MTP Act ADVANCES IN MEDICAL SCIENCE Consequent Short comings &  Suggestion on Improvement Dr. Avinash Bhondwe President, I...
GOOD Things <ul><li>The  MTP Act  aims to regulate and ensure access to  safe abortion care  and defines ‘when’ ‘where’ an...
MTP Act: Shortcomings <ul><li>MTP   Act  permits women seek legal </li></ul><ul><li>termination of an unwanted pregnancy f...
MTP Act: Shortcomings <ul><li>The default recognition of all public health </li></ul><ul><li>institutions as abortion faci...
MTP Act: Shortcomings <ul><li>Another major critique of the abortion policy </li></ul><ul><li>is its lack of a  link with ...
MTP Act: Shortcomings <ul><li>‘MTP” providers continue to use unsafe abortion practices like  sharp curettage, check curet...
 
MTP Act: Shortcomings <ul><li>Comprehensive abortion care is integral to abortion services. This includes providing  pre-a...
Advances in Medical Science <ul><li>Abortion Pill  </li></ul><ul><li>Infertility Techniques </li></ul><ul><li>Developments...
Medical Abortion <ul><li>MTP using Mifepristrone (RU 486) & Misoprostol approved for up to 7 weeks termination </li></ul><...
Abortion Pill <ul><li>A medical abortion- taking a drug or a combination of drugs orally, intramuscularly and/or vaginally...
60.00  4  Misogon  6  60.00  4  Misoprost 200 (Cipla Ltd.)  5  31.00  4  Misoprost 100 (Cipla Ltd.)  4  30.50  2  Zitotec ...
50.00  10  Ayurvedic  Gynec Forte (Ankit Pharmaceuticals, Ahmedabad, Gujarat)  6  110.00  10  Ayurvedic  CVP Forte (Sterli...
38.00  10  Allopathic  Megestone (Wyeth Health Care)  13  47.00  10  Allopathic  Duibogen (Unichem Laboratories Ltd.) 12  ...
MTP Act: Shortcomings <ul><li>A recent survey in Gujrath Shows Chemists have been prescribing ‘ Abortion Pills ' more than...
MTP rules: Who can perform? <ul><li>A medical practitioner (RMP)  </li></ul><ul><ul><li>who has a recognized medical quali...
MTP Act: Shortcomings <ul><li>The doctors have been prescribing to the patients more than 7 weeks pregnant up to 14 weeks ...
MTP Act: Shortcomings <ul><li>More than 7 weeks Patient presents as Natural Incomplete Abortion and gets treated by the Ob...
Partial Birth Abortion   <ul><li>An  abortion  in which the person performing the abortion, deliberately and intentionally...
What is Infertility treatment?
Case  1 <ul><li>32 years old woman seeks Gynecologist’s treatment for  Infertility by IVF </li></ul><ul><li>After treating...
Case 1 <ul><li>Don’t you think the  Selective Reduction  causes encroachment of the MTP act ? </li></ul><ul><li>Should it ...
 
Genetics Research <ul><li>Medical genetics  interventions can be  </li></ul><ul><li>performed in two ways.  </li></ul><ul>...
Genetics Research <ul><li>The first kind of intervention means that someone gets medical treatment in the normal sense, ho...
Genetics Research <ul><li>Molecular biology scientists have developed a technique that enables parents to  select the sex ...
Genetics Research <ul><li>Pregnancy-associated plasma protein-A  (PAPP-A) largest of the pregnancy associated proteins pro...
Genetics Research <ul><li>Detection of this protein is also used as a first and second trimester diagnostic test for Triso...
Prenatal Diagnostic Methods <ul><li>Prenatal testing  is  testing  for diseases or conditions in a  fetus  or  embryo  bef...
Prenatal Diagnostic Methods <ul><li>Diagnostic prenatal testing can be by  invasive  or  non-invasive  methods.  </li></ul...
Prenatal Diagnostic Methods <ul><li>Non-invasive methods, called &quot;screens&quot;, can only evaluate risk of a conditio...
Prenatal Diagnostics <ul><li>Non-invasive methods , called &quot;screens&quot;, can only evaluate risk of a condition and ...
