Learn — Family planning & MTP

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MTP — Act and procedures

The Medical Termination of Pregnancy Act 1971, as amended in 2021, is the law that says when, by whom and where a pregnancy may be terminated in India. It sets three gestational tiers — up to 20 weeks on the opinion of one registered medical practitioner, 20 to 24 weeks on the opinion of two for specified categories of women, and beyond 24 weeks only with the approval of a State Medical Board for substantial fetal abnormality.

Up to 20 weeks: the opinion of one registered medical practitioner is enough.
From 20 to 24 weeks: two registered medical practitioners must agree, and only for the categories listed in the MTP (Amendment) Rules 2021 — survivors of rape or incest, minors, women whose marital status changed during the pregnancy (widowhood or divorce), women with a physical disability, mentally ill women, fetal malformation carrying a substantial risk of serious handicap, and women in humanitarian settings or disasters declared by the government.
Beyond 24 weeks: only a State or Union Territory Medical Board (which includes a gynaecologist, a paediatrician and a radiologist or sonologist) may permit termination, and only for substantial fetal abnormality.
Grounds at any permitted gestation: risk to the woman's life, grave injury to her physical or mental health, substantial fetal abnormality, and failure of contraception — which the 2021 amendment extended from married couples to any woman and her partner.
Consent is the woman's own, taken in writing on Form C. The written consent of a guardian is added only for a girl under 18 or a mentally ill woman; the husband's consent is never required, and a woman over 18 needs no one else's signature.
Confidentiality is statutory: the name and particulars of the woman may be disclosed only to a person authorised by law, breach is punishable, the admission register is kept as a secret document for five years, and the institution sends a monthly statement to the Chief Medical Officer.
Place: a hospital established or maintained by government, or a place approved for the purpose by the government or by the District Level Committee headed by the Chief Medical Officer.
Methods by gestation: medical abortion with mifepristone 200 mg followed by misoprostol 800 µg up to 9 weeks; manual or electric vacuum aspiration up to 12 weeks; dilatation and evacuation with cervical priming from 13 weeks onwards. Post-abortion contraception is offered at the same sitting.

Emergency contraceptives

Emergency contraception is a method used after unprotected or inadequately protected intercourse to prevent an unintended pregnancy, and it works chiefly by delaying or inhibiting ovulation. It matters because its effect falls with every hour of delay, and because it is not an abortifacient — it has no effect on an already implanted pregnancy, which is the counselling point that decides whether a frightened woman accepts it.

Levonorgestrel 1.5 mg orally as a single dose within 72 hours of intercourse is the standard method in India, available over the counter and free in the public system; efficacy falls from about 95% when taken in the first 24 hours to about 58% at 48 to 72 hours.
Ulipristal acetate 30 mg orally within 120 hours is a progesterone receptor modulator that still works closer to the luteinising hormone surge and holds its effect better than levonorgestrel across the 5 days; it is not part of the Indian national programme supply.
The copper intrauterine device inserted within 5 days of intercourse is the most effective method of all, with a failure rate below 1%, and it converts at once into ongoing contraception for up to 10 years with the Cu-T 380A.
The Yuzpe regimen — ethinyl oestradiol 100 µg with levonorgestrel 0.5 mg, repeated after 12 hours — is the older combined-pill method; it is less effective and far more emetic and is used only when nothing else is available.
Mechanism: levonorgestrel delays or prevents the luteinising hormone surge and therefore ovulation. If ovulation has already occurred it does not work, and it neither disrupts an established pregnancy nor harms a fetus that is already implanted.
Side effects: nausea in about a quarter, vomiting, headache, breast tenderness, and a period that may arrive up to a week early or a week late. If she vomits within 2 hours of the dose, repeat it.
There is no absolute contraindication to levonorgestrel emergency contraception apart from an established pregnancy, where it is simply useless; it is not a regular method, because any ongoing method is far more effective and repeated use disturbs the cycle.
Follow-up: a pregnancy test if the period is more than 7 days late, and a start on an ongoing method at the same visit — a combined or progestogen-only pill quick-started the next day with 7 days of back-up, an injectable, or an intrauterine device.

