Country case-study: sexual and reproductive rights in India

1. What are the barriers to access safe and legal abortion care?

The Indian state’s approach to reproductive rights historically has focused on population control rather than enhancing individual autonomy and removing structural barriers to reproductive health services, which is reflected in the barriers to provision of services. As a consequence of the early adoption of family planning and population control measures in the 1950s, India was one of the first countries to legislate on abortion and legalise conditional abortion. While contraception was also made available, the focus was on meeting targets for sterilisation rather than temporary spacing methods. This has shifted focus away from universal provision of abortion and contraception to meeting top-down targets for population control.

Legal abortions

Since 1971 with the enactment of the Medical Termination of Pregnancy Act (MTP), abortions are permissible in India basis the context and demographic characteristics of the woman seeking services (age, economic status, environment, adverse impacts/improvements on health) [1]. Abortion services shifted dramatically in 2002 upon their classification as a medical procedure[2].

The legality of the abortion is contingent on the mental and physical health of the pregnant woman and the likelihood of the unborn child having a physical or mental abnormality. The mental health of the person, according to Indian law, is likely to be negatively impacted if the pregnancy is without consent (i.e. rape, or the failure of a contraceptive method used by a married couple).[3]

Legality is similarly contingent upon the woman’s consent. If the pregnant woman is below 18 or has a mental illness, her guardians’ consent is required as per the MTP, 2003 Act [4]. A person can only legally seek abortions from identified public hospitals and certified private facilities, unless performed by an obstetrician in emergency scenarios. Practitioners performing illegal procedures and women seeking abortions for reasons external to saving her own life are criminalised by the MTP[5]. If a pregnant woman is below 18 or has a mental illness, her guardians’ consent is required for abortion care services to be lawfully accessed.[6] Women can only legally seek abortion care from identified public hospitals and certified private facilities, unless performed by an obstetrician in emergency scenarios. Practitioners performing illegal procedures and women seeking abortion care for reasons external to saving their own lives are criminalised by the MTP[7].

Although there are several laws in place to ensure that women are afforded abortion care services, the law delegates the regulation of these services to state-level institutions[8]. Hence, states differ greatly in their interpretation and implementation of the rules. These rules and regulations became much more stringent following the rise of sex-selective abortion; evidently, many governments saw restricting access to basic services as the solution, especially the Maharashtra government[9].

Rather than jump through legal loopholes and rely on a guardian to provide consent, which is difficult for many young women, women often seek less safe ‘illegal’ options. According to a study by Guttmacher Institute, the International Institute for Population Sciences and Population Council in 2018, out of 2.2 million surgical abortions, 0.8 million take place outside of legalised institutions in private clinics, with variable safety, costs, and legal repercussion for the doctor and patient[10].

The burden of procuring abortion care is especially felt by unmarried women. As set out in further detail below, the restriction on contraception access by unmarried – as opposed to married – women has placed unmarried women at risk, placing additional burden on them to meet one of the other conditions of receiving legal abortion care. Abortion is legalised up to 20 weeks—between week 1 and 12, legal abortions only require consulting one medical practitioner while gestations of 12-20 weeks requires the consultation of two practitioners[11]. This places decision-making and discretionary power in the hands of the medical provider rather than empowering women to make their own choices.

Challenges in accessing abortion care in rural areas

Both the availability and accessibility of abortion services in rural districts is sparse[12]. 70% of India’s population is rural, where legal abortion services are few and far between—this is especially concerning considering that more than half of abortion-related deaths are linked to inaccessibility. In fact, women in rural settings have a 26% higher chance of dying from complications than their counterparts in urban settings[13]. In addition to the weak infrastructure around which abortion facilities are built, especially in rural areas, complications remain poorly documented. Compounded by the fact that knowledge of safe abortion centres is limited among the general population, it is common for women to have had one unsuccessful abortion attempt before terminating their pregnancy[14].

