Facility-based abortion care in India, 2008-2022: long-run stagnation, pandemic disruption, and an early shift toward later-gestation procedures after the MTP Amendment Act
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Background
Medical termination of pregnancy (MTP) has been legal in India since 1971, and the MTP (Amendment) Act 2021 expanded gestational limits and eligibility. Yet trends in facility-based abortion provision, their disruption by COVID-19, and any early response to the 2021 reform have not been described from routine national data. We quantified 14 years of public and private facility MTP provision by gestational age, geographic access, pandemic disruption, and the post-Amendment shift in later-gestation procedures.
Methods
Analysis of India’s Health Management Information System (HMIS), fiscal years 2008-09 to 2021-22. We extracted monthly MTP counts by gestational band (up to 12 weeks; more than 12 weeks) and sector, post-abortion care indicators, and abortion-related maternal deaths for all districts and states, harmonising definitions across the 2017-18 schema change. We described national and state trends, the share of districts reporting zero MTPs, and — for 2017-2022 — used interrupted time-series models to quantify COVID-19 disruption; we compared the more-than-12-week share before and after the MTP Amendment Act rules (September 2021).
Results
Reported facility MTPs were essentially flat over 14 years, at roughly 0.6-0.74 million per year, despite population growth. The more-than-12-week share of MTPs halved over the period, from 17.5% in 2008-09 to 6.9-9.5% after 2017. Around 5% of districts reported zero MTPs in any given year. COVID-19 reduced total MTPs by about 25% below expected over March 2020-March 2022, with public-sector provision hit harder (-30%) than private (-20%), and post-abortion contraception falling by half and not recovering. Strikingly, more-than-12-week MTPs surged to 155% of expected after the MTP Amendment Act rules took effect in September 2021, and the more-than-12-week share rose from 6.9% pre-pandemic to 9.7% post-Amendment. State MTP deficits over the pandemic exceeded 40% in Rajasthan, Delhi, Assam and Tamil Nadu.
Conclusion
Facility-based abortion provision in India has stagnated in absolute terms for over a decade and is unequally distributed, consistent with the large majority of abortions occurring outside the facility system. COVID-19 caused a substantial, public-sector-concentrated disruption from which post-abortion contraception did not recover, while the earliest post-Amendment data show a measurable shift toward later-gestation facility procedures. Routine data provide an essential, if partial, monitoring tool for abortion-care policy.
