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 that conclude abortions 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, or 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. mtp amendment act, 2021 on 29 january 2020, government of india first introduced the mtp amendment bill 2020, which was passed in lok sabha on 17 march 2020. a year later, the bill was placed in rajya sabha and was passed on 16 march 2021 as the mtp amendment act 2021. the amendments are as below: married clause dropped - the mtp act earlier permitted termination of the pregnancy by only a married woman in the case of failure of contraceptive method or device. with the amendment, unmarried women can now seek safe abortion services on grounds of contraceptive failure. increase in gestation limit - under the mtp act 1971, the time limit for terminating pregnancy was up to 12 weeks on the advice of one doctor and up to 20 weeks on the advice of two doctors. moreover, post 20 weeks terminating pregnancy was not permitted. however, now all women can terminate pregnancy up to 20 weeks on the advice of one doctor and special categories of women (survivors of sexual abuse, minors, victims of rape, incest, disabled women) can seek termination up to 24 weeks. moreover, women/couples can seek termination of pregnancy, anytime during the gestation period for foetal anomalies, as diagnosed by the medical boards. medical boards - the amendments mandate constitution of medical boards in all the states and union territories for diagnosing substantial fetal anomalies. the board will decide if a pregnancy may be terminated after 24 weeks and each board will have a gynecologist, radiologist/sonologist, pediatrician and other members notified by the government. confidentiality - a registered medical practitioner may only reveal the details of a woman whose pregnancy has been terminated to a person authorized by law. violation is punishable with imprisonment up to a year, a fine, or both. mtp rules, 2021 the new rules as per the amendments were announced by the government on october 12. following are the revised rules as per the amendment act: the gestation period upper limit for terminating a pregnancy with 1 doctor's opinion has been extended from 12 weeks to 20 weeks, with the rule being expanded to include unmarried women as well. the gestation period upper limit for termination of pregnancy with 2 doctors' opinion has been extended from 20 weeks to 24 weeks, for the following special categories: survivors of sexual assault or rape or incest minors change of marital status during the pregnancy (widowhood and divorce) women with physical disabilities mentally ill women the foetal anomalies that have substantial risk of being incompatible with life or if the child is born it may suffer from such physical or mental abnormalities to be seriously handicapped women with pregnancy in humanitarian settings or disaster or emergency a state-level medical board will determine the request for termination of a pregnancy longer than 24 weeks in the cases of foetal anomalies. role of the medical board to examine the woman and her reports to approve or deny the request for termination within 3 days of receiving it to ensure that the termination procedure, when advised by the medical board, is carried out with all safety precautions along with appropriate counselling within 5 days of the receipt of the request for medical termination of pregnancy the medical board shall consist of the following a gynaecologist; a paediatrician; a radiologist or sonologist; and other members notified by the state government or union territory even after 50 years of the medical termination of pregnancy act, abortion has not been decriminalised. the indian penal code, 1860 (ipc) makes abortion ('induced miscarriage') a criminal offence under section 312. the mtp act is the exception to this law. the law safeguards registered medical practitioners by laying down certain conditions under which they can terminate the pregnancy. moreover, the mtp act specifically states pregnant "women", hence making abortion services inaccessible to transgender persons, genderqueer and gender non-conforming, as well as others of gender diverse identity who do not identify as women. 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, 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 archived 29 october 2014 at the wayback machine (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. 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 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