Coercion, control or choice?
PREGNANCY is a visual symbol of sexual activity. The social acceptability of the circumstances in which the sexual activity took place thus lies at the core of determining the wantedness of the pregnancy and the options open to a woman who is pregnant.
For a married woman, not considered too old to be sexually active, pregnancy is legitimate (whether the sexual activity took place in consensual circumstances or not; whether she had any say in using contraception or not appears to be irrelevant) and a ‘family affair’. By and large society approves of the family’s right to decide whether the pregnancy is wanted or not and whether an abortion is justified. Justified, incidentally, has little to do with the legal circumstances under which abortion is permitted.
So for example, the family planning programme has succeeded in instilling a small family norm and in many contexts abortion has become completely de-stigmatised and perceived to be an essential tool with which to achieve this – whether in terms of family size (Tamil Nadu is the most telling example) or sex composition (witness the increasing use of sex detection tests). However, moral and religious feelings about abortion do surface occasionally and may play a role in deciding a course of action. Several studies have also noted inter-generational differences on these issues (Ganatra et al. 2000, Mohrankar 2003, Anandhi 2003).
The woman is expected to make choices that are in keeping with her family’s circumstances, needs and wishes. The woman’s own wishes play a role to a greater or lesser extent – depending on her own status within the family at the time. Thus, older women who have proved their fertility and women with more economic means and mobility have a greater role in deciding (Ganatra, Hirve 2002). Alternatively, women with independent support systems and economic means may short circuit the family decision-making process and terminate a pregnancy before the family comes to know about it.
The husband is a key actor although other family members play a role in joint and extended family structures (Malhotra et al. 2003, GIDR 2003, Johnston et al. 2001). It appears that mothers-in-law play less of a role than they do in other decisions, but little is known about the relative roles of different family members in different contexts. What does seem clear is that when there is difference of opinion, it is usually the wishes of the husband that prevail (Barge et al. 2003).
In this context, a woman may be pressured overtly or covertly into ending a pregnancy that she would rather not have. Several studies report that husbands often coerce their wives, not with physical violence but the implication that her fidelity is at stake or that her digression from his wishes will lead him to a second marriage (Gupte et al. 1997, Ganatra 2000). Equally important, women may have to continue a pregnancy that they personally feel they are not in a position to continue with. It is hard to know how often this happens or what the consequences are, as studies on abortion seekers entirely miss this group and surveys that ask whether a particular pregnancy was wanted or not merely scratch the surface of the issue.
When sexually activity takes place in less than socially acceptable situations, the focus is on ensuring that the symbol of the sexual activity, i.e. pregnancy, is not known to anyone. Abortion is one ‘solution’, but as several studies are finding, so is suicide (Ganatra, Hirve 2002, Johnston et al. 2001, Mohrankar 2003). Studies in Bangladesh and Nepal also report that other alternatives may include banishing the women from the community, allowing her to deliver a child in secrecy and then resorting to infanticide or abandoning the child (Fauveau and Blanchet 1989, CREHPA 1998).
What options are actually open to the woman depends again on what is at stake for the family if her pregnancy becomes public, who the concerned man is (caste, class, power and authority issues), the financial and practical involvement or otherwise of the male partner, and the support and sympathy she can garner from her immediate family. The degree to which secrecy becomes important may depend on how much the sexual activity is perceived to be the girl’s fault and how much she is perceived to be a victim. For example, unmarried young girls may find some sympathy, seen as having been lured into sexual activity by older men under the pretext of marriage.
While in some communities and areas within the country, viz. Mizoram, such pregnancies or even a child born out of them may indeed not be a stigma and thus puts a different face on decision-making (Indranee Datta; personal communication), we really do not know much about whether the increasing acceptance of premarital sexual activity even in urban areas has actually led to lower stigmatization if and when pregnancy does occur. Practical difficulties and ethical dilemmas often prevent studies from reaching out to unmarried abortions seekers and our information base remains sparse and largely anecdotal.
