How Getting An Abortion Is Linked To Contraceptive Use

“The doctor said, ‘Women like you come to us only when you are pregnant. Why aren’t you careful?’” Radhika recounted. “When I told him that I missed having my pill for a day, he asked, ‘How can you forget? Do you forget to have your food?’”

Many women seeking abortion, doctors, health workers as well as other stakeholders told this correspondent that often, the first question any health provider asks a person seeking abortion is why they did not use contraception--thereby implying that they were so careless as to get pregnant in the first place.

How a person is treated when they seek abortion often relates to contraception history. Women this correspondent spoke to said that they were denied abortion unless they underwent a permanent sterilisation or at least took a long-acting contraceptive such as intrauterine devices. These systemic denials and attitudes have classist, casteist implications.

While the public health system has a strong focus on giving women their choice of contraception, contraception failure is also a reality. The government-issued Comprehensive Abortion Guidelines says, “No contraceptive is 100% effective and therefore, safe abortion services would always be a necessary component of reproductive healthcare.”

Comparing typical effectiveness of contraceptive methods from the 2013 paper, ‘Understanding Contraceptive Failure’

As per the fifth National Family Health Survey conducted during 2019-21 (NFHS-5), more than three-fourths of married women have a demand for family planning, while only 67% of women are able to avail of a contraceptive method.

“Women always want to seek contraception, especially after a certain age and number of conceptions. But we have seen that family members can pressurise them not to use contraception. Often women come to us without telling their family and take DMPA (Depot Medroxy Progesterone Acetate contraceptive) injections,” said Gunjan Khorgade, research associate from Action Research and Training for Health (ARTH), a non-profit that works towards improving health, especially reproductive health, of the under-privileged in Udaipur.

The burden of contraception invariably falls on women. It requires women like Radhika to remember to take the pill, use contraceptive devices that last for 5-10 years, or a hormonal injection that can last about three months. Temporary methods such as condoms are often frowned upon. When women claim contraceptive failure, they are often not believed.

Men decide the method of contraception but it is the women who use it and bear the consequences of its use, as IndiaSpend reported in September 2020.

‘Uneducated’ poor

Shreya Khemani is a human rights activist who runs New Learning Centre, an education centre for Bahujan children in Raipur. She has helped many women with abortions. She recalled the resident doctor’s behavior towards one such woman who sought abortion at Dr Bhimrao Ambedkar Memorial Hospital, which is attached to its medical college in Raipur.

“The resident doctor asked my saheli (friend), ‘Why don’t you use a contraceptive?’ She told them they use condoms. She is a lower caste labourer. He looked at her with contempt and said, ‘I know what kind of contraceptive women like you use,’” said Khemani.

Khemani explained that this was not just a sexualised gaze, but also casteist. She added that the doctor was insinuating that her friend was a prostitute, and also disbelieving that someone of her social standing could use condoms.

These kinds of stories are all too common in many public hospitals all over the country. Jyoti Jaiswal, head of obstetrics and gynaecology at Dr Bhimrao Ambedkar Memorial Hospital, Raipur admitted there could be some problems in the way their staff spoke to patients. Jaiswal said, “It is our duty to counsel junior doctors to provide respectful maternal care. Their workload makes them frustrated, but they should not be judgemental. We need to reinforce non-judgemental attitudes among residents.”

These attitudes related to contraception have a long history. Right from the time of Independence, there was a lot of focus on controlling the population, said Suchitra Dalvie, gynaecologist and coordinator of Asia Safe Abortion Partnership.

“Our textbooks said that the population bomb will go off, and there will be famines,” said Dalvie. “The narrative was also that the poor people had too many children. As medical students, we heard that the poor are illiterate, uneducated, and stupid. So, any method that is not permanent or long-acting, such as condoms or oral contraceptive pills, is frowned upon.”

Structural and relationship barriers

As per NFHS-5, 3.6% of the women who sought abortions attributed their pregnancies to contraceptive failure.

Take 31-year-old Sarika’s case, for instance. Sarika (named changed) has three sons aged 12, 11 and 4 years. She said she got an Antara injection from a government-run hospital near her house in Rohini, Delhi in December 2023. Antara is an injectable DMPA contraceptive that is supposed to last three months. The three-month period ended around February 2024.

“I was told to come 10 days before the due date for the next dose of Antara. But I got busy and was a few days late. When I went to the hospital, they were out of stock, and asked me to come next week. Aur phir to jante hai ki aadmi manta nahi. (As you know, husbands do not listen to us),” said Sarika.

In April, when she missed her period, she again went to the hospital where a urine test confirmed her pregnancy.

