Abortion In India – Keep Abortion Safe And Legal!

KEY TAKEAWAYS

• Abortion is the termination of a pregnancy by removal or expulsion of an embryo or foetus.
• In India, there are 48.1 million pregnancies annually, of which nearly half are unwanted. Abortion occurs in two thirds of all unplanned pregnancies. 
• The Medical Termination of Pregnancy (MTP) Act is a central law in India that authorizes qualified medical professionals to perform abortions under certain predetermined circumstances.

INTRODUCTION

The removal of a foetus from the uterus before it reaches the viable stage is known as an abortion (in humans, this usually occurs around the 20th week of gestation). Abortions can happen naturally, in which case they are sometimes referred to as miscarriages, or they can be intentionally caused, in which case they are commonly referred to as induced abortions. Well, it’s certainly not as easy as we see in the movies.

When carried out by qualified medical experts using a technique advised by the World Health Organization (WHO) and suitable for the gestational age, abortion is considered a safe medical procedure and a form of healthcare intervention. "Pregnancy terminated voluntarily from a service provider" is the definition of an induced abortion. Early in their pregnancy, pregnant women can also safely and effectively manage a medical abortion on their own outside of a hospital setting, such as at home.

People may find it difficult to make the decision because of the stigma associated with abortion. However, the following are possible general causes of abortion:

• Unexpected pregnancy
• Unstable finances
• Relationship problems
• Health issues
• Not psychologically or emotionally prepared

The Indian Constitution's Article 21, which protects life and personal liberty, has been construed to encompass women's rights, among which is the right to choose to reproduce. The freedom to choose how and when to procreate would encompass both options. The most important thing to remember is that women should have the right to privacy, dignity, and physical integrity. This implies that there ought to be no limitations of any kind placed on the exercise of reproductive options, such as the right of a woman to decline engaging in sexual activity or, conversely, the requirement that contraceptive techniques be used. Abortion is acknowledged as a woman's right by several international human rights conventions. 

• The petitioner in Nand Kishore Sharma v. Union of India contested the constitutionality of the Medical Termination of Pregnancy Act, 1971, arguing that it violated Article 21 of the Indian Constitution. The Court noted that since the Act's goal is to protect the woman's life or alleviate any harm to her bodily or mental well-being and nothing else, it seems to be more in line with Article 21 of the Indian Constitution than against it.
• In the 2017 case Justice K.S. Puttaswamy (Retd.) vs. the Union of India and Others, the Supreme Court upheld women's constitutional right to make reproductive decisions as a part of their personal liberty under Article 21 of the Indian Constitution. However, even though this case establishes a strong body of precedent regarding women's privacy and reproductive rights, it does not fundamentally change the balance of power from the doctor to the woman seeking an abortion.

Even though India has had progressive laws for the past 50 years that has made access to abortion services easier, unsafe abortions still occur today. 

THE HISTORY OF ABORTION

Abortion was illegal and considered a crime, except for situations in which the woman's life was in danger. Individuals who intentionally caused a miscarriage in a pregnant woman could face up to three years in prison and a fine, while those who accessed the service could face up to seven years in prison and a fine.

India took the first step toward legalizing abortion when, in the middle of the 1960s, the government established the Shantilal Shah Committee, which was chaired by physician Dr. Shantilal Shah. The Committee recommended in 1964 that India liberalize its abortion rules to lower the number of unsafe abortions performed there as well as the nation's maternal mortality rate. A medical termination of pregnancy bill was submitted in the Lok Sabha and Rajya Sabha and passed by Parliament in August 1971, based on the Shantilal Shah Committee's recommendations.

On April 1, 1972, the Medical Termination of Pregnancy (MTP) Act became operative, including the entirety of India. In 1975, it underwent more changes to simplify it.

MEDICAL TERMINATION OF PREGNANCY ACT,1970

Ever since the Medical Termination of Pregnancy (MTP) Act was passed in the 1970s, abortions are completely permitted in India under several different circumstances. The MTP Act permits licensed medical professionals to perform abortions in certified facilities for a variety of reasons, including preserving a woman's life, protecting her mental or physical health, a social or economic need, rape, incest, or foetal impairment, as well as if a contraceptive method fails. To increase the number of providers delivering complete abortion care services within the bounds of the law, the act was revised in 2002–2003 to transfer the authority for a private facility to provide abortion services from the state level to the district-level committee. Under the MTP Act, abortion was allowed till 20 weeks of pregnancy.

