When Pregnancies may be Terminated: Pregnancies not exceeding 12 weeks may be terminated based on a single opinion formed in good faith. In case of pregnancies exceeding 12 weeks but less than 20 weeks, termination needs opinion of two doctors. Mifepristrone (RU 486) & Misoprostol are approved for use up to 63 days gestation.

Who may terminate a pregnancy : Only a Registered Medical Practitioner as defined by the MTP Act, can provide surgical abortion and prescribe the drugs.

Grounds for Termination: A pregnancy may be terminated for the following indications :

• If the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical and mental health.
• If there is a substantial risk that if the child was born, it would suffer physical or mental abnormalities as to be seriously handicapped.

Explanations I and II further clarify the following indications:

• Pregnancy alleged by the pregnant woman to have been caused by rape.
• Pregnancy resulting from a failure of any device used by any married woman or her husband for the purpose for limiting children.

The MTP Act does not permit induced abortions on demand. The responsibility rests with the medical practitioner to opine in good faith regarding the presence of a valid legal indication. Such a provider-dependent policy may sometimes result in denial of abortion care to women in need, especially the more vulnerable amongst them.

Secondly it states the need for two doctors to certify opinion for a second trimester MTP, which serves as a major restriction in places where there is scarcity of medical personnel.

Moreover, while the MTP Act permits women seek legal termination of an unwanted pregnancy for a wide range of reasons, the clause about contraceptive failure applies only to married woman.

The MTP Act of 1971 has been an empowering act for the healthcare system and its beneficiaries, setting aside the application of the Indian Penal Code in certain well-defined situations. It allows clinicians to offer legal safe abortion services within well-defined limits. Even today, voluntarily ‘causing miscarriage’ to a woman with child – other than in ‘good faith for the purpose of saving her life’ is a crime under Section 312 of the Indian Penal Code, punishable by simple or rigorous imprisonment and/or fine.

The Pre-Conception Pre-Natal Diagnostic Techniques (PCPNDT) Prevention of Misuse Act was enacted and brought into operation from 1st January, 1996, in order to prevent sex selection which was resulting in termination of pregnancies with a female fetus.

Some states in India still have a ‘two child family norm’ which provides disincentives for those who have more than two children, including being able to run for local political elections. Moreover, people nowadays prefer to have smaller families, but still desire to have sons. This combination creates a demand for sex selection.

Government response to this at state and central level has resulted in community messages being confused to mean that all abortions are illegal, not only those which were the result of sex selection. Thus unfortunately access to safe abortion, especially in the second trimester is getting more restricted.

The belief that a restrictive abortion policy will prevent sex selective abortion is baseless. Policies need to ensure that measures for preventing sex selective abortion do not affect access to safe abortion care for the genuine abortion seeker.

MBBS doctors with postgraduate training or qualifications in gynecology and obstetrics, or those having completed MTP training programmes are recognized to perform MTPs.

Although safe abortion access is legalized, it is not yet a right. India is signatory to ICPD, CEDAW with certain reservations.

Statistics: Unsafe abortions are among the major preventable causes of maternal morbidity and mortality in India. Most of the abortions are not reported and hence the available statistics of abortions in India are of varying reliability.

According to the Consortium on National Consensus for Medical Abortion in India, the available statistics are grossly inadequate as hospitals keep records of only legal and reported abortions. In the following table Number of abortions reported includes legal reported induced abortions.

Year	1972	1975	1980	1985	1990	1995	2000
Number of abortions reported	24300	214197	388405	583704	581215	570914	723142

1st and 2nd trimester abortion services should be available in all the public sector. However, in reality access to safe abortion is denied due to various reasons like lack of medical facilities, lack of doctor in those health centers where facilities are available etc.

The cost ranges from:

For surgical abortions	1st and 2nd Trimester are supposed to be free of cost in a Public Sector
For Medical abortion	Are not yet available in public sector

Abortion services, 1st and 2nd Trimester, are available in easily available in the Private sector. Almost all specialist gynaecologists in the private sector will provide surgical abortion and medical abortions.

The cost ranges from –

For surgical abortions
1st Trimester : 1000-2000 INR
2nd Trimester : 5000 INR

For Medical abortion: 1000INR

Methods used for abortion in the 1st trimester are dilatation and curettage (D&C), Electric Vacuum Aspiration (EVA), manual vacuum aspiration (MVA), Medical methods of abortion MMA with Mifepristone and Misoprostol.

2nd Trimester is done with Ethacridine lactate instillation. MIfepriostone and Misoprostol are increasingly being used, although as of now this is off-label use.

According to the MTP Act, pregnancies may only be terminated in the following settings.

• A hospital established or maintained by the Government.
• A place approved for the purpose of the Act by the Government.

Any procedure performed in a centre which does not have government approval is deemed illegal. In case of Medical methods for termination of pregnancy not exceeding 63 days, it may be prescribed by a registered medical practitioner, having access to a place approved by the Government for surgical and emergency back up when such is indicated.

All approved centres are required to maintain an Admission Register in the format prescribed for at least 5 years from the last entry. This is a secret document and can only be revealed under order of a court.

