These are the highlights of an episode from the ASAP Covid19 conversation series where we invite guests to have conversations with us around the current situation, the pandemic and especially in relation to the communities we work with, and how it has affected the people specially in relation to abortion rights and larger SRHR access. The interview was conducted by Dr Suchitra Dalvie, Coordinator, ASAP.

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Transcribed by Garima, Youth Champion- India & edited by Dr Suchitra Dalvie

Riti is based in Mumbai , is a medical intern and also the co-founder of the group India Safe Abortion Youth Advocates which works to sensitize medical students on issues of gender and rights.

Polly is based in London and is a junior doctor associated with Doctors for Choice UK, which is an organization that campaigns for the decriminalization of abortion in the UK, as well as raising awareness and destigmatizing abortion.

Corrina is also a junior doctor based in London and is currently doing a master’s in reproductive and sexual health. She is the head of education in Doctors for Choice UK.

Suchitra– Thank you all for taking out the time to join us here in this conversation. As far as I’m aware abortion is legal in the UK as well as in India. So, how does it matter whether it’s decriminalized or not and why did you feel the need to set up these organizations?

Riti– In India it has been legalized since 1971 but even today we are seeing a lot of mortality due to unsafe abortions, and the access to abortion is really restrictive even though we have a fairly liberal law on paper. The opinion of the doctor takes priority over the choice of the woman to seek an abortion. Then there is also the point where you have a centralization of all the resources and information in most of the urban areas, whereas most of our population lives in the rural places, where you don’t have enough healthcare services. There is also this stigma around anything that gives women autonomy or addresses issues around sexuality.

Polly– So, I’m in the UK where actually abortions not decriminalized yet. We have a 1967 Act which gave doctors a medical defence to provide abortions if certain criteria are met. So, there are 5 criteria of which any can be met and then people can access abortion but that requires two doctors’ signatures on that form, which obviously has its own restrictions for people accessing care and we think contributes to the stigmatization of abortion. The original law which criminalizes abortion is from the 1800s which is just crazy.

Corrina-It also means that when you want to try and make small changes in the way in which abortion is provided it’s required to go through government. For example, with Covid it became much more difficult to provide face-to-face abortion care. So, lots of places that provided abortion wanted to start providing telemedicine and in anything other than abortion that would have been able to be decided by the medical bodies. But actually, in the UK in England and Scotland and Wales it had to go through the government and then it wasn’t immediately put through and it took a bit of time for that to pass. In Northern Ireland they still haven’t been able to access telemedicine. So, the fact that those controls are still put in at a government level means that it limits any progress in terms of abortion provision that could be made from a medical perspective.

Suchitra– Right, it’s very interesting actually and quite fascinating that India currently has a Penal Code which was originally imposed on it as the British Penal Code in 1860. That also criminalizes abortion or the causing of miscarriage. It criminalizes the woman as well as the provider and just like your Act of 1967 so we have an Act of 1971 which Riti spoke about. That also allows abortions under certain conditions, so it’s not a rights-based approach and is mainly meant to be protective for the doctor against the criminalization. It’s always fascinated me as a doctor that there is no other medical procedure which is protected by a law of Parliament. So clearly this kind of protection of criminalization emerges from ideological positions and nothing to do with medical practice. As you said quite rightly as technology advances and we want to make things easier and better and decentralized it’s impossible to do that without going through Parliament. Since you spoke about Northern Ireland, I also wanted to ask if you have any experience of what is happening in Ireland itself because recently, they had a lot of upheaval around the abortion law after Savita’s death and if there’s anything you want to reflect on? Were you involved in any of the work there?

Polly– In Ireland their law was based around the amendments and the Eighth Amendment in Ireland prevented abortions being legal. As you mentioned Savita Halappanvar died in 2012 because she could not access abortion care when she needed it and I think that really kind of got the ball rolling in terms of politics in the UK and Ireland. Because people were outraged that somebody had died from something which is so preventable. There was a group of doctors there, mainly GPs, and they started the campaigning, long before the eighth amendment was repealed. So, we had one of the original GPs come and speak at one of our conferences a couple of years ago, Marian, and it’s just really inspirational to hear what they’ve done. Even before Northern Ireland decriminalized abortion recently, we were going over there and holding training events and really trying to replicate that from the ground approach that Ireland had as well. And they really were a success story, they got out there, they’ve got the messaging out there, they encouraged people who were from Ireland to come fly back and come vote to repeal the Eighth Amendment.