Prenatal Diagnostics <ul><li>Most often this is performed to test for  birth defects .  </li></ul><ul><li>Common procedure...
Reasons for prenatal diagnosis  <ul><li>There are three purposes of prenatal diagnosis:  </li></ul><ul><li>(1) to enable t...
<ul><li>If a genetic disease is detected, there is often no treatment that can help the fetus until it is born. This does ...
Non-invasive methods <ul><li>Examination of the woman's  uterus  from outside the body.  </li></ul><ul><li>Ultrasound dete...
False Positives  and False Negatives <ul><li>Ultrasound of a fetus, which is considered a screening test, can sometimes mi...
False Positives  and False Negatives <ul><li>Other screening tests, such as the AFP  triple test , can have false positive...
False Positives  and False Negatives <ul><li>A higher  maternal serum AFP  level indicates a greater risk for  Anencephaly...
Imposing Questions <ul><li>These types of research work has lead to few questions- </li></ul><ul><li>Is the mother’s healt...
 
Imposing Questions <ul><li>Who is more important, the  Mother  or the  Fetus ?  The crux is, can we force a mother to </li...
Fetal Viability
Imposing Questions <ul><li>If the  Fetus  is an independent entity and an  Individual , can this individual live outside t...
Imposing Questions <ul><li>by compelling a mother to complete her pregnancy for a fetus she doesn’t want, we are  forcing ...
United Kingdom <ul><li>Abortion was illegal before 1968 act </li></ul><ul><li>In 1971 The act made abortion legal in the U...
International Scenario <ul><li>In  Europe , abortion is usually only allowed up to 12 weeks </li></ul><ul><li>Sweden   18 ...
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Some suggestions about MTP Act

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Mtp act

  1. 1. MTP Act ADVANCES IN MEDICAL SCIENCE Consequent Short comings & Suggestion on Improvement Dr. Avinash Bhondwe President, IMA, Pune
  2. 2. GOOD Things <ul><li>The MTP Act aims to regulate and ensure access to safe abortion care and defines ‘when’ ‘where’ and under ‘what’ conditions abortion is permissible. </li></ul><ul><li>The recent amendment to decentralise </li></ul><ul><li>regulation of abortion care to the district level serves to encourage registration of abortion facilities by minimising administrative delays </li></ul>
  3. 3. MTP Act: Shortcomings <ul><li>MTP Act permits women seek legal </li></ul><ul><li>termination of an unwanted pregnancy for a </li></ul><ul><li>wide range of reasons, the clause about </li></ul><ul><li>contraceptive failure applies only to married </li></ul><ul><li>woman. This discrepancy needs to be corrected </li></ul><ul><li>Fast changing Social Culture & Scientific developments have not been thought of. </li></ul>
  4. 4. MTP Act: Shortcomings <ul><li>The default recognition of all public health </li></ul><ul><li>institutions as abortion facilities also implies </li></ul><ul><li>the responsibility of the government to make </li></ul><ul><li>each public health institution capable of </li></ul><ul><li>providing abortion care and hence makes the state accountable for it. </li></ul><ul><li>The training of Non-Medical & common but educated people has to be planned </li></ul>
  5. 5. MTP Act: Shortcomings <ul><li>Another major critique of the abortion policy </li></ul><ul><li>is its lack of a link with good clinical practice </li></ul><ul><li>and research. </li></ul><ul><li>The MTP Rules define ‘person’ </li></ul><ul><li>and ‘place’ requirements, but do not refer to </li></ul><ul><li>any national or international technical </li></ul><ul><li>guidelines for safe abortion care, in view of rapid scientific advances </li></ul>
