abortn law and policy in india

7/29/2019 Abortn Law and Policy in India

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Abortion Law, Policy and Services in India: A Critical Review

Author(s): Siddhivinayak S. HirveReviewed work(s):Source: Reproductive Health Matters, Vol. 12, No. 24, Supplement: Abortion Law, Policy andPractice in Transition (Nov., 2004), pp. 114-121Published by: Reproductive Health Matters (RHM)Stable URL: http://www.jstor.org/stable/3776122 .

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? 2004ReproductiveealthMatters. llrights eserved.ReproductiveealthMatters 004;12(24Supplement):114-1210968-8080/04 - see frontmatterPII: S0968-8080(04)24017-4ISBN 0-9531210-2-X

REPRODUCTIVEHEALTHmatterswww.rhmjoumal.org.uk

Abortionaw,Policynd Servicesn ndia:ACritical eviewSiddhivinayakHirve

Director,aduRural ealthrogramme,EMHospital,une,ndia. -mail:[email protected]: espite 0 years f iberalegislation,hemajorityf women n India till ack ccessto safeabortionare.This aper riticallyeviews hehistoryf abortionawandpolicynIndia ince he1960s nd researchnabortionervice elivery.mendmentsn2002 and 2003 tothe 1971MedicalTerminationfPregnancyct,ncludingevolutionfregulationf abortionserviceso thedistrictevel, unitive easureso deter rovisionfunsafebortions,ationalisationofphysical equirementsor acilitiesoprovidearly bortion,ndapprovalf medicalabortion,ave ll aimed oexpandafe ervices.roposedmendmentso theMTPAct opreventsex-selectivebortions ould avebeenunethicalndviolatedonfidentiality,nd werenottaken orward.ontinuingroblemsnclude oorregulationf both ublic ndprivateectorservices, physician-onlyolicyhat xcludesmid-levelrovidersnd owregistrationf ruralcomparedourban linics;ll restrictccess.Poor wareness f the aw,unnecessarypousalconsent equirements,ontraceptiveargetsinked oabortion,nd nformalndhigh ees lsoserve s barriers.raining ore roviders,implifyingegistrationrocedures,e-linkinglinicandproviderpproval,nd inkingolicywith p-to-dateechnology,esearchndgoodclinicalpracticere some mmediate easures eeded o mprove omen'sccess to safe abortioncare. 2004 ReproductiveealthMatters. llrightseserved.Keywords:bortionaw andpolicy,bortionervices,ublic s.privateector,rohibitionf sexdetermination,ndiaHE Indian enal Code 1862 and theCodeofCriminal rocedure 898,with heir riginsin the British ffencesgainstthe Person

Act1861,made abortion crime unishable orboth the womanand the abortionistxcept osave the ifeof thewoman.The 1960s and 70ssaw iberalisationf bortionaws across uropeand the Americaswhichcontinued n manyother arts f heworld hroughhe1980s.1'2heliberalisation f abortion aw in India beganin 1964 in the context fhighmaternalmor-tality ue to unsafe bortion. octors requentlycame acrossgravely ll or dyingwomen whohad takenrecourse o unsafe bortions arriedoutbyunskilledractitioners.hey ealisedhatthemajority f women eeking bortionsweremarried nd underno socio-culturalressureo

conceal heir regnanciesnd thatdecriminalis-ing abortionwould encouragewomento seekabortion ervices nlegaland safesettings.3TheShahCommittee,ppointedy heGovern-ment f ndia, arriedut comprehensiveeviewof socio-cultural,egal and medicalaspectsofabortion,nd in 1966 recommendedegalisingabortion o prevent astageof women'shealthand lives on bothcompassionatend medicalgrounds.4 lthoughome States ooked pontheproposedegislations a strategyorreducingpopulation rowth,5heShahCommitteepecifi-callydenied hat hiswas itspurpose. heterm"MedicalTerminationfPregnancy"MTP)wasused to reduceopposition rom ocio-religiousgroups verse o liberalisationf abortion aw.The MTP Act,passed by Parliamentn 1971,

