A ruling by India's top court that grants unmarried women equal abortion rights could end up being largely symbolic without concerted efforts to tackle persistent barriers to the procedure, reproductive rights campaigners say.
Stigma and myths stemming from laws against sex-selective abortion of girls deter many women, campaigners and experts said, while a lack of affordable and rural facilities are hitting poorer and marginalised groups.
"The Supreme Court judgment will mean something only if the very last woman (including) those from marginalised communities get the service," said Apurva Vivek, a lawyer and the founder of an abortion rights initiative.
The court last month upheld women's right to abortion up to 24 weeks of pregnancy regardless of their marital status.
The ruling was significant at a time when the right to abortion has proved contentious globally. The US Supreme Court in June scrapped the landmark 1973 Roe v. Wade decision that had legalised the procedure across the United States.
India's 1971 law had limited the procedure to married women, divorcees, widows, minors, "disabled and mentally ill women" and survivors of sexual assault or rape.
"The law could always be liberally interpreted but the challenge has been access on the ground," said Subha Sri, head of Commonhealth, a Chennai-based coalition of health charities.
Moral judgement and dissuasion of women seeking terminations are commonplace, said rights campaigners.
Abortion services are mostly available in urban areas and at private facilities that are too costly for many, while single adult women are often told that a guardian, partner or parent must approve their abortion request, said Sri.
"There is a lot of gatekeeping on moral grounds. While it is great the recent ruling has made the situation clear, I don't know if things can change," she said.
Unsafe abortion risks
More than 15 million people get abortions in India each year – and at least 800,000 of the procedures are unsafe – according to a 2021 study co-authored by the Center for Reproductive Rights and the National Law University, Delhi. It found women and girls who are poor, illiterate, live in rural areas, or belong to minority religions or oppressed castes are at a significantly higher risk of having unsafe abortions.
Many buy abortion pills, which are widely sold although the law says they should only be given out with a prescription.
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The pills can cause complications - especially if not taken according to medical instructions - including heavy bleeding for days and an incomplete abortion, doctors said.
Other women turn to unqualified abortionists who use outdated metallic instruments which can damage the uterus.
There are about 11,000 public health facilities offering abortions up to 12 weeks of pregnancy in India, and 4,000 provide it up to 24 weeks, according to government data, serving more than 350 million women of childbearing age.
At the gynaecology department at the Government Medical College in Aurangabad, staff said some women had travelled up to 200 kilometres (125 miles) from rural areas in order to access abortion services.
"There are smaller centres closer to their homes but treating doctors are overseeing everything from dog bite cases to vaccinations and do not have the bandwidth to offer this service," said Shrinivas Gadappa, the department head.
"We get cases of women who have gone for unsafe abortions. We just had a case of a woman who had her uterus perforated and could not be saved by the time she reached our hospital."
Lawyer Vivek said vulnerable women in state institutions must get permission from legal guardians - such as one victim of sexual assault she supported whose legal case lasted so long that she passed the 24-week limit for abortions.
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The woman died shortly after giving birth.
"We have handled cases of women rescued from sex work who were forced to keep the pregnancy because officials were unwilling to sign their guardianship forms for lack of clarity if they were legally allowed to do so," said Vivek.
"If women and girls don't need a guardian's consent to keep the pregnancy, why should they need it to terminate one?"
Sex-selective abortion law impacts
India's efforts to tackle sex-selective abortions have also impacted on access to reproductive healthcare, say campaigners.
Posters warning female foeticide is a crime are on display in all clinics, hospitals and diagnostic centres that offer ultrasounds.
Though the campaign has brought results, campaigners and doctors said it has fuelled myths that all abortion is banned.
Less than a quarter of young women in rural areas in two Indian states were aware abortion could be legally accessed, according to research carried out by sexual health non-profit the Ipas Development Foundation (IDF) in 2019.
Social stigma prevents unmarried women from seeking information about terminating pregnancies, said Anisha Aggarwal, a senior director with IDF.
Doctors are required to inform the police when they carry out abortions for those aged under 18 and sexual assault survivors.
A government-appointed official who oversees abortion clinics said some doctors were deterred from offering terminations by the hassle of monthly checks and the fear of police action under laws against sex-selective abortions if they carry out abortions for women in their second trimester.
Class, wealth divides
For those with money and in urban areas, abortions can be readily accessible.
The private Saraogi Hospital in the financial capital Mumbai provides about seven abortions each month.
It costs about Rs 5,000 ($60) - affordable for those in office jobs, but an entire month's income for a domestic help.
The "large majority" of women who lack the cash and connections to pay for such services can face a very different reality, said Sangeeta Rege, director at the Centre for Enquiry into Health and Allied Themes (CEHAT), a health charity.
"Many end up going to a public or private provider who is not in the same league," she said.
"Women struggle every single day in public hospitals."
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