Respectful Abortion Care initiative: How a large‐scale virtual training for providers in India increased knowledge of the new 2021 Medical Termination of Pregnancy Act

In a historic move to ensure comprehensive abortion care, India amended the 1971 Medical Termination of Pregnancy (MTP) Act in 2021, creating an unprecedented opportunity for accelerating safe, respectful, and rights‐based abortion services. The Federation of Obstetric and Gynecological Societies of India (FOGSI), together with World Health Organization (WHO) India and the Ministry of Health and Family Welfare, set up a flagship initiative “Respectful Abortion Care” (RAC) to provide training to obstetricians and gynecologists on the new Act, and also address their values and biases.


| BACKG ROU N D
Nearly 73 million induced abortions occur worldwide every year. 1 Globally, 29% of all pregnancies and 61% of unintended pregnancies end in induced abortions. 1,2In India, the burden of unintended pregnancies and unsafe abortions remains significant.[3] Recent estimates from the World Health Organization (WHO)   show that 44% (95% CI, 42-48) of all pregnancies in India are unintended.The proportion of unintended pregnancies that end in abortion has increased from 47% (95% CI, 36-57) in 1990-1994 to 77% (95% CI, 74-81) in 2015-2019. 1,2Access to safe and CAC is crucial, especially for women with unintended pregnancies who often lack access to effective, timely, and free service due to a myriad of sociocultural, economic, and/or legal barriers. 3ile the Medical Termination of Pregnancy (MTP) Act made abortion legal in various situations in India for almost five decades, unsafe abortions remain the third leading cause of pregnancyrelated deaths in the country. 4The private sector is the leading abortion service provider in the country, accounting for more than half of all abortions services (53%) including management of postabortion complications (70%). 5[8] In 2021, India made a historic amendment to the MTP Act, aiming for a rights-based, holistic, woman-centered approach. 6,7e amendment to the existing MTP Act was a result of extensive consultation led by the Ministry of Health and Family Welfare (MoHFW), Government of India with experts representing a range of stakeholders from central ministries and departments, state governments, WHO, nongovernmental organizations, academic institutions, professional bodies and associations, legal professionals, and all concerned government organizations.The amendment has significant changes, including the role of CAC service providers, confidentiality norms, and special categories (Box 1).Wider acceptance by the obstetrician/gynecologist community is imperative not only to reduce the burden of unsafe abortions, 8,9 but also improve the overall experiences of women and girls.The law now guarantees access for younger and unmarried women; therefore, the role of CAC service providers in India is more important than ever. 3,6,7,10e Federation of Obstetric and Gynecological Societies of • Special case: Increasing the upper gestation limit from 20 to 24 weeks for special categories of women including survivors of rape and other vulnerable women (like differently abled women, minors) etc. [For special/vulnerable categories, MTP is now allowed up to 24 weeks with the opinion of two RMPs.The MTP Act 2021 simplifies minor consent and prioritizes women's well-being.

It makes India the only country where women can legally obtain an MTP during a humanitarian crisis]
• Birth defect: Upper gestation limit does not apply for substantial fetal abnormalities determined by a Medical Board defined in Rules under the Act.[Cases of substantial fetal anomalies are viewed through a humanitarian lens.Whereas, previously, the gestational limit was 20 weeks in all cases, now, there is no limit for pregnancies with substantial fetal abnormalities that are diagnosed by a Medical Board in accordance with the Rules of the MTP Act] • Confidentiality: Name and other particulars of a woman whose pregnancy has been terminated is not revealed except to a person authorized by law.[The 2021 Amendment Act introduces a new privacy clause that prohibits RMPs from revealing details of a terminated pregnancy (except to authorized persons under any law), with a strict penalty for violations.Assurance of privacy will lead to an increase in demand] • Choice: The grounds of failure of contraceptive extended to a woman and her partner, safeguarding access to safe abortion based on choice irrespective of marital status.[The new amendment extends the grounds of failure of contraceptive to any woman and her partner from the earlier limitation of any married woman or her husband.[13][14] Drawing upon the global WHO Abortion Care Guideline (2022), we included the principles of respectful maternity care and recommendations on addressing values and biases to provide nonjudgmental abortion services.RAC was defined as: "care that maintains safety, dignity, respect, confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during and after all types of abortion and or termination of pregnancy". 10Obstetrician/gynecologists in the FOGSI network were targeted through email outreach and registration in virtual trainings through societies.The trainings also included content on promoting dignity, enhancing quality, and providing respectful services. 11

