Take on MA pills over the counter in Nepal

Marie Stopes_2017-6197“It’s a culture.” I answered to one of the freelance journalists. “When you have a headache or something you don’t rush to the hospital. You go directly to the pharmacist.” This article talks about the clandestine procedures are still common in Nepal even if abortion is legal. The abortion law in Nepal does not permit pharmacies to sell any abortion pills without prescription. However, thousands of women are easily accessing MA pills via medical shops/pharmacies nearby. I had causally discussed the reasons behind accessing MA pills in pharmacies rather than authorized health facilities with the women who used self administrative drugs. Most of them shared that pharmacies are convenient as they do not have to go through paper works; no forms, no personal information referring to easily accessible and the other reason is privacy.

Even if it is mentioned strictly that abortion should be performed within a standard health protocol; authorized/certified health facilities and by trained medical professionals, women are accessing services through unregistered medical shops and untrained medical professionals. The study done by CREHPA mentioned that 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. When taken correctly, self-inducing abortions using misoprostol and mifepristone can safely terminate a pregnancy.

The studies also have shown that women prefer visiting pharmacies rather than any Government authorized health facilities for abortion service. However, the Government of Nepal does not have strong action against pharmacies selling various medical abortion pills and resulting to clandestine procedures. 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. Nepal’s pharmaceutical industry is difficult to regulate. Only four brands of misoprostol and mifepristone abortion kits are legal in the country, but at least 20 different brands are smuggled across its porous border with India. The pharmacists have a high incentive to sell them since they can pocket hundreds of rupees each time they sell medical abortion kits. This shows that cost is not barrier for women to access MA pills. They can pay for huge amount buying it from pharmacies rather than visiting government facilities which provides safe abortion free of cost.

Recently Government of Nepal has provided free abortion service in Government health facilities- District Hospitals, Primary Health Care and via Health/sub-health posts. This is in deed great progress while recognizing women’s health and prioritizing abortion to be safe, legal and accessible. However, to measure the impact of free safe abortion services and number of women accessing abortion without stigma in health facilities resulting in reducing clandestine abortion should be performed. This will give us clear picture whether “cost” is what women take in account when they have to access abortion service.

StickerVarious organization like Marie Stopes Nepal and PSI Nepal have recognized working in partnership with pharmacies could result in providing self administration drugs to women with accurate information and instruction to reduce complications. Marie Stopes Nepal has been closely working with pharmacists and orientating them about their mhealth program “Mero Swastha Mero Haath ma”.  The pharmacists provides stickers and wallet cards to the client accessing medical abortion pills over the counter. The client has to register in mobile health platform; type MA and send to 35565 and they receive 19 SMS for 8 days. The SMS are free of cost. It has clear instruction on how to use medical abortion pills step wise mentioning expected results and call to action for any complication. The SMS also provides information on Contact Centre number for emergency and complications (Contact Centre is toll free number and available every day from 7:00 am to 12:00 am). The SMS has information on post abortion family planning and information on Marie Stopes’ clinics.

The Government of Nepal should realize the fact that the pharmacies are more accessible for women that health facilities and they are buying abortion pills in medical shops. To reduce the complications after accessing MA pills over the counter and improve women’s health, government should reform its policy either resulting into strict actions for pharmacies selling unauthorized medical abortion pills (beside four registered MA drugs) or working in coordination with Druggists and Chemists Association to regulate the drugs and making abortion pills accessible to women all over  Nepal with clear instruction plus reasonable price. The restricted law for pharmacies selling MA drugs over the counter has created barrier for pharmacists and among women accessing the drugs. The pharmacists are afraid to be exposed and doing this under the table which has limited the women to get accurate information on usage leading to complications. Also, women have been cheated with high price. They would have accessed service free of cost. However, lack of information about free SA service and stigma associated with abortion is leading women to seek drugs from pharmacists and black market. This needs to be regulated by government of Nepal to reduce complication incidence and improve reproductive health of women.

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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.

12289746_873703786077111_2078844530607308059_nThe 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.

