Medical Termination Medical Termination of Pregnancy act, 1971of Pregnancy act, 1971

ByByM.swethaM.swetha

PerspectivePerspective 26 million pregnancies are terminated annually legally.26 million pregnancies are terminated annually legally. 20 million terminated illegally.20 million terminated illegally. 78000 annual deaths. In India: 11.8% of MMR (GOI, 1990).78000 annual deaths. In India: 11.8% of MMR (GOI, 1990). Abortion care centres are few & far between, Abortion care centres are few & far between,

accessibility is poor, training inadequate and do not meet accessibility is poor, training inadequate and do not meet MTP Act requirements.MTP Act requirements.

Paramedics and quacks are involved more often than Paramedics and quacks are involved more often than not. not.

Aims to improve the maternal health scenario by Aims to improve the maternal health scenario by preventing large number of unsafe abortions and preventing large number of unsafe abortions and consequent high incidence of maternal mortality & consequent high incidence of maternal mortality & morbidity morbidity

Legalizes abortion servicesLegalizes abortion servicesPromotes access to safe abortion services to womenPromotes access to safe abortion services to womenDe-criminalizes the abortion seekerDe-criminalizes the abortion seekerOffers protection to medical practitioners who Offers protection to medical practitioners who

otherwise would be penalized under the Indian Penal otherwise would be penalized under the Indian Penal Code (sections 315-316)Code (sections 315-316)

MTP Act MTP Act lays down when & where pregnancies can be lays down when & where pregnancies can be

terminatedterminated Grants the central govt. power to make rules Grants the central govt. power to make rules

and the state govt. power to frame regulationsand the state govt. power to frame regulations MTP RegulationsMTP Regulations

lays down forms for opinion, maintenance of lays down forms for opinion, maintenance of recordsrecords

custody of forms and reporting of casescustody of forms and reporting of cases

MTP RulesMTP Rules lays down who can terminate the lays down who can terminate the

pregnancy, training requirements, approval pregnancy, training requirements, approval process for place, etcprocess for place, etc. .

Legal abortionsLegal abortionsAbortions are termed legal only when all the Abortions are termed legal only when all the

following conditions are met:following conditions are met: Termination done by a medical practitioner Termination done by a medical practitioner

approved by the Actapproved by the Act Termination done at a place approved Termination done at a place approved

under the Actunder the Act Termination done for conditions and within Termination done for conditions and within

the gestation prescribed by the Actthe gestation prescribed by the Act Other requirements of the rules & Other requirements of the rules &

regulations are complied withregulations are complied with

When can pregnancies be When can pregnancies be terminated? terminated?

Up to 20 weeks gestationUp to 20 weeks gestation With the consent of the women. If the women is With the consent of the women. If the women is

below 18 years or is mentally ill, then with below 18 years or is mentally ill, then with consent of a guardianconsent of a guardian

With the opinion of a registered medical With the opinion of a registered medical practitioner, formed in good faith, under certain practitioner, formed in good faith, under certain circumstancescircumstances

Opinion of two RMPs required for termination of Opinion of two RMPs required for termination of pregnancy between 12 and 20 weekspregnancy between 12 and 20 weeks

Exemptions Exemptions Continuation of pregnancy constitutes risk to the Continuation of pregnancy constitutes risk to the

life or grave injury to the physical or mental health life or grave injury to the physical or mental health of womanof woman

Substantial risk of physical or mental abnormalities Substantial risk of physical or mental abnormalities in the fetus as to render it seriously handicappedin the fetus as to render it seriously handicapped

Pregnancy caused by rape (presumed grave injury Pregnancy caused by rape (presumed grave injury to mental health)to mental health)

Contraceptive failure in married couple (presumed Contraceptive failure in married couple (presumed grave injury to mental health)grave injury to mental health)

Cont……..Cont…….. ““In determining whether the continuance of In determining whether the continuance of

pregnancy would involve such risk of injury to pregnancy would involve such risk of injury to the health (as mentioned above), account may be the health (as mentioned above), account may be taken of the pregnant woman’s actual or taken of the pregnant woman’s actual or reasonable foreseeable environment”reasonable foreseeable environment”

MTP Act: Place for conducting MTP Act: Place for conducting MTPMTP

A hospital established or maintained by A hospital established or maintained by

GovernmentGovernment

oror

A place approved for the purpose of this Act by a A place approved for the purpose of this Act by a

District-level Committee constituted by the District-level Committee constituted by the

government with the CMHO as Chairpersongovernment with the CMHO as Chairperson

For termination up to 12 weeks:For termination up to 12 weeks:

