Abortion in India

Abortion in India is legal in certain circumstances. It can be performed on various grounds until 20 weeks of pregnancy. In exceptional cases, a court may allow a termination after 24 weeks.[1]

When a woman gets a pregnancy terminated voluntarily from a service provider, it is called induced abortion.[2] Spontaneous abortion[2] is the loss of a woman's pregnancy before the 20th week that can be both physically and emotionally painful. In common language it is called as miscarriage

Till 2017, there was a dichotomous classification of abortion as safe and unsafe. Unsafe abortion[3] was defined by WHO as "a procedure for termination of a pregnancy done by an individual who does not have the necessary training or in an environment not conforming to minimal medical standards." However, with abortion technology now becoming safer, this has been replaced by a three tier classification of safe, less safe, and least safe permitting a more nuanced description of the spectrum of varying situations that constitute unsafe abortion and the increasingly widespread substitution of dangerous, invasive methods with use of misoprostol outside the formal health system.

  • Safe abortion:[3] provided by health-care workers and with methods recommended by WHO.
  • Less-safe abortion:[3] done by trained providers using non-recommended methods or using a safe method (e.g. misoprostol) but without adequate information or support from a trained individual.
  • Least-safe abortion:[3] done by a trained provider using dangerous, invasive methods.

Comprehensive Abortion Care (CAC),[4] a term "rooted in the belief that women must be able to access high-quality, affordable abortion care in the communities where they live and work", was first introduced in India by Ipas[5] in 2000. The concept of CAC encompasses care through the entire period from conception to post abortion care and includes pain management.

Abortion law in India

Before 1971 (Indian Penal Code, 1860)

Before 1971, abortion was criminalized under Section 312 of the Indian Penal Code, 1860,[6] describing it as intentionally "causing miscarriage[7]". Except in cases where abortion was carried out to save the life of the woman, it was a punishable offense and criminalized women/providers, with whoever voluntarily caused a woman with child to miscarry[8] facing three years in prison and/or a fine, and the woman availing of the service facing seven years in prison and/or a fine.

It was in the 1960s, when abortion was legal in 15 countries, that deliberations on a legal framework for induced abortion in India was initiated. The alarmingly increased number of abortions taking place put the Ministry of Health and Family Welfare (MoHFW) on alert.[9] To address this, the Government of India instated a Committee in 1964 led by Shantilal Shah[9] to come up with suggestions to draft the abortion law for India. The recommendations of this Committee were accepted in 1970 and introduced [9] in the Parliament as the Medical Termination of Pregnancy Bill. This bill was passed in August 1971 as the Medical Termination of Pregnancy Act.

Shah committee key highlights
  • The Shah Committee was appointed by the Government of India in 1964.
  • The Committee carried out a comprehensive review of the socio-cultural, legal and medical aspects of abortion.
  • The Committee in 1966 recommended legalizing abortion in its report to prevent wastage of women's health and lives on both compassionate and medical grounds.
  • According to the report, in a population of 500 million, the number of abortions per year will be 6.5 million – 2.6 million natural and 3.9 million induced.

Abortion incidence in India

It is estimated that 15.6 million[10] abortions take place in India every year. A significant proportion of these are expected to be unsafe. Unsafe abortion is the third largest cause of maternal mortality leading to death of 10 women each day and thousands more facing morbidities. There is a need to strengthen women's access to CAC services and preventing deaths and disabilities faced by them.

The last large-scale study on induced abortion in India was conducted in 2002 as part of the Abortion Assessment Project. The studies as part of this project estimated 6.4 million[11] abortions annually in India.

The Medical Termination of Pregnancy Act, 1971

The Medical Termination of Pregnancy (MTP) Act, 1971 provides the legal framework for making CAC services available in India. Termination of pregnancy is permitted for a broad range of conditions up to 20 weeks of gestation as detailed below:

  • When continuation of pregnancy is a risk to the life of a pregnant woman or could cause grave injury to her physical or mental health;
  • When there is substantial risk that the child, if born or dead would be seriously handicapped due to physical or mental abnormalities;
  • When pregnancy is caused due to rape (presumed to cause grave injury to the mental health of the woman);
  • When pregnancy is caused due to failure of contraceptives used by a married woman or her husband (presumed to constitute grave injury to mental health of the woman).

The MTP Act specifies – (i) who can terminate a pregnancy; (ii) till when a pregnancy can be terminated; and (iii) where can a pregnancy be terminated. The MTP Rules and Regulations, 2003 detail training and certification requirements for a provider and facility; and provide reporting and documentation requirements for safe and legal termination of pregnancy.

Who can terminate a pregnancy?

As per the MTP Act, pregnancy can be terminated only by a registered medical practitioner (RMP) who meets the following requirements:

(i) has a recognized medical qualification under the Indian Medical Council Act

(ii) whose name is entered in the State Medical Register

(iii) who has such experience or training in gynaecology and obstetrics as per the MTP Rules

Where can a pregnancy be terminated?

All government hospitals are by default permitted to provide CAC services. Facilities in the private sector however require approval of the government. The approval is sought from a committee constituted at the district level called the District Level Committee (DLC) with three to five members. As per the MTP Rules, 2003 the following forms are prescribed for approval of a private place to provide MTP services:

  1. Form A [Sub-Rule (2) of Rule 5]: Application Form for Approval of a Private Place: This form is used by the owner of a private place to apply for approval for provision of MTP services. Form A has to be submitted to the Chief Medical Officer of the district.
  2. Form B [Sub-Rule (6) of Rule 5]: Certificate of Approval: The certificate of approval for private place deemed fit to provide MTP services is issued by the DLC on this format.