Suchitra– I think the campaign in Ireland has been extremely inspirational for all of us advocates and speaking of the work that you did as a result of your involvement in this, it sort of leads me to my next question to all of you. What is it exactly that you do as Doctors for Choice and as ISAY? If you could just tell us a little bit about your activities and what does the mobilization include?

Corrina-Sure, so we do lots of different things as Doctors for Choice. We campaign for decriminalization and destigmatisation of abortion and one of the key things that we do is our educational programs. We think that it’s incredibly important to provide unbiased, non-judgmental, abortion education at every level. So, we train medical students to go in and teach secondary school students about contraception and abortion care. The sexual health curriculum here is variable– there is a new curriculum coming in this year which we hope will improve, but previously it’s been very school dependent. So, if you happen to go through school that has a really good sex ed you might get some abortion teaching but certainly the school I went to and when we run our sessions it seems like you don’t generally tend to get anything at all.

We try to counteract that and we run sort of forty-to-sixty-minute interactive sessions with relatively small class sizes and the feedback has been really brilliant. Most of the children are 14 to 17 and they are thinking about their sexual health, which is brilliant, and we kind of start with the contraception to present them with preventive measures, but then also want to make them aware that abortion services are available and to destigmatize. We think raising awareness is a key part of the destigmatizing process.

One of our co-chairs is the head of the abortion teaching at one of the medical schools in London and me and Polly both went to that medical school. So, we both had the brilliant teaching and I think I can speak for both of us in that it inspired both of us to get more involved in sexual health in abortion care. So, she has developed a really sort of brilliant curriculum that now is at the stage where it can start being taken to other medical schools.

Suchitra– That’s fantastic, I mean a good teacher can make such a difference in so many lives. I know that Riti has had an article published in a peer reviewed journal where she analysed the misogynistic language in medical textbooks. As you mentioned, both of you were lucky enough to have a teacher who inspired you but it really shouldn’t depend on luck. Everyone should have a chance to have that kind of conversation which is as you said, gender sensitive, rights based without any stigma underlying. So maybe if Riti could tell us a little bit more about that article she wrote and talk a little bit about what ISAY does with medical students.

Riti-The article is called ‘Gender perspective in medical education’ and the aim is to analyse the medical curriculum through a gender lens. I found so much in our textbooks that troubled me. I found that women’s health is mainly spoken under maternal and child health and women are always seen through the patriarchal framework of the society. Even when talking about a pregnancy it is always the baby instead of foetus. Under the section of contraception, it’s always under family planning. There is no other way to talk about it and even the text books which are supposed to be the go-to for us, they don’t speak about gender-based violence and things like nutritional deficiency and how they come up. Even the facts that we are reading in our textbooks are research that has been extrapolated from the male body since women were not included in clinical trials earlier. Even when they were allowed if they are of the childbearing age they were exempted. Instead, they just put it as facts and without any context which is so skewed because that’s not how we would improve women’s health or public health in general. At one point, they actually stated there if there is a young couple coming to you for like abortion services, it is better to sit with them and talk it out with them do they really need an abortion.

Suchitra– Encourage them to continue the pregnancy basically?

Riti– Yeah like it’s like a good choice to continue with the pregnancy because you are married and this is the time for kids. Just the stereotypes that we have, there’s a timeline that we follow.

Things like virginity and rape but it’s only rape when it happens to women or sexual assault. These things are not really spoken about in our textbooks and it’s kind of sad because this is the sensitivity you need to provide young medical students who are going to be doctors so as to break the cycle of the stigma and make sure that they are the ones who are providing non-judgmental services further.

I didn’t have good professors in my college who spoke about all this. In fact there were professors who said things in front of 200 people like ‘contraception is unnatural’. Just think how do you approach such a faculty with the gender and rights work we do?!

We work with our peers and do sensitization workshops for medical students where we talk about gender or sexuality and then come to contraception and abortion.

We also have a social media page, where we do campaigns and just have regular polls with busting myths and even on a college campus, we have started various conversations with everyday sexism and the things that happen. It is really important that medical students are sensitized since they are one of the influential people in the community.

Suchitra– Thank you Riti for sharing that and I think ISAY has always been very creative in its outreach. I know that you were nominated for an award for a social media campaign last year and we saw of course the wonderful video that Doctors for Choice just made. We have been sharing it widely on our social media as well.

Riti, as you were speaking about women not being allowed in clinical trials, I was just thinking that the four of us sitting and talking here would not have been possible even like a hundred or 200 years ago when women were not allowed in medical colleges.

