Young People and Unsafe Abortion

Recently the National Daily Newspaper- Kantipur published an article with heading “Abortion Among Teenagers On the Rise”. The article shares, “A 17 year teen girl arrived at Lamjung Model Hospital situated at Beshisahar. The girl who had come from rural part of the district did not agree on continuing her pregnancy and demanded to terminate her pregnancy.”  Don’t you think this is a good news. I am really proud that young people are being vocal about their unwanted pregnancies and taking their own decisions  whether or not to continue with their unwanted pregnancies. The headline of the news should have been “AWESOME TEEN GIRLS CALMING THEIR ABORTION RIGHT AND ACCESSING SAFE ABORTION” – simple !!

The article continues and says “It is clear that underage as well as illicit sexual relationships are increasing along with abortions.” Lamjung Model Hospital is the only authorized abortion centre in the district. Dr. Tilak Babu Ghimire said, “Even the teenage girls of 17-18 years are coming for abortion. We try to convince them not to terminate their pregnancy as far as possible, but they are adamant.” I believe that service providers should be non-judgement and maintain confidentiality. The doctor should be proud on providing safe abortion to young girls, else they would have opt unsafe abortion which could have risk their lives. The article also talks about young women visiting neighboring district to access abortion. This clearly indicates that women do not trust the nearest health facilities- the reason might be service providers being judgmental and the facility does not maintain privacy and confidentiality. In Nepal even if abortion has been legalized and government health facilities provide safe abortion, women still have to travel different places to seek abortion. Another reason could be stigma. Stigma related to abortion has forced women to terminate their unwanted pregnancy seeking service from quack doctors or using herbal products.

For young women, complications from pregnancy and childbirth are the leading cause of death, and unsafe abortion is a major contributor to this mortality. Unsafe abortion can also result in lasting and devastating consequences, including, sepsis, peroration of the uterus or intestines, hemorrhage, chronic pelvic infections, and infertility. (1)

Deaths due to unsafe abortion are on the decline, but the proportion of women dying from unsafe abortion globally remains the same. 

  • MSI_Unsafe_Abortion_Infographic_080714_ARTWORKAccording to the World Health Organization, deaths from unsafe abortion worldwide have dropped from 69,000 in 1990 to 47,000 in 2008.(2)
  • Parallel to this decline, there has also been a one-third decline in maternal mortality from 546,000 deaths in 1990 to 358,000 in 2008. (2)
  • Despite the decline in the number of deaths due to unsafe abortion, the proportion of women dying from unsafe abortion has remained the same at approximately 13% of all maternal deaths.(2)
  • The number of unsafe abortions increased from 19.7 million in 2003 to 21.6 million in 2008 while the unsafe abortions per 1,000 women aged 15-44 years. (2)
  • This increase in the number of unsafe abortions without a corresponding increase in the rate is mainly due to the growing population for women for reproductive age.(2)

Young women account for a significant proportion of unsafe abortion worldwide. However, the article reflects that most of the teenagers are seeking services from safe places like, Lamjung Model Hospital and Marie Stopes Centres. This is commendable that young girls in rural areas of Nepal who are stigmatized for being a girl and getting pregnant before marriage accessing safe and legal abortion services. Without projecting this as a success story of Government of Nepal after making history for legalizing abortion 14 years back, our media is only sensationalizing the reality and reinforcing stigma around abortion.

According to the most recent data available from 2003, almost 14% of all unsafe abortions in developing countries were among women under 20 years of age. 

In developing countries, 2 in 5 unsafe abortions occur among women under age 25, and about 1 in 7 women who have unsafe abortion is under 20. Similarly, in Asia 30% of unsafe abortions are among women under 25 years of age and 60% are in women under 30. 

This is a request to all media personnel to analysis on the impact of your article. Instead of presenting data of abortion as terrifying issue, it would have been great if it was analyzed the difference between safe and unsafe abortions.

Even where abortion is legal millions of women across the world, especially young women, face barrier to access. In context of Nepal, many women, especially adolescents and women from rural Nepal cannot afford to access safe abortion. The geography of Nepal is another reason because of which women are deprived of safe abortion services. Unavailability of trained and certified service providers and continuous supply of Medical Abortion pills, women in many places in Nepal could not access safe abortion service. Stigmatizing abortion is discouraging trained service providers and capable human resources from providing safe abortion services. Even, volunteers like FCHVs are stigmatized for providing information on abortion. Marginalized populations like young persons with disabilities, women living with HIV, LGBTI and others are facing stigma and discrimination when seeking safe abortion services, resulting in denial of care or required authorization. Gestational limits, the need for parental consent for service is another barrier to accessing safe abortion services.

This article is an example that really hit me this month. I had discussion and argument on this. One of the people questioned me, “Why are you advocating and promoting abortion for young people? Why don’t you promote contraception instead? Excuse me! While more young women are using contraception in Nepal, there is till a tremendous unmet need for contraception and young women experience higher failure rates than older women. And I am not advocating for abortion, instead I am advocating for Safe & Legal Abortion. SIMPLE

Recently, I had received a call from Radio Station. The radio station is compiling data and information on abortion. They would like to know number of abortion cases. I replied them that I am not the person to talk about numbers on abortion. They should have visited to respective District Public Health Office and talked to concern department. She asked me what percentage of young girls seek abortion and what is the average age. Why these media people are more concern about the data on young girls accessing abortion. They concern and their queries is indeed stigmatizing young girls accessing safe abortion services. Instead for creating content that would provide wrong message to the community, it would be great if media could be sensible in this issue and support on preventing deaths due to unsafe abortion.

