Situational Analysis
Of
Unsafe Abortion in Nepal
Nepal Country Team:
Family health Division, Govt. of Nepal( FHD)
Nepal Society of Obstetricians and Gynaecologists (NESOG)
Family Planning Association of Nepal (FPAN)
UNFPA, Nepal country office
TCIC/Ipas, Nepal
Centre for Research on Environment Health and Population Activities (CREHPA)
Paropakar Maternity and women’s Hospital ( PMWH)
Marie Stopes International /Sunaulo Pariwar Nepal ( MSI//SPN)
Forum of Women, Law, and Development (FWLD)
Safe Motherhood Network Federation ( SMNF)
Situational Analysis
Of
Unsafe Abortion in Nepal
Dr. Mahesh Puri and Dr. Pushpa Chaudhary
Nepal Society of Obstetricians and Gynaecologists (NESOG)
August, 2008
*This document is developed by Nepal Society of Obstetricians and Gynaecologists
(NESOG) in close collaboration with Family Planning Association of Nepal(FPAN) and
Centre for Research on Environment Health and Population Activities (CREHPA), Nepal
incorporating valuable inputs from members of core working group -the FHD, DoHS,
Govt. of Nepal; UNFPA country office, Nepal; Ipas, Nepal , Paropakar Maternity and
Women’s Hospital, Thapathali; Sunaulo Pariwar Nepal/Marie Stopes International;
Forum of Women, Law, and Development(FWLD, Nepal and Safe Motherhood Network
Federation, Nepal(SMNF).
**Funding for developing this document is provided by UNFPA, Nepal Country office
and publication is funded by IPPF.
-1-
Acknowledgments
We express our sincere thanks and gratefulness to Mrs Shashi Shrestha, the honarable
State Minister of Health &Population and other representatives of the Govt. of Nepal
including Dr. Govind Ojha, The Director General,( DoHS), Dr. Bal Krishna Suvedi,
Director, Family Health Division, Mr. Arjun Bahadur Singh, Director, National Health
Training Centre, and Dr. Meera Ojha, Ministry of Health for their support to this
assessment study and commitment to implement plan of action based on this study.
We express our sincere gratitude to Dr. Dorothy Shaw, the President of FIGO, Dr.
Annibal Faundes, Chief coordinator, FIGO initiative on Unsafe Abortion and Dr.
Shahida Zaidi, the regional coordinator, FIGO initiative on Unsafe Abortion for their
noble effort to reduce the burden of unsafe abortion in the developing world.
Prof. Pramila Pradhan, the president of NESOG and Mr. KP Bista , Director, Family
Planning Association of Nepal deserve special acknowledgement for their valuable
guidance and support in every step of developing this document. We also extend our
thanks to Prof. Sudha Sharma, Director, Paropakar Maternity and Women's Hospital for
her input and suggestions. Our heartiest thanks goes to Dr. Indira Basnet, country
director, Ipas Nepal for her extra ordinary guidance and support in the whole process.
We also wish to express gratitude to all FIGO initiative Core Working Group members
including Dr. Shilu Aryal, Senior Obstetrician and Gynaecologist, Family Health
Division; Dr. Prasanna Gunasekara, UNFPA; Mr. Anand Tamang, Director, CREHPA;
Dr. Lata Bajracharya, Paropakar Maternity and Women's Hospital; Dr. Durga
Manandhar, Marie Stopes International/Sunaulo Parwar- Nepal (MSI/SPN); Mr. Lok
Hari Basyal, Forum for Women, Law and Development (FWLD); and Mr. Sambhu Jang
Rana, Safe Motherhood Network Federation(SMNF). We would also thank Ms. Sapana
Malla Pradhan, FWLD and Dr. Giridhar Sharma Paudel, FPAN for their contribution in
preparation of this report.
We extend our heartfelt thanks to Dr. Pushpa Chaudhary, Focal person for FIGO
initiative and Secretary General, NESOG and Dr. Deeb Shreshtha Dangol ,NESOG
member, Focal point and coordinator from FPAN and congratulate them for their
excellent coordination and commitment throughout this process. Similarly, Mr Ganesh
Shrestha, Member of core working group from Ipas Nepal, deserve special thanks for
his extra effort and contribution.
Our heartiest thanks goes to Dr. Mahesh Puri of CREHPA for his excellent consultancy
for gathering information from published and unpublished reports and documents and
preparing the draft report on “ Situational Analysis of Unsafe Abortion in Nepal”. We
acknowledge the valuable contribution of Elena Preda of AGI who reviewed this
document and approved it on behalf of FIGO.
We are most grateful to Mr. Prabin Shakya, MSI/SPN, Ms Madhabi Bajrachjarya and
Ms. Mukta Shah, TCIC/Ipas, Dr. Asha Pun, Nepal Family Health Project, Dr Chanda
Kakri, Dr. Neera Singh Shrestha, Dr. Suman Risal and Tika Parajuli, all from
Kathmandu Medical College for their support in providing invaluable information and
support to this work. Our special thanks goes to Ms. Melissa Upreti, Center for
Reproductive Rights, USA, Ms. Sona Sethi, Planned Parenthood Federation of America,
-2-
Inc. Bangkok, Thailand and Ms. Lorelei Goodyear, PATH for providing invaluable
information about their institution's activities in Nepal.
Nepal Society of Obstetricians and Gynaecologists express gratitude to UNFPA, IPPF
and Ipas, Nepal funding for accomplishing the first phase of the FIGO initiative on
Unsafe Abortion - Situational Analysis of Unsafe Abortion in Nepal.
-3-
Foreword
Prof. Pramila Pradhan
President, NESOG
Unsafe abortion has substantial detrimental consequences for society, negatively,
affecting woman and their families, public health system and ultimately economic
productivity.
Data shows that around 19 million abortion take place globally every year. The absolute
number of unsafe abortion is highest in Asia at 10 million and 13 % maternal mortality is
due to unsafe abortion and as high as 54% hospital admission are due to induced abortion
complications (MOH 1998). Legalization of abortion in September 2002 has been the
first step in the breakthrough of reproductive rights of the women in Nepal. Many
national NGOs including professional organizations such as Nepal Medical Association
and Nepal Society of Obstetricians and Gynaecologists (NESOG) played an important
role in the advocacy for the legal reform in the late nineties. Centre for Research for
Environment Health and population activities (CREHPA) , Forum for Women, Law and
Development (FWLD) and family planning association of Nepal (FPAN) were the key
players in the movement. Their advocacy work and that of other individual and
organizations with support from INGOs stimulated interest of women’s activist group
and the issue of abortion gained national profile and momentum (2006).
The family health division under the department of health services, ministry of Health
and population has played the lead role in formulating policies, strategies and procedural
order to implement and expand safe abortion services in the country. The first
comprehensive abortion care service in the country was started at the government run
Paropakar Maternity and Women’s hospital in Kathmandu from March 2004
As of midwifery 2008, 508 /482 physicians and 26 nurses were trained for providing
CAC services. The government has approved 206 sites for CAC services in 74 districts
out of 75 districts of the country and total of 212000 women had received the CAC
services a remarkable achievement in reducing maternal mortality and morbidity.
In spite of such good work, there are many challenges like lack of awareness about the
CAC centres, inadequate and unequal distribution of transformation, sex selective
abortion. We need to overcome these as obstacles before Nepalese women will be able to
exercise their rights .
-4-
Foreword
Dr. Pushpa Chaudhary
Focal person for FIGO initiative on Unsafe Abortion, NESOG
The International Federation of Gynaecology and Obstetrics (FIGO), created a Working
Group (WG) on “The Prevention of Unsafe Abortion” and its complications, including
representatives of Obstetrics and Gynaecology Societies and partners from other
organizations with similar area of interest such as IPPF, ICM, UNFPA, WHO and Ipas,
and others in order to reduce maternal mortality and morbidity due to unsafe abortion
and its consequences. The FIGO Executive Board called for a situational analysis of
unsafe abortion in each country or territory with FIGO affiliated societies where burden
of the unsafe abortion is significant to have a basis for preparing a country specific plan
of action.
In Nepal, Nepal Society of Obstetricians & Gynaecologists (NESOG) was entrusted to
prepare this Situations Analysis on Unsafe Abortion in Nepal in close collaboration with
FPAN, the Government and other key stakeholders. The purpose of this Situational
Analysis on Unsafe Abortion in Nepal is to gather and analyze information on the
current level of unwanted pregnancy and its determinants, situation of unsafe abortion in
the country, document the progress made so far in the preventions and management of
unsafe abortions, highlight issues and challenges and suggest areas of activities to
address unsafe abortion in Nepal.
Information for this Situational Analysis has been collected from the published and
unpublished reports and journal articles related to unintended pregnancy and unsafe
abortion. Information was also obtained from the Nepal Demographic Health Surveys
reports, and abortion related studies and reports. Key experts within country and abroad
were contacted via email or telephone and requested for any information they have had
on this issue. Feedback was received from the Core Working Group (WG) for FIGO
Initiative in Nepal and incorporated in this report.
I would like to acknowledge UNFPA, Country office, Nepal for providing Funding
support to develop this document and IPPF for supporting the dissemination workshop of
this situational analysis as well as publication of this document. I would also extend
thanks to Ipas Nepal, core working group members, participants of group work and the
facilitator, Mr. Parimal Jha for contributing and supporting the dissemination workshop.
My special thanks go to Dr. Deeb Shrestha and Mr. Ganesh Shrestha for playing vital
role in the whole process.
I am optimistic that this information will be an asset for all stakeholders and help
develop a realistic and focussed plan of action to reduce the burden of the problem of
unsafe abortion in Nepal.
