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. video on youtube 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. however, the unavailability of drugs has hindered access to safe abortions across india. foundation for reproductive health services india (frhs india) published a research report on the availability of medical abortion drugs in the markets of six indian states, 2020. this report indicated that about 56% chemists reported regulatory barriers to stocking and sale of these drugs. moreover, the conflation in the mtp act and the dcgi approval for usage of ma drugs only exacerbates the problem further. the mtp rules allow an approved provider to prescribe ma drugs at his/her clinic (explanation to section 5 of the mtp rules 2003). whereas, labelling guidelines issued by the central drugs standards control organisation (cdsco, dtab-dcc division) dated 9 august 2019 says "warning: product to be used only under the supervision of a service provider and in a medical facility as specified under the mtp act 2002 and mtp rules 2003". the mtp rules 2003 does not state that the product should be used only in a medical facility. the comprehensive abortion care: training and service delivery guidelines 2018, ministry of health and family welfare, government of india states that ma drugs can be used by a client at home at the discretion of the provider. however, this labelling guidance is being interpreted to say that ma drugs cannot be sold in retail. the cdsco guidance contravenes the mtp rules, which allows prescription of ma drugs. 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 archived 22 december 2016 at the wayback machine: 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 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. 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. statistics globally, 56 million abortions take place every year. 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. 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 970,436, in 2015–16 was 901781, in 2014–15 was 901,839, and in 2013–14 was 790,587. ten women reportedly die due to unsafe abortions every day in india. 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". this study estimates that 15.6 million abortions took place in india in 2015. 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'. this was a multicentre 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 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", 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 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 the hand-operated pump in mva. medical abortion medical abortion is the 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. dilation and curettage 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", 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 and adopt manual/electric aspiration methods. miscarriage leave india was the first country to legalize miscarriage leave. the maternity benefit act 1961 states that in case of miscarriage, a woman will be entitled to paid leave for six weeks immediately following the day of her miscarriage. women are required to submit proof for miscarriage and willful termination of pregnancy (abortion) is excluded. additionally, women with illness arising out of miscarriage shall, on production are also entitled to paid leave of up to one month on submission of relevant medical proofs. reasons for unsafe abortions almost 56% of abortions in india are under the category of unsafe. unsafe abortions is a common recourse for most women in the