 

 

 

 

 

 

 

 

 

Safe Abortion Day

Nepal celebrated its first “Safe Abortion Day” today. The celebration has actually #BustTheMyth regarding policy makers are not positive to abortion laws and policies. Also, it has #BustTheMyth on government officials not being positive to safe abortion law. The event was formally inaugurated by honorable health minister of Nepal Mr. Khag Raj Adhikhari. He shared his experience on abortion topic in parliament where few renown policy makers are still against abortion. The celebration has also brought all the partner organizations and stakeholder together with media to work together for betterment of the safe abortion laws and policies in Nepal.

The program was jointly organized by Family Health Division and partner organization like Sunaulo Parivar Nepal/ Marie Stopes International, Ipas Nepal, Centre For Reproductive Rights, Family Planning Association of Nepal, FWLD, action works, Beyond Beijing, Safe Motherhood Network Federation and Youth Action Nepal.

Youth Champion Advocacy Network Nepal also participated in the program. The slogan for the Safe Abortion Day 2015 address importance on family planning to avoid unwanted pregnancy and emphasis on safe abortion service if needed in safe and legal service sites.

Sharing about abortion scenario worldwide:

  • estimated 22 million unsafe abortion every year
  • nearly all unsafe abortion (98%) occur in developing countries
  • 13% (47000) of the pregnancy related death is due to complication of unsafe abortion (WHO 2012)
  • 5 million are estimated to suffer disability as a result of complications due to unsafe abortion

Safe Abortion program helps government focus on indicators like it helps to reduce MMR and morbidity and helps in creasing CPR and reduction of TFR. Preventing abortion related morbidity and mortality by increasing access to safe abortion services which leads to decrease in MMR. Likewise, preventing future unintended pregnancies by increasing access to post abortion modern contraceptive methods increase CPR and decrease TFR.

Nepal: From Law and Policies to Programs 

  • 2002- Abortion legalization
  • 2003- Procedural Order & Safe Abortion Policy
  • 2004- National Standards, protocol, guidelines, training materials and training centres and first SAS maternity hospital
  • 2007- Introduction of CAC by nurses
  • 2008- Introduction of 2nd trim services
  • 2009- national MA scale up strategy
  • 2011- National SAL implementation guideline
  • 2015- Announcement of free service by government

Facts on Abortion- Current Status in Nepal

  • 25% of pregnancies are unplanned in Nepal (NDHS 2011)
  • Only 38% of women Know that abortion in Nepal is legal
  • Knowledge is very low among no education (20%) and lowest wealth quintile (20%)

Safe Abortion Services: Achievements

  • CAC service is available in government health facilities. CAC is available in all 75 districts at district and upper level health facilities. MA service at health post and primary health post level in 41 districts and second tri are available in 22 hospitals. In addition to Government, NGOs and certain private institutions are also providing safe abortion services.
  • Safe abortion service was started in Nepal in 2004. Since then about 7 lakh fifty thousand benefited from safe abortion services. This saved many deaths of women and morbidity of women also reduce the cost of health services.
  • A study was conducted in 2004, 2007 and 2010 to access the impact of abortion legalization. It was found that by 2010 the percentage of severe complications due to unsafe abortion decreased significantly post abortion legalization.
  • As part of CAC, safe delivery sites also office family planning counseling and services to women after abortion. In Ipas supported 15 districts it was found that among the women who received safe abortion service, 80% use any kind of FP services.

Major Achievements:

  • More than 2245 health care providers trained in SA care under NHTC
  • 809 sites authorized for SA
  • All 75 districts of Nepal has SA sites- even the most remote areas
  • Abortion care is part of HMIS
  • Over 7,00,000 Nepali women have received SA care services
  • About 80% of women also received post abortion contraception
  • Less than 2% experience complication
  • Medical Abortion introduced in 2010 and available in 41 districts in PHC and HP level. (Data up to June 2014, FHD)

There still challenges that Nepal needs to over come like how to address few emerging issues such as abortion as method of contraception, use of emergency contraception as regular contraception particularly among adolescents, sex selective abortions. Another challenge is to provide free abortion services and further scaling up of program ensuring equity and quality. Similarly, we should ensure post abortion contraception particularly LARC and monitoring of free abortion services.