  6. 6. MTP Act: Shortcomings <ul><li>‘MTP” providers continue to use unsafe abortion practices like sharp curettage, check curettage following a vacuum aspiration, general anesthesia, different drug dosage schedules and protocols for medical abortion, etc. </li></ul><ul><li>The scope of an abortion policy needs to be broad enough to internalize emerging advances in reproductive technology and newer practices within the legal framework. </li></ul>
  7. 8. MTP Act: Shortcomings <ul><li>Comprehensive abortion care is integral to abortion services. This includes providing pre-and post-counseling services for contraception, STI and HIV counseling and voluntary testing, extended care up to six weeks after abortion and management of abortion complications . </li></ul><ul><li>Covert and overt coercion for post-abortion contraceptive use in public institutions often compels women to seek unsafe abortion elsewhere. </li></ul><ul><li>Abortion policy also needs to explicitly link up with national and international technical guidelines form management of post-abortion complications. </li></ul>
  8. 9. Advances in Medical Science <ul><li>Abortion Pill </li></ul><ul><li>Infertility Techniques </li></ul><ul><li>Developments in Genetics </li></ul><ul><li>Fetal Age for Viability </li></ul><ul><li>International Scenario </li></ul>
  9. 10. Medical Abortion <ul><li>MTP using Mifepristrone (RU 486) & Misoprostol approved for up to 7 weeks termination </li></ul><ul><li>Only an RMP (as defined by the MTP Act) can prescribe the drugs </li></ul><ul><li>Has to follow MTP Act, Rules & Regulations </li></ul><ul><li>Can prescribe in his/her clinic, provided he/she has access to an approved place </li></ul><ul><li>Should display a certificate from owner of approved place agreeing to provide access </li></ul>
  10. 11. Abortion Pill <ul><li>A medical abortion- taking a drug or a combination of drugs orally, intramuscularly and/or vaginally to terminate a pregnancy. </li></ul><ul><li>Combinations of Mifepristone along with Misoprostol are used after confirming that a woman is pregnant. </li></ul><ul><li>The drugs are considered quite effective in the early stage of pregnancy </li></ul><ul><li>Newer and recent research does indicate that the drugs are effective almost up to the end of the first trimester pregnancy. </li></ul>
  11. 12. 60.00 4 Misogon 6 60.00 4 Misoprost 200 (Cipla Ltd.) 5 31.00 4 Misoprost 100 (Cipla Ltd.) 4 30.50 2 Zitotec 200 (Sun Pharma) 3 60.00 4 Cytolog 200 (Zydus Alidac Ltd.) 2 31.00 4 Cytolog 100 (Zydus Alicac Ltd.) 1 Misoprostol Tablets 325.00 1 Mifyron (German Remedies) 4 930.00 3 MT Pill (Cipla Ltd.)* 3 325.50 1 Mifeprine (Sun Pharma) 2 325.50 1 Mifegest (Zydus Alidac Ltd.) 1 Mifepristone Tablets MRP Rs. Dosage Drugs and Pharmaceutical Company Table 1: Abortifacients Available with Chemists #
  12. 13. 50.00 10 Ayurvedic Gynec Forte (Ankit Pharmaceuticals, Ahmedabad, Gujarat) 6 110.00 10 Ayurvedic CVP Forte (Sterling Lab, Hosur, TN) 5 50.00 3 Ayurvedic Gynaforte 4 50.00 10 Ayurvedic Reglum 3 30.00 6 Ayurvedic CVK Forte 2 14.00 3 Ayurvedic EP Forte (EN PA Forte) (Subina Pharmaceuticals, Indore, MP) 1 MRP for the recommended dosage in Rs. Dosage Type Brand Sr.No.
  13. 14. 38.00 10 Allopathic Megestone (Wyeth Health Care) 13 47.00 10 Allopathic Duibogen (Unichem Laboratories Ltd.) 12 45.00 10 Allopathic Emppea (Rekvina Pharmaceuticals) 11 15.00 2 Ayurvedic NK Capsule 10 50.00 10 Ayurvedic Dyenaforte 9 15.00 6 Ayurvedic CV Forte (Ankit Pharmaceuticals, Ahmedabad, Gujarat) 8 NA NA Ayurvedic Gynolate Forte 7 MRP for the recommended dosage in Rs. Dosage Type Brand Sr.No.