| MATERIAL S AND ME THODS
The initiative followed a carefully drafted plan, which involved forging partnerships with FOGSI, WHO, All India Institute of Medical Sciences (AIIMS), and MoHFW.Content creation included defining and developing the curriculum, which incorporated the WHO SAVER (Safe Abortion Values, Evidence and Rights/Respect) toolkit.
The training roll-out was conducted in six phases over 15 months, utilizing virtual and hybrid sessions, with pre-and post-tests and surveys to evaluate knowledge acquisition and commitments. 11GSI was selected for its ability to reach a large number of obstetricians/gynecologists who are currently the only cadre of healthcare professionals in India authorized to provide the full range of CAC services, including both medical and surgical procedures.As one of the largest membership-based organizations of specialized professionals globally, there was an ambitious aim to reach all 42 000+ members in 272 societies across 36 states and union territories.
A carefully drafted plan (Figure 1) was designed by the core team, consisting of relevant national experts to develop the curriculum, identify master trainers (MTs), and roll out the trainings in a structured manner.Special attention was given to ensuring systematic data collection.The content for the RAC workshop was based on an extensive literature review [12][13][14][15][16][17][18][19][20][21][22][23][24] and utilized relevant materials from the WHO Safe Abortion SAVER toolkit. 25e curriculum was divided into four modules of 20 min each, with 10 min allocated for questions and answers (Box 2).These • Who is authorized to carry out an MTP?
• Has the law been amended to expand MTP services?
• How many registered practitioners' opinions are required if MTP is to be conducted up to 20 weeks and between 20 and 24 weeks?
• Whose consent is required for an MTP in the case of a married women and in the case of an adolescent?
• Is there an upper gestation limit for an MTP in the case of birth defects?
• Is legal evidence needed for an MTP in cases of rape or incest?
• Is MTP available for married or unmarried women including failure of contraception?
In addition, participants were also asked whether they had taken part in or conducted an MTP program (which would explain their level of knowledge of the revisions) as well as whether they agreed or disagreed with the statement that legally restricting abortion leads to a reduction in abortions.

| Phase II (October 2021)
Mock sessions with all MTs to ensure standardized delivery, address program needs, and conduct trainings with standard evidence-based responses.As shown in Figure 2, 97% of participants (increase from 85%)

| Phase III (November and December 2021)
answered that the opinion of one provider is required up to 20 weeks and two providers at 20-24 weeks of gestation.Compared to pretest, 83% of participants (increase from 52%) now knew that in cases of significant birth defects, there is no upper gestational age limit for abortion if determined by a Medical Board.From a previous 85%, 94% of participants now correctly identified that married women do not need their husband's written consent, and in a significant improvement, 57% of participants (increase from 25%) now knew that minors do not need both parents' consent for termination.While knowledge of no longer needing legal evidence in the case of rape or incest up to 24 weeks increased significantly to 49% (from 31%), it still falls slightly below the 50% hoped for level.There was a high awareness of access for unmarried women on the grounds of contraceptive failure, with pre-and post-test results of 95% and 98%, respectively.
Post-training exit surveys on attitude and commitment as an expected outcome of the SAVER modules as part of RAC were completed by all participants as this was needed to receive the certificate of completion.The results demonstrated that 95% of participants expressed strong motivation to either perform or assist an abortion procedure in accordance with the law (Figure 3).

Furthermore, 89% of participants reported experiencing value
clarification through open discussions on sensitive topics, including abortion, in a comfortable manner.Additionally, 96% of participants expressed a strong commitment to the issue of abortion, recognizing its importance.

| DISCUSS ION
[16][17][18][19] Over the last decade in India, even before the amendment to the abortion law in 2021, important strides were taken to improve safety, availability, and accessibility of CAC services.[17][18][19][20] RAC was the first-of-its-kind collaborative effort between a professional association and WHO that disseminated evidence-based information to more than 9000 service providers over a period of   However, it become evident that there was a growing demand to include practical, hands-on sessions on medical and surgical abortion in these training programs.This growing need necessitated significant redesigning of the RAC training program to better align with a physical delivery mode, enabling trainees to gain valuable hands-on experience.

| CON CLUS ION
The RAC initiative clearly demonstrated that collaboration and leadership by professional associations can motivate professionals and lead to increased knowledge and understanding among providers in both public and private sectors.Our main aim was to demonstrate that large-scale online trainings could effectively be done during the pandemic for evidence dissemination and incorporating aspects of Finally, we recognize the significant efforts made to increase access to safe abortion services for women in India.However, it is important to acknowledge that there is still much to be done to address the provider biases, inequities, and rudimentary sociocultural biases that continue to affect women, particularly in rural areas, and young and unmarried women.Hence, addressing the root causes of gender discrimination, while disaggregating personal values from service delivery, and clarifying provider biases remain critical.These need to be systematically included in all capacity building and training efforts on access to safe, legal, and respectful abortion services.

