Denial of Abortion Service in Nepal

In 2002, abortion was legalized in Nepal and made widely available. Abortion is permitted up to 12 weeks gestation on request and up to 18 weeks in cases of rape, incest, and health risks to the woman or fetus. Abortion services were established at most government hospitals, private hospitals, and non-governmental organization clinics. The government of Nepal has taken important steps to include abortion as a component of women’s reproductive health services, enabling nearly 800,000 women to obtain safe, legal services between 2004 and 2014. The government has recently announced that abortion services will be made available free of cost in the public facilities but this will take time to implement.

We, Nepali women are living in most privilege country where abortion is safe and legal. The government of Nepal has respected the women decision to have choices and decisions on their own body. Nepali women make their own decision to terminate their unwanted pregnancy on their own consent.  However in other countries like England, Wales or Scotland a woman must ask a doctor to make that decision to her. Similarly in the country where abortion law is restricted, Government takes decision for a woman whether she could or could not terminate her pregnancy. In most cases, women are denied of abortion services. This is the violation of Human Right.

For example, Northern Ireland where women are denied of abortion. In Ireland, abortion is all but outlawed. For decades, women have traveled to England to access abortion services. You can read an article where titled: Irish woman live-tweets journey for abortion from Ireland to England. Dr. Suchitra Dalvie talks about musings on women’s right to safe abortion questioning “Is it not a modern form of slavery to force a woman to have or continue a pregnancy she does not want? Should a woman’s reproductive function take priority over her own aspirations and desires and capacity to fulfill her own highest potential?

Talking about Nepal and the situation of denying abortion, people are shocked to know when I share them about denial of abortion services in unrestricted environment like Nepal. According to our National Demographic Health Survey (NDHS-2011), only 38 percent of women are aware that abortion is legal in Nepal. In addition, their knowledge of the specific circumstances under which abortion is legal is poor. For rural Nepali women, it is difficult to identify whether they are pregnant or not. Most of the women who reach health facilities for abortion service are of high gestation which means above 12 weeks. Most of our Government certified health facilities are authorized to provide comprehensive safe abortion service till 12 weeks of gestation.

One of the leading NGO in Nepal, Centre for Research on Environment, Health and Population Activities (CREHPA) had conducted a study in 2013 which aimed to examine how often women are being denied care, reasons for denial of legal abortion, options considered after denial, sources of information about illegal abortion, experiences seeking illegal abortion and complications experienced. The study showed that denial of legal abortion is common in Nepal. It is common among women from poor family and marginalized communities. Some of the reason for denial of abortion service could be:

1. High gestational age is the reason for denial of abortion as service providers hesitate to go against laws and they are not competent enough to terminate pregnancy of high gestation.
2. Most of the government health facilities are authorized to provide safe abortion services. However, women have been denied of the service due to absence of trained and skilled service providers. Most of the time lack of continuous supply of medical abortion in health facilities is another reason for denial. This has led women to buy unauthorized drugs over the counter which has led to complications among women.

The study has also explained that denial of abortion service has forced women to continue with their pregnancies. Evidence has suggested that children fare best when they are wanted and loved. Similarly, rejection of abortion is leading women to access illegal abortion by self inducing unauthorized drugs and going for traditional methods which can result in incomplete abortion or complications.

This means even if the law is liberal, in certain condition we are forcing women to seek illegal and unsafe abortion. I believe that abortion should be accessible in any gestation age. However, the abortion procedure should be safe which does not keep women at the risk to lose their lives.

Recommendation for improving women’s access to legal care:

1. High impact awareness campaign on pregnancy, abortion, abortion law and services available. For example: interactive radio programs, street dramas
2. Reduce stigma related to abortion.
3. Mobilizing Female Community Health Workers or community mobilizers door to door with interpersonal communication approach to orient people about early detection of pregnancy.
4. Train more providers at all levels to provide abortion and to refer appropriately
5. Promote free helpline numbers like Meri Saathi Free Helpline no. 16600119756 or 9801119756 in community level to call to get detail information on safe abortion, procedures, laws and service centres.
6. Introducing mobile health application like one initiated by Marie Stopes Nepal to registered through SMS and get instruction and information on using self induced medical abortion pills.

 

 

 

 

 

 

 

 

 

UNSAFE ABORTION ALARMING AFFAIRS

The article is originally published in fortnightly magazine- New Spotlight. You can read the original article here. 