As per the provisions of the MTP Act, only the consent of woman whose pregnancy is being terminated is required. However, in case of a minor i.e. below the age of 18 years, or a mentally ill woman, consent of guardian (MTP Act defines guardian as someone who has the care of the minor. This does not imply that only parent/s are required to consent.) is required for termination. The MTP Rules, 2003 prescribe that consent needs to be documented on Form C as detailed below:

  1. Form C [Rule 9] Consent Form: This form is used to document consent of the woman seeking termination. Pregnancy of a woman who is above 18 years of age can be terminated with only her consent. If she is below 18 years of age or mentally ill, written consent of the guardian is required.

Whose opinion is required for termination of pregnancy?

The MTP Act details that for terminations up to 12 weeks, the opinion of a single Registered Medical Practitioner (RMP) is required and for terminations between 12 and 20 weeks the opinion of two RMP's is required. However, termination is conducted by one RMP. The MTP Regulations, 2003 prescribe opinion of RMP/s to be recorded on Form I as detailed below:

  1. Form I [Regulation 3] Opinion Form: This form is used to record opinion of the RMPs’ for termination of pregnancy. For termination up to 12 weeks of gestation, opinion of one RMP is required whereas for the length of pregnancy between 12 and 20 weeks, opinion of two RMPs is required.
The MTP Regulations, 2003
  1. Form III [Regulation 5] Admission Register: This template is used to document details of women whose pregnancies have been terminated at the facility. The register needs to be retained for a period of five years till the end of the calendar year it relates to.
  2. Form II [(Regulation 4(5)] Monthly Statement: This form is used to report MTP performed at a hospital or approved place during the month. The head of the hospital or owner of the approved place should send the monthly report of MTP cases to the Chief Medical Officer of the district.

MTP Act, Amendments, 2002

The Medical Termination of Pregnancy (MTP) Act 1971, was amended in 2002 to facilitate better implementation and increase access for women especially in the private health sector.

  1. The amendments to the MTP Act in 2002 decentralized the process of approval of a private place to offer abortion services to the district level. The District level committee is empowered to approve a private place to offer MTP services in order to increase the number of providers offering CAC services in the legal ambit.
  2. The word ‘lunatic’ was substituted with the words ‘mentally ill person’. This change in language was instituted to lay emphasis that "mentally ill person" means a person who is in need for treatment by reason of any mental disorder other than mental retardation.
  3. For ensuring compliance and safety of women, stricter penalties were introduced for MTPs being conducted in unapproved sites or by untrained medical providers by the Act.

MTP Rules, 2003

The MTP Rules facilitate better implementation and increase access for women especially in the private health sector.

  • Composition and tenure of District Level Committee: The MTP rules 2003, define composition of the committee stating that one member of the committee should be a Gynecologist /Surgeon/ Anesthetist and other members should be from the local medical profession, non-government organizations, and Panchayati Raj Institution of the district and one member of the Committee should be a woman.
  • Approved place for providing medical termination of pregnancies: The MTP Rules 2003, provide specific guidelines pertaining to equipment, facilities, drugs, and referral linkages to higher facilities required by an approved place for providing quality CAC and post abortion services.
  • Inspection of private place: The MTP Rules 2003 state that an approved can be inspected by the Chief Medical Officer (CMO), as often as may be necessary with a view to verify whether termination of pregnancies are being done therein under safe and hygienic conditions.
  • Cancellation or suspension of a certificate of approval for a private place: As per the MTP Rules 2003, if the CMO of the District is satisfied that the facilities specified in rule 5 are not being properly maintained therein and the termination of pregnancy at such place cannot be made under safe and hygienic conditions, she/he shall make a report of the fact to the Committee giving the detail of the deficiency or defects found at the place. The committee may, if satisfied, can suspend or, cancel the approval of the place provided that the committee gives the owner of the place a chance of representation before the certificate issued under rule 5 is cancelled.

Proposed Amendments to the MTP Act, 2014

The Government took cognizance of the challenges faced by women in accessing safe abortion services and in 2006 constituted an expert group to review the existing provisions of the MTP Act to propose draft amendments. A series of expert group meetings were held from 2006- 2010 to identify strategies for strengthening access to safe abortion services. In 2013 a national consultation was held which was attended by a range of stakeholders further emphasized the need for amendments to the MTP Act. In 2014, MoHFW shared the Medical Termination of Pregnancy Amendment Bill 2014 in the public domain. The proposed amendments to the MTP Act were primarily based on increasing the availability of safe and legal abortion services for women in the country.

  • Expanding the provider base
  • Increasing the upper gestation limit for legal MTPs
  • Increasing access to legal abortion services for women
  • Increasing clarity of the MTP law

Expanding provider base: In order to increase the availability of safe and legal abortion services, it has been recommended to increase the base of legal MTP providers by including medical practitioners with bachelor's degree in Ayurveda, Siddha, Unani or Homeopathy. These categories of Indian System of Medicines (ISM) practitioners have Obstetrician and Gynecology (ObGyn) training and abortion services as part of their undergraduate curriculum. It has also been recommended to include nurses with a three and half year's degree and registered with the Nursing Council of India, into the base of legal providers for abortion services. In addition, it has also been recommended that Auxiliary Nurse Midwives (ANM) posted at high case load service delivery points be included as legal providers of MMA only. These recommendations are supported by two Indian studies[12][13] that conclude abortion care can safely and effectively be provided by nurses and AYUSH practitioners.

Provisions to increase the gestation limit for abortions: It is recommended to increase the gestational limit for seeking abortions on grounds of fetal abnormality beyond 20 weeks. This would result in making abortion available at any time during the pregnancy, if the fetus is diagnosed with severe fetal abnormalities. In addition, further to the above recommendations, it is also proposed to include increasing the gestation limit for safe abortion services for vulnerable categories of women expected to include survivors of rape and incest, single women (unmarried/ divorced/ widowed) and other vulnerable women (women with disabilities) to 24 weeks. The amendments to the MTP Rules would define the details for the same.