According to the Consortium on National Consensus for Medical Abortion in India, every year an average of about 11 million abortions take place annually and around 20,000 women die every year due to abortion related complications. Most abortion-related maternal deaths are attributable to unsafe abortions.

All abortion equipment is available in India. There are currently 20 brands of Mife-Miso being sold. The Combipack is also being sold since September 2009.

Neutral Various pharmaceuticals manufacture Mifepristone and Misoprostol. The tablets are made available as individual or as kits at the pharmacist.

Pregnancies may only be terminated in the following settings.

• A hospital established or maintained by the Government.
• A place approved for the purpose of the Act by the Government.

For approval:

• The Government should be satisfied with safety and hygiene.
• The following facilities should be provided.
• An OT table and instruments for abdominal and gynaecological surgery.
• Anesthetic, resuscitation and sterilisation equipment.
• Drugs and parenteral fluids for emergency use.

Any procedure performed in a centre which does not have government approval is deemed illegal.

District hospital (first referral) level:
The District level facilities should offer all primary-care level abortion services as outlined by the Government, even though they may be available at primary care level. Hospitals should offer abortion care on an outpatient’s basis which is safe, minimizes costs and enhances convenience to the women.

Secondary and Tertiary referral hospitals:
According to Government standards, secondary and tertiary hospitals should have staff and facility capacity to perform abortions in all circumstances permitted by law and to manage all complications of unsafe abortion. The provision of abortion care at teaching hospitals is particularly important to ensure that relevant cadres of health professionals develop competence in abortion service delivery during clinical training rotations.

A large pool of informal providers meets the gap between demand for abortion services and the low availability in the formal sector. Informal providers include herbalists, faith healers, traditional birth attendants, even nurses or auxiliary nurse midwives, paramedics and unqualified persons (Dais, magicians, ozha and other indigenous providers). They may also include practitioners of Indian systems of medicine (ISM) including homeopaths and ayurvedic physicians, largely located in villages and small towns.

In rural remote and tribal areas, where services of formal providers are not readily available, women depend on them. At the same time, in rural areas the informal providers are preferred for inducing abortion among women who conceive out of wedlock because of the confidence in them for maintaining secrecy and protecting the family honour.

According to Abortion Assessment Project of India Report, of the total abortion facilities surveyed, public sector accounts for only one-fourth of the facilities. This low level of investment by the state in the context of large scale poverty limits access of women to abortion services.This is exacerbated by the fact that PHCs which are mandated by policy to provide abortion services are not doing it in any significant numbers, as most public facilities are either district, sub-divisional or rural hospitals. The availability of abortion facilities in both better and less developed regions is reasonably good at 4 facilities per 1,00,000 population with public facilities accounting for one-fourth of this. A large proportion of the legal providers are gynaecologists and a majority of them are female providers.

It encourages the promotion of family planning services to prevent unwanted pregnancies and at the same time recognises the importance of providing safe, affordable, accessible and acceptable abortion services to women who need to terminate an unwanted pregnancy.

The recent amendment to decentralize regulation of abortion care to the district level serves to encourage registration of abortion facilities by minimising administrative delays. While defining corrective measures to deter abortion facilities that provide unsafe abortion care, the Act offers full protection to registered providers from any legal proceedings for any injury caused to a woman seeking abortion.

Hindu, Muslim, Christian, Sikh, Jewish, Jains, Buddhists all have conservative / orthodox elements that would be anti abortion.

All Ob Gyns are taught abortion procedures as part of undergraduate and post graduate studies.

The MTP Act of 1971 did not provide abortion as a right to women. It expanded the permitted reasons for abortion in India, legalising abortion subject to the fulfilment of certain conditions. Abortion on any grounds other than those specified in the law is an offence punishable under the Indian Penal Code.

The Medical Termination of Pregnancy Act, 1971, discriminates against unmarried women by not recognising that unwanted pregnancies in unmarried women could result in at least as much anguish and suffering as that experienced by married women.

The number of medical practitioners required to give their assent for termination of the pregnancy is contingent upon the duration of the pregnancy. Pregancy of > 12 weeks require consent of two doctors.

Non allopathic doctors are not included as service providers of abortion. If we expand these services through these providers many women will be benefited especially in the rural areas where access to same abortion is a major problem.

Though abortion has been legal in India since 1971, the community is not aware about it and therefore most of them fall prey to unsafe illegal methods of abortion. More advocacy is needed to make community aware about this issue.

Asia Safe Abortion Partnership is a network of activists, providers, researchers and others who have a feminist perspective and alsoa rights based approach while focusing on women sexual and reproductive health and rights. Asia Safe Abortion Partnership-ASAP is an affiliate of International Consortium for Medical Abortion (ICMA) and has collaboration with various organizations.

We work in 15 countries across Asia. ASAP serves as a forum for information and experience sharing, strategic thinking and planning for a collective vision aimed towards regional and international advocacy. We support our members in undertaking research activities, capacity building and networking. We work to promote new technologies, including manual vacuum aspiration and medical abortion. We manage an e – forum which has a regular discussion and updates on issues related to women’s health and rights.