Socio-economic factors

In relation to metrics relating to socioeconomic factors, namely levels of poverty and education, illiterate women are 48% more likely to have an unsafe abortion and women in households with minimal asset holdings are 45% more likely to undergo unsafe abortions[15]. These socio-demographic disadvantages are exaggerated for Indigenous women in India. Indigenous populations in India account for 8.2% of the population, 27% of which reside in Jharkhand[16]. Along with the lack of access and availability of information or facilities for abortion, 84% of Indigenous women in Jharkhand do not have access to or do not use any form of contraception, whereas this is the case for 59% of non-indigenous women[17]. The lack of contraceptive use in addition to the unavailability of abortion care services essentially strips Indigenous women of their reproductive autonomy and exacerbates the disproportionate demographic, economic, and social challenges they face.

Financial Barriers

Costs vary according to the medical condition of the woman, her demographic characteristics, type of procedure performed, and her reasons for seeking an abortion—unmarried women charged more, seemingly poor women charged less[18]. While there is an acknowledgement of increasing financial accessibility by creating a pricing grade, this is all based on subjective assessments without any form of price standardisation.

Chemical/ abortion pills are offered by chemists above retail price. Although this may involve fewer indirect and direct costs, the mark-ups still make this option unaffordable for some. Chemists then offer home-remedies or ayurvedic medicine, which are supposedly in higher demand than pharmaceutically manufactured products[19]. However, these remedies are more likely to be unsafe.

Barriers within the health system

A 2005 survey found that 94% of primary health centres and 60% of community health centres[20] did not offer any abortion care services. As of 2014, many of these centres remain under-staffed, under-resourced, and below Indian Public Health Standards[21].

On the other hand, private clinics require government approval to provide abortion services—a bureaucratic task that most providers abstain from. Approval is a central government requirement whose enforcement is delegated to state governments. Depending on the party in power, private clinics face different approval processes based on their state. Approval applications must be sent to District Level Committees (DLCs) consisting of 3-5 members, and the DLC must return a certificate of approval in order for a private clinic to legally practice abortions. The certification system is inherently contradictory: professionals can only undergo training if they are certified, however, to be certified, at least one trained professional must already be employed[23]. As a consequence, if these facilities do choose to perform abortion services without seeking approval, they are automatically doing so illegally.

These barriers combine to increase the number of illegal abortions performed, thereby spreading the lack awareness around its legality along with stigma.

In order to overcome these barriers, public-private partnerships are developing in parallel and are increasingly common to improve the provisioning and knowledge of safe, legal, and modern services via initiatives such as government programs for low-income women and healthcare practitioner networks[24].

Lack of awareness and training among healthcare professionals

According to survey results by the Consortium for Safe Abortions in India, there is a general lack of awareness of the few legal services that do exist, and therefore, a greater dependency on and knowledge of facilities operating illegally[25].

The majority of unsuccessful abortions women experience can be traced back to the purchase of non-prescriptive drugs which may be falsely advertised by chemists as an alternative and cheaper option to prescriptive abortifacients. In 2005, less than a fourth of chemists surveyed in Bihar and Jharkhand knew the correct dosage and use of the medical abortion pill, and only half were certain of the legality of abortion[26].

Similarly, reproductive health training is largely absent from medical school curriculums and misinformation persists regarding the legality of the procedure[27]. Like the subjective assessment embedded in the decision to charge an individual a certain price, the availability of medical abortions can change drastically based on doctor’s personal opinions. In some scenarios, these biases are heightened, especially if doctors (across genders) have a paternalistic or culturally imbued view of young and unmarried women.

Heightened industry barriers for sexual violence survivors

In 2005, India passed legislation[28] addressing and outlining the rights of survivors of domestic and sexual violence, introducing amendments to the criminal code which made the failure by public and private actors to immediately treat victims of sexual violence a crime[29]. In practice, these policies have not yet been implemented.

Based on a study foregrounding the experience of survivors compiled by the Centre for Enquiry into Health and Allied Themes (CEHAT), instead of being offered the care they are entitled to by law, private and public facilities have refused to do so via direct, indirect, or conditional means[30]. Practitioners directly refuse to provide abortions if it is the woman’s first pregnancy, in open defiance of the domestic violence legislation. In the case of public facilities especially, practitioners often refuse to treat survivors beyond the 20-week mark, despite the fact that this is made possible by domestic violence legislation [31]. Studies have documented that service providers may make the abortion conditional upon receiving spousal consent or the woman opting in to sterilisation. As a result, providers can deliberately provide misinformation, leading the survivor astray, delaying their care, and potentially towards unsafe and illegal procedures. Misinformation and delays in care, unfortunately, are very common for rape survivors, including child rape survivors[32].