I don’t know if you all have read the booklet on ‘Witches, midwives and nurses’, which talks about how the witch hunts kind of destroyed a whole generation of women healers and replaced it with this so-called ‘modern’ medical system. So, it’s no surprise that it’s not gender sensitive or women- centred because it emerged from roots which were seriously misogynistic. There are some documents, I think from Harvard probably, which say that women should not be allowed into medical colleges because their brains are too small and if they undertake rigorous academic work, their ovaries may stop functioning and if a woman can’t reproduce then what use is she?

This sounds hilarious right now and we have come a long way from those days but there are still so many challenges. Virginity is still a part of the medical textbook. Why is virginity in a medical textbook and why is it an issue?? So why are these social cultural aspects of patriarchal control not being spoken about ?

I think it’s amazing the work that everyone is doing and I wanted to ask you in the context of the current pandemic, what are the issues that you are seeing in terms of access ? We know that very often doctors themselves are seen as one of the biggest barriers, as Riti said. I don’t know whether conscientious objection is a big issue in the UK and if that is affecting access even right now in terms of the pandemic? And what is the situation in public sector and private sector services?

Polly– Conscientious objection is written into the UK law so doctors have a right to opt out of providing abortion care but they still have the usual professional duties to make sure that someone who needs to access care, can. So we always teach about the difference between conscientious objection and conscientious obstruction and how those two things aren’t the same.

If someone does actively try to obstruct a woman or a person from accessing abortion and dissuade them that’s against GMC the General Medical Council regulations. So, I think the sad reality is we don’t hear about all of the cases of conscientious obstruction that are going on in the country and occasionally a case will come to light and it will be in the papers. However, I do think we’ve been relatively lucky in the change of law, short term law and that covid brought about with telemedicine. As Corrina was saying previously the original 1967 Act, it said that the abortion had to be provided in a registered facility. So, usually that was a clinic or and then we took it a step further and just over a year ago when the second tablet for a medical abortion was allowed to be taken at home. So, that meant the person could travel home and take that home without the risk of having an abortion on the way. Now the new covid legislation says that somebody can take have an abortion at home and so telemedicine is allowed. They have to have a consultation on the phone with a medical professional but they are allowed to have that abortion at home and from what I have heard from services it’s really revolutionized how they’re practicing.

I think for a long-time people knew that telemedicine worked and there are people like Women on Web who have been practicing that in countries where access is really difficult for a long time. In fact, even women in the UK were accessing Women on Web just because they can get an appointment.

So, I think that’s been positive but obviously it goes without saying people who are in homes where it’s difficult they might be in an abusive relationship or their family might not know about their position. I think that’s really difficult and I don’t know how we get around that, other than to try to provide contraception where possible. And I know that one of the independent abortion providers here are selling emergency contraception online and I think that’s a good initiative for people who might find themselves in a difficult situation.

Suchitra– So just a clarification question Polly — pre-pandemic abortion services in the UK are available through the NHS or do people have to go to a private provider and then it’s paid for by the insurance? How does it work, if you could just explain?

Polly– So, it’s paid for by the NHS but most of them are done in independent settings. One of the major providers is called the British pregnancy advisory service. It’s not private because the NHS outsources those clinics. But it’s just because there’s not as many NHS facilities as these independent providers who are set up and they run really well and obviously that poses an issue of training. Because it’s really difficult to get any training in abortion care if you’re not in a hospital that’s lucky
have a clinic.

Suchitra– So, is it also a kind of systematized ‘othering’ to go to some other place for abortion whereas everything else is in one hospital. Is that part of your strategy to try and integrate the abortion services within?

Polly– Yeah absolutely and I think you know Bpas themselves want that. Ideally, we would like to integrate.

Suchitra– That’s very interesting to know, Corrina do you want to add something?

Corrina– As early medical abortion is becoming more and more widely used in the UK it’s definitely more of a campaign to get it included in GP services, as well. Currently GPs aren’t a registered place so they can’t deliver any abortion provision at all, Northern Ireland being an exception. So,in England Scotland and Wales you have to either go to a health facility in the NHS or an independent provider and that really creates this othering environment. That is something that doctors for choice is pushing for as part of decriminalization, to allow abortion care to be undertaken by GP’s.