Intrauterine device (Cu-T)

An intrauterine device is a small T-shaped device placed in the uterine cavity that gives highly effective, long-acting and fully reversible contraception without any daily action by the user. It matters because it is the mainstay of India's spacing programme — Cu-T 380A for 10 years, Cu-T 375 for 5 years, with postpartum and post-abortion insertion built into the service — and because nearly all of its complications belong to the first few weeks after insertion, which is exactly where the nurse's counselling and follow-up act.

Cu-T 380A carries 380 mm² of copper and is effective for 10 years; Cu-T 375 carries 375 mm² and is effective for 5 years. The levonorgestrel-releasing intrauterine system (52 mg) works for 5 years and reduces menstrual loss instead of increasing it.
Failure is under 1 per 100 women in the first year (about 0.6 to 0.8 for the Cu-T 380A) — comparable with sterilisation and better than any method that depends on the user remembering something.
Mechanism: copper ions are spermicidal and immobilise sperm, and a sterile foreign-body inflammatory reaction in the endometrium prevents fertilisation. It is not an abortifacient.
Timing of insertion: within the first 7 days of the cycle, or at any time when pregnancy can reasonably be excluded; postpartum within 48 hours of delivery or after 6 weeks; immediately after an uncomplicated first- or second-trimester abortion; and as emergency contraception within 5 days of unprotected intercourse.
Absolute contraindications: known or suspected pregnancy, active pelvic infection or purulent cervicitis, puerperal or post-abortal sepsis, undiagnosed abnormal vaginal bleeding, a distorted uterine cavity from a large fibroid or a congenital anomaly, gestational trophoblastic disease, genital tuberculosis, and cervical or endometrial cancer. Copper devices are additionally avoided in Wilson's disease and copper allergy.
Side effects: heavier, longer and more painful periods for the first 3 to 6 months — the commonest reason for removal — with intermenstrual spotting and cramping for a day or two after insertion, managed with an NSAID and reassurance rather than removal.
Complications: uterine perforation at insertion in about 1 per 1000 insertions, expulsion in 2 to 10% and highest in the first 3 months and after postpartum insertion, and infection confined to the first 20 days after insertion — after which the risk is that of her sexual exposure, not of the device.
Pregnancy with a device in place: exclude an ectopic, and if the threads are visible and the pregnancy is under 12 weeks remove the device, because leaving it raises the risk of miscarriage, sepsis and preterm birth.
Follow-up is after the next period or at 6 weeks, then annually; teach her to feel the threads after every period and to return at once if they are missing, longer or shorter.

OCP — MALA-D, MALA-N, absolute contraindications

Oral contraceptives are daily hormonal tablets — either a combination of an oestrogen with a progestogen or a progestogen alone — that prevent pregnancy chiefly by suppressing ovulation. They matter because they are the commonest reversible method asked for at the counter, and because almost every examinable point about them is a safety point: who must never take them, what to do about a missed tablet, and which symptom means stopping the pill today.