7 •
India (FOGSI), together with WHO India and the MoHFW, set up a flagship Respectful Abortion Care (RAC) initiative.The goal was K E Y W O R D S abortion, India, legal changes, obstetricians/gynecologists, respectful care, training BOX 1 Features of the MTP Amendment of 2021 6,Provider: One provider for termination of pregnancy up to 20 weeks of gestation and opinion of two providers for termination between 20 and 24 weeks of gestation only.[Previously, only married women could obtain an MTP up to 20 weeks with two registered medical practitioner (RMP) opinions; today, any woman in India, married or unmarried, can safely obtain an MTP up to 20 weeks with the opinion of one RMP and between 20 and 24 weeks of gestation with the opinion of two RMPs] modules were meant to inform about the law, explore personal values, engage with experts, and equip participants with the tools to communicate effectively on evidence-based information and key recommendations from WHO guidance on sexual and reproductive health and rights with a focus on CAC, including contraception, safe abortion, and postabortion care.The training sessions were highly interactive with built-in spot quizzes, and question and answer sessions at the end of each topic.The training sessions were planned to be conducted virtually and lasted for a duration of 2 h.Experts from the FOGSI network helped deliver the trainings.MTs were identified to deliver the RAC content in a standardized manner across the country.A set criterion was developed for selection of MTs to include experts and leaders especially from abortion subcommittees of all societies.The requirements for MT selection were: one leader per society, more than 15 years of practice (public or private), national/state recognition, more than 10 years of teaching experience, and motivation for participation.National-level training of MTs was done to ensure that they could conduct the trainings on their own.One observer from WHO or FOGSI participated in all subsequent training to ensure quality and consistency of program implementation.The goal was to have at least 300 MTs representing all societies.However, owing to the leadership of FOGSI ultimately, RAC had 690 MTs trained by WHO experts in the RAC content delivery and standardized roll-out of trainings.Pre-and post-test surveys were developed and tested with MTs to gather information on knowledge acquisition after training and generate commitments on carrying forward the lessons of RAC trainings in their everyday lives.A set of questions was asked to assess participant's knowledge, attitudes, and comprehension around abortion care and the recent amendments to the MTP Act 2021.The questions on the recent revisions to the MTP were: Attitude and commitments on safe abortion values, evidence, and rights/respect as a part of RAC were assessed in a post-training exit survey only.RAC training was divided into six phases conducted in a cascade approach over a period of 15 months from September 2021 to December 2022.Three months were spent on preparation including MTs, curriculum, and SAVER adaptation.The MTP amendment and its subsequent rules were finalized by the Government of India by the end of 2021.2.1 | Phase I (September 2021) Curriculum development, finalization and vetting, pre-and post-test questionnaire framing, development of exit survey form, design of training certificates, and data collection template design process started.
Three hundred MTs trained and training timeline and schedule finalized.In addition, more champions from across the 272 societies were also identified and trained as additional MTs.Care was taken to ensure all training timings would take place between outpatient departments or during their break from their clinical schedules to optimize participation.Trainees were sent reminders via email and encouraged to register for RAC sessions on any day as per the MT training schedule.F I G U R E 1 Summary of RAC initiative preparation and roll-out in India-September 2021-December 2022.FOGSI, Federation of Obstetric and Gynecological Societies of India; MoHFW, Ministry of Health and Family Welfare; MT, Master trainer; RAC, Respectful Abortion Care; UT, union territories; WHO, World Health Organization.

STEP 1 :STEP 3 :STEP 5 :
Partnership and FOGSI flagship established 5 members -Core team with FOGSI-WHO supported by MoHFW STEP 2: Literature Review for Content Creation Completed Target audience and goal defined Reach 42 000 Ob/Gyns in 270 societies across 36 State/UTs in India STEP 4: RAC MTs and FOGSI member training rolled out Phase I (Sept 21) RAC modules vetted, and certificates finalized Phase II (Oct 21) Mock training sessions conducted with core team and MTs identified Phase III (Nov-Dec 21) 300 MTs trained and training timeline created, and logistics done Phase IV (Jan-Jun22) 60% of all training sessions completed with 690 total master trainers Phase V (Jul-Nov22) Pandemic situation improved; hybrid sessions conducted 30% online & 10% hybrid (in-person) in select cities Phase VI (Dec22) Wrap-up with all training materials shared with 42 000 members via email and SAVER microsite future reference Results and Research Paper Documented 42 000+ Ob/Gyns across India received RAC modules by email 9051 Ob/Gyns completed full 2-h RAC training online 9051 Ob/Gyns participated in exit survey were aware of recent amendments; and 94% were aware that RMPs can provide abortions.Knowledge on details of the amendment improved significantly as measured by the post-training assessment (Figure 2).The pairedsample t test demonstrated that there was a significant increase in overall knowledge test score (t = 2.94; P < 0.0186, 95% CI) from before the RAC training (mean ± SD 73.4 ± 29.32) to after the RAC training (85.4 ± 19.36).

