Facility-based abortion care in India's public health system: 14-year trends, geographic inequalities, and the impact of the 2021 MTP Amendment Act

Background: In 2021, India amended its Medical Termination of Pregnancy (MTP) Act, expanding gestational limits up to 24 weeks for vulnerable categories and removing the requirement for a second medical opinion up to 20 weeks. We investigated 14-year trends in facility-reported MTPs, geographic access gaps, and whether the 2021 amendment changed late-gestation service provision. Methods: Analysis of monthly district-level HMIS reports, fiscal years 2008-09 to 2021-22. We extracted total facility MTPs, early ([≤]12 weeks) and later (>12 weeks) gestation procedures, post-abortion contraception adoption, and districts reporting zero MTPs. Interrupted time-series models evaluated COVID-19 disruption and post-2021 amendment shifts. Results: Public facilities recorded 8.9 million MTPs over 14 years, with annual totals holding flat at 0.60-0.75 million, representing a small fraction of India's estimated true abortion incidence. Persistent geographic disparities were documented: ~5% of all districts reported zero public facility MTPs annually. Following the September 2021 notification of MTP Amendment Rules, public facilities recorded a rapid 55% surge in >12-week procedures above pre-amendment trends, raising the late-gestation share from 6.9% to 9.7%. Post-abortion contraception provision experienced a deep 50% collapse during the 2020 lockdown that failed to recover through 2022. Conclusion: Routine service records provide the first empirical evidence that the 2021 MTP Amendment Act successfully expanded facility access to later-gestation abortion care. However, flat overall public reporting and persistent zero-reporting district clusters highlight severe lingering supply-side barriers and an unmet need for post-abortion family planning integration.