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SS Hirve ReproductiveealthMatters004;12(24 Supplement):114-121legalised bortionnallof ndiaexcept he tatesofJammund Kashmir.Despitemorethan 30 yearsof liberal egis-lation, owever,hemajorityfwomen n ndiastill ackaccess to safe abortion are.Thispapercriticallyeviews hehistoryf bortionawandpolicyreformn India (Box 1), and epidemio-logical ndquality f are tudies ince he1960s.It dentifiesarriersogoodpracticend recom-mends olicy ndprogrammehanges ecessaryto mproveccess to safe bortion are.The MedicalTerminationfPregnancyAct1971 and Regulations 975TheMTP Act No.34of 1971)6confers ullpro-tectiono a registeredllopathicmedical racti-tioner gainst ny egalor criminal roceedingsfor ny njuryausedto a woman eekingbor-tion, rovidedhat he bortion as done ngoodfaith nder heterms ftheAct.TheAct allowsan unwanted regnancyo be terminatedp to20 weeks ofpregnancy,nd requires seconddoctor's pproval f the pregnancys beyond12weeks.Thegroundsnclude raverisk o thephysical r mentalhealth f the woman n heractual rforeseeablenvironment,s whenpreg-nancyresults rom ontraceptiveailure,r onhumanitarianrounds, r if pregnancy esultsfrom sex crime uch as rape or intercoursewith mentally-challengedoman, roneugenicgrounds, here here s reasonto suspect ub-Box .Abortionolicyventsn ndia1964 - MinistryfHealthnd amilylanningonstitutesShah ommittee1966 - Shah ommitteeeport1971 - MTPAct assed1972 - MTP ct nforcedn ll f ndiaxceptammuandKashmir1975 - MTP ulesndRegulationsramed2002 - MTPAmendment)ct

- MifepristonepprovedormedicalbortionyDrugontrollereneralf ndia2003 - MTP ulesndRegulationsmended2004 - Nationalonsensusuidelinesormedicalabortionunderevelopment)

stantial isk hat hechild,fborn,would ufferfrom eformityr disease.The law allowsanyhospitalmaintainedytheGovernmento per-formbortions,utrequirespproval rcertifi-cation f nyfacilityntheprivateector.In the vent f bortiono savea woman's ife,the aw makesexceptions:he doctorneednothave he tipulatedxperiencer rainingut tillneeds o be a registeredllopathicmedical rac-titioner, secondopinion s notnecessary orabortionseyond 2weeks ndthefacilityeednothaveprior ertification.TheMedicalTerminationfPregnancy ulesandRegulations9757 efinehe riteriandpro-cedures or pproval fan abortion acility,ro-cedures or onsent, eeping ecords ndreports,and ensuring onfidentiality.nyterminationofpregnancyoneat a hospital r other acilitywithout riorapprovalof the Governmentsdeemedllegal nd theonus s onthehospital oobtain rior pproval.AbortionnIndia1970-2000The nitial ears rom 972 o 1986afteregalisa-tion f abortionhowed nly marginalncrease(8-10%) in the number f approved bortionfacilitiesnd thenumber f abortionseportedbythose acilities.n contrast,he ate 1980s nd90s showed decliningrend n the number fabortionsreportedn approvedfacilities.6n1997, ome wo-thirdsfapprovedacilities ereurban-based linics, eflectingngoing eriousinequityn urbanvs. rural ccess to approvedabortion acilitiesn a stillpredominantlyuralcountry.8n themid-1990s,ess than10%of theestimatedotalnumber f bortions ere eportedto thegovernment.911ata on abortions ccur-ringoutsideapprovedfacilities re rare andunreliable.stimatesating rom hebeginningof the 1990sto morerecentyearsare largelyspeculativend have rangedfrom -11 illegalabortionserformedor veryegal bortion.3,12,13Thus,although t maynot be the case thatabortionsnunapprovedacilitiesre allunsafe,it can stillbe assumed hatsafeabortion areis still not widelyavailable. In most states,less than20% of primary ealthcentres ro-videabortion ervices.14,15venwhere heydoso, womenprefero seek abortion n thepri-vate ector,eading ounder-utilisationfpublicfacilities.urther,hequality fabortionervices

