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.

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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.