  14. 15. MTP Act: Shortcomings <ul><li>A recent survey in Gujrath Shows Chemists have been prescribing ‘ Abortion Pills ' more than doctors. </li></ul><ul><li>US has allowed RU468 to be sold over the counter </li></ul><ul><li>What about the Recognized Place ? </li></ul><ul><li>What about the trained or authorized Doctor? </li></ul>
  15. 16. MTP rules: Who can perform? <ul><li>A medical practitioner (RMP) </li></ul><ul><ul><li>who has a recognized medical qualification as defined in clause (h) of section 2 of Indian Medical Council Act, 1956 </li></ul></ul><ul><ul><li>Whose name has been entered in a State Medical Register and </li></ul></ul><ul><ul><li>Who has such experience or training in Gynecology and Obstetrics as prescribed by Rules made under the Act </li></ul></ul>
  16. 17. MTP Act: Shortcomings <ul><li>The doctors have been prescribing to the patients more than 7 weeks pregnant up to 14 weeks </li></ul><ul><li>Limits set by MTP Act? </li></ul><ul><li>Dosages? Doctors know it can be given per vaginally after 7 weeks to induce abortions. </li></ul>
  17. 18. MTP Act: Shortcomings <ul><li>More than 7 weeks Patient presents as Natural Incomplete Abortion and gets treated by the Obstetrician- </li></ul><ul><li>Dosages? </li></ul><ul><li>Abortion or preterm labour? </li></ul><ul><li>MTP Act Nowhere. </li></ul>
  18. 19. Partial Birth Abortion <ul><li>An abortion in which the person performing the abortion, deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother, for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and performs the overt act, other than completion of delivery, that kills the partially delivered living fetus. </li></ul>
  19. 20. What is Infertility treatment?
  20. 21. Case 1 <ul><li>32 years old woman seeks Gynecologist’s treatment for Infertility by IVF </li></ul><ul><li>After treating for few months woman gets pregnant with quadruplets </li></ul><ul><li>Gynecologists decides unless 3 embryos are ‘ selectively killed ’ and one embryo is allowed to develop, a viable pregnancy would not occur </li></ul><ul><li>After the selective reduction the dead embryos would be absorbed in the mother’s body and they would not be expelled from uterus </li></ul>
  21. 22. Case 1 <ul><li>Don’t you think the Selective Reduction causes encroachment of the MTP act ? </li></ul><ul><li>Should it be included in the act? </li></ul><ul><li>Is it necessary to take mother’s permission ? </li></ul><ul><li>What if she does not agree? </li></ul>
  22. 24. Genetics Research <ul><li>Medical genetics interventions can be </li></ul><ul><li>performed in two ways. </li></ul><ul><li>First, genetic defects may be repaired ( gene therapy ). </li></ul><ul><li>Secondly, a possible future individual (an embryo or a possible combination of gametes) may be preselected because of its favourable genetic make-up (by using genetic diagnostic methods and procedures from reproductive medicine ­ so called Preimplantation Genetic Diagnosis ). </li></ul>
  23. 25. Genetics Research <ul><li>The first kind of intervention means that someone gets medical treatment in the normal sense, however, </li></ul><ul><li>Second kind does not. Rather, in that case, the potential patient is exchanged for another individual who is in no need of treatment. </li></ul>
  24. 26. Genetics Research <ul><li>Molecular biology scientists have developed a technique that enables parents to select the sex of their future child . This technique simply separates the X carrying sperms from Y carrying sperms and then inseminates females with the preferred sex chromosomes. This procedure is banned in India. </li></ul><ul><li>Potential parents with sex-linked diseases may choose to have a girl, avoiding the possibility of having a boy with hemophilia, for example. Should sex selection for medical and non-medical reasons be available for parents? </li></ul>
  25. 27. Genetics Research <ul><li>Pregnancy-associated plasma protein-A (PAPP-A) largest of the pregnancy associated proteins produced by both embryo and placenta </li></ul><ul><li>( syncytiocytotrophoblasts ) during pregnancy </li></ul><ul><li>This protein is thought to have several different functions, including preventing recognition of the fetus by the maternal immune system, matrix mineralization and angiogenesis. Levels of PAPP-A rise from first detection in the first trimester until term. </li></ul>