Increasing access to legal abortion services for women: The Act in its current form imposes some operational barriers that limit women's access to safe and legal abortion services. The amendments propose to:

  • Reducing the condition of requirement of the opinion of two health care providers for second trimester pregnancies to one health care provider only, as this is seen as a hindrance in access to safe abortion services by women in situations where two providers are not available: In 1971 when the MTP Act was passed about four decades ago dilatation and curettage (D&C) was the only available technology for termination of pregnancies. D&C now is an outdated invasive medical procedure that requires the use of a metal curette for removing products of conception. The provisions in the MTP Act for opinion of two medical providers or third party authorization for ensuring women's safety needs to be reduced in light of newer and safer technological advancements that make abortion a very safe out-patient medical procedure. The WHO 2012 guidance on Safe abortion: technical and policy guidance for health systems also recommends reducing third party authorization. The WHO 2012 guidance defines a woman seeking an abortion as an "autonomous adult", which means that "mentally competent adults do not require the authorization of any third party", stating that "health-care providers should not impose a requirement of third-party authorization unless required by law and related regulations".
  • Extending the indication of contraception to include unmarried women: As per the provisions of the MTP Act, contraceptive failure is the only condition that applies to married women. The proposal for amendment includes making contraceptive failure applicable for all women and their partners as with other reasons for termination of pregnancy under the MTP Act.

Increasing clarity on the MTP Act

  • The MTP Act does not have a definition of termination of pregnancy. For this purpose, it has been recommended to include a definition for termination of pregnancy.
  • It has been recommended to replace the term "registered medical practitioner" with "registered health care provider". This would cover the expanded provider base being suggested, by bringing in Nurses and ANMs as well as Ayurveda, Unani, Siddha and Homoeopath practitioners as legitimate providers of abortion service.

Policy and Programmatic Interventions of the Government

The MTP Act 1971 provides the legal framework for provision of induced abortion services in India. However, to ensure effective roll-out of services there is a need for standards, guidelines and standard operating procedures.

The Government of India has taken several measures to ensure the implementation of the MTP Act and make CAC services available to women. Some of them include:

  • Comprehensive Abortion Care–Service Delivery and Training Guidelines 2010 were issued by MoHFW in 2010. These guidelines provide comprehensive information on all aspects of abortion care including counselling, legal issues, abortion provision, and post abortion contraception for programme managers and doctors. These guidelines are being used by all states and union territories to standardize CAC trainings and service delivery.
  • In 2014, MoHFW took cognizance of technological updates and global best practice and constituted an expert group to update the Comprehensive Abortion Care–Service Delivery and Training Guidelines. The revised CAC guidelines were issued in 2014.
  • CAC training package: To ensure consistency in CAC trainings across the country, MoHFW developed a standardized training package including trainer's manual, provider's manual, and operational guidelines on CAC and a CD of training games. This package was developed after consultation with experts and issued by the MoHFW in 2014. It is being used for training MBBS doctors as certified providers in all states and union territories.
  • Trainer's manual: The manual is designed to provide trainers with detailed guidelines and aids for conducting CAC trainings. The manual aims to enhance skills of doctors for providing respectful, confidential and high quality CAC services to women.
  • Provider's manual: The manual is designed to provide requisite clinical skills to the providers, increase the capacity of nursing staff to support the providers and provide detailed guidelines on how to conduct the CAC services.
  • Operational guidelines on CAC services: The Operational Guidelines on CAC services were also included as part of the training package with the objective to guide programme managers on implementation of women centered CAC at all levels of public health facilities.
  • State Program Implementation Plans (PIPs): All states and union territories are required to submit their annual Programme Implementation Plans as part of the National Health Mission for implementation of health interventions at public health facilities. These are reviewed by MoHFW and fund allocation is made on the Record of Proceedings (RoPs) after approval in the National Program Coordination Committee (NPCC). All states include budgets for CAC implementation including training, service delivery, procurement, orientation workshops etc. in the annual PIP.
  • Ensuring Access to Safe Abortion and Addressing Gender Biased Sex Selection: The MTP Act and the PC&PNDT Acts are designed to regulate completely different areas. However, at the level of implementation, the need for clarity in keeping the implementation apart has been articulated often. UNFPA and Ipas had collaborated in 2012 to draft frequently asked questions on interlinkages of gender biased sex selection and access to safe abortions.[14] This document was designed to provide clarity on the provisions of the two laws to policy makers.
  • A need for clarity in implementation of the two laws and keeping them apart continued to be articulated from the states and districts. This was re-emphasized at the Government of India (GoI) - Ipas Development Foundation (IDF) national consultation on Prioritizing CAC for Women within NHM[15] held on 19–20 May 2014. GoI constituted an expert group to review the situation on ground and draft the required guidelines.
  • For addressing conflation of the Medical Termination of the Pregnancy (MTP) Act 1971, and Pre-Conception and Pre-Natal Diagnostic Techniques (PC&PNDT) Act 2012, and ensuring unimpeded access to CAC services MoHFW, GoI issued a Guidance Handbook and ready reckoner on Ensuring Access to Safe Abortion and Addressing Gender Biased Sex Selection. The experts reviewed the provisions of both the acts and the situation on the ground and drafted a guidance handbook on ensuring access to safe abortion and addressing gender biased sex selection. The handbook contains simplified guidelines on both laws and is designed to provide information to implementing authorities of the MTP Act and PC&PNDT Act; providers; compliance with the laws for providers of services under both the laws; and information on designing and implementing communication on both these issues. The ready reckoner provides a quick reference to the Guidance Handbook.
  • Health Management Information System (HMIS) is an initiative by the MoHFW, GoI under the National Health Mission to provide comprehensive information on all indicators for health services being offered primarily in the public sector. HMIS has provisions for real-time facility based reporting. This portal is dynamic and is updated daily. It provides reports on health service delivery by indicator and state. Abortion service delivery is also recorded in the HMIS system. Recent reports show that reporting on abortion service delivery is highly under-reported. It captures abortion indicators such as abortion up to 12 weeks of pregnancy, abortion more than 12 weeks of pregnancy, number of women treated for post abortion complications, and number of women provided with post abortion contraception.
  • National mass media campaign: The first ever national mass media campaign on making abortion safer was launched by the MoHFW, GoI in 2014. IDF worked in close collaboration with the MoHFW to develop this mass media campaign. The campaign focuses on normalizing abortion, with the key message safety in early abortion.