-5-
Abbreviations and Acronyms
ATF
BCC
CAC
CREHPA
FIGO
FP
FPAN
GoN
IEC
INGO
IPPF
IUD
MMR
MTP
NESOG
NGO
PAC
PEAP
PHC
PMO
RH
RTI
SRH
TCIC
UNFPA
WFS
WHO
Abortion Task Force
Behaviour Change Communications
Comprehensive Abortion Care
Centre for Research on Environment and Population Activities
Federation of Gynaecology and Obstetrics
Family Planning
Family Planning Association Nepal
Government of Nepal
Information, Education and Communication
International Non-governmental Organization
International Planned Parenthood Federation
Intra-uterine Device
Maternal Mortality Ratio
Medical Termination of Pregnancy
Nepal Society of Obstetricians & Gynaecologists
Non-governmental Organization
Post-abortion Care
Public Education and Advocacy Project
Primary Health Care Centre
Private Medical Outlets
Reproductive Health
Reproductive Tract Infection
Sexual and Reproductive Health
Technical Committee for Implementation of Comprehensive Abortion
Care
United Nations Population Fund
World Fertility Survey
World Health Organisation
Table of Contents
Page No
CHAPTER 1: Introduction ..................................................................................................... 1
CHAPTER 2: Extent and determinants of unintended pregnancy................................... 4
2.1
2.2
2.3
2.4
Extent of unintended pregnancy ................................................................................ 4
Determinants of unintended pregnancy ..................................................................... 4
Fertility preference ..................................................................................................... 6
Causes of unintended pregnancy ............................................................................... 7
CHAPTER 3: Legal framework of abortion ......................................................................... 9
3.1
Abortion law: Global context..................................................................................... 9
3.2
Aabortion law in Nepal before 2002 ........................................................................ 10
3.3
Efforts to legalise abortion in Nepal ........................................................................ 12
3.4 The current status of lagal framework of abortion in Nepal and its
implementation .................................................................................................................. 15
CHAPTER 4: Unsafe abortion ............................................................................................. 17
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Magnitude of the problem: Worldwide.................................................................... 17
Unsafe abortion in Nepal before legalization .......................................................... 18
Unsafe abortion procedures used in pre-legalisation era ......................................... 20
Unsafe abortion after legalization of abortion ......................................................... 21
Unsafe abortion procedures after legalization of abortion ....................................... 25
Abortion related death reported in printed media .................................................... 26
Reasons for unsafe abortions in Nepal..................................................................... 28
CHAPTER 5: Efforts to prevent unsafe abortions ........................................................... 33
5.1
5.2
5.3
Efforts of the Government ....................................................................................... 33
Efforts of the national organizations ........................................................................ 35
Contribution of INGOs ............................................................................................ 41
CHAPTER 6: Issues and challenges of current abortion care services ............................ 44
References
Annexes
48-51
52 - 61
List of Tables
Page No.
Table 2.1
Knowledge of specific contraceptive methods among currently married
Women age 15-49 and men age 15-59 …………………………………………..7
Table 3.1
Abortion law in South Asia ……………………………………………………10
Table 4.1
Induced abortion in Nepal during pre-legalisation era ……………………….19
Table 4.2
Literacy status of women and their spouses receiving abortion service from
untrained and trained personnel ………………………………………………..21
Table 4.3
Facility-wise annual caseloads of PAC clients in selected health facilities
outside Kathmandu Valley …………………………………………………..22
Table 4.4
Trend in PAC clients and percentage of induced abortions complications
Among PAC clients in Maternity Hospital (2058-2063)……………………….23
Table 4.5
Number of seriously complicated induced abortion out of the total
induced abortion case to total PAC clients in Maternity Hospital …………….23
Table 4.6
Procedure used for abortion resulting into complication/incomplete abortion
and subsequent admission at PAC units …………………………………….24
Table 4.7
Unsafe abortion procedure used in Nepal ……………………………………...25
Table 4.8
Persons assisting the abortion procedure resulting into complication/
incomplete
abortion
and
subsequent
admission
at
units….………………25
Table 4.9
PAC
Details of abortion related deaths reported in printed media ………………….27
Table 4.10 CAC service days and service fee at selected CAC centres…………………31
Table 5.1
Progress made in CAC service expansion and the number of clients
Receiving the services ….…………………………………………………….34
List of Figures
Page No.
……………………………………………………4
Figure 2.1
Fertility planning status
Figure 2.2
Fertility planning by mother's age at birth ……………………………………...5
Figure 2.3
Fertility planning by birth order ………………………………………………..5
Figure 2.4
Percentage of currently married women age 15-49 who want no
more children, by residence and education …………………………………….6
Figure 2.5
Percentage of currently married women age 15-49 with unmet need
for family planning ……………………………………………………………..7
Figure 2.6
Percentage of currently married women age 15-49 using
a contraceptive method
………………………………………………………8
Figure 2.7
CPR and unmet need for FP ……………………………………………………..8
Figure 3.1
Grounds on which abortion is permitted (percentage of countries)
Figure 4.1
Percentage distribution of unsafe abortion by age group in
the different regions ………………………………………………………….17
Figure 4.2
The Causes of Maternal Mortality: Global Estimates
Figure 4.3
Number of deaths due to unsafe abortion per 100000 unsafe abortions, by
sub region, 2003…………………………………………………………………18
Figure 4.4
Abortion cases as percentage of total obstetric & gynaecological admissions
in selected major hospitals ……………………………………………………..20
Figure 4.5
Trend in awareness on legalization of abortion ………………………………..28
Figure 4.6
Level of knowledge on approved CAC centres among married and
unmarried men and women: 2005………………………………………………29
………….9
……………………….17
CHAPTER 1
Introduction
Each year approximately 205 million women become pregnant worldwide, as reported
in the year 2003 of which around 30 million pregnancies end in spontaneous abortion or
still births and some 130 million women go on to deliver live born infants (Sedgh, et al,
2007). Worldwide, an estimated 36 per cent of pregnancies are unplanned and some 16
per cent of births are thought to be 'unwanted' or mistimed. Unintended pregnancies are
common in both developing and developed countries. In developed countries, of the 23
million pregnancies occurring every year, an estimated 44 per cent are unintended. In
developing countries, of the 182 million pregnancies occurring every year, an estimated
35 per cent are unintended (AGI, 1999; Sedgh, et al, 2007; UN, 2005 ).
An estimated 42 million pregnancies around the world that were terminated through
induced abortion in the year 2003, about 19 million of them were performed outside the
legal system. Most of these illegal abortions are considered unsafe because they are often
performed by unskilled providers or under unhygienic conditions or both. Of these
women, 35 million live in developing countries, and 6.6 million in developed countries.
Globally, about 58 per cent of all women having abortions live in Asia, 11 per cent in
Africa, and 9 per cent in Latin America and the Caribbean. The remainders live in
Europe (17 per cent) and elsewhere in the developed world. The prevalence of unsafe
abortions remain maximum in the 82 countries with the most restrictive legislations, as
high as 23 unsafe abortions per 1000 women aged 15–49 years. By contrast, 52 countries
that allow abortion on request have a
Abortion is the termination of a pregnancy
median unsafe abortion rate as low as 2 before the foetus has attained viability, i.e.
per 1000 women of reproductive age become capable of independent extra-uterine
life.
(Berer, 2004).
Approximately one in four women
having an unsafe abortion is likely to
face complications, including life
threatening complication and will seek
hospital care, putting extra constraint on
scarce
resources
(WHO,
2007).
Moreover, in developing countries, the
risk of death following complications of
unsafe abortion procedures is several
times higher than that of an abortion
performed
safely
by
skilled
professionals (WHO, 2003)
Induced abortion is the deliberate termination of
a pregnancy before the foetus has attained
viability, i.e. become capable of independent
extra-uterine life.
Spontaneous abortion is the spontaneous
termination of a pregnancy before the foetus has
attained viability, i.e. become capable of
independent extra-uterine life. This is often
referred to as a miscarriage.
(WHO, 2006a)
Unsafe abortion is defined as a procedure for
terminating an unwanted pregnancy either by
persons lacking the necessary skills or in an
environment lacking the minimal medical
standards, or both
(WHO, 2003)
1
Country context
Nepal is a predominately hilly and mountainous small land-locked country bordering with
the People’s Republic of China in the north and India in the east, south and west. The
country has diverse cultures, climates, traditions and languages. A large percentage of the
population live in rural areas, with limited access to basic infrastructure or services. The
country is divided into three geographic regions: the terai (plains belt), the hills, and the
mountains. As one moves from the terai up to the mountains, living conditions and access
to health care become increasingly constrained resulting in wide discrepancies in health
services in different regions.
Total area of the country is 147,181 square kilometres. The population is about 28
millions with 781, 686 live births occurring every year (CBS, 2002). The population has
more than doubled in the last 30 years. Life expectancy is one of the lowest in the world:
60.7 years for women and 60.1 years for men (NDHS, 2006). The country is one of the
poorest and least developed countries in the world with almost one-third of its population
living below the poverty line (Ministry of Finance, 2006). Development is largely
hindered by topography, marked caste and class distinction and unequal distribution of
power and resources, as well as by severe gender discrimination in spheres of public and
private life. Women’s access to education, property, and economic resources is often
limited, particularly in rural areas, where approximately 86 per cent of Nepalese
Population live.
Nepal Demographic Health Survey , 2006 showed a remarkable decline in Maternal
Mortality Ratio (MMR) from 539 deaths (CI 392-686) for the period 1989-1995 to 281
deaths (CI:178-384) per 100,000 live births for the period 1999-2005 (NDHS, 2006). In
contrast, estimation made by WHO/UNICEF/UNFPA/World Bank (based on reviews of
all data available for Nepal and adjusted for under registration and misclassification)
showed
much
higher
MMR
of
830
per
100,000
live
births
(WHO/UNICEF/UNFPA/World Bank, 2005). However, it has been argued that this
estimation was consequently high due to the use of old data on proportion of births
attended by skilled personnel in estimation process (Pant et. al, 2008). Nevertheless,
Nepal still falls in those countries with the highest maternal deaths in the world. It is
estimated that up to 50 percent of all maternal deaths in Nepal's hospitals, are attributable
to complications of unsafe abortion (Thapa et.al., 1992) Beside unsafe abortions, Nepal’s
high maternal mortality and morbidity rates are associated with a number of other factors,
such as early, closely spaced, and repeated pregnancies; poor health and nutritional status
of women; insufficient facilities of essential obstetric care; inaccessibility of health
services; low utilization of health services; harmful traditional beliefs and practices and
the low status of women.
According to the NDHS 2006, only 44 percent of women have received at least one
antenatal visit from a health professional. In rural areas, the rate was even lower at 38 per
cent. Moreover, 82 per cent of all women deliver at home, often under unhygienic
conditions and with untrained attendants. Only 19 per cent and 18 percent of women
delivered their babies with the assistance of a skilled birth attendant (doctor, nurse or
midwife) and at a health facility, respectively. Although the total fertility rate has dropped
from 4.1 children in 1996 to 3.1 in 2006, fertility is still high in the mountain region (4.1
children) and among poor people (4.7 children among the lowest quintile) (NDHS, 2006).
In view of the high prevalence of home deliveries, low use of SBAs at birth, low
utilisation of antenatal care and socio-economic and cultural barriers to accessing care as
2
well as an extremely constrained supply side for service provision, Nepalese women
continue to suffer from pregnancy related complications.