A practitioner who has assisted a registered A practitioner who has assisted a registered medical practitioner in performing 25 cases of medical practitioner in performing 25 cases of MTP of which at least 5 were performed MTP of which at least 5 were performed independently in a hospital established or independently in a hospital established or maintained or a training institute approved for maintained or a training institute approved for this purpose by the Governmentthis purpose by the Government

For termination up to 20 weeksFor termination up to 20 weeks A practitioner who holds a post-graduate A practitioner who holds a post-graduate

degree or diploma in Obstetrics and degree or diploma in Obstetrics and GynecologyGynecology

A practitioner who has completed six months A practitioner who has completed six months house job in Obstetrics and Gynecologyhouse job in Obstetrics and Gynecology

A practitioner who has at least one-year A practitioner who has at least one-year experience in practice of Obstetrics and experience in practice of Obstetrics and Gynecology at a hospital which has all Gynecology at a hospital which has all facilitiesfacilities

A practitioner registered in state medical A practitioner registered in state medical register immediately before commencement of register immediately before commencement of the Act, experience in practice of Obstetrics the Act, experience in practice of Obstetrics and Gynecology for a period not less than and Gynecology for a period not less than three years.three years.

For termination of pregnancy at For termination of pregnancy at any stageany stage

It can be done by medical practitioner when the It can be done by medical practitioner when the life of mother is in danger.life of mother is in danger.

It is done only in hospitals with adequate It is done only in hospitals with adequate facilities are there.facilities are there.

Methods of AbortionMethods of AbortionA. Surgical: A. Surgical: By using mechanical device they r removing the By using mechanical device they r removing the

fetus fetus Disadvantages of Surgical abortion:-Disadvantages of Surgical abortion:-

Requires highly skilled personnel, because:-Requires highly skilled personnel, because:- Blind technique.Blind technique. Pregnant uterus is very soft & prone to injuryPregnant uterus is very soft & prone to injury

Methods of AbortionMethods of Abortion SurgicalSurgical….contd….contd..

Requirement of Anaesthesia: GA or localRequirement of Anaesthesia: GA or local Higher chance ofHigher chance of septic abortion.septic abortion.

Mostly following illegal induced abortion Mostly following illegal induced abortion (>90%). 6.5% from legal surgical abortion.(>90%). 6.5% from legal surgical abortion.

Very high mortality: 6-13%Very high mortality: 6-13% Serious morbidity including fecal fistula.Serious morbidity including fecal fistula.

Methods of AbortionMethods of Abortion Medical:-Medical:- also called “Chemical abortion”.also called “Chemical abortion”.

Advantages:-Advantages:- Possible at earlier stage of pregnancy.Possible at earlier stage of pregnancy. Private procedure.Private procedure. No trauma to the utrus cevix and other organs.No trauma to the utrus cevix and other organs. Post-abortal endometritis very rare.Post-abortal endometritis very rare. No anaesthetic hazards.No anaesthetic hazards.

Methods of AbortionMethods of Abortion Medical abortionMedical abortion….contd.….contd.

Disadvantages:-Disadvantages:- Lengthy procedureLengthy procedure UncertainUncertain Unpredictable (timing).Unpredictable (timing). Failure rate: 2-10%.Failure rate: 2-10%. Psychological effect.Psychological effect. Difficulty in diagnosing ectopic pregnancy.Difficulty in diagnosing ectopic pregnancy. Side-effects of drugs.Side-effects of drugs.

Mifepristone, MisoprololMifepristone, Misoprolol Antagonizes progesterone at target Antagonizes progesterone at target

tissue.tissue.

Approval of a place Approval of a place up to 12 up to 12 weeks MTPweeks MTP

Gynecology examination/ labor tableGynecology examination/ labor table Resuscitation and sterilization equipment Resuscitation and sterilization equipment Drugs & parental fluidsDrugs & parental fluids B ack up facilities for treatment of shock B ack up facilities for treatment of shock Facilities for transportationFacilities for transportation

Approval of a place Approval of a place up to up to 20weeks MTP20weeks MTP

All requirements for up to 12 weeks +All requirements for up to 12 weeks + Operation table and instruments for performing Operation table and instruments for performing

abdominal or gynecological surgeryabdominal or gynecological surgery Anesthetic equipment, resuscitation equipment Anesthetic equipment, resuscitation equipment

and sterilization equipmentand sterilization equipment Drugs & parental fluids notified for emergency Drugs & parental fluids notified for emergency

use, notified by Government of India from time to use, notified by Government of India from time to time.time.