Since the MTP Act only permitted abortions for a maximum of 20 weeks, any abortion performed after that point would require a judicial bypass. Judicial bypass has been granted by the courts on an individual basis. But the judiciary was unable to establish a precise legal framework to control the circumvention procedure. Judges have broad discretion because there are no enforceable precedents. Furthermore, conflicting rulings have left it unclear when a woman or girl is legally allowed to get an MTP which goes beyond 20 weeks. 

The legal system lacks a clear framework that would specify when an MTP is permitted to last longer than 20 weeks, how to carry out away with the requirement for court and medical board approval, and how to deal with the fundamental problem of medical professionals refusing to approve lawful abortions.

• In a 2017 decision, the Supreme Court dismissed the serious psychological risks associated with bringing an undesired pregnancy to term on behalf of the petitioner, who wished to end her pregnancy when it was past 27 weeks. The medical board advised against the abortion since the foetus might be "born alive" and survive for an unpredictable period. This opinion served as the foundation for the court's ruling. When deciding whether to accept the MTP, the claimant's mental state doesn't seem to have come up for discussion rather, the foetus was prioritized over the mother.
• The Indian Supreme Court noted that there is a "compelling state interest in protecting the life of the prospective child" in the situation of pregnant women in Suchita Srivastava v. Chandigarh Administration. Consequently, a pregnancy can only be terminated if all requirements outlined in the relevant statute have been met. Therefore, it is equally possible to see the Medical Termination of Pregnancy Act, 1971's provisions as appropriate limitations on the exercise of reproductive choices. 

METHODS – HOW CAN A PREGNANCY BE TERMINATED MEDICALLY?

While its legal, many women struggle to understand what the abortion procedure is all about, and what are the different types they can opt for. Here, lets learn about the different techniques that can be used. 

DILATION AND CURETTAGE

When abortion became legal in India in 1971, the dilatation and curettage (D&C) method was the only option accessible. The invasive medical technique that goes by the name "the use of anaesthesia for removing products of conception using a metal curette" is this outdated method, which carries a risk of uterine infections or haemorrhage. In a joint statement, WHO and FIGO recommended that hospitals with the necessary equipment switch from curettage to manual and electric aspiration techniques.

SURGICAL ABORTION

The term "surgical abortion" describes the methods used in clinics to end a pregnancy. Vacuum aspiration and Dilatation and Evacuation (D&E) are the two basic surgical abortion methods. The duration of your pregnancy is taken into consideration when using the two methods. Vacuum aspiration is performed for a maximum of 16 weeks following the patient's last menstruation, but D&E can be utilized for up to 20 weeks. While D and E can take up to 30 minutes, the vacuum aspiration process only takes ten to fifteen minutes.

Like medical abortions, surgical abortions can cause adverse effects in women such as cramps, nausea, bleeding, and sweating. Infection risk is greater than it is with medical abortion.

If a woman is past the 24-week mark in her pregnancy and is unable to undergo a D&E, she should consider having an induction abortion. To induce labour and trigger contractions that will expel the foetus, the doctor will prescribe a medication that you must take in a hospital setting.

MANUAL VACUUM ASPIRATION

Manual vacuum aspiration, also known as MVA, is a "safe and effective method of abortion that involves evacuation of the uterine contents by the use of a hand-held plastic aspirator”, that is "associated with less blood loss, shorter hospital stays and a reduced need for anaesthetic drugs”. The WHO advises using this type of abortion for early pregnancy termination.

ELECTRIC VACUUM ASPIRATION

Insofar as it involves a suction method, electric vacuum aspiration (EVA) is like manual vacuum aspiration (MVA). However, instead of using a hand pump as in MVA, EVA employs an electric pump.

INDUCTION ABORTION

If a woman is past the 24-week mark in her pregnancy and is unable to undergo a D&E, she should consider having an induction abortion. In order to induce labor and trigger contractions that will expel the foetus, the doctor will prescribe a medication that you must take in a hospital setting. The two medications that are authorized for use in India are misoprostol and mifepristone.

RAPE VICTIMS – DOES RAPE JUSTIFY ABORTION?

The answer is YES! It does. Going through an unwanted pregnancy is the last thing any rape victim would want to face.

