New Delhi, India – On an unusually quiet afternoon at Stree Clinic in Delhi’s eastern neighbourhood, Pratibha* solemnly walked across the corridor with a paper slip in hand as her husband and three-year-old son waited outside the building. The 28-year-old, dressed in a red salwar kameez, was there for a dose of DMPA or depot-medroxyprogesterone acetate (commonly known by its brand name Depo-Provera in many countries), a form of injectable contraceptive.

A few months ago, following an unintended pregnancy, she had sought the assistance of a community health worker for ‘safai’, a Hindi word that translates to cleaning and which several Indian women used to refer to abortion. Pratibha, a domestic worker, wanted only one child but her family had insisted on a second one. A third pregnancy this time, however, would place a heavier economic burden on the family so her husband agreed when she suggested abortion. Initially, she was terrified. “I kept wondering what if something happened to me. My children are so young,” she said. Pratibha had heard from other women in the neighbourhood that it was possible to terminate a pregnancy. But until then, she did not know what the procedure was like or whether it was legal and safe for her. Later, a safe surgical abortion at a private facility left her feeling guilty about “ending a life”. “If we had not faltered on our end, this need not have happened,” she said.

Taking DMPA was Pratibha’s way to ensure she didn’t have to go through an abortion and the guilt again. She also eventually wanted to consider sterilisation. But she carried a fear so strong about the operation probably leading to death that she was going to wait until her children were older and able to live without her, just in case the worst happened. Male birth control methods weren’t given equal consideration. She had to be the one taking the steps, she conceded.

Globally, almost half of all pregnancies are unintended – one in seven of such cases occur in India – and a large proportion of them end in abortions. India is considered to have one of the more liberal abortion laws which is fairly broad in its ambit. Ideally, the result should be easy access to safe services, better maternal health, and rights. But 67% of all abortions in the country are classified as unsafe. Unsafe abortions also remained the third highest cause of maternal mortality, with almost eight Indian women dying as a result of it every day. Young women aged 15-19 were at the highest risk of such deaths.

Pratibha’s experience provides a glimpse of the circumstances under which many Indian women access reproductive services, the fear and lack of awareness, and how strenuous the process can be for them.

Around the same time that the U.S. Supreme Court overturned Roe v Wade, and the dire consequences of restrictive abortion policies came to the fore globally, including in countries like Poland, India’s highest court upheld women’s right to abortion up to 24 weeks into pregnancy regardless of marital status. It observed that the judgment referred to persons other than cis-gender women who may require access to safe abortion.

The verdict came in response to a petition by a 25-year-old single woman who had first been denied permission for abortion at 22 weeks of pregnancy by the High Court, which the Supreme Court of India eventually granted.

Following an amendment last year to India’s Medical Termination of Pregnancy (MTP) Act, which dates back to 1971, the maximum permissible time for abortion was extended from 20 weeks to 24 weeks. According to the law, only certain categories of women – rape survivors, minors, women with physical and mental disabilities, women who became widows or divorcees during pregnancy, and women in disasters or emergencies – can avail abortion between 20 and 24 weeks with the consent of two medical professionals. Prohibiting unmarried women from accessing abortion at that stage would amount to discrimination and as subscribing to ‘narrow patriarchal principles about what constitutes “permissible sex”’, the Court said.

“The rights of reproductive autonomy, dignity, and privacy under Article 21 [right to life] give an unmarried woman the right of choice on whether or not to bear a child, on a similar footing of a married woman,” the bench added. Equally significant was the fact that even though India’s law does not consider non-consensual sex by husbands as rape, the court noted that for the purpose of abortions, the term rape or sexual assault would now include marital rape and allow married women to terminate pregnancies caused as a result of it.

The judgment has been hailed widely as a milestone. But experts also say that given the limitations placed by the socio-cultural landscape within which the abortion law is being implemented and the legal barriers that still exist – which the court acknowledged – India has a long way to go.

“[There is ] the deeply entrenched patriarchal environment in which motherhood is glorified, in which marriage is seen as sort of compulsory, and there is this general feeling that abortion is not a good thing,” said Dr. Suchitra Dalvie, a gynaecologist and coordinator of Asia Safe Abortion Partnership.

Additionally, women are seldom able to make decisions about their own reproductive healthcare without the influence and control of their partners or families, said Dr. Sushma Sharma, doctor-in-charge at Parivar Seva Sanstha, the non-profit which runs Stree Clinic. They also find it hard to talk about or report widely rampant sexual violence by their husbands.

“We then have a medical system which is fairly misogynistic and is not very supportive of women from the point of view of their rights, agency, and dignity,” Dr. Dalvie said. “So, a lot of women are treated badly and even cruelly when they come for abortions.” There is also a lot of coercion for contraception, she added.

Studies have found that the fear of criminalisation – under the penal code, abortion is still a crime in India except for the provisions of the MTP Act, which further overlaps with laws that prohibit sex-selection, and protect children from sexual abuse – inherent bias, and stigma lead several medical practitioners to either deny women the right to abortion or demand legal documents and spousal and guardian permissions that the law does not ask for. The repercussions of this are amplified by the fact that India severely lacks practitioners who are trained and approved to provide abortion as per law. In rural health facilities, the shortfall in obstetrician-gynaecologists is at nearly 70%

As the recent judgment highlighted, all of these factors often compelled women to go to courts for permissions, seek out services of unqualified persons, or carry a pregnancy to term against their will. Women from lower socioeconomic backgrounds, including those who are young and single, suffered the most as a result.

At Stree Clinic, 34-year-old Sushila* came in to consult about the treatment of an incomplete abortion. As she spoke to the clinic-in-charge Poonam Tara, her concerns ranged from costs and worry about pain to whether the doctor would rebuke her. Two weeks ago, she had decided to self-administer abortion pills at home without consulting a doctor – unable to eventually follow the correct usage guidelines due to excessive bleeding – because it felt like the safe and discreet option.

Sushila isn’t alone. A Lancet study found that 73% of all abortions in India in 2015 were done outside of health facilities by ingesting abortion pills. Dr. Dalvie said this is a reality – and generally a safe choice – that points to the need for public health care to be more accessible and better equipped to support such self-management abortions with correct and adequate information as well as treatment if complications arise.

She emphasised the need for the abortion law to evolve to be more pregnant person-centric and rights-based. The Supreme Court of India’s ruling also acknowledged it: “The decision to have or not to have an abortion is borne out of complicated life circumstances, which only the woman can choose on her own terms without external interference or influence.”

Sushila and Pratibha’s lives and neighbourhoods do not truly mirror this judgment yet. But experts hope it serves as a step in bringing societal change in the two things they both wish for: greater awareness and autonomy in their reproductive choices.

Names have been changed to protect their identity.