Please read this piece as well to get more incite on the articles publish on abortion by Youth Champion Advocacy Network Nepal.

 

Women with Disability and SRHR 

The disability prevalence rate in Nepal is nearly 2% according to National Demographic Health Survey, 2011. It is nearly 1.7% when it comes to women. Disability is both a cause and a consequence of poverty, where persons with disabilities are not only economically disempowered, but socially and culturally disempowered and excluded.

Women and girls with disabilities face triple discrimination: by being female, having a disability and being amongst the poorest of the poor. They are often subjected to discrimination in accessing education, employment and health care and are at a greater risk of violence, injury, abuse, neglect or exploitation. They are often excluded from the social life of their communities and family. Women with disabilities are particularly disadvantaged due to the multiple forms of discrimination they experience. For example, disabled girls are the least prioritized in terms of access to school and education. Development activities such as income-generating programs for women are largely not accessible to women with disabilities and do not take active steps to include disabled women. Furthermore, girls and women who have a disability are more likely to become victims of physical and sexual abuse.

Approximately 15% of the population, nearly 1 billion people live with a disability. Of which, 80% live in developing countries- 19% of women and 12% of men. Various health related issues are leading to disability. People with a disability face many obstacles in their physical and social environments that prevent then from fully excising rights and participating in social, cultural and professional life as others in society do.

Women with disabilities have traditionally remained invisible in both disability and gender policies. Effective inclusion of women and girls with disabilities in development interventions requires specific strategies and mainstreaming strategies, often referred to as a twin track approach.

Women with Disabilities and their SRHR

Last week I met one of my friend who is also person with disability and she shared her experience on the assumption that disabled women are asexual. This has led women with disabilities a barrier to access reproductive health care, contraception, and sexuality information and social resistance to reproduction and mothering. Disabled women are at risk for a range of undesirable outcomes, including coercive sterilization. This remains me that persons with disabilities have the same sexual and reproductive health needs as other people. Yet they often face barriers to information and services. The ignorance and attitudes of society and individuals, including health care providers, raise most of these barriers, not the disabilities themselves.

Talking to her I remember an incident when I was traveling to Jumla. I met a mother of mentally retarded girl. Her concern was safety of her daughter. At home there is no one for her daughter to look after her 24 hours. She came to the headquarter of Jumla to inquiry about the female sterilization service to a girl with disability. 

The interim constitution of Nepal ensures equality, freedom, justice and dignity of all individuals and implicitly mandates an inclusive society for all including persons with disabilities.

The persons with disabilities are often overlooked or neglected. Many persons with disabilities are marginalized, they are deprived of freedom, and their human rights are violated. Persons with disabilities have been denied information about sexual and reproductive health. Furthermore, they have often been denied the right to establish relationships and to decide whether, when, and with whom to have a family. Many have been subjected to forced sterilizations, forced abortions or forced marriages. In crisis situations these risks are multiplied.

It is hard to estimate the exact number of persons with disabilities who are affected by the earthquake or died in Nepal by the 25th April’s earthquake since there is no any system with government or any other agencies to track disability specific data at the time of emergency and post emergency situation. 

National Federation of the Disabled Nepal (NFDN), in coordination with its member organizations, has started collecting data of persons with disabilities who are affected by earthquake and have lost their lives. But due to the heavy destruction caused by disaster in district and lack of resource the data collection is getting a bit slow. So far, NFDN has updated the information of 1000 persons with disabilities. 930 out of that are affected in different ways and 30 have been killed. As per the information updated from different districts, the affected persons with disabilities are living on the following condition in the post quake situation.

Violence against persons with disabilities is intermingled by the fact that the victims may be physically or financially dependent on those who abuse them. When they come forward to report such abuse, the medical, legal and social service system are often unresponsive and inaccessible. They face many barriers to care and information about SRHR, GBV and abuse. There is a myth regarding persons with disabilities that they might not be sexually active has reinforce the obstacle toward accessing SRH services. However, research shows, the persons with disabilities are as sexually active a persons without disabilities. SRH services are often inaccessible to persons with disabilities for many reasons, including physical barriers, the lack of disability-related clinical services, and stigma and discrimination.

Attitudes of people differ from place to place and among different types of disability. The great majority of persons with disabilities face prejudice and stigma in their daily lives.Parents of children with disabilities often find themselves socially isolated. Stigma, poverty and lack of support systems take a toll on such families.

The most effective way to advocate for women with disabilities and their access to SRH services is to establish a dialogue with local organizations of and for persons with disabilities and other organizations working on behalf of persons with disabilities. “Nothing about us without us” is a key principle among persons with disabilities. The Convention on the Rights of Persons with Disabilities reflects this principle. It underscores the importance of including persons with disabilities at all stages of policy development, program planning, and implementation. Too often, persons with disabilities and organizations of persons with disabilities are consulted only after a policy or program has been designed. Persons with disabilities must be more than just recipients of SRH programs and resources. Policies and programs at all levels are consistently better when organizations of persons with disabilities take part in planning from the outset.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

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.