Youth Champions during Humanitarian Crisis

Youth Champions Nepal were planning for its country seminar to introduce itself among network working in dedication to young people’s sexual and reproductive health & rights when Nepal was struck by its worst earthquake in nearly a century on April 25, 2015. The earthquake destroyed nearly 600,000 and damaged almost 300,000 homes, and displaced some 2.8 million people. More than 8.800 people were killed, tens of thousands were injured. The people are still frightened by aftershocks and the devastation was compounded by number of powerful aftershocks.

Once the earthquake struck our cities, there was urgent need for food, water, shelter and other basic stuffs including first aid. There were numerous causalities reported in district hospitals. The first step of our Youth Champions Network in Nepal we distributed rice, dal, water, sugar, oils, traps & tents, etc. This is what we immediately understood about a humanitarian crisis of this nature. This was the first experience for us living in Kathmandu valley and dealing with natural disaster. But in-coordination with Asia Safe Abortion partnership we realized, there is also an urgent need to provide life-saving reproductive health services and to prevent and respond to gender based violence. Asia Safe Abortion Partnership allowed to use funds to prepare “Hygiene Kits” and distribute among women and girls being affected by earthquake.

“I am sharing about the situation in my community “Bhaktapur”. Since Bhaktapur is a very old and traditional city, most of the houses are made of mud and wood. The earthquake had destroyed most of the old and traditional homes of the Bhaktapur city. People are now staying in open places like field, party palaces, ground and even in dumping sites. We have been calling those places as “CAMPS”. As, the earth has decreased its vibration and we are getting after shocks which we are used to, people who have their house safe and fine to stay have returned to their places.


Among the people in the camps, there are limited tents, electricity, water and food. The people who have lost everything and do not have any alternatives are staying in the camps. As per our team’s observation, there are many pregnant women in the camps. In particular camp, there are 2- 3 women who are pregnant and 1-2 women who recently gave birth to their child. There are more than 25 campsites in Bhaktapur. Some of the places are unreachable as the pathways are closed due to destruction.

Since, there is no work at all and most of the people are emotionally challenged, alcohol has been the best alternatives to pass the time and means of entertainment in the camps. This is also affecting young women and they might be in risk of sexual abuse in coming days. Likewise, smoking among men has been tremendous which is in directly affecting pregnant women and women who just have delivered. As we have set-up our HELP DESK in Bhaktapur Hospitals, there are many changes regarding pregnancy after the devastating earthquake. I personally attended a couple, who were 3 months pregnant and came to visit hospital after the women started to feel the pain on her stomach as she jumped to escape from falling home. But the case was not serious.

Other remarkable affect on women’s health is there are physically and mentally been challenged by the situation. In one side, they have lost their near and dear ones and on other side they have lost their properties. In same time, there is overburden of the work to single women as they have lost their husband and now they suddenly have the responsibility of running the house. Other major effect is on sanitation. There are no proper toilets in CAMPs. Similarly scarcity of water, people are defecating wherever they like. There have been spread of many diseases and women have been the worse affected.

People in camps are mostly provided with raw noodles and biscuits. Proper nutritious food is not available to young women, pregnant women and women who have just delivered. Essential medication like TT, ANC/PNC, iron tab, etc. is also not available. There is a scarcity of contraceptives and we are unable to provide with much help, there are also women who had miscarriage during the situation but there is no care available for them. Health camps are being conducted by different organizations and medical teams have been mobilized but no one is focusing on women’s Sexual and Reproductive health.”- one of our Youth Champions Nepal

Likewise, our youth champions working in coordination with Bhaktapur Youth Information Centre were engaged in assessing pregnant women, lactating women, adolescent girls their SRH and VAW. By, there were many articles online as well in print media which had been reporting continuously about women and girls in crisis situations who face special perils. Pregnant women need ante-natal care, a clean, safe place to give birth and medical attention in the event of complications. new mothers need vital nutrients and postpartum care. And women and girls of all ages need protection from gender based violence, including sexual violence, which tragically follows in the wake of most humanitarian crisis.