India has enacted several laws that acknowledge survivors of sexual and domestic abuse have a right to healthcare. These include the pertinent sections on sexual assault in the Criminal Law Amendment Act of 2013, the Protection of Children from Sexual Offenses Act (POCSO) 2012, and the Protection of Women from Domestic assault Act (PWDVA) 2005. 

In reaction to copious amounts of information demonstrating that rape survivors in India's health systems are mistreated, the latter two regulations require public and private institutions to offer rapid treatment to victimized parties. They also specify the consequences of non-compliance.

• According to the ruling in Bashir Khan v. State of Punjab, the Director General of Police shall give general instructions to all the police stations that register cases of rape and who come by information that the victim has become pregnant to render all assistance to secure appropriate medical opinions and also provide assistance for admission in government hospitals and render medical assistance as a measure of support to the traumatized victim in order to ensure that the victim of rape who becomes pregnant does not lose time by applying from court to court provides consent and there is evidence that the rape was the cause of the pregnancy.

The only circumstances in which it would be necessary to request authorization from the court would be where there is disagreement over whether the pregnancy needs to be terminated, or when two medical professionals have different opinions. In cases when there is little resistance, the victim provides her own consent, the guardian provides consent, and there is evidence that the pregnancy was caused by rape, it is scarcely necessary.

Rape victim treatment is covered by the recently enacted Section 357C of the Criminal Law Act of 2013 (formerly the Code of Criminal Procedure, 1973). It requires all hospitals, public or private, owned by the federal government, state governments, local governments, or any other entity, to give rape victims free medical attention or first aid right away. In addition, Section 166B has been added to the IPC, stating that "anyone who violates the provisions of section 357C of the Code of Criminal Procedure, 1973, while in charge of a hospital, whether public or private, whether run by the Central Government, the State Government, local bodies or any other person, shall be punished with imprisonment for a term which may extend to one year or with fine or with both.”

MARITAL RAPE

The Supreme Court ruled on Thursday that a husband's coercive sexual behaviour can be considered rape under the Medical Termination of Pregnancy (MTP) Act, giving victims of marital rape the same legal right to an abortion as other survivors of rape.

According to the MTP Act and Rules, "a husband's act of sexual assault or rape committed on his wife" would be considered "rape." 

For the sole purpose of the MTP Act and any rules and regulations created thereunder, marital rape must be included in the definition of rape. The highest court noted that any other reading would have the effect of forcing a woman to bear and raise a child with a spouse who abuses her mentally and physically.

• In X v. Principal Secretary, the Supreme Court allowed the petitioner to end her 22-week pregnancy. The Court determined that dividing someone's rights based just on their marital status is unconstitutional, a ruling that was applauded by proponents of reproductive rights. It also acknowledged the unfulfilled demands of survivors of marital rape in cases of unintended pregnancies.

POCSO CASES

 According to the POCSO 2012, all licensed medical professionals must provide emergency care, including access to abortion, to minors who have been sexually assaulted, that emergency contraception and abortion services must be provided as part of the initial treatment provided to rape survivors. It is crucial to create a balance between the unborn child's right to life and the victim of child rape when it comes to ending the victim's pregnancy; this balance should always favour the child rape victim.

Victims of child rape face peril on both fronts - whether they give birth or choose to abort. Not to mention, a child may not have the strength needed to carry the weight of a pregnancy. In the early years of development, the pelvic bones are not fully formed to support pregnancy and allow for the baby's passage during birth. Furthermore, it's important to consider the risks associated with teen pregnancy and abortion.

• The Court noted in R and Anr. v. State of Haryana that "streamlining the system in this regard is required because some abortions are necessary beyond the statutory limit in the light of the circumstances under which they are sought." The MTP Act is insufficient legislation that seems to have been created primarily to support the family planning initiative. Women's rights to terminate pregnancies are regulated by the MTP Act. The MTP Act's stated goals are to assist women who are raped, assist women who become pregnant because of contraceptive failure (which applies to married women), or lower the likelihood that children with serious disabilities will be born. 

The Protection of Children from Sexual Offenses, Rule Five, 2012 provide that "a police officer shall make arrangements to take the child to the nearest hospital or medical care facility centre for emergency medical care whenever he or she comes to know about the commission of an offence on a child." Additionally, the licensed medical professional providing emergency treatment must attend to the child's needs, including discussing emergency contraception and potential pregnancy with the pubertal child's parent or any other person the youngster feels comfortable and confident in.

