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 is 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 marital status.
The ruling was significant at a time when the right to abortion has proved contentious globally.
The United States Supreme Court in June scrapped the landmark 1973 Roe v. Wade decision that had legalised the procedure across the US.
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.
Abortion services were mostly available in urban areas and at private facilities that were too costly for many, while single adult women were often told that a guardian, partner or parent must approve their abortion request, said Sri.
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 Centre 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 although the law says they should only be given out with a prescription. The pills could 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Other women turn to unqualified abortionists who use outdated metallic instruments which can damage the uterus.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 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 in western India, staff said some women had travelled up to 200km from rural areas to access abortion services.
"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," said Shrinivas Gadappa, the department head.
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.
The woman died shortly after giving birth.
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 prevented 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.
For those with money and in urban areas, abortions can be readily accessible.
It costs about 5,000 rupees, affordable for those in office jobs, but an entire month's income for a domestic help.
The "large majority" of women who lacked the cash and connections to pay for such services could face a very different reality, said Sangeeta Rege, director at the Centre for Enquiry into Health and Allied Themes, a health charity.
"Many end up going to a public or private provider who is not in the same league.
Women struggle every single day in public hospitals."
The writer is from the Reuters news agency
The views expressed in this article are the author's own and do not necessarily reflect those of the New Straits Times