“There is a drunken man in our tent. We are mostly girls and women in the tent and we don’t feel safe, him being around. I went and told the camp management committee but they told me to come and complain only if something happens, but won’t that be too late? It’s a day time, but he can do anything to us at night.” A young girl taking shelter in a temporary camp in Kamalbinayak, Bhaktapur.”- One of BYIF volunteers

One of our Youth Champions met Mrs. Sarita Fhutuwar of Balambau, Changunarayan. She is a mother of two daughter and now is pregnant of 8 months. She thought she would have a normal delivery as before but due to earthquake she is in deep thought and is not sure about her post pregnancy. Her house is also badly collapsed and now.lives outside the house in tent. This is the time where she (every pregnant women)has to be given especial care but situation is just the opposite. Keeping in mind her health and situation we BYIF supported her with.some supplements like horlicks, nuts and biscuits(which is enough until delivery). She was also assured that with help of FPAN we will refer her to hospital nearby for safe delivery. This has made her feel much secure and relief.

Then we released we need to come up with a kit that address immediate need of pregnant women, lactating women, adolescent girls and children. Youth Champions Nepal planned to develop hygiene kit with materials like maxi, sari, towel, soap, panties, comb, cream, mosquito coils, sanitary pads (home-made), socks, tooth paste, tooth brush, diapers, supplemental food for babies, torch, napkins, ear buds, nail cutters and more.


Nepal and Nepalese are rising from rubble. The crisis in Nepal is far from over. As Monsoon is here, it has been followed by landslides. Aftershocks are regular occurrences but monsoon has made it difficult for locals to clear all rubble. Meanwhile, human traffickers are targeting the region to abduct vulnerable women and girls. In many ways the dangers are as great as ever.

A Little Angel: Not a Bride

A girl child is perceived as a little angel by a proud parent. Meanwhile, there is this tradition: child marriage where parents decide their girl child’s marriage once she steps on the earth. That is why I am saying A little Angel is not a Bride.

During my childhood I have requested my grand parents to tell me the bed time stories. Yeap! you guessed is correct!! It was all about princess and her prince charming. When I was too young, there was only one Nepali Television channel which used to broadcast different program in social issue. I was unknown about child marriage issue until I had watched award winning film produced by UNICEF “Ujeli: A Child Bride in Nepal”. By then, 40% of women in Nepal marry before the age of 14. Early marriage has resulted in a lack of education for girls as well as an extremely high mortality rate during child birth. UJELI: A Child Bride in Nepal documented the life of a girl forced into marriage at a young age. It is hoped that dialogue and debate will be stimulated in Nepal regarding the risk to women’s health when young girls marry. It was broadcast in 1992 through Nepali Television. Now, I clearly do not remember the whole serial but have vivid memory of some episodes. It was filmed on location in the Rasuwa district of Nepal, the dramatized story of 10 year old Ujeli. Against the advice of her teacher and doctor, who warn of the dangers of early child bearing, Ujeli’s parent arrange for her to be married. Excluded from school and forced to work from dusk to dawn, Ujeli rapidly assumes the responsibilities of an adult woman, including motherhood. At that time period, the maternal mortality rate was 850 per 100,000 live births is among the highest in the world.

Child marriage is a global problem which affects millions across the world but especially girls in South Asia. The Government of Nepal has signed many international instruments designed to tackle this problem and has passed a law forbidding child marriage but has found it difficult to eradicate the phenomenon due to weak enforcement and low levels of awareness. In Nepal, by law both boys and girls can marry at the age of 18 with parental permission and at the age of 20 without it. By custom, however, some communities have been arranging the marriage of children under the age of 18 for generations. Child marriage has numerous adverse effects on the overall well being of children who are mentally, psychologically, emotionally and physically unfit for married life. It constitutes a violation of child rights and must be abolished. There is no up to date national level information or data on child marriage. But there has been changing paradigms and patterns of child marriage. Because the majority of Nepal’s population is illiterate, ignorant and disadvantaged, age old traditions and customs are not easy to do away with. However, education and awareness among people, especially those living in the rural areas, can make a difference. Unless people are made aware of the devastating  multi-prolonged effects of early marriage, they will not strive to eliminate it from society. People should also be made aware of human rights so that they are aware of their own rights of children. Only then will parents be motivated to ensure that their children enjoy their right to a childhood.