Abortion in India

Abortion in India is legal under various circumstances. It can be performed until 24 weeks of pregnancy. In exceptional cases, a court may allow a termination after 24 weeks.
When a woman gets a pregnancy terminated voluntarily from a service provider, it is called induced abortion. Spontaneous abortion 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 a miscarriage.
Till 2017, there was a dichotomous classification of abortion as safe and unsafe. Unsafe abortion 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 However, with abortion technology now becoming safer, this has been replaced by a three tier classification of safe, less safe, and least safe permitting a more nuanced description of the spectrum of varying situations that constitute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.
Comprehensive Abortion Care (CAC), 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 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, 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 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. 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.
Abortion incidence in India.
It is estimated that 15.6 million 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 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:
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:
Whose consent is 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 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:
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:
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.
MTP Rules, 2003.
The MTP Rules facilitate better implementation and increase access for women especially in the private health sector.
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 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 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:
Increasing clarity on the MTP Act
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:
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.
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:
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 970436, in 2015–16 was 901781, in 2014–15 was 901839, and in 2013–14 was 790587. 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 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", 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.
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 (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", 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.
Legalizing 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 suffering illness arising out of miscarriage shall, on production are also entitled to paid leave of upto one month on submission of relevant medical proofs. 
Why do women have unsafe abortions?
Almost 56% of abortions in India are under the category of unsafe. Unsafe abortions, the third leading cause 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. 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. 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. Some of the common causes of unsafe abortions include attempting abortion at home, and visiting uncertified providers such as quacks. 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 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.
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.