Suchitra– In fact some of us are now starting to advocate for self-managed abortions, saying that people are managing so many things for themselves nowadays– like diabetics are managing their testing as well as insulin. Women have been managing their own miscarriages and even births for millennia. So with the advent of medical abortion telemedicine is one step but potentially self-managed abortion would kind of be the next step, so that’s good to know thank you. Riti, do you want to tell us something about what’s happening with access to safe abortion in public health sector currently because I think you’re working as an intern in a public hospital?

Riti– Yeah so, as of now because of the pandemic most of the OPDs are shut and even when abortion has been termed essential, it is still a major hassle to access a public health centre because that means you have to get out of your house. All the public transport has been shut in at least in Mumbai right now. Even after one reaches there’s always the panic that once you go out, you’re going to get infected. If you get a good doctor, if they are willing to provide you with an abortion without making you wait, it’s really good but that’s not always the case. The thing is the public health sector is right now really overwhelmed and not a lot of private clinics are yet open, so that is creating a major hassle. People who use go to private healthcare sectors for seeking abortion or just any health care services they are not able to go there. And there’s also a lot of reluctance to step out of your house and that’s creating another hurdle. Sometimes the partner knows and sometimes they don’t or if the person is unmarried and they can’t speak to anyone in their family. It’s just making it more and more difficult to give a reason to get out of the house and the situation really varies for the person. I have seen people put up listings for consultations online so why not the same for abortion?

It’s getting a little difficult and the lockdown is just being extended for months and months which is making the scenario difficult.

Suchitra– What you’re saying Riti, reminds me of a quote from Rudolf Virchow who’s known as the ‘father’ of social medicine. That’s a whole different conversation as to how there are fathers of everything and mothers of no one because you didn’t let women into medical colleges! But he very famously said that ‘medicine is a social science and politics is nothing but medicine on a large scale’. And I think this pandemic and the way everyone has responded to it politically, government wise health care facility wise, I think it really shows the truth. The way you respond to a pandemic like this has a lot of political overtones and undertones and intricacies in which women’s health and particularly safe abortion access is still getting trapped within the politics of all that.

As Riti said, if you get a good doctor you may still get access, but it shouldn’t be a roll of the dice. It should be something that you expect to receive because it’s your right, it’s your right to dignity, it’s your right to health, it’s your right to benefit from scientific progress. So what messages would you like to give for health care providers, for health policy makers, for people who are assigning budgets and deciding what goes where? In the post pandemic world what would you want the new normal to look like? Corrina, do you want to say something?

Corrina– I think to sort of highlight as Polly mentioned, what good telemedicine has done in terms of easing abortion access and the positive feedback that they’re getting from that, because the feeling is that once we are post- pandemic there will be a push back to go back to the way that abortion provision was prior to covid-19. So I think it would be just to highlight firstly what a common procedure this is. One in three women in the UK will have an abortion by the time they’re at the end of their reproductive lifespan. So it’s probably the most common procedure that anyone regardless of gender will undergo and so to sort of pay attention to that.

Also, as we mentioned before, that everything has to go back to government and extra layers of regulation, to really look critically at what they add. Because we always say at doctors for choice that decriminalization isn’t deregulation. So, it’s not suddenly going be that anyone and everyone can provide in any way that they want. There will still be medical guidance in the same way as there is for every other medical procedure in the world and so just sort of critical look at that and remove as many barriers as you can and to providing not just abortion provision but wider sexual health reproductive health provision.

There are lots of barriers in England, Scotland and Wales for wider sort of access to contraception and some of them are linked to the abortion provision, some of them are slightly separate and I think to look at the importance of all of it, look at how commonly it’s required. And to just trust pregnant people to make their own decisions and if it’s a decision that is their own choice and not coerced, then what is our role as a healthcare provider other than to support them to complete the decision.

Suchitra– Absolutely, and a lot of this stigma really does stem from the stigma around sexuality and this sort of fear particularly of young women’s sexuality. It is this same fear which also blocks sexuality education, access to contraception, abortion– it’s all kind of along the spectrum. While I was going through medical college and even post-graduation none of these political issues were ever a part of our conversations. As I got involved in development work I realized that this political conversation is actually the most critical one to have. The biomechanical and technical, one can pick up any time but the social determinants and the political conversation is really what gives us the position of so much strength and power. So thank you to all of you and we hope to continue conversations with you further, as Corrina said we don’t know when this pandemic and this situation is going to end but hopefully at some point it will. And we may have the chance to have a conversation afterwards to reflect on what we felt as it was going through and what the new normal looks like now. So, thank you all very much and we hope to catch up with you again.