Medical Methods of Abortion (MMA)

MMA is a method of termination of pregnancy using a combination of drugs. These drugs have been approved for use in India by the Drug Controller General of India. MMA has been globally recognized as a method of choice for women seeking CAC services. World over, women prefer to adopt MMA while seeking safe abortion services given the confidentiality and safety it offers to them.

Technical Material on MMA
  • MMA Training Package: The MMA training package was issued by the MoHFW in 2016. The package was developed to make abortion services and care through MMA in the public sector accessible for women who need it. The training package includes a handbook on medical methods of abortion, a ready reckoner on MMA for the provider, MMA follow-up card and an e-module on MMA.
  • Handbook on Medical Methods of Abortion: The Handbook was developed by the Maternal Health division of the MoHFW in 2016 to provide detailed technical information to CAC trained Gynecologists and Medical officers on providing MMA services to women at their facilities. The handbook provides detailed information on drugs; counselling; documentation formats; contraception; and treatment of side effects and potential complications.
  • E-module on Medical Methods of Abortion: The e- module was developed by the MoHFW, GoI as an online MMA-specific refresher course for CAC- trained providers and gynecologists for improving their skills and knowledge to improve quality of CAC services for women.
  • Medical Methods of Abortion (MMA) Ready Reckoner for the Provider: The ready reckoner acts as a quick reference tool for drug dosage and schedule, the must do's for each day of visit and important instructions for the women on every visit.
  • MMA follow-up card: The card is provided to women undergoing abortion to help them keep track of the MMA process and identify symptoms of post abortion complications (if any) during the 15 days of MMA process.

Community Mobilization for RMNCHA activities

Community health workers that bridge the gap between community and the health system. ASHA's play a significant role in provision of information about health services, establishing linkage between and health facilities, providing community level health care and as an activist, building people's understanding of health rights and enables them to access their entitlements at the public health facilities to women on a range of issues including CAC. The National Health Systems Resource Centre (NHSRC) has worked closely with the MoHFW to develop training packages for Accredited Social Health Activist (ASHA) to enable them to provide the required information to women at the community level and facilitate linkages with the facilities. ASHA training modules developed by MoHFW and NHSRC are a key component under the National Health Mission to provide ASHAs with information on relevant topics. Information on CAC and related topics is available in three of seven modules:

  • ASHA training module II details on the legality of abortion in India under MTP Act 1971. It lays downs the roles and responsibilities of ASHAs for creating awareness and ensuring access to CAC services for women. The module also elaborates on surgical and medical abortion, post abortion care and post abortion contraception.
  • ASHA training module III details on the relevance of family planning methods and the different methods of family planning. The module emphasizes the need to counsel women to adopt family planning methods to prevent unwanted pregnancies.
  • ASHA training module VII details the need for safe abortion services and the critical role of ASHAs in assisting women access these services. The module aims to train AHSAs to counsel women on the different methods of abortion, risks associated with unsafe abortion, identifying symptoms of post abortion complications, advising on appropriate referrals and counselling women on post abortion contraception.

Communication on CAC

CAC service is an integral component of the maternal health programme under NHM. However, awareness among men and women about legality as well as availability of abortion services is very low. IDF too has conducted studies to understand the awareness about abortion legality among men and women and found that awareness and legality was low.[16][17] Even though some of the people are aware of their legal rights regarding abortion, they are unaware of where they can access abortion services. This non-accessibility of abortion services is primarily on moral and political grounds. Also, women are not readily supplied with information about abortion services, nor about the option of abortion unless in emergency circumstances or cases where the baby is unhealthy.[18]

Statistics

Globally, 56 million abortions take place every year.[19] In South and Central Asia, an estimated 16 million abortions took place between 2010 and 2014, while 13 million abortions occurred in Eastern Asia alone.[20]

There is significant variance in the estimates for the number of abortions reported and the total number of estimated abortions taking place in India. According to HMIS reports, the total number of spontaneous/induced abortions that took place in India in 2016-17 was 970436, in 2015-16 was 901781, in 2014-15 was 901839, and in 2013-14 was 790587.[21] Ten women reportedly die due to unsafe abortions every day in India.[22] The data, which is dynamic in nature, can be accessed on the Health Management Information System (HMIS) portal here.

The Guttmacher Institute, New York, International Institute for Population Sciences (IIPS), Mumbai and Population Council, New Delhi conducted the first study in India to estimate the incidence of abortion. The results from this study were published in Lancet Global Health journal in December 2017 in the form of a paper titled ‘The incidence of abortion and unintended pregnancy in India, 2015'.[23] This study estimates that 15.6 million abortions took place in India in 2015.[24] 3.4 million (22%) of these took place in health facilities, 11.5 million (73%) were done through medical methods outside facilities, and 5% are expected to have been done through other methods. The study further found the abortion rate at 47 abortions per 1000 women aged 15-49 years. The study highlights the need for strengthening public health system to provide abortion service delivery. This would include ensuring availability of trained providers, including non-allopathic providers by amending the MTP Act and expanding the provider base as well as streamlining availability of drugs and supplies. Another strategy is to streamline the process of approving private-sector facilities to provide CAC services and strengthening counseling and post-abortion contraception services in efforts to strengthen quality of care for women seeking CAC services.