“They asked me why I did not use condoms and said I got pregnant for that reason,” said Sarika. She found it difficult to get an abortion at the public hospital. Sarika then spoke to the ASHA worker near her house, who suggested that she could come to Parivar Seva Sanstha clinic in a couple days.

Parivar Seva Sanstha is non-profit which provides safe reproductive health services at affordable cost--this includes abortion, contraception, as well as sterilisation services. Sarika eventually even got a sterilisation operation there after a month in May 2024.

As we understand from Sarika’s story, it is not just the lack of knowledge that leads to contraceptive failure, but also other barriers. She got busy, the hospital did not have stock, and she was not able to negotiate with her husband.

A US-based study talks about structural barriers to contraceptive failures, which include not only health literacy and beliefs but also financial and logistical barriers when methods are too difficult or inconvenient to access and use. Relationship instability can also drive contraceptive failure.

Post-abortion contraceptive a ‘must’

Many women seeking abortion in health facilities complain that they are compelled to undergo permanent contraception procedures like sterilisation surgery or at least long-acting ones like intrauterine devices.

Neelam Rao, who runs the Parivar Seva Sanstha clinic in Rohini, has heard many such stories of women seeking abortion at their centre.

“(Healthcare) providers are rigid about abortion and ask women to undergo a sterilisation surgery along with abortion. Some clients are not willing to undergo sterilisation surgery or even use an intrauterine device. If a woman has just one child, or has two girl children, the society (samaj) insists that she try for another child,” said Rao.

Studies at ARTH have also shown that women may not want to use an irreversible contraceptive method as they may wish to maintain their fertility potential in case of widowhood, remarriage, or death of a child.

IndiaSpend spoke to a gynaecologist from Sanjay Gandhi Memorial Hospital in Delhi who did not want to be on the record, but answered some queries. The gynaecologist complained that many women do not opt for contraceptive devices, or refuse to consider sterilisation despite having two children.

“We encourage women to undergo abortion services with contraception,” said the doctor, adding that they cannot force it on a client. When asked if they do abortions without providing some kind of contraception or sterilisation, she said, “That's rare.”

While the Comprehensive Abortion Guidelines talk about promoting post-abortion contraception, they also say that nobody should not be denied abortion irrespective of their decision to refuse concurrent contraception.

“We get many patients who undergo 5-6 abortions without using contraceptives. These patients are so afraid of using, for example, intrauterine devices and say there could be complications. But, they disregard the medical and surgical complications of abortion. They are popping abortion pills like chana,” said Jaiswal. She said she often counsels women seeking abortion about contraception patiently, and it often works.

Dalvie said that women who seek abortion multiple times could be facing intimate partner violence and sexual violence, including instances where partners refuse to use condoms, for instance.

“It is the poor woman who has no negotiation over her body and her sex life who gets trapped in a situation where she wants abortion and is coerced into a method of contraception or refused abortion. In our medical practice, it is assumed that if a woman can’t control her life, we (doctors) are making her life better by insisting on sterilisation, without realising that we are also taking away her autonomy,” said Dalvie.

Sterlisation highest goal

Family planning programmes all over the country have unofficial targets (called expected level of achievement) set on sterilisation or placing long-term contraceptives such as intrauterine devices like Copper T. As per NFHS-5, female sterilisation remains the most popular method of contraception, and the numbers rose from 36% to 37.9% in five years. Male sterilisation, even though it's safer and easier, remains unchanged at 0.3%.

A small percentage of people who undergo sterilisation surgery can still get pregnant. The internationally acceptable failure rate for sterilisation is less than 1%, though some studies show a higher rate of failure depending on the method.

In 2007, Raipur resident Chhaya (name changed) underwent a sterlisation surgery after she gave birth to her third child. But in about a year, she was pregnant again. Women whose sterilisation surgery fails often suffer a lot of shame.

“I kept thinking, where do I go? Who can help me? We were poor and had no idea what was happening. We only told my brother-in-law, who told us that if we tell anyone about the pregnancy, it will be embarrassing. I kept thinking people would laugh at us,” said Chhaya. She secretly took medical abortion pills, and terminated her pregnancy.

Activists who work with women said that women are often blamed for getting pregnant after sterilisation surgery, as it indicates that they started working and lifting heavy weights or got intimate with their husbands too soon (and against medical advice) after the surgery.

Almost as if she assumed that this correspondent did not believe her, Chhaya showed the cut made on her stomach during the sterilisation surgery. Following her sterilisation surgery, she had abortions a total of six times between 2007 and 2017, she said.

“The same thing kept happening to me. I underwent abortion six times. I would buy abortion pills from the medical store within a month of the pregnancy. I would take the pills and quietly lie down,” said Chhaya.