• In the case of Ashaben v. State of Gujarat, the Gujarat High Court interpreted Section 5 of the MTP Act restrictively, holding the victim prisoner before allowing her to request termination. In response to a 24-week pregnant woman's application to the High Court, the Court noted: "Clearly, Section 5 of the Act refers to a pregnant woman's right to terminate her pregnancy in the event that it is determined necessary to preserve her life. There is no mention in Section 5 of a pregnant woman's ability to end her pregnancy before 20 weeks on the grounds that she was raped during conception.”

It does not apply to any other situation; rather, it is limited to situations in which the pregnant woman's life would be in jeopardy if the pregnancy were not ended. 

Without a doubt, a licensed medical professional must form the opinion in that regard, and it must be formed in good faith. The phrase "good faith" makes it clear that the opinion must be supported by the examination needed to establish one of these. 

The challenge is that there are no legal guidelines under the MTP Act for doctors or courts to follow when deciding on abortion after 20 weeks.

• However, The Delhi High Court granted permission for a 13-year-old victim of rape to have her pregnancy medically terminated after 26 weeks in July 2022. The court reasoned that the girl's suffering would be exacerbated if she had to assume the role of mother at an early age. On the advice of a medical board, the Kerala High Court allowed a young rape survivor to have her 28-week pregnancy terminated in August 2022.
• A 15-year-old girl who had eloped to get married asked the Delhi High Court for permission to terminate her 25-week pregnancy. However, the medical body tasked with reviewing her case concluded both the mother's and the foetus’s lives would be seriously jeopardized by the termination. The girl was then refused permission by the High Court to have an abortion.
• In XYZ v. State of Maharashtra (2021), the court permitted a minor to end her pregnancy in the 26th week after considering her socioeconomic status and the potential negative effects of carrying the pregnancy to term on her mental health.

CURRENT SCENARIO – MAKING ABORTION SAFE.

The impact of the MTP Act should be evaluated in light of shifting social conditions, attitudes, and values in India, a nation with a great deal of social baggage on top of societal ills like poverty and illiteracy. In its most basic form, the societal ramifications of the MTP Act can be divided into two categories: abortion for married women and abortion for single girls. The meanings of these two are quite different. Married women in the MTP Act are not stigmatized by society, while single females find it difficult to fit in. The fact that it is taboo makes safe abortions difficult to perform, sometimes negating the abortion's primary goal—the woman's health. 

The concept to enact legislation that would reconcile the ethical and legal perspectives was established by the long-running ethical discussion about the legal position regarding the prevention of undesired pregnancies around the world. The ethical debates surrounding medical abortion termination of pregnancy persist in India despite legal and judicial regulation. Even though a lot of people think that medically ending a pregnancy is unethical, women now have the freedom to do so.

The Medical Termination of Pregnancy (Amendment) Act of 2021 increased the maximum gestational limit for abortion from 20 to 24 weeks, and it went into effect in September of that year. The amendment was hailed as the next step toward more progressive Indian abortion legislation, even though it did not recognize abortion on demand as a pregnant person's right. The amendment was a response to numerous women who had undesired pregnancies that went beyond the acceptable gestation period requesting access to safe medical support through the Indian courts. 

With the 2021 amendment and the 2022 ruling, India made progress, but it did not stray far from the gestational restrictions and grounds-based approaches. Despite the modification, the MTP Act maintains its provider-centricity and gives service providers the authority to make decisions rather than acknowledging that abortion should be made available to expectant mothers upon request and whenever necessary. 

The legal framework surrounding the abortion law in India also saw a turning point in September 2022 when the Supreme Court upheld women's right to reproductive and decisional autonomy by eliminating the "artificial distinction" between married and single women and granting judicial recognition to "marital rape" for the purposes of abortion.