  26. 28. Genetics Research <ul><li>Detection of this protein is also used as a first and second trimester diagnostic test for Trisomy 21. Down Syndrome </li></ul><ul><li>Maternal serum concentrations are related to subsequent fetal growth and this relationship has suggested that it can be used as a diagnostic test for adverse pregnancy outcomes (intrauterine growth restriction, premature birth, pre-eclampsia, and stillbirth). </li></ul>
  27. 29. Prenatal Diagnostic Methods <ul><li>Prenatal testing is testing for diseases or conditions in a fetus or embryo before it is born. The aim is to detect birth defects such as neural tube defects , Down syndrome , chromosome abnormalities, genetic diseases and other conditions. It can also be used to determine its sex . </li></ul>
  28. 30. Prenatal Diagnostic Methods <ul><li>Diagnostic prenatal testing can be by invasive or non-invasive methods. </li></ul><ul><li>Invasive methods involves probes or needles being inserted into the placenta,. </li></ul><ul><li>Amniocentesis , which can be done from about 14 weeks gestation, and usually up to about 20 weeks, </li></ul><ul><li>Chorionic Villus Sampling , which can be done earlier (between 9.5 and 12.5 weeks gestation) but which is slightly more risky to the fetus. </li></ul><ul><li>. </li></ul>
  29. 31. Prenatal Diagnostic Methods <ul><li>Non-invasive methods, called &quot;screens&quot;, can only evaluate risk of a condition and cannot determine 100% if the fetus has a condition. Non-invasive techniques include examinations of the woman's womb through ultrasonography and </li></ul><ul><li>maternal serum screens (i.e. Alpha-fetoprotein ). If an abnormality is indicated by a non-invasive procedure, a more invasive technique may be employed to gather more information </li></ul>
  30. 32. Prenatal Diagnostics <ul><li>Non-invasive methods , called &quot;screens&quot;, can only evaluate risk of a condition and cannot determine 100% if the fetus has a condition. </li></ul><ul><li>Ultrasonography : </li></ul><ul><li>Alpha-fetoprotein :Examinations of the woman's womb through maternal serum screens. </li></ul><ul><li>If an abnormality is indicated by a non-invasive procedure, a more invasive technique may be employed to gather more information </li></ul>
  31. 33. Prenatal Diagnostics <ul><li>Most often this is performed to test for birth defects . </li></ul><ul><li>Common procedures include amniocentesis , sonograms , nuchal translucency testing, or genetic screening. </li></ul><ul><li>The tests can be used to check for conditions such as Down syndrome , spina bifida , cleft palate , Tay Sachs disease , sickle cell anemia , thalassemia , cystic fibrosis , and fragile x syndrome . </li></ul><ul><li>In some cases, the tests are administered to determine if the fetus will be aborted . </li></ul>
  32. 34. Reasons for prenatal diagnosis <ul><li>There are three purposes of prenatal diagnosis: </li></ul><ul><li>(1) to enable timely medical or surgical treatment of a condition before or after birth, </li></ul><ul><li>(2) to give the parents the chance to abort a fetus with the diagnosed condition, and </li></ul><ul><li>(3) to give parents the chance to &quot;prepare&quot; for a baby with a health problem or disability, or for the likelihood of a stillbirth. </li></ul><ul><li>Having this information in advance of the birth means that healthcare staff can better prepare themselves and parents for the delivery of a child with a health problem. </li></ul>
  33. 35. <ul><li>If a genetic disease is detected, there is often no treatment that can help the fetus until it is born. This does give parents the option to consider abortion . </li></ul><ul><li>If abortion isn't an option for a particular couple (because of their own beliefs or the laws of their country), invasive prenatal diagnosis of such a condition is unhelpful as the test puts the fetus at risk, and knowing the result doesn't help the fetus. </li></ul>
  34. 36. Non-invasive methods <ul><li>Examination of the woman's uterus from outside the body. </li></ul><ul><li>Ultrasound detection - Commonly dating scans (sometimes known as booking scans ) from 7 weeks to confirm pregnancy dates and look for twins . The specialised nuchal scan at 11-13 weeks may be used to identify higher risks of Downs syndrome. Later morphology scans from 18 weeks may check for any abnormal development. </li></ul><ul><li>Listening to the fetal heartbeat (see stethoscope ) often known as a non-stress test </li></ul>