Although Nepal has made many progresses in the last decade in establishing the rights of women, it is still a country with highest records of girl child marriages. Nepal’s law and constitution guarantee the right to reproductive health, but unsafe abortion continues to be a killer of young and adolescent girls. At a time Nepalese women celebrated the International Women’s Day calling for equal rights to women, unsafe abortion is creating a major health problem among the women.

When the Nepalese women were celebrating the International Women’s Day calling for women’s liberation, one hundred young women called Meri Sathi Free Helpline 16600119756 (ntc) or 9801119756 (ncell), the telephone counseling service run by Sunaulo Parivar Nepal (SPN), to acquire information about sexual and reproductive health.

The call center, which provides counseling service every Monday to Friday from 9:30 am – 7:00 pm and from 9:30 am- 5:30 pm on Sunday, is the lifeline for many young women who want to know about reproductive health, pregnancy and maternal health.

Their questions range from sex, women’s health, unwanted pregnancy, legal abortion, family planning methods and about the reproductive rights. The callers are overwhelmingly young people aged between15-21.

According to Shreejana Bajracharya – Senior Communications Consultant at Sunaulo Parivar Nepal, implementing partner of Marie Stopes International Nepal , a majority of queries are related to sexual relations, legal abortion, pregnancy and family planning. “We also respond to the queries through SMSes,” said Bajracharya.

“Our Meri Saathi Free Helpline has trained and skilled counselors on hand 6 days a week to offer expert advice and support – from your initial consultation to treatment aftercare,” said Bajracharya. “If one is unable to talk to friends or family, they can speak to a Marie Stopes Nepal counseling or service providers at Marie Stopes International (MSI) Centers. Marie Stopes Centers take one’s privacy seriously and any counseling conversations will be confidential.”

As a country with one of the highest numbers of girl child marriages in the world, Nepal is benefiting from the counseling service provided by organizations like Sunaulo Parivar Nepal, which has been a savior for many young and adolescent girls as sex related matters, family planning methods and reproductive health are still regarded as taboo topics in the society.

Although the counseling seems to be very ordinary, it helps to reduce the maternal mortality rate saving the life of young mothers who wanted to prevent unwanted pregnancy.

Along with the government hospitals, Sunaulo Parivar Nepal has been providing the much needed safe abortion clinical services with trained manpower. They provide the comprehensive abortion care that ensured pre and post care and usage of completely safe technology.

According to the data released by Ministry of Health, 751,694 women have benefited from the safe abortion services since it started. This saved many deaths of women and morbidity of women.

Abortion has become legal in Nepal and a safe choice for women seeking to end unintended pregnancies. But for many women, ingrained fear and shame about abortions have remained. Sunaulo Parivar Nepal has been working for the nation’s availability of SAS techniques with effective pail management and post-procedure family planning information and services. Despite availability of service, 47,000 women still die every year due to unsafe abortion in Nepal.

“ I feel proud to say that my initiative has played a vital role in reducing maternal mortality rate in the country and saving young and adolescent girls from untimely death,” said Kamla Thapa, president of Sunaulo Parivar Nepal.

Trauma of Unsafe Abortion

Subhadra Chand, 18, a resident of Darchula, died on the way to Dadeldhura Hospital due to complications related to unsafe abortion last month. Similarly, Kanchi Rokaya, 20, mother of two, a resident of remote Mugu district, died at the district hospital in Mugu due to complications during abortion.
 
These two incidents are not new as dozens of young women in far-west and mid-western region, are dying annually due to the complications related to the unsafe abortion.
Unsafe abortion risks lives of many women in Far-West as hospitals and other health facilities in these districts receive cases of abortion-related complications. As there is a lack of proper medical infrastructure for safe abortion, many pregnant women opt for unsafe abortion risking their lives.

According to a study, 25% of pregnancies are still unplanned in Nepal and only 38% of women know that abortion is legal. Knowledge is very low among illiterates (20%) and lowest health quintile (22%).

Although safe abortion became legal in Nepal from 2002 followed by national standards, protocols, guidelines, training materials and training centers and safe abortion services were available in maternity hospital from 2004, and with free services, a large number of women still don’t know about this.