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SS Hirve ReproductiveealthMatters004;12(24Supplement):114-121in both thepublicand private ectorss oftenpoor n terms f echniquesed, ounselling,ri-vacyandconfidentiality.hemajorityfdoctorsstillprefer ilatation nd curettageDEtC)forearly bortion, ith ess than a quarter fpro-vidersreportedlysingvacuumaspiration.8'16Awarenessfthe egalityf abortions low andmisconceptionsbout he awamongwomen ndprovidersreprevalent.17-21Abortionaw reformince 000India has committed tself to safeguardinghuman and reproductiveights rticulatednvarious nternationalorums.22-25fter longconsultativerocess nvolving ariousgovern-mental ndnon-governmentalgencies, rofes-sionalbodies ndactivists,he ndian arliamentenacted he MedicalTerminationfPregnancy(Amendment)ct 2002 and amendedRules ndRegulations2003.26'27In an effort o reduce the bureaucracy orobtaining pprovalof facilities,he new Actdecentralisedegulation f abortionfacilitiesfromhe State evel to District ommitteeshatare empoweredo approve nd regulate bor-tionfacilities.t alsoprovides unitivemeasuresof 2-7 years mprisonmentor ndividual ro-viders nd owners f facilities otapproved yor maintained y theGovernment.o reduceadministrativeelays,he mendedMTPRules27define timeframe orregistrationnd man-date the District ommitteeo inspect facilitywithin womonths freceivingn applicationfor egistrationndprocess heapprovalwithinthenext womonthsfno deficienciesrefound,or within womonths fter ectificationfanynoteddeficiency. owever, he amendedMTPRules do not specifymeasures o be taken fapprovalproceduresre stillnot completednthestipulatedimeframe.Whilephysicaltandardsor facilityrovid-ingsecond rimesterbortionsemain he same(operatingable,abdominalor gynaecologicalsurgeryquipment,oyle's pparatusor eneralanaesthesia, utoclave,drugsand suppliesforemergencyesuscitation)he mendedMTPRulesrationalisehe physical tandards equired orfirst rimesterbortions.acilitiesreno longerrequiredo have on-site apabilityfmanagingemergencyomplications.owever,very acilityneeds to have personnel rained o recognise

complicationsnd provide r be able to referwomen o facilitiesapableofemergencyare.The mendedMTPRules lsorecognise edicalabortionmethods ndallow a registerededicalpractitionere.g.thefamilyhysician)oprovidemifepristonemisoprostoln a clinic ettingoterminatepregnancypto evenweeks, rovidedthatthe doctorhas either n-site apabilityraccess oa facilityapable fperformingurgicalabortionn the eventof a failed r incompletemedical bortion.owever,heDrugControllerfIndiahasapprovedmifepristonerovisionnly ya gynaecologist,hus ffectivelyestrictingccessto women n urban areas. National onsensusguidelinesnd protocols28or medical bortionarecurrentlyeing eveloped.Currentaw andpolicy: hat sstillmissing?A majorcriticism f the MTP Act s itsstrongmedicalbias. The "physicians nly" policyforproviders xcludes mid-levelhealthprovidersand practitionersf alternative ystemsofmedicine. herequirementfa secondmedicalopinionfor secondtrimesterbortion urtherrestrictsccess,especiallynrural reas.

The MTPAct mandates he Stateto provideabortion ervices t all publichospitals.How-ever, he lack of required pprovalforpublichealthfacilitiesxemptshepublic ector romthe sameregulatoryrocesses hat pply o theprivate ector.The assumption hat a healthinstitutionyvirtue fbeing n thepublic ec-tor s accountable o thepublic, nd has well-functioning egulatoryrocesses hatdo notneed xplicationn awandpolicy,snot orrect.Often,nysuchregulationsendto be defunctor lack transparency.n the contextof poorquality bortionare nthepublic ector,8'29hesame exacting tandardshould be appliedasin theprivate ector nd subjectto the sameauditprocedureshat reexpected ftheprivatesector.ronically,owever,heprivateector nIndia also remains astly nregulatednd oftenlackstheself-disciplineecessaryo adhere othequality tandardspecifiedn the aw.A majorgapin abortionolicyn India s thelack of explicitpolicyon good clinicalprac-tice and research. ational echnical uidelinespublishedn200130 o notconform ithWHO'sinternationaluidance31nd fail o ensure ood

