“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.
Various 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.