While these abortions were physically taxing for Chhaya, she was also going through a tough time at home as she said her in-laws were harassing her. She said they taunted her for falling sick often and not contributing enough to the household work.

Chhaya underwent these repeated abortions despite using condoms. She asked her husband to undergo a vasectomy, but he told her that he was terrified of the procedure. The pregnancies came to a halt only in 2017, she said. Chhaya is now in her 50s. Her son is now 22 years old, and her daughters are 19 and 18 years old. She said that the repeated procedures have taken a toll on her body.

“I was healthy before. My body is very weak now,” she said.

‘Have another child’

In Rajasthan’s Pratapgarh district, Ramabai Meena (name changed), a 35-year-old woman from the tribal Bhil community, met with a similar fate. Seven years after undergoing a sterilisation surgery in 2014, she realised she was pregnant in 2021, in the middle of the second Covid-19 wave.

“I didn't even know I was pregnant. The ASHA worker said that I looked pregnant after which I went to the hosptial to check. I was four months pregnant by then. I did not know the sterlisation surgery had failed. I thought I was safe,” said Ramabai. At the time, her son was 10 years old and her daughter was six.

At the primary health centre in Pratapgarh, Ramabai (name changed) was denied an abortion on the ground that it was "unsafe" although she was well within the legal limit of 20 weeks.

At the government primary health centre, she asked for an abortion. “The doctor told me, ‘Yeh baccha hone do. Wapis nasbandi karva denge. (Give birth to this child. We will do sterilisation surgery again),” said Ramabai.

The doctor, she said, also refused to provide an abortion on the ground that it was “unsafe” after four months of pregnancy, and was more comfortable conducting an abortion of one or two months pregnancy. Indian abortion law provides abortion up to 20 weeks, and 24 weeks under some conditions.

Left: A self-care kit containing condoms, emergency contraceptive pills and pregnancy tests at a community health centre in Udaipur. Right: A poster detailing contraceptive methods. How a person seeking abortion is treated often relates to their contraception history.

“I was scared. I had already undergone a sterilisation surgery. What will happen? How will I manage?” said Rambai. When asked if she was referred to the district hospital at Pratapgarh where abortions are provided during the second trimester, she shook her head. She was not aware of this option.

Ramabai delivered her son in November 2021. She has stopped working in their farm to take care of the child. She was keen to control her fertility, and learned the rhythm method from an ASHA worker, whereby women can track their menstrual cycles to calculate their ovulation period to prevent further pregnancies.

Ramabai said she could not imagine undergoing a sterilisation surgery again. She underwent sterilisation surgery with 40 other women in one day, and was made to lie on the floor for recovery.

She described a kind of assembly line where women went to the operating table one by one. “I went early in the morning, and the doctor conducted the surgery around 4 p.m. There were two beds in the operating theatre where two women were made to lie down. One was operated upon by the only doctor there while the other waited,” said Ramabai.

In 2014, 14 women died of botched surgeries in a sterilisation camp in Chhattisgarh. In 2016, the Supreme Court banned mass sterilisation camps. The conditions are often deplorable, as described in some fact-finding reports by different non profits who have investigated these camps.

Vijay Pal Singh works with Prayas, which is involved in health rights in Pratapgarh district and the nearby Chittorgarh district. With the help of Prayas, Ramabai filed papers for a claim under the government’s Family Planning Indemnity Scheme. Under the scheme, women who die after sterlisation surgery, or have failures of surgery, can claim indemnity.

“Why do women opt for a sterilisation surgery? Because they do not want more children. It is obvious then that if there is a failure of this surgery, they may want to undergo abortion. The state and government doctors and health workers should help them in that case,” said Singh.

The record showed that Ramabai was 17 weeks pregnant when she filed the claims under the Family Planning Indemnity Scheme, well before the 20-week deadline for abortion in the country for her circumstances. If her claim is cleared by the government, Ramabai will get Rs 30,000. Singh called this amount “meagre”.

“This is a systemic failure which is just geared towards providing services (sterilisation surgery), but does not counsel patients properly about the procedure, side effects, and who she should approach if something goes wrong,” said Singh.

Last March, her claim was rejected at the district level as her sterilisation certificate did not have a date for when she was to go for her post-operative check up, during which they check if she is pregnant or not. Singh said the surgeon should have filled in the date, and it was not the responsibility of the patient. Prayas has, pro bono, helped Rambai to file a case before the Jodhpur High Court.

“We are very poor. How will I bring up my children and get them educated? I have been worried. How will I take care of this (third) child?,” said Ramabai.

This is the third story in a four-part series on abortion access in the country, reported from four states--Delhi, Rajasthan, Chhattisgarh and Uttar Pradesh. You can read the first part here and the second part here.

This series is supported by the Pulitzer Center.

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