Since the late 1960s, the Government of Nepal (GoN) has acknowledged the link
between population growth and economic growth. Family planning services in the
country started by the Family Planning Association of Nepal (a non governmental
organization) in 1959. Nepal Family Planning and Maternal and Child Health Project
was established in 1968 and gradually expanded to all 75 districts in Nepal. Now the
family planning services is an integral part of the government health services. Currently,
temporary family planning methods (male condoms, contraceptive pills, and injectable)
are provided on a regular basis in national, regional, zonal, and district hospitals as well
as lower level health facilities such as primary health care centres, health posts, sub
health posts, outreach clinics through peripheral health workers and volunteers. Services
such as Norplant implants and Intra uterine devices are available at a limited number of
hospitals, health centres, and selected health posts where trained service providers are
available. Depending on the district, sterilization services are provided at static sites (21
districts) through scheduled 'seasonal' or 'mobile' outreach services (NDHS, 2006)
The family planning programme of the government supports several approaches,
including outreach programs, community-based programs, and private sector
involvement. Besides government programmes, a number of national and international
non-governmental organizations (I/NGOs) are also currently involved in the delivery of
family planning services at the grass-root level. In addition to service delivery, a few
NGOs are also involved in behaviour change communication programmes including
Information, Education and Communication (IEC) and adult education classes with a
focus on family planning.
Until 2002, abortion was illegal in almost all circumstances in Nepal except to save
women’s life with advice of medical doctor as per guideline of Nepal medical council
( personal communication). However, there is enough evidence to prove that induced
abortion was fairly widespread clandestinely throughout the country contributing
significantly to the high maternal mortality and morbidity figures (FHD/MoH, 1998).
According to a study conducted by Ministry of Health, 54 percent of all maternal deaths
occurring in the government hospitals were due to unsafe abortion (FHD/MoH, 1998). It
was also not uncommon to find many women in terai (Plain) towns going to India to get
rid of unwanted conceptions. Studies conducted by Centre for Research on Environment
Health and Population Activities (CREHPA) in 1997, 1999 and 2000 on post-abortion
care at 10 major hospitals of the country showed that between 20% and 60% of the
women admitted as in Obstetric and Gynaecology unit were abortion complication cases
(CREHPA, 2000b).
In Nepal, abortion was legalized in September, 2002 after many years of intensive
research, advocacy and lobbying. Legalization of abortion has created a new paradigm
and challenges for Nepal. As in many countries where abortion laws were revised from a
highly restrictive to a liberal abortion law, the demand for abortion by Nepalese couples
is bound to increase initially and for some years and then stabilize. Although not all
unintended pregnancies result in induced abortion, it is likely that more and more women
with unintended pregnancy would seek abortion services in the changed circumstances.
However, there are many obstacles that Nepalese women face to be able to exercise their
rights to safe and legal abortion service.
3
CHAPTER 2
Extent and determinants of unintended pregnancy
Unintended pregnancy is an important public health concern in both the developing and
the developed world because of its association with adverse social and health outcomes
for mothers, children and the family as a whole. These include the higher likelihood of
unsafe abortion, and the late initiation and under utilization of pre natal and post natal
care.
2.1
Extent of unintended pregnancy
Although the prevalence of unintended pregnancy is gradually decreasing over the years,
it is still very high in Nepal. The 2006 DHS study estimated that 30 per cent of births (16
% unwanted, 14% mistimed) in the five years preceding the survey were unintended. The
corresponding figure for the year 1996 and 2001 was 38 and 35 per cent respectively.
Unplanned pregnancies have also decreased
among
married
adolescents
currently
Figure 2.1
Fertility planning status
contributing to about one fourth (24%) of births
100
while in 1996, it was about one third of births.
Similarly, another study conducted amongst 500
80
69
clients attending a government hospital for
64
62
pregnancy test revealed that 70 of these young
60
women aged 15-24 years had their current
%
40
pregnancy unintended (Sharma, 2002). Another
22
19 18
study reported that about 20 per cent of the
14 16
20
14
married women aged 15-24 years have at least
one experience of unintended pregnancy
0
1996, NFHS
2001, NDHS
2006, NDHS
(Tamang et. al., 2002). Similarly, findings of
another study conducted among young married
Wanted then Wanted later Wanted no more
couples in five districts of Nepal in 2003
suggest that a woman has at least one
unintended pregnancy before the age of 24 years (Puri et al, 2006).
It was estimated that women on average have 1.1 children more than their ideal number
of two children. This means that the total fertility is 55 per cent higher than it would be if
unwanted births were avoided in this country (NDHS, 2006). The gap between wanted
and observed fertility is greater among women living in rural areas than in urban areas.
Among ecological zones, the difference in the two rates is higher in the mountain zone
(1.6) and smallest in the terai (1.0).Among development regions, the gap varies between
one child per woman in the Central development region to 1.3 children per woman in the
mid-western region.
2.2
Determinants of unintended pregnancy
2.2.1
Maternal age
Generally, age of a woman at the time of conception could influence whether the
pregnancy is mistimed or unwanted, because age is related to woman’s level of maturity
4
as well as biological, social, and emotional preparedness for the responsibilities of
childbearing. Studies have documented the association between age of the woman at the
time of pregnancy and an unintended pregnancy (Pratt and Horn, 1985; Forrest, 1994). In
general, unintended births increase with mother’s age but mistimed pregnancies are more
frequent amongst younger age
groups compared with older age
Figure 2.2 Fertility planning by mother's age at birth
groups (Adetnunji, 1998). In
100
Nepal, unwanted births increase
from about 2 per cent amongst
80
mother below 20 years of age to
72
as high as 72 per cent amongst
60
53
%
women aged 40-44 years
40
40
(NDHS, 2006). In contrast,
mistimed births decreased with
22
21
20
18
mother's age at birth.
10
8
<20
2.2.2
5
2
0
20-24
25-29
30-34
3
35-39
2
40-44
Age
Number of children
Wanted later
Wanted no more
Studies
have shown that
generally the higher the parity the greater the likelihood of pregnancies be unintended
(Adetunji, 1998). In Nepal, proportion of unwanted births increase with increasing birth
order. For example, The
Nepal Demographic and
Figure 2.3
Fertility planning by birth order
Health Survey, 2006 show
that 44 percent of births of
100
order four and higher and
83
74
over one in five births of
80
68
order three are unwanted.
60
51
Mistimed births are more
%
44
40
often among low parity
22
21
17
women than high parity, a
20
0
11
6
pattern similar to that found
4
0
in 2001. Another study
1
2
3
4+
conducted among young
Birth order
couples in Nepal revealed
Wanted then
Wanted later
Wanted no more
that as parity increases, the
percentage
of
women
reporting unintended pregnancy increased from about 52 per cent with no child to 69 per
cent women with three or more children (Puri et. al., 2006)
2.2.3
Level of education
Education can be interpreted as a measure of self-efficacy, competence and capacity to
make informed decision. It is expected that an educated woman would not have a
pregnancy that she is not prepared for provided she has access to means of avoiding it. For
example, in the 41 developing countries that participated in the World Fertility Survey
(WFS), women with elementary education or less were much more likely than the better
educated ones to have an unplanned pregnancies or an unwanted birth (Bongaarts, 1997).
The Nepal DHS 2006 has shown that the gap between wanted and observed fertility
decreases with increasing level of education. Women with no education tend to have 1.3
5
children more than they said they wanted, compared with women with a School Level
Certificate and higher education who had just 0.3 children more than they said they
wanted.
2.2.4
Social deprivation
Social deprivation is often considered as one of the determinants of unintended
pregnancy. Generally social deprivation includes the elements such as income,
ethnicity/caste or social class, educational level, health status and employment status of
the young women (Tabberer et al., 2000). For example, in the United States and Britain,
there is a clear negative relationship between economic status and having a child before
the age of 20 years that is generally unintended. In contrast, a Nigerian study revealed
that respondents in professional jobs (teaching and medicine) were significantly more
likely to report an unwanted pregnancy compared with unemployed women (Okonofua
et al., 1999). Unfortunately, there is paucity of such study in Nepal that has looked into
the relationship between social deprivation and unintended pregnancy. However, Nepal
DHS 2006 revealed that there is an inverse relationship between wealth quintile and
wanted fertility. The gap between wanted and actual fertility is 2.2 children among
women in the lowest wealth quintile and 0.5 among women in the highest wealth quintile
(NDHS, 2006). Another study among young couples found that the medium class family
was more likely to experience unintended pregnancy than either the poor or the rich class
family (Puri, et. al., 2006). The same study also documented that there is little difference
in the percentages of unintended pregnancy amongst the women in five major different
ethnic groups (Tharu, Brahmin/chhetri, Newar, Rai/limbu and occupational caste).
However, this study also indicated that the Tharu women reported lower level of
unintended pregnancies compared to other ethnic groups.
2.3
Fertility preference
Information on fertility preference provides insight into a couple's attitude towards future
childbearing, desired completed family size and prevailing unmet need for contraception.
2.3.1
Desire for children
An important indicator of the
potential demand for family
planning is the percentage of
women who want no more
children. Figure 2.4 presents
trend in the percentage of
currently married women aged
15-49 years who want no more
children. Overall, the percentage
of currently married women
wanting no more children
increased from 59 per cent in
1996 to 71 per cent in 2006, an
increase of 21 per cent, with
proportionately more increase in
rural areas than in urban areas
(22% versus 5%).
Figure 2.4
100
Percentage of currently married women age
15-49 who want no more children, by
residence and education
90
80
75 75
71
70
60
70
65
58
76
68
60
56
65
61
71
66
60 59
53
62
57 59
Some
SLC and
secondary
above
59
50
40
30
20
10
0
Urban
Rural
No
education
Residence
Education
1996 NFHS
6
P rimary
2001 NDHS
2006 NDHS
Total
The overall increase in the percentage of currently married women wanting no more
children was mostly concentrated among women with primary education and those with no
education. The percentage of women who want no more children, increased by 28 per cent
among women with no education and 15 per cent among women with primary education
(Macro International Inc, 2007).
2.3.2
Unmet need for family planning
Figure 2.5 shows unmet need for
Figure 2.5 Percentage of currently married women age 15family planning among currently
49 with unmet need for family planning
married women in the reproductive
age. The data revealed that there has
35
been a decline in the unmet need for
31
28
30
family planning over the past 10
25
years, with unmet need in 2006
25
being 22 per cent lower than it was
17
20
16
15
14
in 1996 (25% versus 31%). There
15
11
was a 34 per cent decrease in the
9
10
proportion of women with unmet
5
need for spacing, while the
0
proportion of women with an unmet
Unmet need for Unmet need for
Total unmet
need for limiting decreased by 11
spacing
limiting
need
per cent during the same period. The
decline in unmet need over the last
1996 NFHS
2001 NDHS
2006 NDHS
10 years was more obvious in rural
areas (21% than in urban areas (9%).