Even in marriage, pregnancy may be seen as a shameful symbol of sexual activity (older woman; when the husband has had a vasectomy or when he is away from home for long periods of time) and one that needs to be erased before it is known to the wider family, neighbourhood or community (Gupte et al. 1997, Sinha et al. 1998).
However, marriage also provides a way in which to legitimize sexual activity and make it appear acceptable. Thus, some studies have found that pregnancies that occur from extramarital relationships as well as nonconsensual extramarital sex that takes place with family members, can be destigmatized as having happened in marriage and premarital sexual activity can appear to be marital if the girl can be married off soon after.
In both cases, the key to further action is the recognition and acceptance of the pregnancy. There is evidence that when the woman misses a period she will try home remedies designed to bring on periods (Maitra 1998, Ganatra 2000, Barge 2003). Many visit formal and informal providers located close by in the community for herbs and concoctions and in more urban areas chemists for over-the-counter medicines. In urban areas, a visit to the doctor and even over-the-counter use of urine tests is gaining ground (Barua 2003) and may help in early pregnancy detection. There is no doubt that this is a period when most women are uncertain whether they are pregnant. These measures are tried as a way of determining that they are, or alternatively reassuring themselves that they are not.
Ironically, for those pregnant in socially illegitimate settings where the pregnancy needs to be got rid of fast, are precisely situations where the recognition of pregnancy often takes the longest. Denial, lack of knowledge of physiology, irregular menstruation in the early years after menarche, often lead to waiting until the pregnancy becomes physically evident. For some women the very act of approaching a provider for a way to being on a delayed period is an admission of pregnancy or at the very least a cause for suspicion. Some studies have reported that women may ask their male partners, other male members friends or older women in the family to act as a go-between and procure these medicines for them (Maitra 1998, Johnston et al. 2001). Even for married women in some settings, the shame of being examined by a male doctor may lead them to use their husbands as intermediaries in order to obtain medication from providers and chemists (Johnston et al. 2001).
In a situation where the concept of treating a delayed period is an essential first step in the abortion seeking process, what are the potential implications of the newer technologies of medical abortion (i.e. tablets that can be used to abort a pregnancy in the first seven weeks or so following the last menstrual period)? Would an abortion inducing tablet meet the women’s needs, especially vulnerable women’s needs for confidentiality and secrecy? Will women perceive this technology as an abortifacient or as one more medicine available to bring on a delayed period?
While the drug mifepristone (commonly known as RU 486) has been licensed for use only under supervision of a gynaecologist, anecdotal reports and qualitative studies do find that like most other drugs in India, it too may already be available over-the-counter in some settings. While there is no question that the drugs are safe and effective we simply do not know what the implications of the drug being used in this way are. These are questions we need to understand better in order to exploit the potential of this technology to expand women’s access and meet their needs.
What role do family members play at this stage? We can assume that in areas where there is a cultural tradition of sitting separate during menstruation there may be some questions raised and delayed periods noticed. Otherwise it is unlikely that anyone else will know until the woman tells. Some studies have talked of women consulting another female member first; some have talked of the husband as being the first person who knows, but how, when and in what sequence (if indeed it is such a linear process) other family members come to know is again a matter of conjecture. Far less is known about when and how much the natal families are involved in this process although there is some evidence that like for other maternal illnesses, natal families, while removed from any of the decisions, are called upon to provide the finances.
Reaching a provider to actually conduct the abortion may itself be a long process involving several different providers and sometimes the use of informal information networks that include friends and paramedical workers in the neighbourhood (Ramchander and Pelto 2002, Maitra 1998). Women in low access areas have little choice as services are simply not available. When options and choices exit, studies have shown that women seem to prefer private providers. The choices are often one of practical necessity or of negative exclusion (avoid a government clinic because they will insist on a sterilization; avoid a particular doctor because he is too expensive) rather than a choice because of some positive features of a particular provider.