Inconsistent jurisprudence

The general lack of clarity regarding the circumstances in which a woman may lawfully terminate her pregnancy is compounded by inconsistent rulings. Whilst a 2019 supreme court verdict allowed a woman from Mumbai to terminate her pregnancy at 24 weeks due to a foetus abnormality that would endanger her life, earlier cases have penalised women seeking abortions after the 20-week limit even when medically-verifiable conditions existed. in early 2017 ruled against a woman who underwent an abortion (diagnosed with down syndrome) at 26 weeks—6 weeks after the 20-week ceiling[33].

Similarly, women are made to bear the brunt of administrative delays: there has been at least one case where a woman was preventing from undertaking an abortion after the 20 week mark even though she had made her abortion request at 17 weeks. [34]

Innacurate and misleading health information

Misinformation regarding sexual and reproductive health is pervasive in India, owing at least in part to the absence of comprehensive sex education. Currently only 25% of men and women aged 15-24 have obtained some form of sex education[35]. Rationales for the absence of sexual and reproductive rights at all levels of education include the following assumptions: sexual ill-health is not necessarily fatal, nor does it place burdens on the public sector, the cost of implementing this program provides no benefit in return, there are few scientific studying sexual health and there are no links to more serious diseases[36].  In the absence of formal education in public schools, adolescents often rely on their social networks or information that is readily available through media sources or pornography[37].

In an attempt to counter misinformation, India’s National Health Portal designated February 12 as India’s annual Sexual and Reproductive Health Awareness Day[38]. In tandem, the National Population Stabilisation Fund launched a helpline offering information on contraception, abortions, and pregnancy, among other subjects[39]. However, the impact of these efforts on public awareness relating to reproductive rights is unclear. 

Barriers as perceived by women

Beyond the barriers listed above, women must also consider the location of the facility, whether or not they will require their husband’s consent. The husband’s consent is not mandated by law but is an informal ‘requirement’ posed by many primary and community health centres, whether their visit will be kept confidential, the gender of the healthcare provider, as well the support available from their staff[40]. Stigma and lack of awareness (particularly in terms of the availability of legal services) are rampant among women populations as well. Fear of judgement or harassment, as well as the minimal services available (particularly for young unmarried women) coerce women into choosing the unsafe and potentially dangerous options. Legally, women are free to make a ‘choice’, although most women do not feel empowered to do so or are not given the right to consider exercising their autonomy[41]. The ability to make a decision depends on a variety of factors, each woman facing her own social and economic battles. However, the fact remains that women’s reproductive bodies are at the whims of insufficient physical, social, cultural and economic infrastructures as opposed to their own agency.

2. What are the barriers to access basic contraception?

Despite initiatives such as the Millennium Development Goals (MDGs), programmes taken on by the UNFPA, and the supposed implementation and development of national family planning methods (mostly centred around women sterilisation targets), there has been little variation in terms of unwanted pregnancies and contraception use in India[42].

According to the National Health Survey 2015-16, the need for contraception stands at 13% and the use of modern contraceptive methods stands at under 50%[43]. Additionally, 1 in 7 married women report that they no longer want to get pregnant but are not currently using any form of contraception[44].

The urban and rural divide

Access to contraceptive methods is markedly different in rural and urban spaces. Rural women have limited exposure to mass media and other information infrastructures. Though community health workers known as Accredited Social Health Activists are in theory present in every village in India to advise on family planning, knowledge of contraception remains scarce, with some women reporting that they “didn’t know about having less children[45].”

When it comes to agency, a study in rural areas of Rajasthan finds that for young women, the taboo around contraception and sex for non-reproductive reasons is largely insurmountable; therefore, (unsafe) abortion is an easier avenue to exercise one’s agency than seeking contraception[46].

Socio-economic barriers

Public facilities have become hubs for permanent contraceptive methods whereas other modern spacing methods can only be obtained through private facilities; presenting compounded financial, social, and geographic barriers for the majority of women. In fact, methods that are shrouded with perceptions of being less effective (spermicides, diaphragms, or implants) are entirely excluded from national family planning programmes and completely neglected by health workers[47].