Source: NDHS
However, unmet need rose among
women living in urban areas over the past 5 years (from 16% to 20%) (Macro
International Inc, 2007).
2.4
Causes of unintended pregnancy
Unintended pregnancy can
result generally from nonuse of contraceptives,
contraceptive failure and,
less commonly as a result
of rape or incest (AGI,
1999). Despite almost all
Nepali married men and
women being aware about
the contraceptive methods,
contraceptive
use
is
surprising very low. Only
44 percent of currently
married women are using
modern
method
of
contraception. About 25
per cent of the women
want to delay pregnancy or
not to have any more child
Table 2.1 Knowledge of specific contraceptive methods among
currently married women age 15-49 and men age 15-59
Method
Any method
Any modern method
Female sterilization
Male sterilization
Pill
IUD
Injectables
Implants
Condom
Any traditional
method
Rhythm method
Withdrawal
7
Percentage of
women
1996
2001
2006
NFHS NFHS NDH
S
98.4
99.5
99.9
98.3
99.5
99.9
96.3
99.1
98.7
89.7
98.2
96.3
80.5
93.4
95.4
35.9
54.7
67.2
85.0
97.3
98.8
57.3
79.8
83.5
75.3
91.0
96.8
44.4
55.4
51.6
37.0
29.1
Percentage of
men
2001
2006
NDHS NDHS
99.6
99.6
98.6
98.4
90.3
59.3
94.2
72.1
97.1
81.0
99.9
99.9
98.6
98.8
92.2
67.0
94.8
73.6
99.5
78.3
35.1
34.5
62.8
66.9
41.1
39.8
70.7
69.8
Source: NDHS, 1996, 2001& 2006
but still are not using any method of contraception (NDHS, 2006). Moreover, only about
14 per cent currently married women aged 15-19 are using any modern method of
contraception. There is substantial difference in use of contraceptive methods among
subgroups of currently married women. Women in urban areas are more likely to use a
family planning method compared to rural women (54% versus 43%), reflecting wider
availability and easier access to
methods in urban than in rural
Figure 2.6 Percentage of currently married women
areas. Wealth has a positive effect
age 15-49 using a contraceptive method
on women's contraceptive use,
with modern contraceptive use
48
increasing markedly as household
50
44
wealth increases, from 30 per cent
39
40
35
among married women in the
29
lowest quintile to 54 percent
30
26
among those in the highest wealth
20
quintile (NDHS, 2006). Most
women who were sterilised were
10
3 4 4
over 30 years of age, while
injectables are popular among
0
Any modern
Any traditional
Any method
women aged 20-44 years.
method
method
Common causes of not using
1996 NFHS 2001 DHS 2006 NDHS
contraception are several including
fear of the technology, lack of
affordable and accessible contraception services, lack of knowledge on reliable and
suitable contraception, fear of side effects as well as limited numbers of male
contraceptive methods. Moreover,, restraint by husbands, family, or the community and
sexual inequality in many cultures together with failure to understand the risk of
pregnancies or the impact of another child on the family economy are contributing factors
for women’s ability to control own fertility.
Unintended pregnancy also results from failure of contraception. A Nepalese study found
that 20 per cent of women in rural and
16 per cent in urban area (aged 15-49)
Figure 2.7 CPR and unmet need for FP
reported method failure as the reason for
10 0
their unintended pregnancies (Tamang et
al., 2002).
80
60
%
40
20
48
39
31
29
25
28
0
19 9 6 N F H S
CP R
2001 N D H S
2006 N D H S
Unm e t ne e d
Source: NDHS 1996, 2001 & 2006
contraceptive failures (CREHPA, 2000b).
8
In another study conducted by
CREHPA in 2000 entitled "Roles
Perceived by Private Medical Outlets
(PMO)
in
Preventing
Unsafe
Abortions" over 50-60 per cent of the
private medical outlets mentioned that
they receive clients with pregnancy
due to contraceptive failure. In
Pokhara, over one third (35%) of the
PMOs mentioned that they have
received more than 10 clients with
CHAPTER 3
Legal framework of abortion
3.1
Abortion law in global context
The incidence of unsafe abortion is influenced by the legal provisions governing access
to safe abortion, as well as the availability and quality of legal abortion services.
Restrictive legalisation is associated with a high incidence of unsafe abortion (WHO,
2007). According to United Nations Population Division, in almost all countries (97%),
abortion is permitted to save women's life (Figure 3.1). Only in five countries in the
world (Chile, El Salvador, The Holy See, Malta and Nicaragua), abortion is not
permitted at any circumstances. In two-thirds of countries (67%), abortion is permitted
when it is necessary to preserve the physical health of the woman and many countries
(64%) specifically allow abortion to protect mental health of the pregnant woman.
Permitting abortion in cases of rape or incest is a common provision (United Nations,
Department of Economic and Social Affairs, Population Division, 2007). About in half
of countries, abortion is permitted in case of rape and incest (48%) or foetal impairment
(45%). One-third of the countries allow abortion on economic and social grounds while
over a quarter of countries allow abortion on request (United Nations, Department of
Economic and Social Affairs, Population Division, 2007).
Figure 3.1
Grounds on which abortion is permitted (percentage of
countries)
97
96
97
To save the woman's life
67
To pre se rve physical
he alth
88
60
64
To pre se rve me ntal he alth
86
57
48
Rape or ince st
84
37
45
Foe tal impairme nt
84
32
34
Economic or social
re asons
78
19
28
O n re que st
67
15
0
10
20
30
40
50
60
70
%
W orld
More de ve lope d countrie s
Le ss de ve lope d countrie s
9
80
90
100
Figure 3.1 clearly reveals that the abortion laws and policies are more restrictive in the
developing countries compare to developed countries. In developed countries, abortion is
permitted for economic or social reasons in 78 per cent of countries and on request in 67
per cent of countries. In contrast, only 19 per cent of developing countries permitted
abortion for economic or social reasons, while in 15 per cent of developing countries on
request (United Nations, Department of Economic and Social Affairs, Population
Division, 2007)
Table 3.1 Abortion law in other countries of South Asia
Country
1. India
Year of law
Legal of a broad range of medical and social grounds
including physical and mental health, rape, suspected
deformity in the foetus, contraceptive failure in a married
women
2. Bangladesh
1972
To save the life of the woman
1861
Menstrual regulation up to 10 weeks legal since 1974 as an
interim health measure to establish non-pregnancy.
1974
3. Pakistan
Abortion up to four months is not a crime if it is carried out
to provide necessary treatment
1991
Comments
Parental consent required
for women less than 18
years.
Necessary treatment is
not clearly defined
4. Sri Lanka
1883
To save the life of the woman
5. Maldives
Abortion is prohibited in the Maldives except for approved
certain medical reasons
6. Bhutan
Abortion not permitted
even in the case of rape
or incest
Not clear. Probably abortion is allowed only to save the life
of the woman
3.2
Abortion law in Nepal before 2002
Traditionally, abortion was restricted in Nepal either on the grounds of law or culture,
religion, customs, and traditions. Abortion was only done to save women’s life on
medical ground with consent of two doctors in hospital as per Nepal medical council
guideline (personal communication).
In ancient time, according to Manusmriti, consumption of any food item touched or
served by a woman who has had an abortion was considered as a sin. In the Kirant Era,
Abortion was considered as sin, but no proper system of trial and punishment existed. In
the Lichhchhavi Era, although no separate legal provision relating abortion existed, the
act of abortion was considered to be immoral and the culprit received punishment. In the
Malla Era, law on trail and punishment for crimes of abortion was made quite liberal to
protect the interest of the high castes families (MoHP/WHO/CREHPA, 2006). During
that time abortion was permitted if the pregnancy was due to sexual relationship between
10
a high caste and a low caste person. No precise legal provision regarding abortion can be
found before the Shah Era of 1853.
The Country Code (Mulki Ain, 1910 B.S) introduced in a written form for the first time
in 1853, has a separate legal provision on abortion. As per this provision, both the
woman and the person performing the abortion could be imprisoned. Though the Muliki
Ain was amended several times, extensive revision was made in 1963 (Thapa S., 2004).
The Muluki Ain, 2020, prohibited abortion, even if it was result of rape or incest and it
was characterized as an offence against life. The sections 28 to 33 of the Muluki Ain
Box 1. Key events in the law reform process
9 July 1996: Private bill to reform abortion law introduced in the national Assembly by FPAN President
9 September 1997: Creation of special committee and several meets to discuss the bill and recommend it to
the National Assembly
26 June 1999: Private bill declared null and void.
25 September 1999: Ministry of Law, Injustice and Parliamentary Affairs introduces the Muluki Ain 11th
amendment Bill in the House of Representative.
18 August 2000: House of Representative sends the Bill to the law, justice and parliamentary committee
for discussion and recommendation.
Nov 2000: Government Reproductive Health Steering Committee agrees to support submission of a
proposal to amend the abortion law.
8 October 2001: Law, Justice and Parliamentary Committee return the Bill with its recommendations to the
full House of Representatives.
9 October 2001: House of Representative passes the Bill and sends it to the National Assembly.
13 October 2001: National Assembly votes down the Bill because of disagreement over provisions on
women’s property rights.
Nov. 2001: Proposal accepted and FHD asked to draft a section on abortion for inclusion in the 11 th
amendment to the country code.
Feb. 2002: Abortion Task force formed to draft key documents and lay the foundations for implementation
once the law was passed.
14 March 2002: Amendment passed – Abortion no longer illegal.
June 2002: Literature review of global lessons learned in abortion law reform [6], from which basic
procedural and programmatic principles were derived.
6 Sept.2002: Royal Assent given for the new law, but services still cannot begin without approval of the
procedural order.
Nov.2002: Technical Committee for the Implementation of Comprehensive Abortion Services (TCIC) was
formed as an implementation body within the Family Health Division.
Dec. 2003: Procedural Order approved.
18 March 2004: First legal abortion service site was commenced at the Maternity Hospital in Kathmandu
Source: MoHP/WHO/CREHPA, 2006; Thapa, 2004
2020 dealt with the crimes of abortion and infanticide under the chapter on Jyan (life)
and provided trial and punishment for those crimes in that chapter. Any person who
performed an abortion on a pregnant woman with her consent, causing her to miscarry,
both the person who performed the abortion and the woman were sentenced to one year
to one and half years imprisonment. The duration of prison term depended on whether
the foetus was less than six months or over six months old. However, for a person who
performed an abortion on a woman without her consent, the punishment ranged from 2
years for a foetus less than six months to 3 years for a foetus over six months.