Mechanism: the progestogen suppresses the luteinising hormone surge and so ovulation, thickens cervical mucus and thins the endometrium, while the oestrogen suppresses follicle-stimulating hormone and stabilises the endometrium to give cycle control.
Mala-D is the subsidised socially marketed combined pill and Mala-N the free pill supplied through sub-centres and ASHAs. Each cycle pack holds 21 hormone tablets of levonorgestrel 0.15 mg with ethinyl oestradiol 0.03 mg, plus 7 brown ferrous fumarate tablets taken without a break.
Starting: take the first tablet on day 1 to 5 of the cycle — day 1 needs no back-up — then one tablet at the same time daily, starting the next pack the day after the last brown tablet. A later start needs 7 days of an additional method.
Absolute contraindications (WHO Medical Eligibility Criteria category 4): pregnancy, breastfeeding under 6 weeks postpartum, age 35 or over with 15 or more cigarettes a day, blood pressure 160/100 mmHg or above, current or past venous thromboembolism or a known thrombogenic mutation, ischaemic heart disease or stroke, complicated valvular heart disease, migraine with aura at any age, current breast cancer, diabetes with vascular complications or of more than 20 years' duration, severe cirrhosis and liver tumours, and major surgery with prolonged immobilisation.
Smoking is the commonest examined trap and it turns on age: under 35 any amount of smoking is category 2; at 35 or over, fewer than 15 cigarettes a day is category 3 and 15 or more is category 4.
Missed-pill rule for a 30–35 µg pill: one missed tablet — take it as soon as remembered, even if that means two in one day, with no back-up needed. Two or more missed — take the most recent one, continue the pack, use condoms for 7 days, and if they were missed in the third week skip the brown tablets and start the next pack immediately; consider emergency contraception if tablets were missed in the first week with unprotected intercourse.
The progestogen-only pill is the choice when oestrogen is contraindicated or during breastfeeding, and it must be taken at the same hour every day with only a 3-hour window. India's own weekly pill, Chhaya, is centchroman (ormeloxifene) 30 mg — twice a week for the first 12 weeks and then once a week on the same day — a non-steroidal selective oestrogen receptor modulator.
The ACHES warning signs tell her to stop the pill and seek care: severe Abdominal pain, Chest pain or breathlessness, severe Headache or a first migraine with aura, Eye problems with visual loss or blurring, and Severe leg pain or swelling in one calf.
Interactions: rifampicin, rifabutin, phenytoin, carbamazepine, phenobarbitone, topiramate and St John's wort induce hepatic enzymes and reduce efficacy, so an alternative or additional method is needed; ordinary broad-spectrum antibiotics do not.
Non-contraceptive benefits: lighter, more regular and less painful periods, less iron-deficiency anaemia, fewer functional ovarian cysts, and a substantial long-term reduction in ovarian and endometrial cancer. Fertility returns within one to three cycles of stopping.

Vasectomy and tubectomy

Vasectomy and tubectomy are the permanent methods of contraception — occlusion of the vas deferens in the man and of the fallopian tubes in the woman. They matter because they are the most used methods in India and the ones most tightly governed by law and by standards: consent must be the client's own, free and revocable until the moment of the procedure, eligibility is fixed, and quality and compensation sit under the Family Planning Indemnity Scheme.

Eligibility under the MoHFW standards: the client is married or in a stable relationship, of sound mind, has at least one living child over one year old, and for female sterilisation the wife's age is between 22 and 49 years. Consent is the client's own on the prescribed form — the spouse's signature is not required, and consent may be withdrawn at any time before the procedure.
No-scalpel vasectomy is the preferred male technique: a single midline puncture under local anaesthesia taking 10 to 15 minutes as an outpatient, with less bleeding, less infection and faster recovery than the incisional method.
Vasectomy is not effective at once — the couple uses another method for 3 months or about 20 ejaculations, and azoospermia is confirmed on semen examination before they rely on it.
Female techniques: minilaparotomy with the modified Pomeroy method, done in the interval period or postpartum within 7 days of delivery, and laparoscopic occlusion with a Falope ring or clips. The other named ligation methods are Parkland, Irving, Uchida and Kroener (fimbriectomy).
Failure rates: about 1 in 200 for female sterilisation and about 1 in 2000 for vasectomy — so a missed period afterwards is always investigated, and a substantial proportion of post-sterilisation pregnancies are ectopic.
Timing for the woman: within 7 days of delivery or after 6 weeks; at the same sitting as a caesarean section; immediately after an uncomplicated MTP; or in the interval period within the first half of the cycle once pregnancy is excluded.
Counselling is the legal heart of the procedure: it is permanent, reversal is difficult and often fails, it does not affect libido, potency, menstruation or the ability to work, it gives no protection against sexually transmitted infections, and equally effective long-acting reversible methods must be offered first.
Follow-up: watch for scrotal haematoma and infection after vasectomy, and for wound infection, bleeding and bowel or bladder injury after tubectomy; issue the sterilisation certificate and explain the Family Planning Indemnity Scheme.

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