Inaccurate and misleading information on contraception

Some contraceptives are unpopular given persisting misconceptions. For example, the unpopularity of IUDs stems from notions that they can make women go ‘crazy’ or eventually end up choking and killing women[48].

Misconceptions surrounding contraceptives for men have a reverberating impact for women’s access to contraception. Within the public-health system, education and communication regarding male sterilisation and contraceptive methods are insufficient. Often men inform their doctors that vasectomies are the equivalent of castration, or that they believe that condoms diminish sexual pleasure[49]. These beliefs and fears are reflected in condom distribution and availability. In 2008-2009, 660 million condoms were distributed in India whereas only 320 million condoms were distributed from 2015-2016[50]. Over the same time period, the quantity of emergency pills sold to women doubled from 1 to 2 million[51].

In 2016, the National Health Policy proposed to increase the numbers of male sterilisation but did not clarify how it would do so[52]. Nonetheless, the solution to minimising barriers is not to increase male sterilisation, but to provide access and awareness of all forms of contraception and implementing measures to increase women’s autonomy in making a choice.

Women very rarely have complete decisional autonomy about decisions regarding their own body. Male approaches to contraception have an impact on how contraceptives are advertised, distributed, and sold, forcing women to take on the burden of protecting themselves while potentially damaging aspects of their overall reproductive health.

Sterilisation as a dominant form of contraception

Since the foundation of India’s national family planning programme in 1952, the Indian government’s efforts have been geared towards decreasing the number of births rather than affording individuals the agency to plan for and avoid pregnancies[53]. As a result, family planning is skewed towards a Malthusian notion of population control, not taking enough initiative towards meeting the specific and individualised needs of women nationwide. 

India, as of September 2018, remains the country with the highest number of sterilisations in the world—this has been supported historically not only by the national government, but by the World Bank (WB), US government, and the Ford Foundation[54]. In fact, a USAID white paper in 2014 called for the number of sterilisations to increase globally[55]. Notwithstanding this recommendation, the Indian government initiated Mission Parivar Vikas which released three hormonal pills or oral contraceptives. Even then, sterilisation is on the rise—in the last decade, the number of sterilisations has risen from 34-49%[56].

Women’s sterilisation accounts for approximately 86% of contraceptive use while male sterilisation has decreased from 1% to 0.3%[57]. This is unsurprising given the fact that doctors, nurses, and women themselves are incentivised via payment to continue to promote sterilisation over other methods,[58] and the prevalence of sterilisation camps across the country. In 2016, finally, the Indian Supreme Court ruling directed that all government and NGO run sterilisation camps would be deemed illegal [59]. However, women could still undergo sterilisation if they so wished[60]. The illegality of camps does not guarantee the discontinuation of forced women’s sterilisation, in the same way that the legality of abortion care and the mandatory provision of contraception does not guarantee its access.

Here, two barriers become clear. Firstly, the reproductive body and autonomy over the reproductive body is negotiated and partly determined by geopolitical relations. This is not a new phenomenon. However, it demonstrates the structural nature of barriers that are viewed beyond infrastructural challenges. Secondly, the popularity of sterilisation as a contraceptive method trumps the probability that other methods will gain the same traction and popularity.

In response to this, according to the 2017 National Health Policy, the Indian government plans to increase the ratio of male sterilisation to 5%[61]. It is unclear how this sterilisation target will be met or enforced by the government; however, the desire to rely on sterilisation demonstrates an unwillingness to make other contraceptive methods more widely available.

Misinformed healthcare professionals

One of the places in India infamous for having significant barriers to access to contraceptive pills is Chennai. The phrase “out of stock” became prolific as women went from pharmacy to pharmacy seeking contraception[62]. This is astonishing as Chennai, the capital of Tamil Nadu, is one of the key urban centres in India and the fourth most populous metropolitan area in the country.