Prior to this study, the last available estimate for incidence of abortion at 6.4 million abortions per year in India was from the ‘Abortion Assessment Project – India’.[25] This was a multicentric study of 380 abortion facilities (of which 285 were private) carried out across six States. The study found that "on average there were four formal abortion facilities (medically qualified though not necessarily certified to carry out abortions) per 100,000 population in India and an average of 1.2 providers per facility". Out of the total formal abortion providers, 55% were gynecologists and 64% of the facilities had at least one female provider. The study further found that only 31% of the reasons for seeking abortion by women were within grounds permitted under the MTP Act, the other reasons being unwanted pregnancy, economic reasons and unwanted sex of the foetus.

Methods of abortion

Manual Vacuum Aspiration (MVA)

Manual Vacuum Aspiration (MVA) is a "safe and effective method of abortion that involves evacuation of the uterine contents by the use of a hand-held plastic aspirator",[26] which is "associated with less blood loss, shorter hospital stays and a reduced need for anesthetic drugs". This method of abortion is recommended by the WHO for early termination of pregnancy.

Electric Vacuum Aspiration (EVA)

The Electric Vacuum Aspiration (EVA) is similar to the MVA insofar as it involves a suction method, but the former uses an electric pump to create suction instead of a manual pump.

Medical Methods of Abortion (MMA)

The Medical Methods of Abortion (MMA) is a method of termination of pregnancy by drugs. It is a "non-invasive method of ending an unwanted pregnancy that women can use in a range of settings, and often in their own homes". The two drugs approved for use in India are Mifepristone and Misoprostol.

  • Mifepristone (RU 486): Progesterone is a hormone required for the growth of the foetus. This drug has anti – progesterone action so it stops the growth of the fetus. The process of medical abortion is started with this drug.
  • Misoprostol- This drug is used to induce softening of the cervix so that it is dilated easily. It also produces uterine contractions. Due to cervical softening and contraction of the uterine muscles, it helps to expel the contents from the uterus.

In India, use of these drugs (Mifepristone and Misoprostol) for termination of pregnancy is approved up to nine weeks. This method can increase access to safe abortion services for women since it allows providers to offer CAC services where MVA or other abortion methods are not feasible.[27]

Dilation and Curettage (D&C)

The only abortion technique available when abortion was decriminalized in India in 1971 was the Dilation and Curettage (D&C) method. This dated method is an invasive medical procedure which requires "the use of anesthesia for removing products of conception using a metal curette",[28] often running the risk of hemorrhage or uterine infections. WHO and FIGO issued a joint recommendation which stated that properly equipped hospitals should abandon curettage[29] and adopt manual/electric aspiration methods.

Why do women have unsafe abortions?

Almost 56% of abortions in India are under the category of unsafe.[30]Unsafe abortions, the third leading cause[31] of maternal deaths in India, is a common recourse for most women in the country, including in the rural pockets, due to various social, economic and logistical barriers. Stigma is another dimension that prevents women from seeking abortion care from approved facilities.[32] Also, when a woman is legally not allowed to abort, or lacks access to trained providers, she is forced to go to illegal providers, who may be untrained, or may perform the procedure under unhygienic conditions.[33] Doing so can lead to diseases like cancer. An incident occurred in which a woman from Guwahati, Assam went through abortion in a private clinic. The abortion was carried out by an inexperienced medical practitioner. After one month of the process, she felt pain in her abdominal region which grew as time passed. She was later diagnosed with choriocarcinoma, a form of cancer that occurs in a women's uterus.[34] Some of the common causes of unsafe abortions include attempting abortion at home, and visiting uncertified providers such as quacks.[35] Very often the reason for this is limited or poor awareness about legality and availability of abortion services.

Profile of women seeking abortion

A client profile study[36] focusing on the socio-economic profiles of women seeking abortion services, and costs of receiving abortion services at public health facilities in Madhya Pradesh, India, revealed that "57% of women of who received abortion care at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary health level facilities (58%) than secondary level facilities, and among women presenting for postabortion complications (67%) than induced abortion." Further, the study found that women admitted to spending no money to access abortion services as they are free at public facilities. Poor women, it was reported, "spend INR 64 (USD 1) while visiting primary level facilities and INR 256 (USD 4) while visiting urban hospitals, primarily for transportation and food". The study concluded that the "improved availability of safe abortion services at the primary level in Madhya Pradesh has helped meeting the need of safe abortion services among poor, which eventually will help reducing the maternal mortality and morbidity due to unsafe abortion".

Safe abortion and gender-biased sex selection

Gender-biased sex selection and safe abortion are mutually exclusive issues within the purview of Indian law. While the MTP Act provides a framework for provision of abortion services, the PC&PNDT Act regulates the misuse of diagnostic techniques for determination of sex of the foetus. Both the laws have a very clearly defined purpose, however, there is still conflation in the implementation of the two laws and this has an implication on access to safe abortion services for women. For addressing this issue a group of organizations and individuals working on the issue came together to launch Pratigya Campaign for Gender Equality and Safe Abortion in 2013. The campaign provides a platform to address the issue of sex selection while protecting women's right to safe, legal abortion services in India. The campaign also created an information kit for the media on the subject.[37]

Recent court cases for late-term termination of pregnancy

The MTP Act allows for termination of pregnancy up to 20 weeks of pregnancy. In case termination of pregnancy is immediately necessary to save the life of the woman, this limit does not apply (Section 5 of the MTP Act). There are however cases of diagnosed foetal abnormalities and cases of women who are survivors of sexual abuse who have reached out to the Court with requests for termination of pregnancy beyond 20 weeks. A recent report by the Center for Reproductive Rights analyzed some of these cases that have come to court in a comprehensive report.

Media has covered many of these cases actively. Listed below are some of the significant cases with requests for late term termination that have come to the court for permission.