11
If a woman used a drug procured from somebody or a device with somebody's help with
the intention of terminating the pregnancy leading to abortion the maximum
punishment for her was one and half years of imprisonment. But, if a woman expelled a
live foetus (as a result of abortion attempts by using abortificients) and the foetus died
later, the woman was accused of abandoning a live-born child and causing its death
through exposure. Thus In this situation, in accordance with Sec.18 of the Chapter the
woman was convicted of murder and liable to life imprisonment as well as confiscation
of her entire pregnancy (CREHPA, 2000a).
Despite restrictive abortion law, induced abortion was not uncommon in the country and
most of them were unsafe. Usually such acts had prior consent or support from their
spouse, male partners and relatives. Safe abortions were easily accessible in towns at a
price to those who could afford them or across the border in India where abortion is
legal. Women who relied on traditional abortionist in the villages for pregnancy
termination and following septic or incomplete abortion, they could easily undergo
evacuation procedure and other treatment safely at any government hospitals without any
fear of prosecution. Even though it was easy for the clinicians at the hospitals to
distinguish between induced abortions and miscarriages, documentation was not usually
done to specify the nature of pregnancy termination in the hospital register. Moreover,
these patients usually did not reveal the fact and they were admitted as cases of
spontaneous miscarriage (CREHPA, 2000). On the other hand, the harsh provisions of
the old law contributed to a recurring situation in which an induced abortion and
sometimes even spontaneous abortion, would be deliberately misclassified as a crime of
infanticide, wilful killing or murder, in order to have a woman convicted and
incarcerated, so that she would lose her rights to any family property (Thapa, 2004).
A nationwide survey on women in prison for abortion conducted by CREHPA in 1997
showed that out of the 406 women who were in prison for different crimes at the time
of the survey, 20 percent of them (80 women) were convicted for abortion-related
crimes. Nearly one-third of them were in the prisons since past 3-5 years or even more.
Court cases were pending for more half of these women (56%). The same study revealed
that women especially from rural areas who were poor, illiterate and had low social
status, frequently became victim of exploitation and imprisoned on charges of abortion
and infanticides. Since the law did not clearly differentiate between Garbhapaat
(abortion) and Jaatak (infanticide), prosecutors normally chose the latter. These accused
women rarely have any lawyer to fight their cases in the court. Although in all
circumstances abortions were motivated and carried out with the assistance of spouse or
male partner, in most cases it was the women and not their spouse or male partner, who
were convicted for the crime (CREHPA, 2000). A study conducted by FWLD in 2006
found that 16 women and 2 men were in the prison for abortion or abortion related
offences in 2006.
3.3 Efforts to legalise abortion in Nepal
For more than two decades, efforts were made to liberalize the abortion law in Nepal
when it was first initiated in the 1970s (Thapa, 2004). The Family Planning Association
of Nepal had organized a conference in 1974 to discuss the medical rationale and
relevance of making abortion legally accessible and available to women with unwanted
pregnancy. The government of Nepal organized two national level consensus building
conferences on need to regulate population growth through maternal and child health
programmes as well as the scope of abortion as an effective method of regulating
12
fertility. Later on, National Commission of Population recommended the government for
legalization of abortion resulting from contraceptive failure. Therefore, in the 1970s,
liberalization of abortion was largely discussed as a mean to control fertility but not as a
matter of maternal health or rights. In the mid-1980s a National Forum was organized by
the Nepal Women’s Organization (NWO) to examine the legal status of abortion and
make concrete recommendation to the government to reform the law. The forum came
into the consensus that abortion should be legalized if the pregnancy results from rape or
incest. However, it was not taken into consideration by the national legislature as it was
considered too sensitive issue and the movement was also not so strong at that time to
push the legislature into action. This momentum also could not become that strong
because of the US policy on abortion as the Global Gag Rule was first implemented in
mid-1980s. The policy restricted non-US NGOs receiving funds from US to work for
abortion service related areas (Thapa, 2002).
In 1987, WHO launched the Safe Motherhood initiative and Family Health Division took
responsibility of developing safe motherhood policy and plan of action in 1993 with the
technical support of WHO which involved compiling and reviewing evidences, bringing
together key providers including national and international organizations, raising
awareness and preparing for a programme for 1994-97 (MOH, 1993; MOH 2002). One
of the important elements of this policy was to liberalize existing abortion law aiming to
reduce high maternal mortality and morbidity from unsafe abortion in the country
(Thapa, 2004). Along with the Safe Motherhood policy, efforts were made to educate
legislators and other stake holders regarding the plight of Nepalese women and the
feasibility and necessity of improving their status through policy legislative and
programmatic intervention. In this connection, several workshops were organised for
policymakers, legislators, International and National NGOs engaged in health sectors,
researchers, citizen groups, physicians, nurses and the media. The Ministry of Health
formed a "Network Group" of seven experts from different institutions to advice on the
submission of an abortion bill to the parliament (MoHP/WHO/CREHPA, 2006). A
symposium was organized by the Population and Social Committee of the National
Parliament, Nepal Medical Association, Nepal Society of Obstetricians and
Gynaecologists (NESOG) and FPAN in 1996 and all the participants viewed that
abortion for the first trimester pregnancy should be made legal, if performed by
registered and trained medical practitioners (HMG, 1996)
Effective advocacy for legal reform began in 1996 when Family Planning Association of
Nepal (FPAN) introduced a private bill in the Parliament. Although the bill was about
liberalisation of the abortion law, it was called the “Pregnancy Protection Bill”. This first
bill was debated several times by the National Assembly’s Special Committee over a
year time period, but unfortunately, it did not make much headway toward a final vote
due to expiration of the term of office of the bill’s sponsor (Mr. Sunil Kumar Bhandari).
As a result it was rendered null and void (Thapa, 2004).
The Ministry of Law, Justice and Parliamentary Affairs brought the Muluki Ain 11th
Amendment) Bill, 1997 before the parliament which included various rights related to
women such as women’s right to property inheritance, child marriage, polygamy, rape
including the legalization of conditional abortion. The Bill was presented to the House of
Representatives on 11/8/1997 and passed through several stages before it lapsed as a
result of the dissolution of the House of Representatives on 15/1/1999. The government
reintroduced the Bill in the House on 20/9/1999, within a few months of the general
election in 1999. Amendments to the bill was made when the bill was presented to the
13
Parliament for the second time that proposed, among other things, the right of pregnant
women to seek abortion that should to be provided on her own free consent (without
needing consent of others). The Bill was initially approved by the House of
Representatives in October 2001, but rejected by the National Assembly due to
continuing disagreements over women’s property rights (FWLD ,2003; Thapa, 2004).
Many national NGOs including professional organizations such as Nepal Medical
Association and Nepal Society of Obstetricians and Gynaecologists played important
role in the advocacy for the legal reform in the late nineties. Center for Research on
Environment Health and Population Activities (CREHPA), Forum for Women, Law and
Development (FWLD) and FPAN were the key players in the movement. Their advocacy
work and that of other individuals and organizations, with support from INGOs,
stimulated the interest of women’s activist groups, and the issue of abortion gained
national profile and momentum (MoHP/WHO/CREHPA, 2006).
An important factor promoting reform was empirical evidence from well-conducted
studies which was synthesised and disseminated to stakeholders. In 1984, a benchmark
study was carried out in five hospitals in and around Kathmandu valley. This study
examined all cases of women hospitalised due to complications of induced abortion over
a period of one year. It was found that as high as 50 per cent of all maternal deaths in the
study hospitals were due to abortion related complications (Thapa et. al.1992). In 199294, a six month prospective study was carried out in four public and one private clinic in
Kathmandu. This study confirmed many of the findings of the first urban-based study ten
years before. In 1996, a public opinion poll survey on abortion was undertaken for the
first time in Nepal by CREHPA in order to find out the public opinion concerning
abortion and whether abortion should be legalized or not. In the following years, surveys
and opinion polls on abortion related issues were conducted among different segment of
the population and stakeholders such as the medical doctors including Obstetricians &
Gynaecologists, paramedics, locally elected representatives in the villages, etc. These
surveys showed that practically all segments of Nepalese society were in favour of
legalizing abortion. In addition, in 1998 and 1999 two facility-based studies were
conducted by CREHPA. These studies showed that between 20 and 60 per cent of all
obstetric and gynaecological admissions in major hospitals of the country were abortion
complication cases (CREHPA, 1998; CREHPA, 1999). Majority of the government
hospitals lack sufficient human resource , equipment and space to deal with abortion
related complications. Hospitals beds were occupied by abortion complication cases for
longer period (CREHPA, 2000). The 1997 nationwide prison study conducted by
CREHPA showed that one in five women in prison had been convicted for charges of
abortion and infanticides. These findings added human rights, welfare, social justices and
equal-treatment under-the- law dimension to argue for abortion law reform.
CREHPA initiated Public Education and Advocacy Program (PEAP) against unsafe
abortion as a national program in 1999 with funding support of the Ford Foundation in
response to the policy issues raised in their research concerning unsafe and illegal
abortions in Nepal. The PEAP was implemented intensively in the eastern region of the
country in the partnership with 21 district level NGOs and was subsequently expanded in
remaining part of the country (2000-2002).
FWLD focused on the legal implications of the existing abortion law, particularly to
women imprisoned for abortion related offences. While working to help women in
prisons around the country on abortion or “infanticide” charges, FWLD published a
14
number of articles and reports in conjunction with other NGOs and INGOs. These
publications highlighted the plight of the (mostly poor) women suffering under the
effects of the existing discriminatory law, claiming that the illegal status of abortion
constituted a violation of human rights. FWLD and other related national NGO's worked
closely with Centre for Reproductive Rights (CRR), to draft legislation for amendment
of laws in the Country Code that discriminated against women, including the
criminalisation of abortion (MoHP/WHO/CREHPA, 2006).
In March 2002, the House of Representatives passed the 11th amendment of Mulki Ain,
six years after it was registered in the Parliament and the royal seal of approval was
given by the King in September 2002. The new legislation is an outcome of persistent
advocacy efforts of many rights based organizations and activities supported by research
studies and public opinion polls.
3.4
The present law on abortion in Nepal and its implementation
Abortion was legalized in Nepal under the 11th amendment to the Country Code (Mulki
Ain) in March 2002, received royal assent in September 2002. The law grants women's
rights to control over and decide on their unintended pregnancies. Abortion is legal in
Nepal on the following grounds:

Up to 12 weeks of
gestation for any
woman

Up to 18 weeks of
gestation
if
pregnancy results
from rape or incest

At
any
time
during pregnancy,
with the advice of
a
medical
practitioner or if
the physical or
mental health or
life of the pregnant
woman is at risk or
if the foetus is
deformed
and
incompatible with
life.
Abortion
will
punishable
on
following grounds:

be
the
Box 2.