In 2005, the Drug Control General of India allowed for contraceptive pills to be sold over the counter. This nationwide move was met with resistance, particularly in Tamil Nadu where groups such as Responsible Parents Forum (RPF) and Satvika Samuga Sevakar (SSSS) rallied against the directive because of fears of it encouraging “sexual liberty” (specifically pre-marital sex, which is culturally stigmatised)[63]. In protest, RPF and SSSS claimed that contraceptive pills induced abortions, even though medical professionals consistently denied the validity of their claims[64]. In response to these protests, the Directorate of Drug Control in Tamil Nadu claimed that the drugs were falsely branded (as per the Drugs and Cosmetics Act), recalled several contraceptive pills, and banned their sale starting October 2006[65]. Despite the fact that the RPF and the SSSS have disbanded, the repercussions of their actions still shape the reality of accessing contraception in Chennai. Because of the stigma, taboo, and ban on these products, several chemists are under the impression that abortion care and contraception are illegal. However, the demand for contraceptives still exists, therefore many chemists offer home remedies or ayurvedic contraceptives which contribute to spreading further misinformation regarding safe and modern contraceptive use.

3. What are the hurdles in accessing non-biased medical reproductive health information?

The National Family Health Surveys (NFHS) can provide insight into the availability of information on certain aspects of reproductive health (estimates of fertility, infant and child-mortality family planning, maternal and child health care)[66]. An analysis (of data collected before 1999) conducted with a broader understanding of reproductive health, including contraceptives and abortions elucidates the information gaps and outlines barriers to non-biased information. Moreover, the continuation of certain barriers to restriction can highlight the necessity for progressive and structural change.

When examining awareness of family planning options, two out of three couples using contraception have involved the sterilisation of the woman as awareness for women’s sterilisation is nearly universal[67]. At the same time, there is an unmet need for contraception as 9% of births remain unwanted[68]. While data on family planning is acquired through a relatively robust questionnaire, data on the extent to which women and men are aware of all contraceptive options, the decision-making process involved in choosing to use a contraceptive, and any coercion or constraints faced by women remains absent.

Maternal morbidity, along with family planning, ranks high in the list of priorities for governments to address. Although there is a greater acknowledgement of complications during pregnancies, the significance of ante and prenatal care is less substantial. Similar to data collection and questioning regarding family planning, data on maternal health lacks information on the woman’s experience with pregnancy and the contextual factors related to potential complications or fatalities[69]. This gap is both informed by and informs the quality and depth of information on factors impacting reproductive health for a diverse range of women; the depth of which is lacking.

As of 1999, the NFHS only reported on the sexual activity of married women, leaving information on adult unmarried women and adolescent girls in the dark[70]. Consequently, any data on adult unmarried women adolescent girls seeking reproductive health services is unattainable. Considering that these populations are already vulnerable to being denied service, this data would be essential to a nuanced understanding of the socio-cultural realities of accessing reproductive services.

Taboo and superstition, fuelled by a lack of access and availability to education, lead to women going in for dangerous and unsafe practices. Historically and contemporarily, women have been constrained in asserting their authority in decision-making processes due to a general lack of information. Additionally, widespread misinformation and inaction by government and private actors to make resources more available and deliver high quality care further limit the avenues through which women, girls, men, and boys, can obtain unbiased information.

Continuing old constraints

According to a 2015 study conducted in Jharkhand, a state in eastern India, married women were more likely to receive information via social outreach whereas unmarried women largely rely on traditional media. Television, cinema, and newspaper are the most common outlets as internet penetration and access was only about 1% at the time of the study[71].

Acquiring information is laden with a sense of being unsafe due to the lack of awareness and communication on existing legal and regulatory reproductive health frameworks. Moreover, married rural women are restricted by their husbands more so than unmarried rural women are by their parents[72]. In rural settings, in addition to the lack of physical infrastructure, there is an absence of interoperability between different actors and community members; an interoperability and cooperation is necessary to share information and create a safe environment[73]. Given the number of development organisations that set up camp in rural areas (unlike government institutions), information on these topics can be associated with fear or distrust.

Per the study in Jharkhand, many women had little say in when to have sex. Most married women who were satisfied with the number of children they had resorted to sterilisation as a contraceptive, and the majority of women were not aware of other contraceptive options nor the legality of abortion care[74].