  • In December 2017, a 13-year old rape survivor's father approached the Bombay High Court seeking permission for the termination of 26-week foetus. The girl was repeatedly raped by her cousin. Considering the report of the medical board which claimed that there was greater risk to the pregnant girl's life if continued., The Court held that the girl was physically incapable to deliver a child, and granted permission for termination.[38]
  • A 15-year-old girl who had eloped to marry, sought permission from the Delhi High Court to abort her 25-week pregnancy. The medical board assigned to examine her case, however, reported that termination would pose serious risks to the lives of both the foetus and the mother. Subsequently, the High Court denied the girl permission to undergo an abortion.[39]
  • A woman from Thane approached the Bombay High Court in December 2017, seeking permission to terminate her 22-week old foetus that was diagnosed as suffering from various infirmities. The report of the medical committee ascertained that the child, if born, may suffer from mental retardation, while admitting that terminating the pregnancy at this stage would be risky. After the petitioner expressed her willingness to take the risk, the Court permitted her to undergo abortion.[40]
  • After the foetus of a 24-year-old woman from Pune was diagnosed with a cardiac anomaly, she approached the Bombay High Court seeking permission to abort her 24-week foetus. The medical board asked to examine the woman advised abortion while reporting that the child, if born, may have to undergo multiple surgeries. The Court consequently, granted permission for the abortion.[41]
  • In November 2017, a woman approached the Bombay High Court for permission to terminate her pregnancy in 26th week of gestation on grounds of skeletal and neurological abnormalities. Further to the opinion of the medical board constituted by the court, she was granted permission to terminate her pregnancy due to fetal abnormalities incompatible with life.[42]
  • Foetuses of two women, in their 29th and 30th week of pregnancy were both diagnosed with suffering from Arnold Chiari Type II syndrome. Based on the report of JJ Hospital in Mumbai, the Supreme Court in October 2017 held that both foetuses were identical and that the continuation of pregnancy would harm both, thereby permitting the termination of pregnancy for both women.[43]
  • In October 2017, a 16-year old rape survivor's father approached the Bombay High Court, seeking permission for the termination of his daughter's pregnancy in 27th week of gestation. The High Court denied the request. The decision was made following a report presented by a panel of doctors who examined her, which suggested that an abortion at this stage would pose potential risks to her health.[44]
  • In another incident in October 2017, a minor rape victim in her 23rd week of pregnancy had approached the Jharkhand High Court for permission to abort her foetus. While the medical board set up to examine the matter observed that it would be dangerous to abort at this stage, the board took it up as a challenge. The Court permitted the termination of pregnancy, and directed the government to make arrangements for the stay of the victim's parents.[45]
  • In October 2017, a 16-year old's father had approached the Punjab and Haryana High Court to seek permission for the termination of her 26-week pregnancy that resulted from rape. The Court, following the report of the medical board that stated the abortion can be undertaken with the understanding that it involves risks, allowed the abortion and directed the board to carry out the necessary procedures.[46]
  • The mother of a 19-year-old girl suffering from mild to moderate mental retardation had approached the High Court of Himachal Pradesh in October 2017 for permission to terminate the girl's 32-week pregnancy. The medical board constituted by the High Court observed that if the pregnancy were continued, the foetus would suffer severe cognitive and motor impairments even after surgery. The Court therefore granted permission for the termination of the pregnancy.[47]
  • In September 2017, the mother of a 13-year old rape survivor moved the apex court for permission to terminate her 32-week pregnancy. The Supreme Court permitted the abortion citing that it was a result of sexual abuse and the victim did not want to carry on with it, despite opposition from the Centre that argued that the pregnancy was too advanced.[48]
  • In September 2017, a woman in her 31st week of pregnancy sought permission to terminate her pregnancy as both kidneys of the foetus were found to be not functioning. Noting that the continuation of pregnancy will cause more mental anguish to her, the Supreme Court granted her permission.[49]
  • A 17-year rape victim approached the Karnataka High Court in September 2017 seeking permission to terminate her pregnancy that had exceeded 20 weeks, arguing that she will suffer mentally if she had to deliver her baby at such a young age. The Court, however, rejected the plea following the report of the medical board that suggested that termination of the pregnancy would not be good for the girl and the foetus.[50]
  • In August 2017, a 20-year-old woman from Pune approached the Supreme Court, seeking permission to abort her 24-week foetus that was diagnosed as having no skull. After the medical board reported that there was no treatment possible for the condition, the Supreme Court granted permission for the termination of the pregnancy.[51]
  • A 10-year-old girl in Chandigarh was found to be 26-weeks pregnant by local doctors, after which the District Court was approached to allow her to undergo an abortion. The girl, who was raped several times by her maternal uncle, was denied permission by the court in July 2017 to undergo abortion,[52] after it was later revealed in another examination that the foetus was 32-weeks old.[53]
  • In July 2017, the 24-week foetus of a 21-year-old woman from Mumbai was diagnosed with mental abnormalities. Following this, renowned gynaecologist Dr. Nikhil Datar helped the husband of the woman file a petition in the Supreme Court, to allow her to undergo an abortion. The Supreme Court granted the permission.[54]
  • In July 2017, a 19-year old rape survivor approached the Gujarat High Court seeking permission to terminate her 26-week pregnancy. While the girl pled that she was "totally innocent and will have to face punishment for her entire life for the crime committed by someone else", the plea was rejected by the High Court which argued that "the risk from abortion was higher than delivery at term".[55]
  • In June 2017, a Kolkata-based woman filed a petition in the Supreme Court, challenging Section 3 of the MTP Act which denies permission to abort the foetus beyond 20 weeks of pregnancy. The woman discovered that her foetus had congenital defect when she was 23 weeks pregnant, and had crossed the 20-week benchmark within which it is legal to terminate a pregnancy.[56] The Supreme Court in response, appointed a medical board of seven senior doctors in Kolkata, directed it to examine her. The apex court has called for a need to amend the MTP Act, to make it more "meaningful".[57]
  • In May 2017, a medical board of eight doctors referred the case of a 10-year old pregnant girl who was raped by her stepfather, to the city court in Haryana. The board was unsure of the gestation, and concluded that it could be between 18–22 weeks. The city court advised the board to choose one of two ways – either to go ahead with the abortion by considering it to be below 18 weeks, or "wait for the pregnancy to complete its full term if they feel the unborn child has surpassed the age cap". Following this, the board decided to go ahead with the abortion.[58]
  • In May 2017, a 16-year old rape survivor and her father approached the Gujarat High Court seeking permission to abort her foetus that had grown beyond 20 weeks. The Court allowed the teen to undergo abortion, citing that the abortion was not likely to endanger the life of the girl based on the medical opinion of a doctor.[59]
  • In May 2017, an HIV-positive destitute rape victim approached the Patna High Court with a plea to terminate her pregnancy. After the High Court turned down the plea, saying that "it was a compelling responsibility of the state to keep the child alive", the Supreme Court was approached. The apex court then granted permission to abort the now 26-week old foetus, directing an AIIMS medical board to examine her. It stated that "a woman, who has already become a destitute, being sexually assaulted and suffering from a serious ailment, should not go through further suffering. The quintessential purpose of life is the dignity of life and all efforts are to be made to sustain it."[60]
  • In April 2017, the mother of a 16-year old rape victim in Madhya Pradesh approached the Indore bench of the High Court seeking permission for the termination of her daughter's 33-week pregnancy. The plea was rejected by the bench, arguing that the "foetus was grown and an abortion was unjustified".[61]
  • In March 2017, a 28-year-old woman from Mumbai approached the Supreme Court to seek permission to terminate her 27-week pregnancy after discovering that the foetus was suffering from Arnold Chiari Type II syndrome - a condition similar to the one she saw her brother grow up with. The Supreme Court denied her permission for an abortion, ruling that there are chances the baby may be born alive.[62]
  • In February 2017, a 37-year-old woman in her 27th week of pregnancy approached the Supreme Court for permission to abort her foetus that was found to be suffering from Down Syndrome. After the medical board appointed by the Court advised against an abortion, the apex court denied her permission to terminate the pregnancy, citing that the baby could be "born alive" if the pregnancy was allowed to continue, while admitting that it was "very sad for a mother to bring up a mentally retarded child". The foetus was detected with a rare abnormality called the Arnold-Chiari malformation, where the brain and spinal cord connect.[63]
  • In January 2017, a 22-year-old woman sought permission from the Supreme Court to abort her 24-week foetus on medical grounds. Further to the medical board's report which revealed that the foetus was without scalp with bleak chances of survival, posing a threat to the life of the woman, the apex court granted her permission to undergo abortion.[64]
  • In July 2016, a 26-year old rape victim approached the Supreme Court seeking permission to terminate her 24-week pregnancy, as the foetus was detected with Anencephaly, a condition whereby most part of the brain, scull and scalp is missing. The medical board, after having examined her on the directions of the Supreme Court, declared that the woman's life was in danger. The apex court then granted her permission to abort the foetus.[65]
  • In February 2016, an 18-year old rape victim sought permission from the Gujarat High Court to abort her 24-week foetus after having unsuccessfully attempted suicide by consuming acid. The panel of doctors submitted their report, following which, the High Court granted permission, citing that the continuation of the pregnancy "may result in a grave injury to her mental health".[66]
  • In the Samar Ghosh v. Jaya Ghosh case of March 2011, the Supreme Court examined whether a woman's decision to terminate a pregnancy without her husband's knowledge or consent would amount to mental cruelty. The Court in this case ruled that "if the wife undergoes vasectomy (sic) or abortion without medical reason or without the consent or knowledge of her husband, such as act may lead to mental cruelty".[67]
  • In November 2011, in the Dr. Mangla Dogra & Others v. Anil Kumar Malhotra & Others case dealing with the issue of whether a husband has a right to provide consent for abortion, the High Court of Punjab and Haryana stated that "the MTP Act requires consent from just one person: the woman undergoing a medical termination of pregnancy. A husband cannot force his wife to continue a pregnancy".[67]
  • In September 2009, in the Krupa Prolifers v. State of Kerala case, the Kerala High Court, while addressing the issue of regulating emergency contraception under the MTP Act, ruled that "emergency contraception does not cause termination of pregnancy and cannot be regulated by the MTP Act".[67]
  • In August 2009, the Supreme Court addressed the Suchitra Srivastava & Another v. Chandigarh Administration case on the issue of whether the state can consent to a termination as a guardian for a "mentally ill" woman who was raped in her state-run facility. The Court ruled that the facts must be examined in such a case, and where the woman is "not a minor and has a "mild" mental illness, the Court has to ensure her reproductive rights, including the right to continue a pregnancy".[67]
  • In July 2008, a woman approached the Bombay High Court seeking permission to abort her 26-week old foetus that was diagnosed with congenital heart defect. The High Court turned down the plea, arguing that "if born, the foetus would not suffer from any serious handicap".[68]

