severely restricted or non-existent, cross borders to travel to India to get the abortion services. The travel restrictions due to lockdown and sealed borders closed the option to seek safe abortion services across the borders for these women.

And yet, there are also instances of countries and women in these countries finding alternatives to meet their immediate health need. In India, there are stories from the field that suggest that women accessed medical abortion pills through pharmacies or through Private Health Care providers and managed their abortion at home. National level service provider agencies such as the Family Planning Association of India and Foundation fo Research in Reproductive Health Services opened clinics wherever lockdown was discontinued, advertised about open facilities and services in local newspapers and through audio-visual and social media, co-opted frontline workers to communicate service availability with the local community, used their own ambulances and vehicles that had permits to ply even during lockdown to bring women to the facility and even reduced cost of services.

In Bangladesh, the Family Planning Association of Bangladesh (FPAB) provided safe abortion services (medical & surgical) and treatment of incomplete abortion. Where the mobility of clients was affected, FPAB made its outreach services through community-based Reproductive Health Promoters (RHP). While there are no relaxation or revisions in government rules, the anecdotal evidence suggests that women were getting medical abortion drugs from their nearest pharmacies.[3] The abortion law in Nepal has a mandatory clause for a woman to visit a clinic to access abortion care prior to the pandemic. In May 2020, the Ministry of Health (MoH), Nepal, de-medicalised abortion and approved the home use of medical abortion pills under a self-care approach.  The Family Planning Association of Nepal (FPAN), played an important role in ensuring these services. In Pakistan, the national network coalition of 40+ local and international organizations, worked closely with the Government, to provide outpatient safe abortion services, post-abortion care, post abortion counselling and contraception to women.[4]

Some of the countries in the region, used hotlines and opened doors to telemedicine services and this opened a possibility of self-managed abortion, which has been widely used in Europe and USA. Hotlines and telehealth were acknowledged as an alternative in Nepal. In Pakistan, hotlines were first launched in 2010. These hotlines have been providing accurate information on Misoprostol for women who have been wanting to self-manage their abortions. The Ipas Pakistan brought out an initiative of telehealth where in the providers counselled and helped women to manage their own abortions outside health facilities, with MA Pills and developed a refer healthcare network for post abortion care if needed .[5]

We are still in very early stages of understanding what the impact of Covid-19 will be on reproductive choices and access to abortion. The health system may need to be prepared for an increase in demand for second trimester abortions, increased unsafe abortions and increased number of child births for those pregnancies carried till term.

During this pandemic we saw that telehealth made it possible for womento access information and services on safe abortion. Studies done globally have enough evidence to show that the use of telemedicine by trained healthcare providers, trained pharmacists and trained safe abortion information hotlines, to provide accurate information on using medical abortion pills for self-managed abortion at home up to 12 weeks of pregnancy, is safe and effective, and that serious complications are rare. Studies in the region have shown that with simple training, pharmacists can manage the provision of abortion pills, provide information on their safe use, and counsel on complications when required.[6]

These studies and the evidence from the ground during lockdown, should be used as an advocacy tool to make policy level changes and revisit the laws on abortion. There is a need to research on the safety of second trimester abortions at home and the role of the health system in supporting them. The world is going through a period of crisis, while the need for them has increased, safe abortion services are compromised, we can look at this health crisis as an opportunity to reshape the existing laws to ease access to abortion care.

With editorial support from Dr. Alka Barua, Abortion Theme Leader, CommonHealth


[1] Safe abortion services amid COVID19 – Agile, adaptive & innovative response from South Asia. SARO COVID19 Response-3, May 2020

[2] The Diplomat: Why COVID-19 Must Not Constrain Access to Abortion in India by Tarini Mehta. June 24, 2020.

[3]https://reliefweb.int/sites/reliefweb.int/files/resources/SARO%20COVID19%20Update%203%20%28Safe%20Abortion%29.pdf

[4]https://reliefweb.int/sites/reliefweb.int/files/resources/SARO%20COVID19%20Update%203%20%28Safe%20Abortion%29.pdf

[5]https://www.ipas.org/news/telehealth-initiative-answers-the-need-of-the-hour-in-pakistan/

[6]Anand Tamang, Mahesh Puri, Sazina Masud, Minal Singh, Punam Sharma. Medical abortion can be provided safely and effectively by pharmacy workers trained within a harm reduction framework: Nepal. Contraception 18 September 2017;97(2):137-43. doi: 10.1016/j.contraception.2017.09.004

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Published by CommonHealth: Coalition for Maternal-Neonatal Health and Safe Abortion

Constituted in 2006, CommonHealth is a multi-state coalition of organizations and individuals working towards changing this unacceptable situation and advocating for better access to sexual and reproductive health and health care, with a specific focus on maternal health and safe abortion with a rights perspective CommonHealth members are from diverse fields working towards the realisation of reproductive health and rights in different geographies within the country. The coalition advocates for increased access to sexual and reproductive health care and services to improve health conditions of women especially for women from poor, vulnerable and marginalized communities.

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