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SS Hirve ReproductiveealthMatters004;12(24 Supplement):114-121clinical racticeven tapprovedbortionacili-ties.Consequently,harp urettagey39-79%ofproviders8nd continued se ofgeneral naes-thesian8-15%/ofreportedbortion acilitiesrestill revalent.32ndiahassimply otfound wayto ensure heuse of mprovednd safer bortionpractices rought bout through esearch ndcontinuouslyvolving eproductiveechnology.Abortionawandpolicy: otentialndactual buseIn the1960s, bortion iscoursewas influencedlargely ymedical nd demographiconcerns.Thehuman ndreproductiveights gendatookcentretagepost-ICPD. heNational opulationPolicy f ndia200033 ncourageshepromotionoffamily lanningervicesopreventnwantedpregnancies,ut also recogniseshe mportanceofprovisionf safe abortionerviceswhich reaffordable,ccessible ndacceptable orwomenwho need toterminaten unwanted regnancy.In India,though bortion s legallypermissibleunder widerange fsituations,hedoctor asthe final ay.A womanhas to ustify hatherpregnancy ccurreddespiteher havingtriedto preventt or that t had been intended utcircumstanceshangedor made it unwantedlater. herealitymaybethat hepregnancy asunwanted rom hestart, utto ustifybortionwithin he egalframework,hewomanmayfeelshe has to say it was contraceptiveailure,creatingn environmentffalsehood.Abortion aw is always open to differinginterpretationsnd though he present ocio-political environmentllows a more liberalinterpretationnmost ases,there s always hetheoreticalanger fmore estrictiventerpreta-tionsunderdifferentocio-politicalnd demo-graphic ompulsions, ithout singlewordofthe textofthe awbeingaltered.34ventoday,although ection of he 1971Actdoes notdenyabortion are tounmarriedrseparatedwomenorwidows, he use of thephrase"Where nypregnancy ccursas a result ffailure f anydeviceormethod sedbyany married' omanorherhusbandfor hepurpose flimitinghenumber fchildren..."maybemisconstruedodenyabortion ervices o unmarried omenorrequire marriedwoman'shusband's onsent.Though activistshave argued for replacing"married oman"with allwomen",his ecom-

mendation as notyetbeen takenup by theGovernment,s it would mply acit ecognitionand sanctionof sexual relations mongthosewhoareunmarriedrwerepreviously arried.Anotherrea ofpotential buse ofwoman'sreproductiveightss themandatoryeportingofpost-abortionontraceptivese required yMTPregulationsForm ),which heStatemayuse to compel abortionproviders o achievefamily lanning argets.uchmonitoringftenresultsn a form f coercion f women eekingabortion,speciallynthepublic ector.17Barriersnabortionervice eliveryAbortion are,as withmuchof health are inIndia, emains eglected,speciallynthepublicsector.Poor qualityof care and a poorworkethos n thepublichealth ector ompoundedby neffectualegislationorfailure o mplementit) have resultedn an unregulatedrowth fprivateectorervices hichsoftenxploitativeinnature.Althoughndia's abortion olicy ndlaw are progressive,ffectiveranslationntoimprovedccess to safeabortion are is oftenimpeded ymisguidedndunnecessaryractices.The law empowersstate governments oregulate bortion ervices. hough tateshaveadapted heserules nd regulations,heydifferin theirinterpretationnd implementation.With he ntent fensuring afetyndprevent-ingunsafeabortions,ome Stateshave addedlayersofnon-essentialroceduresnd createdadministrativeelays n theregulatoryrocessand unnecessarycontrols.Maharashtra,forexample,equireshere obe a bloodbankwithin5 km of any abortionfacility, requirementthat s both mpracticalndunnecessary.omeStates Delhiand Haryana require hefloorarea and architecturallansof thehospital nddetailsof provision f car parking o be sub-mittedor egistration.35heoverallmindsetftheseStates s to control atherhanfacilitateabortion ervices. hediscriminatoryature fsuchoverzealous egulation ecomesapparentwhen hese equirementsreapplied nly o theprivateector nd notthepublic ector.Thetime nd efforteeded o procure erti-fication fan abortion acilitylso reflectsheStates' ttitudendapproachowardsbortion.nspite fthenewtime ramepecifiedor he er-tificationrocess,mismanagement,ureaucratic