Key Documents related to Abortion Law
Implementation
The procedural Order: Defines clinical procedures, service provision
facilities, client consent procedures and listing of approved providers.
The Abortion Policy: Link between maternal mortality and unsafe
abortion made explicit, and need to respect the right of the women to
informed choice about continuing a pregnancy. Specifies that systems
must be easy to implement and administer.
The Abortion Strategy: Comprehensive abortion services to be
introduced as part of the National Reproductive Health Strategy, with
the ultimate goal of access at primary health care level. Competencybased training at approved (public and private) training sites to be
provided for physicians and nurses. Government made responsible for
monitoring standards. Women must be treated respectfully and
confidentially. Services must be affordable for all.
The Implementation Plan: Two-year implementation plan with the
goal of reducing maternal morbidity and mortality from unsafe
abortions. Activities under four headings: training; service delivery;
information; education, communication/advocacy; and monitoring and
evaluation.
Reference and Training manuals: Based on the WHO guidelines,
Nepal standards and guidelines were published in the Reference
Manual. The Training Manual developed includes clinical protocols
and training curricula, covering all aspects of a quality comprehensive
abortion care programme, including clinical procedures, counselling
guidelines, equipment and facilities.
Pilot Behaviour Change and Communication (BCC) strategy:
Outlines a community based approach to behaviour change work to be
piloted in two districts
Source: FHD/MoHP/CREHPA/FWLD/Ipas/PATH, 2005
Sex selective abortion. Amniocentesis is prohibited for purposes of sex
determination for abortion. Anyone found guilty of conducting or causing to be
15
conducted such as amniocentesis test is to be punished with imprisonment of 3-6
months. Anyone found guilty of perfuming or causing to be performed an
abortion on the basis of sex selection is to be punished with one additional year of
imprisonment.

Abortion without the consent of the pregnant woman
The abortion law safeguard the rights of an unmarried woman to abortion. In case of a
minor (below 16 years of age), the presence of a guardian is necessary for any decision
regarding abortion. Privacy and confidentiality of the woman receiving abortion services
are also guaranteed by the law.
The Abortion Task Force (ATF) was formed by the Family Health Division, DoHS, in
February 2002 to plan and implement the law. The ATF assisted the FHD/DoHS in
drafting and finalising the policy guidance and the safe abortion Procedural Order. The
FWLD and CREHPA were among the National Abortion Task Force members invited to
give feedback on the draft Procedural Order. Stepping towards the implementation of the
abortion law the National Abortion Policy was developed in 2002 which guarantees
access to safe and affordable abortion services to every woman without discrimination.
Similarly, the Safe Abortion Service Procedure 2003 describes the criteria for listing
(approving) providers as well as health institutions as Comprehensive Abortion Care
(CAC) centre and explains procedures for safe pregnancy termination.
The ATF was dissolved in December 2002 after completion of its terms and a new
technical committee -Technical Committee for Implementation of Comprehensive
Abortion Care (TCIC) was formed in February 2003 to support the implementation of
the CAC services.
The TCIC working group responsible for drafting the reference and training manuals
received technical assistance form Ipas to ensure that these manuals confirmed fully to
the WHO technical and policy guidance on safe abortion. The first CAC service in the
country was started at the government run Paropkar Maternity and Women’s Hospital
located in Kathmandu approximately one and a half year after the legalization (March
2004). Since then, the number of government approved facilities had expanded rapidly to
increase wider access to legal and safe abortion services in the country.
16
CHAPTER 4
Unsafe abortion
4.1
Magnitude of the problem: Worldwide
Unsafe abortion continues to a major public health problem in many countries. Globally,
19-20 million unsafe abortions are estimated have occurred each year from 1993 to 2003.
Overall, 97 per cent of all unsafe abortions in 2003 were in developing countries. Owing
to the population size, Asia has the highest number of unsafe abortions (9.8 million)
followed by Africa (5.5 million) and Latin America and the Caribbean (3.9 million)
respectively. Worldwide, the rate of unsafe abortion has declined slightly between 1995
and 2003, but the proportion of all abortions that were unsafe increased from 44% to
48% in the same interval (WHO, 2007).
The age pattern of unsafe abortion is critical to have a better understanding of the
barriers to access and to tailor
Figure 4.1 Percentage distribution of unsafe abortion by
intervention
focussed
to
age group in the different regions
target age group. A recent
review found that two third of
unsafe abortions occur among
women aged 15-30 years.
More importantly from a
public health perspective, 2.5
million, or almost 15 per cent
of all abortions in developing
countries are among women
who belong to 19 years or
below age group. Figure 4.1
illustrates the age pattern of
unsafe abortion, which differs
markedly from region to
Source: WHO, 2007
region.
Worldwide, an estimated 5 million women
are hospitalized every year for treatment of
complications related to unsafe abortion
(Singh, 2006). Of these, more than 3 million
suffer from the effects of reproductive tract
infection (RTI), and almost 1.7 million will
develop secondary infertility. Unsafe
abortion accounts for 13 per cent of
maternal deaths (WHO, 2007).
Figure 4.2 The Causes of Maternal
Mortality: Global Estimates
Other
indirect
causes
7%
Indirect
causes
20%
Haemorrhage
25%
Sepsis
15%
Eclampsia
12%
Unsafe
abortion
13%
Obstructed
labour
8%
Source: WHO, 2006b
17
The estimated case-fatality rate (deaths per 100,000 unsafe abortion procedures) range
from as high as 750 per 100,000 in sub-Saharan Africa to as low as 10 Per 100,000 in
developed regions, with an
average of 350 per 100,000 for
Figure 4.3 Number of deaths due to unsafe
developing
regions.
The
abortion per 100000 unsafe abortions,
difference
in
the
risk
of
death
by sub region, 2003
40
Central America
associated with unsafe abortion
50
South America
across sub regions of the
100
South-eastern Asia
developing world can be seen in
Northern Africa
130
Figure 4.3. (WHO, 2007).
Southern Africa
130
Carribbean
4.2
Unsafe abortion in Nepal
before legalization
160
260
Western Asia
300
Oceania
380
South central Asia
Eastern Africa
770
Western Africa
820
Middle Africa
880
0
200
400
600
800
1000
Case fatality per 100000 unsafe abortion procedures
Source: WHO,
2007
Information on induced abortion
(both safe and unsafe) prior to
legalisation is very limited.
However, few available studies
suggest that despite the illegal
status of abortion, induced
abortion was fairly widespread in
the country (Table 4.1).
In 1984, the benchmark study carried out in five major hospitals in and around
Kathmandu valley, reported 1576 cases of abortions. Of these, 1411 cases (89.5 per cent)
were spontaneous abortions, 124 cases (7.9 per cent) were induced abortions and 41
cases (2.6 per cent) were possibly induced abortions (Thapa et al., 1992). Another
hospital-based study conducted amongst 1241 abortion cases recruited in government
hospitals and private clinics in Kathmandu valley found that 234 (18.8 per cent) were
induced abortions cases (Tamang, 1996). Another study, conducted in 1985 in seven
rural districts of Nepal included data from community based surveillance, providers of
abortion services and hospitals. Information on induced and possibly induced abortions
was obtained on a total of 13, 229 women of reproductive age (15-49 years) in these
communities (IDS, 1986). This study reported a total of 109 induced abortion cases in a
period of approximately 30 months. This study also revealed that Traditional Birth
attendants (TBAs) were reported to be the primary source of abortion service providers
for a significant proportion of women in the rural communities. Studies conducted by
CREHPA (1998, 1999) have shown that between 20 per cent and 61 per cent of all
obstetric and gynaecological admissions in major hospitals of the country were abortion
complication cases. These studies also found that the treatment of abortion complications
in hospitals consumed a significant share of resources, including hospital beds, blood
supply, and medication, and often requires access to operating theatres, anaesthesia and
medical specialist. The cost of treatment of abortion-related complications in these
hospitals ranged from Rs. 1500 to Rs. 10,000 or more (average Rs. 3918 or US$ 52). The
nature of treatment required high doses of antibiotics, blood transfusions, IV fluids and
sometimes hysterectomy operations. Almost all (98%) the women visiting these hospitals
for treatment of abortion complications was married and from poor economic
backgrounds. Women who could afford to pay the high fees for abortions are found
visiting the private clinics available in these towns.
18
Table 4.1
Induced abortion in Nepal during pre-legalisation era
Sources
Thapa et. al,
1992
Methods
Hospital based
Thapa et al,
1994
Community based
surveillance,
providers of
abortion services
and hospitals
Hospital and
private clinic
based
Prison study
7 rural districts
Information obtained
from 13,229 women
of reproductive age
FHD/MOH,
1998
Facility based
and community
survey
Three districts
CREHPA,
1998, 1999
Hospital based
13 major hospitals of
Nepal
CREHPA,
2001
Population
based
NDHS, 2001
Population
based
Tamang et. al
1996
CREHPA,
2000
NDHS, 2006
Puri, 2002
Population
based
Population
based
Coverage
5 major hospitals in
Kathmandu
Govt. hospitals and
private clinics
All 59 prisons in the
country
3 districts of
Kathmandu Valley
2,924 women aged
15-49 years
68 districts
Key findings
• 1576 cases of abortion
• 7.9% induced abortion
• 50% of all maternal deaths in the study
hospitals were due to abortion related
complications
• A total of 109 induced abortion cases
were identified in a period of
approximately 30 months
• TBAs were reported to be primary source
of abortion service
• 1241 abortion cases
• 18.8 induced abortion
• 20% (80 out 406 women) of women in
prisons were convicted for abortion and
infanticides
• Almost all these women were illiterate
and from rural and poor families
• Only 0.3% of men in prisons were
convicted for a abortion and infanticide
• 5 out 132 maternal deaths that occurred
in community were due to abortion
• 54% of the total gynecological and
obstetric admission in hospitals was due
to abortion complications
• 3 out of 31 maternal death in the study
hospital was due to abortion
• 20-61% of all obs. & gyn. admission in
hospitals were abortion complications
• 4.1 % rural and 4.7% urban women
reported abortion
• 1.0 induced abortion
• Abortion more common in urban than in
rural
75 districts (260 PSUs) • 2.1 induced abortion (6.0 and 2.1 rural)
Five districts
997 women aged 1524 years
19
• 49% unintended pregnancy
• 6.5% attempted abortion
• 2.2% succeeded
The Maternal Mortality Figure 4.4 Abortion cases as percentage of total
obstetric & gynaecological admissions in
and Morbidity Study
selected major hospitals
conducted
in
three
Thapathali maternity hospital
61
government hospitals in
1998 found that of the
Gandaki regional hospital
49
total gynaecological and
Bheri zonal hospital
47
obstetric admissions in
Chitwan district hospital
46
hospitals, 54 per cent
Birgunj maternity hospital
25
were due to induced
Koshi zonal hospital
20
abortion
complications
(FHD/MoH, 1998). The
0
20
40
60
80
same study revealed that
%
about 10 per cent of all
Source: CREHPA, 1999
maternal deaths (3 out of
31 deaths) at the study hospitals were due to abortion. Accordingly, a total of 4,478
maternal deaths per year or one death every two hours was also estimated in the same
study (FHD/MoH, 1998).Adequate information on induced abortion before legalisation
is not available by age and ethnicity of women in Nepal. However, a hospital-based
study conducted by CREHPA has showed that, out of all the patients admitted at the
hospital due to induced abortion complications, one-fifth were under 20 years of age
(Tamang and Nepal, 1998).
