abortion in india abortion in india abortion in india has been legal under various circumstances with the introduction of the medical termination of pregnancy (mtp) act, 1971. the medical termination of pregnancy regulations, 2003 were issued under the act to enable women to access safe and legal abortion services. in 2021, mtp amendment act 2021 was passed with certain amendments to the mtp act 1971, such as women being allowed to seek safe abortion services on grounds of contraceptive failure, an increase in gestation limit to 24 weeks for special categories of women, and opinion of one abortion service provider required up to 20 weeks of gestation. abortion can now be performed until 24 weeks of pregnancy as the mtp amendment act 2021 has come into force by notification in gazette from 24 september 2021. the cost of the abortion service is covered fully by the government's public national health insurance funds, ayushman bharat and employees' state insurance with the package rate for surgical abortion being set at ₹15,500 (us$190) which includes consultation, therapy, hospitalization, medication, ultrasound, and follow-up treatments. for medical abortion, the package rate is set at ₹1,500 (us$19) which includes consultation and usg. types of abortion when a woman gets a pregnancy terminated voluntarily from a service provider, it is called induced abortion. spontaneous abortion, also known as miscarriage, is the loss of a woman's pregnancy before the 20th week. this type of abortion can be physically and emotionally painful. till 2017, there was a dichotomous classification of abortion as safe and unsafe. unsafe abortion was defined by the world health organization (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 however, with abortion technology now becoming safer, this has been replaced by a three-tier classification of safe, less safe, and least safe permitting a more nuanced description of the spectrum of varying situations that constitute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 the use of misoprostol outside the formal health system. safe abortion: provided by healthcare workers and with methods recommended by the who. less-safe abortion: 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: done by a trained provider using dangerous, invasive methods. abortion law in india before 1999 (indian penal code, 1860) before 1971, abortion was criminalized under section 312 of the indian penal code, 1860, describing it as intentionally "causing miscarriage". 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 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 deliberation 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. to address this, the government of india instated a committee in 1964 led by shantilal shah to come up with suggestions to draft the abortion law for india. the recommendations of this committee were accepted in 1970 and introduced in the parliament as the medical termination of pregnancy bill. this bill was passed in august 1971 as the medical termination of pregnancy act, which was authored by sripati chandrasekhar. 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 a study in 2018 estimated that 15.6 million abortions took place in india in 2015. 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 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). when the socio-economic condition of the family is poor and the couple already has 2–3 children 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 may 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 a pregnancy may 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: form a : 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. form b : certificate of approval: the certificate of approval for private place deemed fit to provide mtp services is issued by the dlc on this format. consent required for termination of pregnancy 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 woman with mental illness, 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: form c 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. opinions 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: form i 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 form iii 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. form ii 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. 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. 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. 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