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SS Hirve ReproductiveealthMatters004;12(24Supplement):114-121hurdles,ack of response nd corruptionrecommonly ncountered.29 nationwide tudyin 1999of 118abortion acilities evealed er-tificationelays angingrom -7years.36 ow-ever, recent urvey f facilitiesn six Statessurprisinglyndicatedomethinguitedifferent.Of he285private rovidersurveyed,hosewhowere ertified25/%)adbeen bleto dosowithina month. mong hosenotcertified,third adtried nd given up or were stillawaiting er-tification. he remainingwo-thirds ad noteventried o apply, eflectingitherndifferenceor casual ttitudeowardsertification,r gen-eral dislike frecord-keepingnd reportingfpost-abortionomplicationso theState, atherthan cumbersome rocedures s theirreasonfornot seeking ertification.37ow awarenessand misconceptionsbout the law (e.g. thatdoctors eed not seekcertificationftheyworkin smallclinics, ronlydo an occasional bor-tion,or provide bortions ormarriedwomenonly) re other actors hat esultnlow certifi-cation evelsof omefacilities.38Attimes,t s neitherawnorpolicybutpro-viders hemselvesho creates arrierso access.Though he awdoesnotrequire pousaloranythird arty onsent or terminationxcept nthecaseof a minor,nreality,bortionrovidersoftennsist n suchconsent ased on "commonbelief f the aw".Reasonsoften itedforpro-vider nsistencen spousalconsentnclude heneedto safeguardhemselvesgainst ocialandlegalproblemsrising rom bortion omplica-tions rdeath,ndthe owsocial tatus fwomenand their ependencen their usbands.Lastly,o-callednformalees harged ypro-vidersn thepublic ector r exorbitanthargesin the privatesector that exploitwomen'svulnerabilitynd low awarenessof the law,especiallyn circumstanceshere heunwantedpregnancys not socially cceptable, lso addbarriersoaccess.39Abortionnd sexdetermination:differentssuesThePrenatal iagnostic echniquesRegulationandPreventionfMisuse)Act PNDTAct)199440whichwaslater mended ythePre-ConceptionandPre-Natal ex Selection ndDetermination(ProhibitionndRegulation)ct 00241prohibitsthemisuse f antenatal iagnosticestsfor he

purpose fsex determinationhichmay ead tothe abortion ffemale etuses. heseActs alsoprohibitdvertisingf such use of thesetests;require ll facilitiessing hem o be registeredand prohibit ersons onductinguch tests oreveal he exofthefetus.Though the purposes of the PNDT laws(prohibitingex determination)nd the MTPAct (ensuringafe abortion) re distinct,heywere almost inappropriatelyinked. Follow-ing a Public Interest itigation uit filed ntheSupreme ourt yDr Sabu George nd theNGOs CEHAT nd MASUM n 2000 against heGovernmentf India forfailure o implementthePNDTAct, policy eviewmeetingiscussedmodifyingheMTPAct topreventex-selectiveabortionfollowing ex determination.42nesuggestionwas to allow abortion nly up to12weeksofpregnancy,opreventex-selectiveabortions ollowingmniocentesisr sonogra-phy n the econd rimesterfpregnancy,hichcan dentifyetal ex.Otheruggestionsncludedreportinghe identityf any womanseekingabortions well as the ex of the aborted etus.However, xperts esolved hat therewas noneedto amend heMTPAct, s strictmplemen-tation f thePNDTActwas whatwas required.Reportinghe woman's identitywould havebeen a violationof confidentiality.estrictinglegalabortion o 12 weeksofpregnancy ouldhaveforced omen ver12weeks o seek llegalabortion ervices, o matter hattheir easonsfor bortion, ith bvioushealth onsequences.Recordinghe exofthe borted etuswouldnotonlyhave been unethical ut also wouldhavemade abortions arried ut for otherreasonssuspect,ndmightndirectlyavemade accessto safe bortionervicesmoredifficultverall.Abortionaw andpolicy:heway headRecentawandpolicy eforms,hough ot adical,still epresentstepforwardowards nsuringwoman's ighto safe bortionare. t s only nrecent ears hat everal ational-levelonsulta-tiveefforts43-46nvolving olicymakers,rofes-sionalsbodies ikethe Federationf ObstetricsandGynaecologyocieties f ndia FOGSI) ndthe IndianMedical Association IMA),NGOs(notably arivar eva Sanstha,CEHAT,HealthWatch nd theFamily lanningAssociation fIndia) nd health ctivists,avechampionedhe

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SS Hirve ReproductiveealthMatters004;12(24 Supplement):114-121improvementf accesstosafe nd egalabortionservicesn ndia.Manyof heir ecommendationsare nline with heobjectivesndthe trategiesoutlined n the ActionPlan ofIndia'sNationalPopulation olicy, 000.Theynclude:* increasing vailability nd access to safeabortion ervices,* creatingmorequalifiedprovidersincludingmid-level roviders)nd facilities,speciallyinrural reas,* simplifyinghecertificationrocess,* de-linkinglinic ndproviderertification,* linking olicywithtechnologynd researchandgoodclinicalpractice,* applyinguniform tandards for both theprivate ndpublic ectors,nd* ensuringuality fabortion are.