Sterilisation programs for women offer a window into understanding the gap between policy and implementation. The recognition of reproductive rights exists theoretically, and the ways in which access to contraception is framed has changed historically. Initially, when population growth was viewed as an impediment to development, women’s sterilisation was supported by the state under the discourse of population control [75]. As women’s agency, empowerment, and economic participation became increasingly popular among international development actors, these aspects became a part of the policy discourse in India as well, although the target-based approach continued [76]. Although significant judicial steps were taken to make sterilisation camps illegal, practices such as meeting sterilisation targets and refusing to offer services to women with fewer children continue to be practiced today[77]. Therefore, not only is information not available, but interactions with medical practitioners in medical settings (who interpret laws and regulations in their own way, or are following stringent state laws) are nodes in spreading misinformation experientially.

Similarly, while provisions were proposed in 2019 to acknowledge marital rape, and expand menstrual rights, these provisions were not designed to have implications beyond being included at the policy level[78]. Moreover, the method by which menstrual rights will be propagated, according to the proposed bill, is for schools and public authorities to provide sanitary products for free[79].

These band-aid legal solutions and resistance on the part of public and or private institutions do not address the issue of misinformation; they do not work to enforce the law beyond the limited population of women who understand these terms and have the resources and energy to take their grievances to court. Barriers to non-biased information therefore go beyond the absence of education and communication campaigns. In addition to lack of access, lack of agency, autonomy, government inaction, and diminishing quality of care compound the concerns that arise out of lack of access. Negative experiences with institutional health care further combines to fence off access and desire to seek information.

4. How is the use of technology influencing the reproductive rights space?

The provision and restriction of reproductive healthcare services are not mutually exclusive, especially in the case of technology deployment. The discourse supported by institutions that introduce technologies is one of women’s empowerment and protection of their rights. The uptake of technology is preferred for increasing and enhancing the reach, targeting, and customisation of family planning services. To accomplish these goals, each initiative is driven by a combination of international and domestic private, public, and non-governmental actors.

However, in some instances the pursuit of these goals may be counter-productive, and have adverse effects on the needs and entitlements of women.  

Applications and messagaging services

CycleTec Family Advice (CFA)

CFA was a SMS-based system that relayed information about family planning to men and women of all ages across seven states in 2013[80]. Focused on family planning and fertility, this program was developed by the Institute for Reproductive Health at Georgetown University (IRH) and with support from the United States Agency for International Development (USAID), Fertility Awareness for Community Transformation (FACT), and from the United Nations (UN). IRH partnered with HCL Services Ltd. and Nokia to use their network infrastructure. The programming itself and the data collected were intended to inform government policies and action. Whether through international or national efforts, internet and mobile based efforts have become a popular and widely supported means of addressing reproductive health issues in India.  Another trend taking ICT health provision by storm is the uptake of virtual clinics by private actors.

Doctor Insta

Founded in 2015, Doctor Insta is one of the first commercial ventures in virtual healthcare in India[81]. Available all across India, it is a website that provides 24x7 video consultations to patients. Doctor Insta was founded and created by Amit Munjal in partnership with Dr. Parshant Jain. Munjal. The business runs on funds from venture capitalists and angel investors in India and the US.

According to Munjal, who moved to India to start Doctor Insta with Dr. Jain, the motivations behind this initiative were to encourage people to seek out consultations for topics that may be considered taboo, and/or be able to maintain their health while managing a busy schedule. The application version of this platform comes in two versions, one for doctors (for scheduling and notes) and the other version for patients. The charges are INR 400 for a consultation with an individual, an employee-employer deal, with the cost in rural areas going down to INR 100-150[82].

Practo

There are also applications such as Practo that are designed to be aggregators, matching medical professionals with potential patients. Practo was founded in 2008 by Shashank ND and Abhinav Lal, engineering students completing their degree at the National Institute of Technology, Karnataka in Bengaluru. The design of their business models enables doctors to pay extra to book more patients and attain a higher ranking. The effect of this functionality is that it allows doctors with greater financial resources to improve their rankings, and ultimately being perceived as better doctors by the users of the app. It is unclear whether privacy and security standards, commensurate to the sensitivity of data being stored, are taken into consideration by corporations in the design of these applications[83].