Studies on Abortion: A bibliography
  1. Singh, Susheela et al. 2018. The incidence of abortion and unintended pregnancy in India, 2015. The Lancet. 6(1): e111-e120.Stillman, Melissa., Jennifer J. Frost, Susheela Singh, Ann M. Moore and Shveta Kalyanwala. ‘Abortion in India: A Literature Review’. December 2014. Guttmacher Institute.[69]
  2. Desai, Sheila., Marjorie Crowell, Gilda Sedgh and Susheela Singh. Characteristics of Women Obtaining Induced Abortions in Selected Low- and Middle- Income Countries. March 2017. Guttmacher Institute. Vol. 12, Issue 3.[70]
  3. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. 8 October 2016. The Lancet. Vol. 388, No. 10053. pp. 1775–1812.[71]
  4. Iyengar, Kirti., Sharad D. Iyengar and Kristina Gemzell Danielsson. Can India transition from informal abortion provision to safe and formal services? June 2016. The Lancet. Vol. 4, No. 6. e357-e358.[72]
  5. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. 16 July 2016. The Lancet. Vol. 388, No. 10041. pp. 258–267.[73]
  6. Foster, Diana Greene. Unmet need for abortion and woman-centered contraceptive care. 16 July 2016. The Lancet. Vol. 388, No. 10041. pp. 216–217.[74]
  7. Global causes of maternal death: a WHO systematic analysis. June 2014. The Lancet. Vol. 2, No. 6. e323-e333.[75]
  8. Reproductive health, and child health and nutrition in India: meeting the challenge. 22 January 2011. The Lancet. Vol. 377, No. 9762. pp. 332–349.[76]
  9. Unsafe abortion: the preventable pandemic. 25 November 2006. The Lancet. Vol. 368, No. 9550. Pp.[77]
  10. Mifepristone abortion outside the urban research hospital setting in India. 13 January 2001. Vol. 357, No. 9250. pp. 120–122.[78]