Increasingwareness nd dispellingmiscon-ceptions bouttheabortionaw amongst ro-viders ndpolicymakerss ustonestep owardsthis.There s a need to enhance wareness fbothcontraceptivend abortion ervices,spe-cially amongst dolescents,within he largercontext fsexual andreproductiveealth,nte-gratingtrategiesnd nterventionsithin aluesystemsndfamilyndgender elations.35'47For thesepoliciesto be implementedffec-tively,heyneed to be backedby politicalwilland commitmentn terms fadequateresourceallocation, rainingnd infrastructureupport,accompanied ysocial nputs ased onwomen'sneeds.Advocacy ndaction t both entral ndstate evel are required o puttheoperationalstrategieselevant oabortion,s detailedn theNational opulation olicy, 000 intoeffect.References1. BererM.Makingbortionsafe:a matterfgoodpublic ealthpolicy ndpractice.ulletinfWorld ealthOrganization2000;78:580-92.2. Rahman ,Katzive ,HenshawS. A global eviewf aws on

inducedbortion,985-1997.Internationalamily lanningPerspectives998;24:56-64.3. Chhabra ,NunaSC.Abortionin ndia:AnOverview. ewDelhi:Veerendrarinters,994.4. Governmentf ndia.Reportfthe hahCommitteeostudythe uestionf egalizationfabortion. ewDelhi:MinistryofHealth ndFamilylanning,1966.5. Phadke . Pro-choicerpopulationontrol: studyoftheMedical erminationfPregnancyct,Governmentof ndia,1971.1998.At:.6. Governmentf ndia. heMedical erminationfPregnancyctAct o.34,1971].NewDelhi:MinistryfHealthandFamily lanning,971.7. Governmentf ndia. heMedical erminationf

Pregnancyules ndRegulations.ideGSR 543,NewDelhi:Gazettef ndia, 975.8. Barge . Situationnalysisofmedical erminationfpregnancynGujarat,Maharashtra,amilNadu ndUttar radesh.aper resentedatMTPworkshop,ordFoundation,0May1997. n:Bandewar,Ramani ,AsharafA,editors. ealth anoramaNo.2.Mumbai: EHAT,001.p.25-34.9. Chhabra .Abortionn ndia:an overview.emographyndia1996;25(1):83-92.10.Governmentf ndia.FamilyWelfarerogrammen ndia:YearBook1994-95.NewDelhi:MinistryfHealth ndFamilyWelfare,996.11.Henshaw , Singh ,HaasT.The ncidencefabortionworldwide.nternationalamilyPlanningerspectives1999;25(Suppl.):S30-38.12. IndianCouncil fMedicalResearch.llegalAbortionnRural reas:A Task orce tudy.NewDelhi: CMR, 989.13.KarkalM.Abortionaws nd heabortionituationn ndia.Issues nReproductivend

Geneticngineering1991;4(3):223-30.14. IndianCouncil fMedicalResearch. valuation fthequalityffamily elfareservicest theprimaryealthcentreevel: n ICMR askforcetudy. ewDelhi:ICMR, 991.15.KhanME,Barge ,Kumar .AvailabilityndAccess oAbortionervicesn ndia:MythndRealities.aroda:CenterorOperationsesearchandTraining,001.16. Iyengar , yengar.Electiveabortions a primaryealthservicenruralndia: xperiencewithmanual acuumspiration.ReproductiveealthMatters2002;10(19):54-63.17. Ganatra,Hirve,Walawalkar,et l. nducedbortionsnaruralommunitynWesternMaharashtra:revalencendpatterns.orkingaper eries.NewDelhi: ord oundation,1998.18. GupteM,Bandewar,PisalH.Abortioneeds fwomen nIndia: casestudyfruralMaharashtra.eproductiveHealthMatters997;5(9):77-86.