Indira died due to use of herbs from Traditional faith healer (Jankri)
A 25 year old I. Niraula died due to unsafe abortion. She was a mother of five
daughters and was pregnant for the sixth time. She didn’t want to continue this
pregnancy as she suspected that this was again a girl child as the sign and symptoms
were similar to the previous pregnancies therefore she visited a faith healer for
abortion. The faith healer charged her Rs. 50 and inserted different herbs inside her
uterus. Instead of abortion, she got lots of complications after the insertion. She was
badly infected because of unhygienic herbs. She was rushed to the hospital and was
kept in the emergency ward. Doctors tried to save her life but they failed to do so as it
was too late.
Source: Gorkhapatra Daily, September, 1999
4.3
Unsafe abortion procedures used in pre-legalisation era
Prior to legalization, abortion was strictly restricted in the country compelling women to
take any risk to terminate their unwanted pregnancies. Studies carried out before
legalization of abortion documented the use of various herbal and harmful substances to
get rid of unwanted pregnancies. Edible food such as white pumpkin, black sesame seed,
honey, green papaya and use of non-edible substances such as roots of various herbs, raw
vermillion and glass powder were commonly used by women as reported in these
studies. The actual procedures adopted by untrained providers were dangerous and
barbaric. For instance, women admitted in the hospitals for management of abortion
related complication were found to have sticks pasted with cow-dung or herbal mixtures
inserted inside the uterus, injection of unknown medicines, insertion of rubber catheter
dipped into unidentified substances, etc. Some women tried to self induced abortion by
20
consuming honey, chemical powder (sindur and nir), anti-worm medicines, oral pills,
and so on (Tamang, 1996; Tamang et al., 1999).
The 1997 prison study revealed that few women made a number of unsuccessful attempts
to terminate the pregnancy by taking abortifacient drugs or even undergoing physical
tortures like pressing the abdomen with a heavy grinding stone to kill the baby inside the
womb (CREHPA, 2000). Due to factors like illiteracy, ignorance (about safe abortion
practices), lack of access to safe abortion services, lack of spouse or family support, fear
of legal and social sanctions, etc., many of these women have resorted to abortion at a
very late stage of pregnancy or allowed the unwanted pregnancy to a full term and then
abandon or kill the newborn.
There is an association between Table 4.2 Literacy status of women and their
"safe/unsafe" abortion practices and
spouses receiving abortion service from
untrained and trained personnel
levels of education of woman and her
husband. The 1992-94 longitudinal
Service providers
study on determinants of induced Literacy status
Untrained
Trained
abortion showed that majority of Client's literacy status
women who had sought the assistance Illiterate
51.2
14.2
of untrained persons for pregnancy Primary level
15.1
8.5
15.1
12.0
termination were illiterate and not Secondary level
18.6
65.2
many amongst their spouses had SLC above
Husband's
literacy
status
attained higher education. Over one9.3
2.8
third of them had consulted untrained Illiterate
Primary level
19.8
3.5
providers during second trimester, Secondary level
33.2
10.6
which is considered be advanced stage SLC above
36.5
83.0
to attempt abortion. Contrary to this,
Source: Tamang, 1996
most women utilizing the services of
trained medical professionals (doctors) for pregnancy were educated and even their
husband had high educational qualifications. Moreover, educated women sought abortion
services at earlier stages of pregnancy i.e. during the first trimester (Tamang, 1996).
Similarly another study conducted in 1997 showed that women requesting induced
abortion in private clinics in Kathmandu were educated (Thapa et. al., Padhya, 2001).
Few studies in pre-legalisation era also documented reasons for abortion. For example, a
community study conducted in seven rural districts revealed that the primary reason for
seeking abortion reported by the majority of women was economic hardship, largely due
to too many children (IDS, 1986). Other studies found that mistimed pregnancy, failure
of contraception, economic factors, risk to health or life and rape or incest were the main
reasons for abortion (CREHPA, 2000, Duwadi et. al., 2007; Puri et al, 2007; Tamang,
1996)
4.4
Unsafe abortion after legalization of abortion
The post-legalization trend in unsafe abortion for the country is difficult to measure in
light of the lack of information or records on induced abortion related admissions at
health institutions or lack of population-based surveys on abortion after the legal reform.
One of the main sources of data of this kind would be number of clients visiting postabortion care (PAC) services due to complicated induced abortion. The PAC units of
most of the government hospitals do not separate out induced abortion cases from
21
spontaneous abortion cases. As a result, the number of clients with unsafe abortions
seeking PAC services from these hospitals cannot be ascertained. Nevertheless, limited
information suggests that even after legalization of abortion, both the government and
private sector health institutions receive PAC clients who have been exposed to unsafe
abortions and the Nepalese women are still dying because of unsafe abortion.
Table 4.3 shows the annual number of PAC admissions in selected government and nongovernmental health facilities and the number of induced abortion with complications
admitted in these health institutions. It can be seen from the table that there has been
decline in the total PAC admissions in most of the government hospitals between the
period of 2003 and 2005, except in government hospitals located in Dang, Kanchanpur
and Baglung districts. In these three districts, the number of PAC admission has
increased over the years. The increase in PAC admissions was also observed in FPAN
clinic in Itahari. Since most of the facilities do not separated out induced abortion related
admissions from the total PAC admission in their clinic records, it is difficult to assess
whether there has been increase or decline of clients with complications of unsafe
abortion in these facilities (MoHP/WHO/CREHPA, 2006).
Table 4.3 Facility-wise annual caseloads of PAC clients in selected health facilities outside
Kathmandu Valley
Name of the facility
Government Health Facility
Western Regional Hospital, Kaski,
Pokhara
Dhading District Hospital, Dhading
Mahendra Hospital, Gorahi, Dang
Seti Zonal Hospital, Dhangadi, Kailali
Mahakali Zonal Hospital, Kanchanpur,
Kailali
Koshi Zonal Hospital, Biratnagar,
Morang
Bhim Hospital, Bhairahawa,
Rupandehi.
Dhankuta District Hospital, Dhankuta
Makwanpur District Hospital, Hetauda,
Makwanpur
Mahendra Adarsha Chikitshalaya,
Bharatpur, Chitwan
Lahaan District Hospital, Siraha
Baglung District Hospital, Baglung
Solukhumbu District Hospital, Phalpu
Bheri Zonal Hospital
Total
Non-government health facility
FPAN, Itahari
Nepalgunj Medical College, Kohalpur,
Nepalgunj
Total
Total PAC clients
% of induced clients to total
PAC clients
2003
2004
2005
2003
2004
2005
418
698
273
*
2.7
2.6
18
33
91
42
21
54
101
50
13
64
57
132
*
*
*
*
*
*
*
2.0
*
*
*
*
185
230
171
1.6
3.5
7.0
48
104
57
*
*
*
34
48
30
43
33
33
*
*
*
*
*
*
172
157
137
13.9
19.7
10.2
11
47
1
N.A
1148
19
61
2
N.A
1570
8
69
1
48
1096
*
2.1
*
N.A
25
*
4.9
*
N.A
62
*
2.9
*
N.A
35
35
N.A
74
68
114
73
*
N.A
*
2.9
*
5.6
35
142
197
-
2
8
Source: MOHP/WHO/CREHPA, 2006
* Records do not segregate induced abortion related admissions from the total PAC admissions.
N.A = Information not available
22
Table 4.4
Table 4.4 shows the annual number of
Trend in PAC clients and percentage of
induced abortions complications among
PAC clients in Maternity Hospital
(2058-2063)
# of
# of IA
% of IA
PAC
complications clients to total
clients
PAC clients
cases of PAC clients and the number
of cases of induced abortion with Year
complications visiting Maternity (B.S)
Hospital over six years period (three
years before legalisation and three 2058
1217
55
4.5
years after legalisation). The data 2059
1333
59
4.4
1409
49
3.5
revealed that the proportion of 2060
2061
1396
57
4.1
induced abortion among PAC clients
2062
1446
71
4.9
visiting Maternity Hospital has not
2063
1481
63
4.3
been significantly different in last six
Total
8282
354
4.3
years. However, the number of
Source: Thapa et al, 2007
complicated induced abortion has
been declined in past three years (2061 to 2063). It was also found that the number of
septic sock has been reduced significantly in recent years (Table 4.5).
Table 4.5
Number of life threatening complicated induced abortion out of the total
induced abortion case to total PAC clients in Maternity Hospital
Total number of induced abortion
among PAC clients
Total number of complicated
septic induced abortion among
PAC clients
Types of complications
Septic Shock
Septic ARF
Haematuria
Hb<5gm %
DIC
Uterine Perforation
Uterine perforation and ruptured
appendix
Bowl perforation
Peritonitis
Total
2058
55
2059
59
2060
49
18
18
16
(32.7)
(30.5)
11
1
4
1
2
1
20
Year
2061
57
2062
71
2063
63
Total
354
14
11
9
86
(32.6)
(24.6)
(15.5)
(14.2)
(24.3)
9
1
7
1
1
-
4
4
4
-
2
2
4
7
-
3
1
2
12
-
2
5
10
-
31
3
2
26
2
36
1
1
1
21
1
1
16
1
1
15
1
4
1
4
18
19
109*
Source: Thapa et. al., 2007
* The total number could not add up due to multiple complications present in a woman
and number within parenthesis indicates percent.
Another study conducted by CREHPA in 2006 found that among 503 PAC clients who
were admitted at different hospitals and clinics in two months period (January 10 to
March 10, 2006), 103 (20%) were diagnosed as complications of induced abortion.
Among these women half of them had experienced complications (51%) from the MVA
procedure they had undergone at the government and private sector health facilities
(MoHP/WHO/CREHPA, 2006). Type of complications included bleeding, perforation of
uterus and retained POC (incomplete abortion). This is not surprising if one compares
the number of women receiving MVA (abortion) services from these facilities during the
same two months period which was very large - approximately 2500. The complication
rate of MVA procedure is 2.1% (52/2500 x 100). Another study that analysed the three
years CAC data (2061-2063) of Maternity Hospital found that the complication rate at
23
CAC unit was 2.05 per cent (0.3%
during procedure and 1.75% after
procedure) (Thapa et. al., 2007).