Kilkari

Additionally, questions around data security, digital literacy, and privacy are raising concerns about the way in which many ‘m-’ or ‘e-’ based initiatives are implemented.

Kilkari is a free messaging service designed by the Ministry of Health and Family Welfare and BBC Media Action, touted as the largest in the world with over 8.95 million subscribers. Through audio messages relying on Interactive Voice Response, Kilkari offers weekly health information (directed at women and their husbands) for mother and child throughout the duration of the pregnancy until the child is 2 years old[84]. To participate in this program, women must register their personal and pregnancy information with the public health system[85]. By implication, Kilkari users are part of a database on which there is little available information, raising some doubt as to the applicable privacy standards, if any exist.

Databases as a condition to access

Continuing along the lines of restrictions via databases, some hospitals are asking women to present Aadhaar cards (centralised biometric identification) in order to receive care. Further, any woman hoping to take part in maternal health welfare programs must present their Aadhaar cards at public hospitals. In fact, without any official government notices, many public hospitals are now demanding Aadhaar cards before allowing women to avail themselves of reproductive health procedures. In a notable case in 2017, a Chandigarh hospital reportedly refused to provide services to a patient who did not have an Aadhaar card[86]. This has led to the denial of essential services and fundamental rights to those who have not been able to enroll themselves in the Aadhaar database, and in the case of benefits, opened a bank account and seeded it with the Aadhaar.

Not only does this actively restrict some women from accessing services, but it collects data on women seeking reproductive health care services which is then centralised and shared among associated parties. Associated parties include anyone who has access to an individual’s Aadhaar number and can request information through the Unique Identification Authority of India (UIDAI). This includes most government bodies and since 2019, banks, telecoms, and “any entity,” according to India’s Minister for Law & IT, Ravi Shankar Prasad[87]. If health records are digitally archived, risks of dissemination of confidential information may increase depending on access and security settings. Where these are insufficient, the right to confidentiality and privacy may easily be undermined.

The reality is that data leaks are common in this digital system. The latest reported incident took place on April 1st, 2019, a government agency data breach made the health records of 12.5 million pregnant women available online [88].  The exposed records included patients’ names, contact details, disease information, pregnancy status and complications, as well as procedures, such as abortions, that they had undergone. Despite the sensitive nature of the information leaked and the potentially serious implications for the safety of the women involved, it took the government a month to remove the medical records from the public eye.

Public practices of datafication

The Indian government’s e-Governance program titled “Digital India” spearheads the integration of ICT and big data technologies in the ‘advancement’ of sexual and reproductive health and rights[89]. One of the primary motivations driving this integration is to digitise the supply side of reproductive services. Continuing the use of market-driven language, government officials position technology as the way to bridge the gap between the demand (unmet need for reproductive services) and supply of these services. Apps such as E-mitra and ANMOL, information disseminated via mobile phones, or data collection by the government and international organisations (e.g. the Bill & Melinda Gates Foundation who pledged 80 million-dollars in 2016 to robustly collecting gender disaggregated data)[90] fall under the umbrella of digitally-mediated products responsible for surveying and distributing reproductive health services.

Mass data collection and dissemination through digital platforms, apps, and mobile networks is largely unregulated, while also ignoring contextual particularities [91]. The inaugural government programmes relying on data collection are the Health Management Information System in Andhra Pradesh in 2008, and the national Mother and Child Tracking System (MCTS) in 2011[92]. By collecting data on maternal health in the ante-natal and postnatal periods, these initiatives seek to improve accessibility, improve quality of care, and create more complete government databases to monitor family planning and population control. The MCTS was driven by a desire to create a system of e-governance in India along with the possibility of cross-sectoral digitalisation, a main sector being the healthcare sector. Granular data on each patient was collected by primary and community health centres. In 2018, the MCTS transferred in a phased manner to an RCH portal which aims to provide doctors and health workers access to real-time data on patients through an online application called ANMOL[93]. More research is required to determine the extent to which this application has been successful in meeting these objectives.