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SS Hirve ReproductiveealthMatters004;12(24Supplement):114-12119.Ganatra ,Hirve ,RaoVN.Sexselectivebortions:videncefrom communityased tudyin Westernndia.AsiaPacificPopulationournal001;

16(2):109-24.20. Ganatra ,Hirve . Inducedabortionsmong dolescentwomenn ruralMaharashtra,India.ReproductiveealthMatters002;10(19):76-85.21. Malhotra ,Nyblade,Parasuraman, et al.RealizingReproductivehoice ndRights:AbortionndContraceptionin ndia.WashingtonC:InternationalenterorResearchnWomen,003.22. United ations. eportftheInternationalonferencenPopulationndDevelopment,Cairo, -13September994.NewYork:UN,1995.23. United ations. eportftheFourthWorld onferenceonWomen,eijing,4-15 September995.NewYork:UN,1996.24. United ations. eyActionsortheFurthermplementationftheProgrammefActionftheInternationalonferencenPopulationndDevelopment.NewYork:UN,1999.25. United ations.urtherctionsand nitiativeso mplementtheBeijing eclarationndPlatformorAction. ewYork:UN,2000.A/S-23/10/Revl(Suppl.3). t:.26. Governmentf ndia.MedicalTerminationfPregnancy(Amendment)ct No.64 f2002].NewDelhi:MinistryfHealthndFamilyWelfare,2002.27. Governmentf ndia.MedicalTerminationfPregnancyRules ndRegulations.ideGSR485(E) nd486(E).NewDelhi:Gazettef ndia,2003.28. Governmentf ndia.ConsortiumorNationalConsensusorMedicalAbortion

in ndia:ProceedingsndRecommendations.ewDelhi:All ndia nstitutefMedicalSciences,ndMinistryfHealth ndFamilyWelfare,March 003.29. Bandewar. QualityfAbortion are:A RealityromMedical, egal nd Women'sPerspective.une:CEHAT,2002.30. Governmentf ndiaGuidelinesormedicalfficersformedical erminationfpregnancyptoeightweeksusingmanual acuumaspirationechnique.ewDelhi:Maternalealth ivision,DepartmentfFamilyWelfare,MinistryfHealthndFamilyWelfare,001.31. World ealth rganization.afeAbortion:echnicalndPolicyGuidanceorHealth ystems.Geneva:WHO, 003.32. Kalpagam . PSS experienceofearlybortionervices.Paper resentedtNationalConferencenMaking arlyAbortionafe ndAccessible.Parivar evaSanstha. gra,11-13October 000.33. Governmentf ndia.NationalPopulation olicy,000.NewDelhi:DepartmentfFamilyWelfare, inistryfHealth ndFamilyWelfare,000.34. Jesani , yerA.Women ndabortion.conomict oliticalWeekly993;27;2591-94.35. Hirve . Abortionolicyin ndia:Lacunae ndFutureChallenges.bortionAssessmentroject,ndia.Mumbai: EHAT, ealthWatch,2003.36. Sheriar . Manual acuumaspirationecentralizingearlybortionervices.Paper resentedt:NationalConferencenMaking arlyAbortionafe ndAccessible.Parivareva Sanstha. gra,11-13October 000.37. DuggalR,Barge . Synthesisofmulticentricacilityurvey:a summary.bortion

Assessmentrojectndia.PresentedtDisseminationMeeting, ewDelhi, 5-26November003.38. FederationfObstetricsndGynaecologicalocietiesfIndia. afe bortionsavelives:understandingheMTPAct.Mumbai:MTPCommittee,Medico-LegalommitteeFOGSI;NewDelhi: pas ndia,2002.39. Banerjee .Rapid ssessmentfabortionlients: qualitativecasestudyn selected istrictsof Orissa. aper resentedtOrissa tate-level orkshopnMaking bortionafe ndAccessible.arivarevaSanstha. hubhaneshwar,15-17October 001.40. Governmentf ndia.ThePrenatal iagnostic echniques(RegulationndPreventionfmisuse) ct, 994.NewDelhi:Gazette f ndia, 996.41. Governmentf ndia.ThePre-ConceptionndPre-NatalSexSelection/Determination(ProhibitionndRegulation)Act, 002.NewDelhi:Gazetteof ndia, 003.42. Governmentf ndia.MinutesofExpert roupMeetingoreviewMTPAct n the ontextofPNDTAct.17April 002;ChairedyJt. ecretary,CH,MinistryfHealthndFamilyWelfare,ewDelhi.No.M. 2015/15/98-MCH.43. Parivareva Sanstha.Workshoponservice eliveryystemninducedbortion.arivarSevaSanstha, ewDelhi,21-22February994.44. Family lanning ssociationof ndia.Reportfa nationalconsultativeeetingorimprovingccess o safeabortionervicesn ndia.Mumbai,0 September-1October002.45. Centeror nquiryntoHealthand Allied hemes. ccess osafe nd egal bortionissues ndconcerns:tate-level onsultation,une,

