Women's health

Opinion: Denying abortion to a 10-year-old rape victim is to inflict more violence on her

The Supreme Court denied medical termination of pregnancy after doctors said it was not safe either for the girl or the foetus.

On Friday, the Supreme Court refused to allow an abortion for a pregnant 10-year old girl who was raped allegedly by her uncle. The Chandigarh resident’s plea for abortion was turned down last week by the district court. News reports also suggest that she had an anomaly in her heart and had to be operated for it three years ago.

The doctors’ panel at Postgraduate Institute of Medical Education and Research, Chandigarh who examined the girl said that a medical termination was not safe either for the girl or the foetus, NDTV reported.

The girl is reportedly 32 weeks pregnant now. From the medical point of view there is no basis to say that her pregnancy is going to get safer as it progresses. In fact, it is only going to get more dangerous. The child is only 10 years old with a complication of heart disease and it is not safe for her to carry a full size foetus and deliver it. While a girl can get pregnant as soon as she starts menstruating, her pelvic bones are not fully developed till several years later and therefore carrying a pregnancy and delivering it can result in several complications for her.

The fact that the doctors said that they were considering two lives – that of the pregnant girl and that of the foetus – is unacceptable. This articulation of “the health of the foetus” in this scenario is worrying, since it is juxtaposed against the health of the girl who is carrying the pregnancy, herself a young child in this case. It is indeed cruel to force the girl to bring the foetus to maturity as she alone will bear the physical and mental trauma of pregnancy and childbirth.

This child is also a survivor of sexual violence. A psychiatric evaluation of the girl suggested that she is unaware of her pregnancy. It is also medically necessary for her to heal from the sexual violence and forcing her to continue the pregnancy that is an outcome of rape will impede her healing and obtaining any closure.

Restrictive policies

The Medical Termination of Pregnancy Act allows for abortion outside of the criteria laid down by the Act. Section 5 of the Act says that the restriction of 20 weeks of pregnancy does not apply if two registered doctors form an opinion in good faith that the termination of such a pregnancy is necessary to save the life of the pregnant woman. This section should have been invoked.

Even so, the Medical Termination of Pregnancy Act is restrictive and there is a lot of evidence to show that abortion may be safely allowed up to much later in the pregnancy, at least up to 24 weeks.

In 2014, the Ministry of Health and Family Welfare prepared a draft amendment to the law, which provided for abortion at up to 24 weeks. This amendment does not seem to be making progress.

A news report on the order said that the Supreme Court asked the Solicitor General Ranjit Kumar to consider its suggestion to set up a permanent medical court in every state to take a prompt decision on prospects of early abortion. While this is a welcome decision, we have to place it in the larger context of access to abortion. The state level board does not guarantee access to abortion. A woman dies because of unsafe abortion every two hours in this country. By restricting access to safe abortion, we are pushing them towards unsafe abortion.

Health system barriers

Most states do not provide access to abortion in institutions of primary health care. Abortion services are only provided at district hospitals or at medical colleges within the public sector. Women are then pushed to seek abortion in the private sector, which is expensive and exploitative. There is evidence to show that the more desperate the woman is, the higher the price of abortion services. High prices then force her to go to unqualified providers performing abortions.

We know that women who delay decisions to get abortions are women in very difficult circumstances. They might be single women, women who have become pregnant outside of marriage, victims of sexual violence, or with no wherewithal to access safe abortion services.

Instead of violating women’s right to make choices about their bodies, the state would do better to provide better and safer medical services.

The writer is a gynaecologist with the Rural Women’s Social Education Centre in Kanchipuram district, Tamil Nadu, and the chairperson of CommonHealth, a national level coalition for maternal and neonatal health and safe abortion.

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.