Recent news on abortion
  • 6 February 2017, DNA: ‘Mum’s not the only word’[79]
  • 25 February 2017, The Hindu: ‘Twenty-week abortion deadline adds more pain to rape victims’[80]
  • 27 February 2017, The Indian Express: ‘The Responsibility of Choice’[81]
  • 28 March 2017, Business Standard: ‘Behaviour change can improve knowledge about safe abortions’[82]
  • 31 March 2017, The Times of India: ‘Give women the choice: Why the 20 week abortion limit must be relaxed in case of foetal abnormalities’[83]
  • 1 April 2017, Outlook: ‘Whose Womb Is It?’[84]
  • 4 April 2017, The Indian Express: ‘Medical Termination of Pregnancy Act needs changes, it can traumatize women’[85]
  • 16 April 2017, Deccan Chronicle: ‘Discourse: Returning women their body’[86]
  • 11 May 2017, The Wire: ‘India’s Abortion Laws Need to Change and in the Pro-Choice Direction’[87]
  • 13 May 2017, Deccan Herald: 'Unfulfilled Commitment’[88]
  • 17 May 2017, The Hindu: ‘Draft Medical Termination of Pregnancy (Amendment) Bill, 2014’[89]
  • 17 May 2017, Hindustan Times: ‘Googling, taking abortions pills at home sounds like a bad idea, but it isn’t: Study’[90]
  • 18 May 2017, The Indian Express: ‘Teenage abortion: Law forces them to keep it a secret as system lacks adolescent sex education’[91]
  • 26 May 2017, The Asian Age: ‘Pregnancy Act amendments on hold’[92]
  • 1 August 2017, Hindustan Times: ‘Health ministry to keep amendment on allowing abortion in 24 weeks unchanged’[93]
  • 6 August 2017, The Week: ‘10 and Mum’[94]
  • 6 August 2017, The Week: ‘Failure to Deliver’[95]
  • 7 August 2017, The Week: ‘Accessible Abortion’[96]
  • 7 August 2017, The Times of India: ‘Need to change law banning abortions after 20 weeks of pregnancy: Doctors’[97]
  • 25thAugust 2017, The Week: ‘In MP, poor women bear rising costs of abortion’[98]
  • 7 September 2017, The Week: ‘Abortion law: India needs a holistic approach’[99]
  • 12 September 2017, Quartz: ‘Women’s bodies are under attack: The alarming reality of reproductive rights in India and the US’[100]
  • 13 September 2017, The New Indian Express: ‘Safe abortions still a dream in India’[101]
  • 14 September 2017, The Telegraph: ‘Ticking away’[102]
  • 23 September 2017, The New Indian Express: ‘Let’s talk abortion’[103]
  • 23 September 2017, Youth Ki Awaaz: ‘Comprehensive Abortion Care(CAC) And Its Barriers’[104]
  • 23 September 2017, Youth Ki Awaaz: ‘In Numbers: What Unsafe Abortions Are Doing To Millions Of Indian Women’[105]
  • 24 September 2017, NDTV: ‘Abortion Laws: Caught In a Time warp?’[106]
  • 27 September 2017, The Wire: ‘Untangling the Legal Knots on Reproductive Rights Is a Step Towards Helping Indian Women’[107]
  • 29 September 2017, The India Saga: ‘25 Million Unsafe Abortions Were Performed Globally Between 2010-2014, The Lancet’[108]
  • 2 October 2017, DNA: ‘Ten die every day due to unsafe abortions in India’[109]
  • 5 October 2017, The Times of India: ‘Abortions may be legal in India, but 60% are unsafe: Study’[110]
  • 8 October 2017, The Hindu: ‘Self-managing abortions safely’[111]
  • 21 October 2017, The Print: ‘MTP Act amendments: Fear of foeticide may be trumping women’s reproductive rights’[112]
  • 21 October 2017, DNA: ‘Aadhaar, a problem for women seeking abortions’[113]
  • 8 November 2017, Scroll: ‘Government doctors are being trained to help women in India get safe and legal abortions’[114]
  • 10 November 2017, Mint: ‘Abortion comes at a steep price in India’[115]
  • 25 November 2017, The Hindustan Times: ‘Safe abortions: Why India needs more trained providers’[116]
  • 28 November 2017, The Week: ‘AYUSH docs, paramedics may not be allowed to perform abortions’[117]
  • 5 December 2017, The Indian Express: ‘What’s wrong with India’s abortion laws?’[118]
  • 5 December 2017, The Better India: ‘Once progressive our 46-year-old abortion law needs move with the times’[119]
  • 9 December 2017, The Pioneer: ‘It’s time to amend our abortion law’[120]
  • 29 January 2020, India’s cabinet passed a bill to give women more time to get an abortion which extended abortion deadline from 20 weeks up to 24 weeks.[121]
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See also

References
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