• In December 2017, a Thane lady went before the Bombay High Court to ask for permission to abort her 22-week-old foetus, which had been diagnosed with many malformations. The medical committee's assessment acknowledged that it would be dangerous to end the pregnancy at this point but also determined that the kid, if delivered, might have an intellectual handicap. Following the petitioner's declaration of her readiness to assume the risk, the Court allowed her to undergo adoption.
• In November 2017, a woman approached the Bombay High Court for permission to terminate her pregnancy in 26th week of gestation on grounds of skeletal and neurological abnormalities. Further to the opinion of the medical board constituted by the court, she was granted permission to terminate her pregnancy due to fetal abnormalities incompatible with life.
• The mother of a 16-year-old Madhya Pradesh rape victim went to the Indore High Court bench in April 2017 to ask for permission to end her daughter's 33-week pregnancy. The bench denied the request, stating that the "abortion was unjustified because the foetus was grown."
• In Z v. State of Bihar (2018), the highest court criticized the "negligence and carelessness" of the authorities in failing to terminate the pregnancy as allowed by law, acknowledging the disastrous effects of needless delays and a lack of promptitude in the attitude of authorities when dealing with pregnancies.

PARLIAMENTARY DEBATES OVER ABORTION LAWS

In a recent Supreme Court decision, a woman successfully requested a medical abortion after 24 weeks of pregnancy, arguing that her partner had raped her under false pretences of marriage.

In another case, the Delhi High Court intervened and ordered a medical investigation to determine whether the 16-year-old was fit for abortion in response to the heartbreaking story of how she had been abducted by strangers, sexually assaulted for two years, and then found abandoned close to the Delhi University campus. The Medical Termination of Pregnancy Act (MTP Act) allowable period was exceeded by the decisions in both cases. 

The MTP (Amendment) Bill received overwhelming support from members during the Lok Sabha's March 17, 2020, debate. Key points from the debate:

• India will now be able to count itself among the countries with extremely progressive laws that permit abortions for a variety of medical, humanitarian, and societal reasons.
• Data from 2017 showed that while 59 countries permitted the technique, just seven—Canada, China, the Netherlands, North Korea, Singapore, the United States, and Vietnam—permitted it beyond 20 weeks. India has since joined them.
• Criminalization makes abortions more stigmatized. Because of this stigma, women are compelled to seek out risky abortions, which are frequently performed by unlicensed medical professionals in unregistered facilities.
• Unwed pregnancies are a serious problem that require immediate treatment.
• New issues arise in the modern day, and solutions to them must also be modern.
• One of the 1971 Act's regressive elements is relaxed because the Bill also applies to single women. 
• Currently, 56% of abortions performed in our nation are dangerous; of 6.4 million abortions performed annually in India, 3.6 million are unsafe, accounting for 13% of maternal fatalities in the country. To stop these maternal fatalities, safe abortion is necessary. The significance of this bill increases when one considers that India's Sustainable Development Goal is to reduce the country's maternal death ratio from 122 per lakh live births to 70 per lakh live births by 2030. It is certainly excellent that we are presently among the nations with the highest upper gestational limit.

PROPOSED AMENDMENTS IN THE NEW BILL

To guarantee that everyone has access to quality healthcare, the new Medical Termination of Pregnancy (Amendment) Act 2021 increases access to safe and authorized abortion services on social, medical, eugenic, and therapeutic grounds.

• Termination due to Failure of Contraceptive technique or Device: A married woman may end a pregnancy up to 20 weeks in accordance with the Act if a contraceptive technique or device fails. For this reason, it also permits single women to end a pregnancy. 
• Opinion Required for Termination of Pregnancy: Up to 20 weeks of gestation, one Registered Medical Practitioner (RMP)'s opinion is required for pregnancy termination. 
• - Views of two RMPs regarding the termination of a 20–24-week pregnancy is required. 
• If significant foetal abnormalities are found, a pregnancy may be terminated after 24 weeks with the approval of the state-level medical board.
• Upper Gestation Limit for Special Categories: This raises the maximum gestation period for women who fall into specific categories, such as rape survivors, incest victims, and other vulnerable women (such as minors and women with disabilities). The previous limit was set at 20 weeks. 
• Confidentiality: Unless authorized by an enacted law, the "name and other particulars of a woman whose pregnancy has been terminated shall not be revealed."
• The new law will help achieve Sustainable Development Goals by reducing avoidable maternal death. 
• Ensures that everyone has access to sexual and reproductive health and rights and focuses on lowering the maternal mortality ratio. 
• The reforms will guarantee women's dignity, autonomy, secrecy, and fairness when it comes to accessing safe abortion services. They will also broaden the scope of these services for women.
• The Act only permits abortion after 24 weeks if a Medical Board determines that there are significant defects in the foetus. This suggests that a Writ Petition is the sole option available in cases where rape necessitates an abortion, and the pregnancy is longer than 24 weeks.
• The Act mandates that only physicians board certified in obstetrics or gynaecology may perform abortions. Because there is a 75% shortfall of these doctors in remote community health clinics, pregnant women may still have trouble accessing safe abortion facilities.

