This Sunday, we bring to you an article from our archives. Dr. Nozer Sheriar, who is known to have championed the cause of rights of women to safe abortion, answers 8 crucial questions on the medicolegal aspects of MTP. In his recent webinar, his talk was replete with compassion for female patients and was instrumental in guiding doctors as well. Here we share a part of the Q&A session between Dr. Sheriar and Dr. Niranjan Chavan, where he answers viewers’ questions while also sensitising them on the matter from the point of view of women.

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Question 1: Ultrasound in a few smaller towns is compulsory in all cases of MTP but many women do not wish sonography and choose to buy pills from a medical store and attempt illegal method of abortion. Is there a way to eliminate compulsory ultrasound from the PCPNDT act?

Dr. Sheriar: We have comprehensive guidelines to abortion in India and these apply throughout the country. However, ultrasound is not compulsory at least for the diagnosis of pregnancy. Yes, it is desirable if it is available, but it is not mandatory.

The PCPNDT authorities cannot mandate clinical decisions to do an ultrasound. It has certain responsibilities and power but this is outside its power. There is a code of conduct in the Act and one of the point stops authorities from making such arbitrary decisions. One of the points states that they cannot conflate the PCPNDT and the MTP Acts. So you need to take this up at a society level; get together and talk to authorities.

Sometimes, authorities make these decisions with good intentions but do not realise their consequences. We need to find out why women opt for self-medication. Is it because access is difficult or is it because when they come to us, we are judgemental especially with younger women and unmarried women? Is it because they are worried about confidentiality when they come to us or is it about the cost? Also, when women go to a chemist instead of coming to you, they miss out on counselling. A woman may have a safe abortion but she will also miss out on post-abortion contraception. So keep these things in mind, figure out alternatives, and then take up the cause.

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Question 2: How do you confirm the age for a seemingly minor patient? Do we inform the police and if yes, then should the doctor do it or ask the hospital administration? What about patient confidentiality?

Dr. Sheriar: This is a major conflation between two acts – MTP and POCSO and we, as responsible practitioners, have to abide by each and every act of law. With regards to the age proof, technically you don’t need to ask the age, but in today’s environment, if you have a doubt, please do ask.

You could accept any reliable identification with proof of age to know their age. Once you know the patient is under 18, you have no choice but to report it to the authorities. Confidentiality in the original MTP came under regulations, not the act or the rules. Confidentiality is not breached if you inform the concerned authority. If someone is breaking the law, you cannot claim confidentiality, you do not have to wait for permission before reporting it to the police. The law says so.

You could simply pick up the phone and inform the police, submit a hand-written note, or inform them via an email. As a practitioner, you must know the number of the police station closest to your clinic or hospital, or the unit that looks into complaints on women and children. Remember, you also need to preserve your evidence and keep it safe to the extent that no one should be allowed to even open the refrigerator that stores it.

You cannot force a girl to continue with the pregnancy in an attempt to not destroy the evidence. The POCSO Act also says that refusing medical care to a woman is a breach of the act. If you don’t terminate the pregnancy, which is what she wants, then it is you who is breaking the law. So, please report such cases, fulfil your responsibility of abiding by the law, do the right thing, and keep yourself safe.

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Question 3: Should pregnancy in a teenage girl (after rape) be registered as a medico-legal case? Does the girl have to be treated at a government hospital only?

Dr. Sheriar: If she is a teenager, the POCSO act applies. If it is a rape, it is notifiable. The Criminal Procedure Manual states that if you know of it, you must report it. You don’t have to be at a public hospital, a private hospital has equal responsibility. A private hospital can be taken to task if it turns away such a patient and sends her somewhere else. Private hospitals have to up their scale and keep kits to treat victims of rape. Hospitals must keep kits that can help them procure evidence, have doctors trained to collect evidence because that is always the lacuna when it comes to conviction in such cases. Even as a private doctor, make sure your capacity is upgraded to be able to do justice.

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Question 4: Is Aadhar card needed for prescribing oral MTP drugs?

Dr. Sheriar: You may ask for it to know the patient’s age. Also, ensure you fill up Form C. The girl/woman will also have to sign it to give consent and the form requires her to mention her age[U4] . Within reasonable limits, that also is protection because if she misrepresents and lies, you become a victim but then again, a contract cannot be signed by a minor. So it is a tricky situation. But as long as you follow the protocol, you would be protected.

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Question 5: Giving abortion pills for 8.6 weeks or 62 days can be questioned by the authorities, so should they be given pills for 63 days?

Dr. Sheriar: The Drug Controller General of India has approved the use of pills for up to 63 days. So you can ask your patients to take them for 63 days.

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Question 6: Does a to-be-born baby have any right?

Dr. Sheriar: As per the constitution of India, rights exist only for those who are born. You can’t have a conflict of interest but when you have a choice, the woman’s interest comes above all else. There is a lot written about foetal rights but those rights are subsumed under the rights of the woman. She knows what she is doing and why, she probably knows about contraception, too and despite that if she is pregnant and has opted for an abortion, you have to support her. Make it safe and dignified for her. Keep your focus on the woman who needs abortion.

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Question 7: How can we get MTP registration online?

Dr. Sheriar: This can’t happen because authorities have to come in physically, but I do agree that some system has to be put in place.

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Question 8: If medical abortions can now be done in clinics, who do certain municipality corporations not provide MTP registrations to clinics, nor allow abortions without MTP registration? Please comment.

Dr. Sheriar: Yes, these are the grey areas. However, the MTP act does allow you to perform MTP and medication abortion in clinics. The rules of the government of India apply to the entire country, so municipalities cannot contravene laws and rules established by the central government. The problem is about reporting.

Firstly, you need access to a registered site. It could be someone else’s site but the doctor has to be willing to allow you to use it as a registered site for your practice. For example, I have a letter from a friend who owns a hospital, and I have framed it in my clinic. So I can perform medication abortions saying I have access to his clinic. Although it would be unfair on my part to report my MTPs in his name, so the BMC has registered my private consulting room as an MTP clinic. I agree that this seems grey but there is a system, whereby you can apply and they will register your clinic. And for the last decade, I have been reporting every medication abortion of mine from my private consulting room to BMC, both online and in hard copy. So it is doable.

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To view the webinar, click here.

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This article was originally published on November 5, 2020.

Disclaimer-

The views and opinions expressed in this article are those of the speaker's and do not necessarily reflect the official policy or position of M3 India.

Dr. Nozer Sheriar is an obstetrician and gynecologist with a longstanding commitment to the advocacy and promotion of women's health, rights and access to safe abortion.

Prof. Dr. Niranjan Chavan is the Unit Chief in the Dept. of Obstetrics & Gynaecology, at a prominent Mumbai hospital.