Catalysing Choice: Behavioral Interventions for Reproductive Autonomyand Abortion Rights Advocacy
One afternoon at work, I received a frantic call from a woman I knew well, and her panicked
tone immediately set off alarms. She asked, “I don’t want to continue this pregnancy, but the
doctor insists that I have to. Is abortion illegal?” This woman, a domestic worker who had been
with my family for years and someone I deeply cared about, had endured the trauma of a
stillbirth just a year before. This time, concerned about her health, she did not wish to proceed
with the pregnancy. Yet, instead of offering support, the doctor harshly reprimanded her, urging
her to embrace motherhood.
A few months later, a friend reached out, asking if I knew of a compassionate gynaecologist in
my hometown. She shared the story of a distant friend, a young college student, who was told
by a doctor that a medical abortion would cost one lakh rupees, despite she being only a few
weeks pregnant. The stigma surrounding abortion meant the girl couldn’t seek help from her
family and had to rely on her friend instead. Together, they found a more understanding doctor,
and the girl spent the weekend in a guesthouse while taking the abortion medication.
Reflecting on these incidents, I realized that even in Assam’s most urban city, both a 30-yearold
woman and a young woman in her early twenties, from different socio-economic
backgrounds, encountered significant barriers to exercising their reproductive rights, especially
the right to safe abortion. This led me to pursue advocacy for abortion rights, working with
parliamentarians and civil societies as part of my role as a Safe Abortion for Everyone (SAFE)
Fellow at The YP Foundation. In this article, I’ll analyse the issue from a commentator’s
perspective.
As Martin Luther King Jr. poignantly noted, “Of all the forms of inequality, injustice in health
is the most shocking and inhumane.” At the heart of reproductive autonomy is a woman’s right
to make decisions about her own body and reproductive choices, which is central to her
fundamental rights to equality and privacy.i Yet, globally, only 35% of women of reproductive
age live in countries where abortion is available on request.ii In India, the high rate of unsafe
abortions and resulting maternal mortality in the 1960s prompted lawmakers to pass the
Medical Termination of Pregnancy Act (MTP Act) in 1971.
However, despite being in effect for over five decades, India’s abortion law has fallen short in
guaranteeing reproductive autonomy. One of the biggest challenges is the lack of awareness and
sensitivity among key stakeholders, limiting widespread access to safe abortion services. A
recent study by the Foundation for Reproductive Health Services India (FRHS India) found that
one-third of women interviewed did not consider abortion a health right, and only 40% were
aware of the legality of abortion under the MTP Act.iii This lack of awareness often leads to
delays in seeking care, resulting in more advanced pregnancies when abortion options become
increasingly limited.iv A 2018 study in Assam and Madhya Pradesh revealed that 62% of
women surveyed viewed abortion as a “sin”vi
Often, a significant proportion of abortion cases are self-managed abortions (SMA) at home,
reflecting women’s hesitation to access safe services due to the deeply ingrained stigma
surrounding abortion in a patriarchal society. SMAs are more common among women with less
education, those from rural areas and lower socio-economic backgrounds, and adolescent
girls.vii This disparity in access to safe abortion based on socio-economic background is further
supported by data from the NFHS-5 (2019-21). Abortion rates in urban areas (4%) are higher
than in rural areas (2.5%). Only 1.7% of women from the lowest wealth quintile access abortion
services, compared to 4.1% from the highest quintile. Women’s education is also a crucial
factor, with a 3.4% abortion rate among those with higher education and 1.9% among those
with no schooling. These statistics highlight the persistent inequality in abortion access and
raise questions about the efficacy of the MTP Act.viii
Access to safe abortion is significantly influenced by the attitudes of service providers. While
abortion is legal in India, this does not guarantee that healthcare providers fully support
reproductive choice. There are instances where providers refuse to perform abortions during
first pregnancies, citing exaggerated concerns about infertility or potential risks to the woman’s
health. Some providers overemphasize the dangers of bleeding and encourage surgical abortions
over medical abortion pills. Women with multiple children are often told that they can only
obtain an abortion if they agree to sterilization or the insertion of a Copper-T. Additionally,
some providers still insist on obtaining the husband’s consent, despite this not being a legal
requirement.ix Laws such as the Protection of Children from Sexual Offences (POCSO) Act of
2012 and the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act of 1994
further complicate access by introducing criminal liability for providers.x Despite efforts by the
Supreme Court to clarify and expand the scope of the Medical Termination of Pregnancy
(MTP) Act, providers’ personal biases, often shaped by social and cultural norms, continue to
create barriers to reproductive autonomy.