Regulatory bodyRegulatory body District level MTP CommitteeDistrict level MTP Committee

Minimum of 3 & Maximum of 5 membersMinimum of 3 & Maximum of 5 membersincluding chairperson (CM H O)including chairperson (CM H O)

Composition of the committee:Composition of the committee: One medical person (Gynic /Surgeon/ Anesthetist)One medical person (Gynic /Surgeon/ Anesthetist) One member from local medical profession; NGO & One member from local medical profession; NGO &

Panchayati Raj Institution of the district.Panchayati Raj Institution of the district. At least one member shall be a woman.At least one member shall be a woman.

Tenure 2 calendar yearsTenure 2 calendar years NGO members shall not have more than NGO members shall not have more than

22termsterms

Approval ProcessApproval Process Application in Form A to be addressed to CMHO by place Application in Form A to be addressed to CMHO by place

seeking approvalseeking approval CMHO verifies or inspects the place to satisfy that CMHO verifies or inspects the place to satisfy that

termination can be done under safe & hygienic termination can be done under safe & hygienic conditionsconditions

CMHO recommends approval to the committeeCMHO recommends approval to the committee Committee considers application & recommendation and Committee considers application & recommendation and

approve and issue certificate of approval in Form Bapprove and issue certificate of approval in Form B

Cont……..Cont…….. Place to be inspected within 2 months of Place to be inspected within 2 months of

receiving applicationreceiving application Certificate to be issued within 2 months of Certificate to be issued within 2 months of

inspectioninspection If deficiency found, within 2 months of deficiency If deficiency found, within 2 months of deficiency

having been rectifiedhaving been rectified

Inspection/cancellationInspection/cancellation CMHOs to inspect to ensure safe & hygienic CMHOs to inspect to ensure safe & hygienic

conditions for conduction of MTPs.conditions for conduction of MTPs. Call for information and seize in case found Call for information and seize in case found

otherwise CMHO to report the committee for otherwise CMHO to report the committee for unsafe and unhygienic conditions.unsafe and unhygienic conditions.

Committee can suspend or cancel approval after Committee can suspend or cancel approval after giving the owner an opportunity for giving the owner an opportunity for representationrepresentation

Owner can reapply to the committee after making Owner can reapply to the committee after making additions and improvements.additions and improvements.

During suspension the place be deemed as non-During suspension the place be deemed as non-approvedapproved

MTP regulationsMTP regulations Power to states to make regulations regarding MTP Power to states to make regulations regarding MTP

servicesservices Regulations for Union Territories by Central Govt.Regulations for Union Territories by Central Govt. Application of central govt. regulations in the absence Application of central govt. regulations in the absence

of state regulationsof state regulations Forms to be required for making opinion, admission Forms to be required for making opinion, admission

register and reporting of MTPsregister and reporting of MTPs Custody of formsCustody of forms Prevention of disclosure of informationPrevention of disclosure of information

MTP regulations: opinion formsMTP regulations: opinion forms F or an MTP, opinion of an approved RMP F or an MTP, opinion of an approved RMP

(2 RMPs for 2(2 RMPs for 2ndnd trimester) is required. trimester) is required. The provider(s) is required to certify his/her The provider(s) is required to certify his/her

opinion in Form I within three hours of opinion in Form I within three hours of terminating a pregnancy.terminating a pregnancy.

Declining sex ratios…Declining sex ratios…• Census 2001 confirmed apprehensions of declining juvenile Census 2001 confirmed apprehensions of declining juvenile

sex ratios. sex ratios. • Parallel with steep increase in availability of ultrasound Parallel with steep increase in availability of ultrasound

machines and use during pregnancymachines and use during pregnancy• Sex determination testing followed by second trimester Sex determination testing followed by second trimester

abortion- major pathway for sex selectionabortion- major pathway for sex selection• Public interest litigation triggered amendments in Act of 1994Public interest litigation triggered amendments in Act of 1994• Focus on “female feticide” as having attained endemic Focus on “female feticide” as having attained endemic

proportionsproportions

Safe Abortion and Sex Selection Safe Abortion and Sex Selection PathwaysPathways

Sexual violenceSexual violence Unwanted pregnancyUnwanted pregnancy Unwanted sex Unwanted sex

Desire for sonDesire for son

Sex determinationSex determination

AbortionAbortion

Choices along the thin edge separating the Choices along the thin edge separating the two are:two are:◦Restricting access to abortion to prevent sex Restricting access to abortion to prevent sex

selectionselection◦Dealing with the two issues separatelyDealing with the two issues separately◦Developing a integrated strategy to address both Developing a integrated strategy to address both

sex selection and unsafe abortion together sex selection and unsafe abortion together