  35. 37. False Positives and False Negatives <ul><li>Ultrasound of a fetus, which is considered a screening test, can sometimes miss subtle abnormalities. For example, studies show that a detailed ultrasound, also called a level 2 ultrasound, can detect about 80% of spina bifida . Ultrasound results may also show &quot;soft signs,&quot; such as an Echogenic intracardiac focus or a Choroid plexus cyst , which are usually normal, but can be associated with an increased risk for chromosome abnormalities </li></ul>
  36. 38. False Positives and False Negatives <ul><li>Other screening tests, such as the AFP triple test , can have false positives and false negatives. Even when the AFP triple test results are positive, usually the pregnancy is normal, but additional diagnostic tests may be offered. Both false positives and false negatives will have a large impact on a couple when they are told the result, or when the child is born. </li></ul><ul><li>Diagnostic tests, such as amniocentesis, are considered to be very accurate for the defects they check for. </li></ul>
  37. 39. False Positives and False Negatives <ul><li>A higher maternal serum AFP level indicates a greater risk for Anencephaly and open Spina bifida . This screening is 80% and 90% sensitive for spina bifida and anencephaly, respectively. </li></ul><ul><li>Amniotic fluid acetylcholinesterase and AFP level are more sensitive and specific than MSAFP in predicting neural tube defects. </li></ul><ul><li>No prenatal test can detect all forms of birth defects and abnormalities </li></ul>
  38. 40. Imposing Questions <ul><li>These types of research work has lead to few questions- </li></ul><ul><li>Is the mother’s health and woman’s right have to be considered? </li></ul><ul><li>Is there any place for the child’s future health & life? </li></ul><ul><li>If the fetal defects are detected after 20 weeks? </li></ul>
  39. 42. Imposing Questions <ul><li>Who is more important, the Mother or the Fetus ? The crux is, can we force a mother to </li></ul><ul><li>(i) carry an unwanted fetus to term, with possible medical complications to the mother during delivery or childbirth, </li></ul><ul><li>(ii) endure postpartum blues, and </li></ul><ul><li>(iii) post-birth, force her to care for an infant that she does not want, </li></ul>
  40. 43. Fetal Viability
  41. 44. Imposing Questions <ul><li>If the Fetus is an independent entity and an Individual , can this individual live outside the mother? </li></ul><ul><li>No, of course not. Fetus born prematurely, i.e. before 37 weeks, may suffer complications even if treated in pre-natal intensive care. </li></ul><ul><li>Absent pre-natal care, they cannot survive as their organs aren’t developed yet. </li></ul>
  42. 45. Imposing Questions <ul><li>by compelling a mother to complete her pregnancy for a fetus she doesn’t want, we are forcing her to provide prenatal care (using her own body) which is not of her own choice, and for which she is obviously not being compensated either. The question is, is that a fair and just in the terms of law? </li></ul>
  43. 46. United Kingdom <ul><li>Abortion was illegal before 1968 act </li></ul><ul><li>In 1971 The act made abortion legal in the UK up to 28 weeks gestation. </li></ul><ul><li>In 1990, the law was amended by the Human Fertilisation and Embryology Act : abortion became legal only up to 24 weeks except in cases where it was necessary to save the life of the woman, there was evidence of extreme fetal abnormality, or there was a grave risk of physical or mental injury to the woman. </li></ul>
  44. 47. International Scenario <ul><li>In Europe , abortion is usually only allowed up to 12 weeks </li></ul><ul><li>Sweden 18 weeks, </li></ul><ul><li>Netherlands 21 weeks, </li></ul><ul><li>Great Britain 24 weeks in </li></ul><ul><li>France , unless the fetus is severely deformed or the woman's health is directly at risk, any abortion after the first twelve weeks is illegal. </li></ul><ul><li>Canada - no laws or restrictions regulating abortion, </li></ul><ul><li>Australia -places heavier restrictions on the procedure. Every Abortion needs permission. Ban on Abortion Pills. </li></ul><ul><li>US: Up to 26 Weeks </li></ul>
  45. 48. THANK YOU
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