To ensure broader access to safe abortion, it is essential to bridge the gap between policy and
practical implementation. The first step is to establish a sustainable mechanism to raise
awareness across the country about the legal right to safe abortion. The government should
launch awareness programs aimed at fostering behavioural change, particularly among
marginalized communities, empowering them to challenge abortion stigma and exercise their
reproductive rights. Research has shown that Behaviour Change Communication (BCC)
interventions can effectively enhance knowledge and improve attitudes toward abortion in areas
where misinformation limits access to safe services.xi
For a BCC intervention to be sustainable, the initial focus should be on understanding the target
community’s beliefs and societal attitudes around motherhood. Once the community’s socioeconomic
context is fully understood, tailored communication strategies—whether highintensity
or low-intensity—should be deployed to raise awareness about reproductive rights.
High-intensity BCC efforts should include interpersonal discussions, community meetings, and
interactive activities to engage adolescent girls and women from various communities. To
ensure long-term impact, women from these communities should be trained as advocates for
abortion rights.
Low-intensity BCC models can use various media such as wall signs, banners, posters, and
community intermediaries. Frontline workers should be trained to share information about the
legality and accessibility of abortion services, the risks of unsafe abortions, and the availability
of safe alternatives. Additionally, they should be equipped to refer women to nearby health
facilities for safe abortion services.xii
Equally critical is training medical practitioners to overcome biases and provide accurate, nonjudgmental
information to those seeking abortions. Regular workshops should cover not only
the bio-medical aspects of abortion but also gender rights and the socio-cultural issues related to
abortion. Medical education materials should address the social stigma and myths surrounding
abortion, helping healthcare providers reflect on and challenge their own prejudices.
Ensuring that all stakeholders in the abortion process—providers, communities, and
advocates—are well-informed about the procedure, its legality, and the importance of dispelling
myths is the key to making safe abortion services accessible to all pregnant persons across the country.
References
i UN General Assembly, International Covenant on Civil and Political Rights, 16
December 1966, United Nations, Treaty Series, vol. 999, p. 171, available at:
https://www.refworld.org/docid/3ae6b3aa0.html
ii Center for Reproductive Rights. (2023, December 20). The World’s Abortion Laws – Center
for Reproductive Rights. https://reproductiverights.org/maps/worlds-abortion-laws/
iii Choudhuri, Debanjana, Ashutosh Kaushik and Alok Shrivastav. “Medical Termination of
Pregnancy Act 2021: A Study to Understand Awareness.” Foundation for Reproductive
Health Services India, December 2022.
iv Assifi, A., Kang, M., Sullivan, E., & Dawson, A. (2020). Abortion care pathways and
service provision for adolescents in high-income countries: A qualitative synthesis of the
evidence. PLOS ONE, 15(11),
e0242015. https://doi.org/10.1371/journal.pone.0242015
v International Institute for Population Sciences (IIPS) and ICF. 2021. National Family Health
Survey (NFHS-5), 2019-21: India. Mumbai: IIPS.
vi Improving knowledge and care seeking behaviour of young women for sexual and
reproductive health in Assam and Madhya Pradesh: Results of the endline community
assessment. Ipas Development Foundation. 2021.
vii Malik, M., Girotra, S., Zode, M., & Basu, S. (2023). Patterns and Predictors of Abortion
Care-Seeking practices in India: evidence from a nationally representative Cross-Sectional
Survey (2019-2021). Cureus. https://doi.org/10.7759/cureus.41263
viii International Institute for Population Sciences (IIPS) and ICF. 2021. National Family
Health Survey (NFHS-5), 2019-21: India. Mumbai: IIPS.
ix Bhate-Deosthali, P., & Rege, S. (2019). Denial of safe abortion to survivors of rape in India.
PubMed, 21(2), 189–198. https://pubmed.ncbi.nlm.nih.gov/31885448
x Chandra, A., Shree, S., & Satish, M. S. M. (2021). Legal barriers to accessing sage
abortion services in India: A fact finding study. National Law School of India
University.
xi Banerjee, S. K., Andersen, K., Warvadekar, J., & Pearson, E. (2013). Effectiveness of a
behavior change communication intervention to improve knowledge and perceptions about
abortion in Bihar and Jharkhand, India. International Perspectives on Sexual and
Reproductive Health, 39(03), 142–152. https://doi.org/10.1363/3914213
xii Ibid.