Again, while women do consider safety, what is considered safe depends on the circumstances in which the pregnancy occurred. For women, in socially acceptable circumstances and with economic means and social support, medical safety and comfort become a criteria. For those in more illegitimate circumstances, the focus is to find a provider who will remove the pregnancy as quickly and quietly as possible. Thus, medical safety takes a back seat to social safety (Gupte et al. 1999). Women may choose medically unsafe providers even in settings where they are within easy reach (Ganatra, Hirve 2002) not because women are ignorant, stupid and illiterate but because non medically safe providers often meet their needs for confidentiality and quickness far better and at lower cost.
By and large, awareness of legality of abortion remains a well-guarded secret and studies in different settings show that women (even those who themselves have had an abortion) either think it is illegal or simply do not know (Malhotra et al. 2003; Ganatra and Hirve 2002). Legality and social acceptability are equated, which further constrains the choices women have in terms of going to a safe provider. The publicity around the PNDT Act in recent years has in fact translated to awareness about the illegality of sex detection. Unfortunately, however, most women (and men) have assumed (wrongly) that the law is actually about a ban on abortions and that the government has now banned all abortions (Barge 2003, Radkar 2003), whether sex-selective or not – a dangerous trend that will likely have a backlash on accessing safe services for any woman in need of abortion services.
With a provider too, women’s choices and ability to be an active partner in her care are limited. Even when she is with a formal provider, she has little choice in deciding the nuances of her treatment. Counselling as and when it exists is usually prescriptive and directive. Information that is given is limited and women themselves often do not ask for and demand information either (Barua 2003). Even where contraceptive services are not expressly linked to her obtaining services, they still do not provide choices that take into account her personal realities. Thus a vicious cycle of repeated pregnancy and abortion often sets in.
The law gives the provider the authority to make medical decisions in good faith, and culture gives them the power to sit in moral judgment. Here too, like with family and society at large, it is often what the provider feels about the circumstance in which the woman got pregnant that determines his or her attitude towards the woman. Many studies have demonstrated that providers can be either openly judgmental or scornful, place additional barriers in the way of treatment and sometimes use the woman’s lack of awareness of her rights as a means of monetary exploitation. Women may be denied services on these moral grounds; worse women who are HIV positive may face additional stigma and barriers (Bharat 2001). The concept of dialogue and discussion is far removed from the day-to-day life experience; in several studies women speak of their expectations as revolving around simply being spoken to nicely, more often expressed in negative (the provider should not be rude, the attendants should not be rude) than in positive terms.
Men’s and families’ role as the gatekeepers of these decisions is reinforced in the setting with the provider. Women accompanied by a male have been known to receive better treatment and many providers insist on a signature from the husband or other family members, sometimes because they are using general anaesthesia or because they believe it is a legal requirement (it is not) but equally to protect themselves from getting embroiled in domestic dispute and to preserve their social acceptability. Women themselves, even when they know it is not a legal requirement, often agree to this idea. In one study they said it was a public admission of responsibility by the husband and a commitment to look after them even if something went wrong (Ganatra et al. 2000), showing that the line between control and cooperation, participation and permission can be very thin indeed.
However, when space and conducive environment exist, women do ask for information and express their curiosity, fear and concern as well (Iyengar and Iyengar 2002). Non-judgmental and caring providers do exist. When choices are given and women have the information and the means to make them, they do exhibit personal preferences, whether in choosing the type of pain control they would like or the method of abortion or the family planning method they would like to use post abortion (Clark et al. 2002, Winikoff et al. 1997). Unfortunately, research and documentation remains focused on the ‘what is wrong’ and needs now to move in the direction of documenting more of these positive experiences and best practices. Only then can we learn about what the problems are and possible ways of dealing with them.
As Byllye Avery, way back in 1970 said, ‘To say to a person who feels beaten down and who does not have the means "you have a choice" is nonsense. For reproductive rights to become a right or a real choice, social structures need to change. But a first essential step is for those of us who provide services or design programmes to begin by simply recognizing the complex conditions under which choices are made... and give women the information, scope and space to emerge out of the experience of dealing with an unwanted pregnancy with their dignity and self esteem intact.’
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