F I G U R E 2
12 months.We created a pool of 690 MTs across 272 societies in 36 states and union territories and provided standardized content to all 42 000+ members of FOGSI.This extensive network of providers has a collective reach of over 300 million women and families throughout India.Even though training modules on CAC existed, we needed 3 months to customize the content based on the 2021 amendments and incorporate innovative ways, like videos and games, from the WHO SAVER toolkit to ensure participants remained engaged.The training was done using a digital platform (Zoom) for sessions, completing surveys, and generating completion certificates and the preand post-test surveys.Having a well-organized secretariat with core team members comprising technical experts and managerial staff with clear roles Change in knowledge of ob/gyns on salient features on the 2021 Medical Termination of Pregnancy Amendment pre-and post Respectful Abortion Care (RAC) trainings (n = 9051).
and responsibilities and running multiple parallel sessions ensured that we were able to reach this massive cohort.We made a conscious effort to select MTs carefully, choosing obstetrician/gynecologists that were highly reputed and whom people admired and respected to drive participation.We were mindful of trainer fatigue and expanded and rotated the MTs to mitigate any impact.It was important to constantly acknowledge that MTs and participants often overcame personal and professional barriers to attend the sessions, given the COVID-19 pandemic.Thus, it was important to keep them motivated and ensure that they felt appreciated for their work.Although online trainings can be cost-effective, substantial efforts are required for meticulous planning and immaculate implementation schedules to ensure success.Even if training can be conducted in person, the online mode should also be made available to accommodate different program requirements.Providing trainees with certificates as a form of recognition further motivates their participation and learning.Through the RAC trainings we were able to demonstrate the effectiveness of online training sessions at scale in improving knowledge and attitudes during the pandemic.Additionally, leadership in addressing a sensitive area like abortion in an based manner sets an example of what can be achieved by working with a strong network of committed healthcare providers, resulting in massive outreach complementing the government machinery.The trainings played a crucial role in fostering commitment among participants to acknowledge the significance of abortion and to be motivated in providing services in accordance with the law.While values clarification and attitude transformation workshops are not new, this was the first organized, large-scale, coordinated attempt to include values and build-in respect as an integral component of CAC trainings.RAC demonstrated that professional associations can take ownership and effectively mobilize providers, but we are far from bringing real change in attitudes toward universal respectful CAC services for all.Those that completed the sessions committed to RAC; however, despite the coordinated efforts less than 1 in 4 participants in India completed the whole course.Without benchmarking attitudes and values beforehand, we were also unable to tell the impact of this part of the training.In addition, one of the limitations of this RAC initiative is that it did not assess whether this type of training resulted in actual changes in practices or not.Once pandemic restrictions were eased, there was a decline in the numbers of trainees, likely owing to online training fatigue, and in-person training was complex in the immediate post-pandemic period; challenges of cost, travel time, competing priorities, and clinical commitments hindered participation.

F I G U R E 3
Exit survey results showing positive attitudes post value clarification, post SAVER (Safe Abortion Values, Evidence, and Rights/Respect) as part of Respectful Abortion Care (n = 9051).have access to safe, comprehensive abortion care Safe abortion services should be given to any women of any age if she chooses it I am well-informed about national and global goals and policies on safe abortion and family planning I know which sources to turn to for reliable guidance on Sexual Reproductive Health Rights, specifically abortion and contraception I can respectfully explain about abortion even if it conflicts with my views I believe all women should have the choice to have decide when they have a baby I feel I can discuss stigmatized issues, including abortion comfortably I feel comfortable talking with my closest family members about my involvement with abortion I support the provision of family planning and contraceptive services I feel comfortable performing and/or assisting an abortion procedure as per law I am clear about my personal values concerning abortion I understand the laws and regulations for the provision of abortion in my country clearly I feel comfortable talking about abortion and family planning/contraceptive services with my patients/clients I believe the issue of abortion is of importance to me Exit survey (% of participants) RAC that address provider bias and values.While we are not there yet, our overarching goal to reach all members with evidence-based information and re-emphasize CAC service delivery without compromising on service quality, safety and incorporating respect was achieved.These trainings served as a reminder to providers about their critical role in ensuring dignity, autonomy, confidentiality, and justice for women who need an abortion.Moving ahead, as mentioned earlier, the training will be redesigned to ensure more tive dissemination through in-person sessions.We will need sustained effort by professional associations like FOGSI, technical agencies like WHO, and government alike to bring about real and long-term change in the attitudes of healthcare providers.National and subnational authorities must continue to streamline certifying facilities for abortion provision, conduct regular refresher training, and address provider values as part of all trainings, public or private, both pre-and in-service to reduce inequality and biases in access.