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SS Hirve ReproductiveealthMatters004;12(24Supplement):114-1217 June 998. n: Bandewar,Ramani ,Asharaf ,editors.Health anorama o.2,Mumbai: EHAT,001.p.49-51.

46. Governmentf ndia, arivarSevaSanstha,pas.NationalConferencenmakingarlyabortionafe ndaccessible.Agra, 1-13October000;

NewDelhi:MinistryfHealthandFamilyWelfare.47. Hirve . Abortion:olicyndpractice.eminar003;532(Dec):14-19.ResumeApres30 ans de legislationiberale,a majoritedes Indiennesn'a toujourspas acces a desavortementsurs.L'articleetrace'histoire e laloiet a politiqueur 'avortementnIndedepuisles annees 60 et la rechercheur ces services.Des amendementsn 2002 et 2003 a la Loi de1971sur l'interruptionedicalede grossessenotamment e transfertux districtsde lareglementationesservices,esmesuresunitivespourdecourageres avortementslandestins,arationalisationes equipements ourpratiquerdes avortementsrecoces, t l'homologationel'avortementedical visaient rendrees ervicesplus surs. Des amendementsour preveniresavortementselectifs elon le sexe du foetus,contrairesl'ethique ta la confidentialite,'ontpas ete adopt6s. Des problemeschroniquesrestreignent'acces,par exemple 'insuffisantereglementationesservices ublics tprives,nepolitiquedu f toutmedical , qui exclut esprestatairesntermediaires,t le faible niveaud'homologationdes dispensairesrurauxparrapportux dispensairesrbains. 'autres reinssont 'ignorance e la loi, l'obligationuperflued'obtenir e consentement u conjoint,desobjectifsontraceptifsies a l'avortementt lescofits lev6s. Pour elargir 'acces a des soinssurs, l faut former avantagede prestataires,simplifier es procedures d'enregistrement,separer 'homologation es dispensairest desprestataires,t associer a politique vec unetechnologie odeme, esrecherchest unebonnepratiquelinique.

ResumenPese a 30 anos de legislaci6niberal,a mayoriade mujeresn la Indiaain carecen e acceso aservicioseabortoeguro.n este rticuloe revisala historia e la ley de abortoy las politicaspertinentesesde ossesenta, asinvestigacionessobre a prestaci6ne servicios e aborto. asenmiendasel2002y2003 laLeyde nterrupcionMedica del Embarazo de 1971, incluida ladevoluci6nde la regulaci6nde los serviciosal nivel distrital,as medidaspunitivasparaobstaculizara practica e abortosnseguros,aracionalizaci6nde los requisitosfisicosparaque se practiquen bortos n etapas iniciales,y la aprobaci6n el abortofarmacol6gico,anprocuradompliar os servicios. as enmiendaspropuestas la leycontra l aborto or elecci6ndel exonohubiesenido ticas hubieranioladola confidencialidad;ortanto,no se levaron acabo.Entreos problemasonstantesiguranaregulaci6neficientee servicios n los sectorespiblicoy privado,a politica s6lomedicos",ueexcluye los profesionalese la salud de nivelintermedio,unbajoregistroe as clinicasuralesen comparaci6non las urbanas;han limitadoel acceso. Otras arrerason:pococonocimientode aley, equisitosnnecesarioseconsentimientodelc6nyuge,lancos nticonceptivosinculadosal aborto y tarifas altas extraoficiales. Elcapacitarmasproveedores,implificarl registro,desvincular la clinica de la aprobaci6ndelproveedor vincular as politicasontecnologiaactualizada, la investigaci6ny las buenaspracticaslinicas onalgunasmedidasnmediatasnecesarias ara mejorarl acceso de las mujeresa losservicios eabortoeguro.

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