CRITICAL ANALYSIS

Maternal survival rates have increased in tandem with improved abortion care quality and safety as countries throughout the world have opened more areas for access to reproductive health services. However, there are significant differences in the safety of abortion operations between nations with strong abortion restrictions and those where abortion is commonly permitted.

USA

The United States have enacted and introduced a variety of abortion-related laws for decades. While some passed legislation to safeguard access to abortion, others tried to outlaw abortion at earlier stages of pregnancy and placed more onerous restrictions on abortion providers.

The Roe v. Wade judgment, which was overturned by the Supreme Court on June 24, 2022, overturns nearly fifty years of precedent that guaranteed the constitutional right to an abortion in the Unites States. The freedom to choose whether to have an abortion is guaranteed by the Constitution, according to the 1973 Roe decision of the Supreme Court, even though restrictions are allowed beyond the first trimester of pregnancy. Along with numerous other Western European countries, the United States was among the first to liberalize its abortion laws after the Roe v. Wade case.

CHINA

China's one-child policy, implemented in 1979 in an attempt to slow, population growth by limiting families to one child, encouraged the use of abortion and liberalized the country's abortion laws in the 1950s. To prevent unplanned births, the legislation that made abortion services broadly accessible also included harsh coercive measures like fines and mandatory sterilization. The cap was raised to three children in 2021, and China's State Council released guidelines for women's development that urged a decrease in "non-medically necessary abortions."

IRELAND

The Irish parliament approved the legalization of pregnancy terminations before twelve weeks of pregnancy and in situations where the mother's health is in jeopardy in 2018. Prior to 1983, when the country's constitution was amended, Ireland had some of the strictest abortion prohibitions in all of Europe, which essentially outlawed the procedure. In 2019, Northern Ireland, a region of the United Kingdom (UK), legalized abortion. Following a vote by the UK Parliament, the 1967 Abortion Act—which gives doctors in England, Scotland, and Wales the legal right to perform abortions—was extended to Northern Ireland as well.

MOROCCO

When Morocco was a French protectorate, the abortion regulation was first enacted in 1920. A king's directive in May 2015 sparked a public debate about the expansion of legal protections after incidents of women dying after unsafe abortions came out. The Moroccan Family Planning Association claims that unmarried women would be excluded because it is illegal to have sex outside of marriage, even though it is generally agreed upon that abortion should be allowed within the first three months if the woman's physical and mental health is in danger, as well as in cases of rape, incest, or congenital malformation.

ETHIOPIA

Ethiopia relaxed its laws regarding abortion in 2005. Abortion was previously restricted to situations in which the woman's life or physical well-being was at risk. The current legislation permits abortion in situations involving rape, incest, or foetal impairment. It also permits abortions when the woman's life or physical health is in jeopardy, when she has a physical or mental disability, or when she is a minor who is not mentally or physically capable of giving birth. In line with WHO recommendations, the government approved the use of misoprostol in conjunction with or instead of mifepristone when it released national standards and guidelines on safe abortion in 2006. A few years later, 27% of abortions were legal, but most of them remained unsafe.

CONCLUSION

The 2021 changes attempted to eliminate several oddities and flaws in the previous legislation, reflecting a progressive legislative outlook. The revisions unquestionably extended the time frame for which an abortion is permissible and included women who are not married, thus expanding the right to reproductive healthcare. The intervention of constitutional courts became essential even as the new law attempted to address various situations, as abortion is not just a medical-technical matter that must be decided within the confines of the law, but rather is a matter of decision-making and ideology that sets off a struggle between several actors, including the State, the family, motherhood, and women's autonomy.

Ultimately, even while a lot has been done to give Indian women more access to safe abortion services, a lot more must be done. Enhancing women's knowledge of their rights and entitlements, as well as their access to information and services, will empower them to make more informed decisions about their reproductive health and lead to better health outcomes.