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Abortion & Unintended Pregnancy

Prior to its amendment in 2002, the abortion law in Nepal was highly restrictive: abortion was permitted only to save a woman’s life. Moreover, unsafe abortion was common, and deaths from abortion related complications accounted for more than half of maternal deaths that occurred in major hospitals. In 2002, the Country Code of Nepal (Muluki Ain) was amended to grant all women the right to terminate a pregnancy at up to 12 weeks gestation on demand, at up to 18 weeks gestation if the pregnancy resulted from rape or incest, and at any gestational age with a doctor’s recommendation if the pregnancy poses a danger to the woman’s life or her physical or mental health or if there is a risk of fatal abnormality or impairment. In addition, the revised law prohibits sex selective abortions and abortions done without the consent of the woman.

During the past decade, the Ministry of Health has developed strategies for implementing the law and expanding access to safe and legal services. These strategies include training clinicians to perform abortions, providing them with necessary equipment, and certifying providers and health facilities. All health facilities that have official approval to provide abortions are expected to perform first trimester abortions. A few lower level facilities such as health posts are approved only to provide medical abortion up to nine weeks gestation. To provide abortions after the first trimester, facilities need separate approval and are required to have staff members trained and certified to provide such abortions. Abortion legalisation has led to a decrease in the number of women presenting severe abortion complications, and it has contributed to a decline in the country’s maternal mortality ratio which fell from 580 maternal deaths per 100,000 live births in 1995 to 190 deaths per 100,000 live births in 2013.

In 2014, the Center for Research on Environment Health and Population Activities (CREHPA) and the Guttmacher Institute conducted a study to generate the first national and regional estimates of abortion incidence in Nepal. This study adopted a modified version of the established Abortion Incidence Complications Methodology which uses indirect estimation techniques to measure the number of abortions occurring each year, the abortion rate and the abortion ratio which also consists of a survey of a nationally representative sample of facilities that provide safe abortion or post-abortion services, and experts on abortion in Nepal.

According to the study many women in Nepal continue to face barriers to obtaining safe and legal procedures. Obstacles include lack of awareness of the legal status of abortion, lack of services, lack of transport to approved facilities, gender norms that hinder women’s decision making autonomy, the often-prohibitive cost of the procedure, and fear of abortion related stigma.

Dr. Kiran Regmi holds the position of Chief Specialist at the Ministry of Health. Her position makes her responsible for policy level work. She is also a female diseases specialist and holds a degree and extentive experience in public health. She has published several articles, and some of her articles have received international recognition. Excerpts of a conversation with Dr Kiran Regmi:

What is family health?
It is the life course approach which ranges from infant health, child health, adolescence health, reproductive health and afterwards. It includes both men and women as family involves both. It means to offer health services to the family’s well being.

What are the indicators of a healthy life style?
To be disease free, mentally healthy, and spiritually healthy means to live a healthy life style. A healthy life style means to exercise well, have a balanced diet, abstain from drugs and develop positive thinking.

How does the Family Health Division function, and what are the areas of focus?
It has several departments which look after family planning, adolescence health, reproductive health and maternal health, duties and problems of health volunteers. It also conducts research, generates evidence and recommends to the Ministry, and the Ministry provides the action plan in return.

What kind of role does a woman play in maintaining a healthy lifestyle for the family and society?
As a daughter or wife or daughter-in-law or mother, women always keep family health on priority. She plays the most significant role when she becomes a mother. It all depends on a mother to give birth to a healthy child. She needs to be aware about all measures to take before birth as well as after birth. The overall upbringing of the child depends upon on her whether it is the kind of education s/he receives or the friend’s circle s/he keeps. Also the gap between children is another important factor she has to consider to maintain a healthy family. Compared to men, women are more conscious about using family planning measures. This is why women need to be literate for an educated society.

What’s the overall scenario of women’s health in Nepal?
About 20 years back it was very pathetic. Women were unaware about regular checkups, and many girls even lacked enough information on menstruation then. Now it has much improved due to increase in access to women health programs. But women from some of the marginalised communities don’t care about their health though government has been introducing various programmes. Maternal mortality rate has reduced by a huge number yet we have a long way to go to be on par with developed countries. Neither can we say nothing has been done nor can we say we have a better picture. In some cases we have set a precedent in matters of women’s health. Prolapse has been a huge problem in women’s health in recent times and we are focusing on it extensively. The government has made all kinds of treatment for prolapse free.

How safe is abortion? What are the major reasons women have abortion?
Fifteen to twenty years back abortion used to be referred as a criminal act and considered very unsafe. Before it was legalised, women used to face jail sentence for having it. In those days abortion was indeed very unsafe. At present, it has witnessed a drastic change and has been much safer.
Women are not independent to make decisions regarding the number of child they want to have. And they accidentally conceive and later abort it. The other reason is preference for a son.

What are the effects of untended pregnancy and abortion on the family?
It has mental, physical as well as financial effects on the family. It also carries the risk of side effects. Overall it has negative impact on the family.

What should be done to control illegal abortion?
Firstly, awareness is a must. Secondly, increase access to family planning measures. Thirdly, educate women about women’s health and safe abortion.

Abortion Incidence
An estimated 323,000 abortions were performed in Nepal in 2014. This number translates to a rate of 42 abortions per 1,000 women aged 15–49. Nationwide, fewer than half (42%) of all abortions were provided legally in government approved facilities. The remainder (58%) were clandestine procedures provided by untrained or unapproved providers or induced by the pregnant woman herself.

Within Nepal, abortion rates for 2014 varied widely by development region, from 21 per 1,000 reproductive age women in the far-western development region to 59 per 1,000 in the more urban central development region, which includes the capital city of Kathmandu.

Several factors may explain the high abortion rate in the central region.

Compared with women and couples in other regions, those in or near the capital may have a greater desire for smaller families, higher risk of unintended pregnancy because of later marriage and greater occurrence of premarital sex and better access to services. In addition, women from neighbouring areas obtain services in the central region.

Provision of abortion and post-abortion care
Some 1,100 government-approved health facilities provided legal abortion, post-abortion care or both in Nepal in 2014. Thirty-seven percent of the estimated 137,000 legal abortions were performed in public-sector facilities, 34% in NGO facilities and 29% in private sector facilities.

An estimated 80,000 women were treated in health facilities in 2014 for complications related to abortion and miscarriage. Sixty eight percent of these women had complications that resulted from a clandestine abortion. Forty-four percent of women receiving post-abortion care were treated in private facilities, 41% in public facilities and 15% in NGO facilities.

Out of every 1,000 women of childbearing age in Nepal, eight were treated for complications of illegal or legal abortions in 2014.

Regional treatment rates for complications ranged from 1.8 per 1,000 in the far-western region to 11.3 per 1,000 in the central region.

Incidence of unintended pregnancy
In 2011, 43% of married women in Nepal used a modern method of contraception. However, half of contraceptive users discontinued use within 12 months of starting.

The unintended pregnancy rate for Nepal was 68 per 1,000 women of reproductive age. It ranged from 47 per 1,000 women in the far-western region to 85 per 1,000 in the central region. Half of pregnancies were unintended (either mistimed or unwanted), and close to one-third (31%) of all pregnancies ended in abortion.

Strategies for reducing unsafe abortions
Increasing access to high quality family planning services, including counselling and the provision of a range of methods and expanding free or low-cost abortion services, and ensure implementation of the government policy to provide free abortion services at public facilities by accrediting health posts, primary health centers, and private and NGO facilities, and equipping them with a provider trained in medication abortion.