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By Rashme Sehgal Public health NGOs claim that the Uttar Pradesh Population Policy downplays abortion as a means of family planning, even though 10,000 women in the state die as a result of unsafe abortions every year. Why is this happening? Especially in a state which records 40,000 maternal mortality deaths every year?
President Bush doesn’t like the word ‘abortion’, and America’s population policy continues to disallow abortion as a means of family planning. But why is the state government of Uttar Pradesh, where 77 women die every day because of pregnancy-related complications, avoiding the use of the word ‘abortion’ in its Population Policy? Could it have something to do with the fact that the state government has chosen to gets its population policy document written by an overseas consulting agency? The Uttar Pradesh Population Policy (UPPP) 2000 was prepared by none other than Future Groups International (FGI), an organisation that undertakes consultancy work on population-related matters. USAID paid FGI $50,000 to prepare the document. FGI is at present fine-tuning a similar document for the states of Jharkhand and Uttaranchal. The problem with getting a document prepared by a foreign agency is that, more often than not, they are unable to contextualise the document to local realities. The UPPP has some glaring absences, the most noticeable of which is the deliberate avoidance of the word ‘abortion’. This makes little sense in a state that witnesses 40,000 maternal mortality deaths every year, of which 10,000 are the result of unsafe abortions, claim several non-governmental organisations working in public health in the state. FGI appears to have forgotten that India already has a national law allowing safe and legal abortions, and that the reproductive and child health approach includes the management of unwanted pregnancies as part of the ‘safe motherhood’ package of services. The omission of safe abortion services in the policy forces women to resort to illegal and unsafe abortions, thereby stepping up the already alarming mortality and morbidity figures in the state. The National Population Policy 2000, prepared by the ministry of family health, admits that unsafe abortion is a key factor in Uttar Pradesh’s high maternal mortality rate. Prasanna Hota, secretary, ministry of family welfare, maintains that “both national and state policies are not being dictated by foreign governments. We have our own national policy and our Medical Termination of Pregnancy (MTP) Act is national and not state-specific”. According to Hota, the de-emphasis on abortion could be the result of two factors: 1) an attempt to put an end to illegal abortions, and 2) to ensure that women in the second trimester of pregnancy are not allowed to go in for abortions, in an effort to prevent female foeticide. NGOs working in the field of reproductive health dismiss both arguments as facetious. Says Dr Abhijit Dasgupta, who works with the Lucknow-based NGO Sahyog: “We are not saying that abortion should be promoted as a means of contraception. But that does not mean that women should be denied access to safe abortion procedures. The document has nothing to say on unsafe abortions, which are responsible for 15-30% of all maternal deaths. We believe 10,000 or more women who die in Uttar Pradesh do so because they end up going to quacks.” Ganesh Pandey of Shramik Bharti believes that the entire package of contraceptive services needs to be upgraded. “What is happening in the state in the name of health services is nothing short of butchery. This problem is further compounded by the fact that the status of women is so low that they dare not raise their voices against the medical community,” he says. Population specialists also claim the UPPP violates other crucial aspects of government policy. For one, it has re-introduced method-specific contraceptive targets, to the extent of 10 lakh sterilisations and 30 lakh spacing method users per year by 2005. This is a complete reversal of the government’s target-free approach. It also violates Article 2 of the United Naations Convention on the Eradicartion of Discrimination Against Women (CEDAW), which underscores the right of individuals to freely decide the timing and spacing of their children. Hota refutes the charges, insisting that the target approach is not being followed. But he has a problem with the target-free approach. “After the Emergency, the target-free approach has become synonymous with doing no work in the health sector,” he says. Rajendra Bhonwal, secretary, family planning in the Uttar Pradesh government, agrees with Hota. “We had set a target of 6 lakh sterilisations for 2002-2003 but we were able to conduct only 4.6 lakh sterilisations. Unable to meet our target, we admit to shortfalls in our programme,” says Bhonwal. Hota believes the major bottleneck is in the implementation of government projects. “There is no demand on the system and, more often than not, the services end up not being utilised. This is coupled with the problem of infrastructure and manpower. Neither doctors nor anaesthetists want to work at the village level,” he says. The ministry of family welfare has set up an empowered action group to provide a basket of intervention schemes and partnerships at the local level. One of these is to stop the transfer of ANMs (auxiliary nurse midwives) from village to village. The objective is to allow them to ‘take root’ in one place so they can develop a sense of commitment. Another scheme proposed by the Uttar Pradesh state government is to get around complicated procedural policies and hire doctors and nurses on a contract basis. Another major flaw in the UPPP is its emphasis on involving the private sector in the area of public health, and charging for contraceptive services. Considering that 40% of the state’s population live below the poverty line and are hardly in a position to avail of these services, this is the surest way of pushing them into the hands of quacks. But a senior USAID official says: “The government cannot be the sole provider of contraceptives. We are tying up with the private sector to help establish a chain of non-profit health clinics in Uttar Pradesh. We believe villagers are in a position to buy condoms. We are presently charging Rs 2 for five condoms, and sales of condoms are rising.” On the other contentious issue of whittling down the role of home-based delivery attendants (dais), the official says: “Most maternal deaths occur due to complications such as sepsis and haemorrhaging. None of these can be handled by dais.” NGOs in the state, however, believe that trained dais perform a very useful task and object strongly to the way their services are being dispensed with. USAID funds are being distributed through SIPSA, which spends $10.5 million a year on training physicians and ANMs and providing contraceptives throughout the state. The organisation, along with officials from USAID, is in the process of preparing a fresh UPPP document. Several Uttar Pradesh-based NGOs, including Chaupaal from Gorakhpur, Shikhar Prashikshan Sansthan from Mirzapur and DISHA from Saharanpur, have written to the ministry of family welfare insisting they be included in the deliberations. Dr Dinesh Singh of Chaupaal points out that SIPSA will not hesitate to consult with ‘experts’ living in Mumbai, but it is not keen to receive inputs from people who have been working in the area of health in Uttar Pradesh for several decades. “During the last round of consultations (when this UPPP document was being prepared) we were not consulted. Nor were copies of the draft document shown to us. I expect them to repeat the same process all over again, and this time around, god knows what they plan to exclude,” he says. (Rashme Sehgal is a Delhi-based journalist. This article concludes her special series of investigative stories for InfoChangeIndia on Uttar Pradesh’s shocking statistics on maternal mortality. See Why 40,000 pregnant women die in UP every year and UP's women die in childbirth for want of a four-rupee dai kit) InfoChange News & Features, June 2004
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