Although the Ministry of Health and Population provides budgets for district hospitals to prepare for safe abortion, these services are inaccessible to many.  
“The government is serious about the trend. We have the District Public Health Division increasing the number of safe abortion centers in health posts,” said Shanta Kumar Shrestha, secretary at the Ministry.

Role of MSI AND SPN

Along with the government centers, Sunaula Parivar Nepal, national NGOs implementing partner of Marie Stopes International in Nepal, also operates 36 static service centers on Family Planning and Safe Abortion Services in 32 districts which are authorized under Government of Nepal.

It has also launched Meri Saathi Free Helpline. Trained counselors have been available to discuss a wide range of issues including birth control, pregnancy options, sexually transmitted infections including HIV & AIDS, and other aspects of reproductive health.
SPN contributed to prevent 126,000 unsafe abortions in 2014. Among non-government organizations, SPN/MSI has been one of the leading organizations in increasing access to modern FP methods and safe abortion services in the country.

SPN contributed about 55% of sterilization and 89% of reported cases of safe abortion services in Nepal. It is estimated that Sunaulo Parivar Nepal’s contribution has helped to avert 1,622 maternal deaths and 153,292 unsafe abortions in 2011.

Sunaulo Parivar Nepal (SPN), established in 1994, is a Nepali non-government organization (NGO) responsible for implementing the Marie Stopes International program in Nepal.

Abortion was legalized in 2001 in Nepal. According to the Abortion law of Nepal, “only listed doctors or health providers can provide abortion services at approved health facilities, clinics, and hospitals with the consent of pregnant women and according to the national standards.

About 800,000 Nepalese women get pregnant every year. Two hundred thousand of total pregnancies are defined as unplanned, unintended and unwanted by Nepalese women.
However, only 80,000 Nepalese women go to approved health facilities or clinics for abortion. About 120,000 Nepalese women go to non-listed clinics or health centers for the termination of pregnancy which is obviously unsafe.

Aananda Tamang, Director of CREHPA, an NGO working in the field of environment, health and population, believed that women opting for abortion no longer had to endure pain during the termination of pregnancy as various researches were being carried out to manufacture painkiller medicines for the same. Majority of the unsafe abortion cases in the country were attributed to social norms and values and cultural beliefs.

Both married and unmarried women are unaware of the abortion related complications and conformation to legal compliance.

“As the unmet need of family planning methods to the young people grows, there is a high possibility of unwanted pregnancy. Given Nepal’s young population’s sexual activity, Nepalese women face more serious complications related to unsafe abortion given the growing unmet need of FP,” said Dr. Ram Hari Aryal, a demographer.

The World Health Organization defines unsafe abortion as a “procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both”. The consequences of unsafe abortion range from minor complications such as bleeding, sepsis, gastro-intestinal disturbances to major complications such as excessive bleeding, hemorrhage, endo-toxic shock to name a few. Although minor complications are treatable some complications may cause long-term reproductive damage such as infertility due to infection.

According to DHS 2011, 34% of current married women have an unmet need for contraception. It means that “women are sexually active, are able to become pregnant, do not want to have a child soon and are not using any method of contraception.”

International Experience

According to new research by Susheela Singh and Isaac Maddow-Zimet of the Guttmacher Institute, there was an estimated 6.9 million women in developing regions who were treated for complications resulting from unsafe abortion in 2012.

Their article, “Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012,” published recently in BJOG: An International Journal of Obstetrics & Gynecology, highlights two alarming realities: the very large number of women who experience complications from unsafe abortions and the significant costs that women, their households and governments incur as a result of treating these complications.

In countries where abortion is illegal or highly restricted, the procedure is often carried out under clandestine conditions that jeopardize women’s health and lives. If a woman’s health is compromised, she may also experience severe financial burdens associated with missing work or receiving medical care. In addition, health systems in developing regions spend a significant portion of their already stretched health care budgets—an estimated total of $232 million each year—on post abortion care.

If the research recommendation is any guide, a country like Nepal should focus on provide family planning services, including counseling and provision of a wide range of contraceptive methods, which should be included as a key component of post abortion care. This would also reduce the incidents of unintended pregnancy, which is the root cause of most pregnancies.

Although women celebrated the International Women Day, sustainable development would not be achieved unless the women’s sexual and reproductive rights were established as fundamental human rights. This needs to be brought under the ambit of every eligible woman.