In 2016, the minister for Women and Child Development proposed mandatorily linking reproductive services with the Aadhaar card for further data linking/centralisation and for the provision of benefits schemes[94].  In addition to the integration of newly developed technologies, as mentioned previously, the Aadhaar is required by public facilities in order to provide any reproductive services. Compounding data surveillance in this fashion, while having meagre data protection infrastructure in place, puts the confidentiality and privacy of women in jeopardy. This is especially dangerous for women who already face barriers to access (i.e. young, unmarried, from rural regions, migrants etc). It also makes women more vulnerable to data breaches and hacks, as has occurred with the Aadhaar database many times[95]. 

Large-scale data infrastructures are on the rise, however the consequences and power imbalances they are imbued with are seldom discussed. In terms of the processing and treatment of data, there is no comprehensible information provided to the patient as to how and where this data is stored, how it is stored, and who can access it. The right to privacy, defined in Puttaswamy v Union of India 2017 as, “the preservation of personal intimacies, the sanctity of family life, marriage, procreation, the home, and sexual orientation…[it] safeguards individual autonomy and recognises the ability of the individual to control vital aspects of his or her life,” is at odds with the operationalisation of big data schemes [96]. In an environment where misinformation, stigmatisation, and the potential for ostracisation are widespread, building a network of data (via nationwide programs or linking the provision of welfare services with Aadhaar cards) on an individual’s reproductive health choices entrenches the vulnerabilities and barriers women face in accessing these services. In each case, reproductive health and the particularities of each woman’s situation is bio-medicalised and digitised into a datapoint.[97] While the nuances of reproductive health are diminished, the identities of those seeking them are amplified.

The emerging use of artificial intelligence

In 2019, the then interim Finance Minister of India—Piyush Goyal—announced budgetary allocations towards a national centre for artificial intelligence. This has important implications for the healthcare sector and is intrinsically linked to meeting Sustainable Development Goals (SDG) targets [98]. AI is increasingly seen as a solution to India’s problems, including poor performance on most maternal and child health indicators.

Maternal and child healthcare is one of the suggested uses of AI as it is considered a process involving quantifiable events: it is for a definite period of time with a fixed number of doctor visits, a fixed amount of postnatal care, and a certain number of immunisations for the child while in infancy. However, in order for AI to work effectively, there must be vast amounts of data available for the AI to process, and be trained on. As of now, there are no concrete government regulations indicating how this data will be collected and or managed except for the public declaration of  aiming to use this data for the “greater good.”[99]

In fact, the Population Fund of India has already implemented AI into one of their programs. This program communicates reproductive and sexual health information to adolescents[100]. The AI design is in the form of a digital avatar—called Dr. Sneha—who is intended to be a virtual companion for young rural women[101]. Of course, this may be advantageous in contexts where consulting with others is highly stigmatised; however, it raises questions as to the handling of users’ data in training the algorithm.

If the only data input into AI revolves around issues of fertility, reproductive health AI will inherently result in the prioritisation of fertility over other aspects of reproductive health, thereby restricting access to them. Moreover, if AI rapidly propagates in the healthcare area without oversight and regulation along with digital literacy training, this has the potential to leave many women vulnerable due to lack of attention to potential violations of data privacy.

5. What foreign organisations have a large anti-reproductive rights presence?

Tensions and inaccessibility within the Indian reproductive health landscape cannot be reduced to polarised views e.g. pro-life vs. pro-choice[102]. The trajectory of reproductive health regulation and service provision has been malleable to industry, technological, and international interests. Barriers and restrictions posed by national and international actors arise as a result of inaction and narrow conceptions of reproductive rights and health.

Life Matters Worldwide—Partners in India

In partnership with the Emmanuel Rural Hospital in Churachandpur, Life Matters Worldwide International advocates against abortion care in India via community and religious groups. Life Matters is a small US-based religious organisation that relies on private and public funds and operates through local church and hospital networks[103]. Their goals include educating, partnering, and mobilising communities in the US and around the world. They focus on achieving these goals via church communities, missionaries, and pregnancy care centres[104]. Since 2003, representatives from Life Matters have actively framed abortions as the ‘taking of lives[105]’.

The support offered to international Life Matters’ affiliates is not financial - in fact it is purely community and education-based to offer alternatives to abortions within pregnancy community centres[106]. By partnering with public hospitals and spreading their message, they seek to restrict abortion care for rural women.