Similarly, another study conducted
among 672 CAC clients in Maternity
Hospital found that the complications
rate was 2.1 per cent (Malla et. al.,
2006).
The CREHPA's study also revealed that
clients often tend to underreport their
gestation age believing that the abortion
fee charged by the service provider is
proportionate to the gestation age, while
few clients did not know to correctly
count the gestation age of their
pregnancies. The service providers also
mentioned that complications of MVA
procedure tends to be higher for higher
uterine gestation age while the risk of
incomplete abortion (retained POC) is
high if MVA is performed for less than
six
weeks
of
gestation
(MoHP/WHO/CREHPA, 2006).
Table 4.6
Procedure used for abortion resulting
into complication/incomplete abortion
and subsequent admission at PAC
units
Procedure Used
A. Oral intake
Ayurvedic/Allopathic
medicines
Unknown medicine
B. Uterine/vaginal device
MVA from GO/private
clinics/NGO facilities
Unknown herbal medicine
(roots/plants/etc.) in the
uterus/vagina
D&C from private
clinics/NGO
Catheter (plain/Foley's)
Plastic pipe (with/without
medicine)
Insertion of Cerviprim jell
inside the uterus
MVA and Misoprostol used
Use of Misoprostol only and
inj. syntocin
Cervical tear by volcelum
Total
# of
clients
%
9
8.6
9
8.6
52
50.6
14
13.6
8
7.8
3
3
2.9
2.9
2
1.9
1
1
1.0
1.0
1
103
1.0
100.0
Another study conducted by CREHPA
Source: MoHP/Ipas/CREHPA, 2006 as reported in
interviewing
19 doctors at 10 MoHP/WHO/CREHPA,2006
governments and 5 NGO managed
health institutions revealed that these
institutions are receiving PAC clients with haemorrhage, infection, retained produce of
conception (POC), sepsis, perforated uterus, perforated intestine and cervical tear
(MOHP/WHO/CREHPA, 2006). The same study also documented that the common
clandestine procedures used for abortion that lead to complications or infections were:
insertion of sticks, insertion of sharp metal objects, insertion of unknown herbs, oral
administration of unknown medicine and insertion of sticks. Over half of the doctors
(53%) reported that the number of PAC admissions at their health facilities with
complications of unsafe abortions has decreased in the last years when compared to the
situations three years ago. Only one in ten of the doctors said that there has been increase
in PAC admissions of induced abortion related complications while about a third
perceived the situation has been the same. Doctors also viewed that the large majority of
the women with induced abortion related complications were from the villages and
socially marginalised communities of urban areas (MOHP/WHO/CREHPA, 2006)
24
4.5
Unsafe abortion procedures after legalization of abortion
The 2006 National Facility-based Table 4.7 Unsafe abortion procedure used in Nepal
Abortion Study of CREHPA Types of edible/non-edible items taken orally: White
showed that nearly a sixth of the pumpkin, Bamboo shoot, Jack fruit/mango, Seed of gourd
women had orally consumed (Ghiraula), Guava stem, Jamuna stem, Cucumber leaves,
allopathic and ayurvedic medicines Timmur (spice), Lemon juice, Tamarind powder , Chhuk,
(17%) while less than this black sesame seed, Misri kanda, Sugar, Honey,
percentage had placed unknown Gunpowder with water, Glass powder etc.
Medicine: Epifort, Mensure, Albendazole, Mensolex,
herbal substances in the uterus to Klot, Ergo tablets, Rajprawantaniwatetc
cause abortion (14%). Very few Types of herb items and faiths: Herbs, Syaula mixed
women had catheter or plastic pipes with cow’s urine, Root of herb, Aaulia, Fachang, Root of
(with or without medicines) placed Pakhanved, Neem (herb), Galechho stem, Water chanted
inside the uterus and there were also by traditional faith healer etc
Types of harmful practices:
Glass powder, raw
very few women who had vermillion powder, Suidi milk (kind of cactus), Press
developed complications after they abdomen with a grinding stone, Heat the stone in fire and
were given Misoprostol along with wrap it in a cloth and press the abdomen with it, Insert the
MVA or syntocinon injection (Table thorn of 'Suidi' (type of cactus) in the vagina, Insert the
4.6). Similarly, another study canulla through the vagina into the uterus, Administer
continuous saline etc
conducted by CREHPA in 2005
identified various types of allopathic and indigenous medicines sold in the Nepalese
market for menstrual regulation and most of these medicines were also prescribed for
inducing an abortion. There is no study that has examined the safety and efficacy of such
drugs for inducing abortion (Tamang et al, 2005). The most popular medicines which are
believed to have abortifacient values are: EP Forte, Mensure, Albendazole, Mensolex,
Klot, Ergo tablets, Rajprawantaniwati, etc. Because of the open border with India, all
these products enter Nepal easily. Mensolex, a homeopathic drug produced in India, is a
good example, which has clear instructions on how to use this drug for abortion and is
sold openly on the Nepalese market. Medical abortion is still in the process of being
introduced officially in Nepal, but with the highly porous Indo-Nepal border and the easy
availability of mifepristone and misoprostrol in Indian chemists’ shops, these drugs have
already entered in Nepalese markets. However, there is a low level of awareness about
mifepristone and misoprostol among most of the health care providers interviewed
(Tamang et. al., 2005; MoHP/WHO/CREHPA, 2006).
Table 4.8
Persons assisting the abortion procedure
resulting
into
complication/incomplete
abortion and subsequent admission at PAC
units
Person assisting in the procedure
# of clients
%
Doctor
50
48.5
Self-induce
15
14.6
Pharmacist
9
8.6
Staff Nurse
6
5.8
Doctor (India)
5
4.8
Female acquaintance(TBA/Sudeni)
4
3.9
Husband forced to take medicine
1
1.0
Outreach health provider
1
1.0
Not known/not revealed
12
11.6
Total
103
100.0
Source: MoHP/Ipas/CREHPA, 2006 as reported in
MoHP/WHO/CREHPA, 2006
A recently completed study on
prenatal sex selection in Nepal
showed that certain traditional
practices such as taking herbs
that are believed to selectively
cause abortion of female foetus
and the herbs do not harm the
male foetus (UNFPA/CREHPA,
2007)
According
the
study
of
CREHPA in 2006, among
persons assisting the abortion
procedure that resulted into
complications, nearly half of the
clients (48%) mentioned that the doctor had carried out the procedure. For about a tenth
25
of the women, the procedure was carried out either by a pharmacist or by a staff nurse.
Most of these health providers had also prescribed "abortifacient" drugs to women
seeking menstrual regulation or abortion (Table 4.6).
In-depth case histories of five women carried out by CREHPA in 2006 at the Maternity
Hospital revealed that that two out of five women had sought the assistance of a
traditional birth attendant (TBA) of their village, one had visited a local female
abortionist and another one a local health centre. The fifth woman had obtained the
abortion service from a nurse working at a local pharmacy (MoHP/WHO/CREHPA,
2006). The method used by the TBA was a crude one – insertion of stick. The nurse had
also inserted stick pasted with unknown medicine. The local abortionists had inserted a
polythene pipe filled with unknown medicine while the health worker had inserted a
catheter filled with some medicine. All the five women were from the adjoining districts
of Kathmandu valley - four of them from the villages. Therefore, it can be argued that
even after legalization unsafe abortion is taking place in the country.
Abortion in Private clinic, a woman died
A 36 year old D. Rana from Dhangadi died due to complication of abortion in a
pharmacy. The abortion was performed by a nurse. Ms. Rana was brought back in the
clinic day after the abortion due to severe lower abdominal pain and P.V. bleeding. The
nurse couldn’t handle the case therefore she was taken to the hospital but unfortunately
she had died on the way to the hospital. Abortion service was available in the
government hospital also where two trained doctors were available but lack of
knowledge about the availability of the service she went to the unsafe place for
abortion. The woman had four sons and a daughter, which made her to abort her sixth
pregnancy which was just two and a half months.
Source: Dhangadhi Post Daily, 4 December, 2007
4. 6
Abortion related death reported in printed media
CREHPA has been monitoring abortion related deaths reported in the leading
newspapers of the country since 1997. There have been 10 abortion related deaths
reported in the newspapers during Aug 1997 to September 2002 (before legalisation of
abortion). Out of 10 deaths, 6 were caused by clandestine abortion practice by private
paramedics. They had used unknown medicines as well as injections for pregnancy
termination. One woman died at the faith healer’s place. The faith healer had inserted
some herbs that caused gas gangrene. She died in the hospital. The remaining three
deaths were caused by a clandestine abortion provider (1death) at his illegal abortion
clinic, by a private doctor (1 death) and by a government outreach services provider (1
death) (MoHP/WHO/CREHPA, 2006).
Similarly, four women died due to complication of unsafe abortion between transitional
periods (October 2002 to February 2004, after Royal assent was given to the new
abortion law and until the introduction of CAC service by the government). Two out of
four deaths were caused by government outreach health service providers. One woman
died in a private doctor’s clinic whereas another women (unmarried) died at Koshi zonal
hospital, Biratnager because of complication of unsafe abortion that was carried out in a
small border town of India called Jogbani (MoHP/WHO/CREHPA, 2006).
After the government started CAC services, no death was reported in the newspapers in
the two consecutive years. (2004-2005). However, 9 deaths were reported between May
26
2006 and January 2008 (Table 4.9). Of the two deaths that were reported in the
newspapers in 2006, one death was due to an attempt made by a private doctor
(Makwanpur district) on a woman with second trimester pregnancy. The second death
was caused by a veterinary doctor (Rutahat district). Both the abortions were attempted
in a private clinic setting which were not approved for CAC services.
Out of nine deaths that were reported in Newspapers in 2007, one death was due to
attempt made by a doctor on a woman with second trimester ( 5months) in his private
clinic (Kaski district). Another woman died in Dailekh district due to an attempt by a
quack in his private clinic. Two women died in Salyan district, one died due to self
administration of medicines at her house and another while getting treatment of abortion
complication in hospital. Salyan district do not have any approved CAC centre. Another
woman died in Chitwan district due attempt made by a nurse (government hospital staff)
in her private clinic. Similarly, another death was caused by a paramedic (Kailali
district). One death was also reported in Baitadi district. Similarly, one death has
occurred caused by a veterinary doctor in his clinic (Rautahat district). Another woman
died while performing actually by a trained CAC provider in his private medical hall
(Makwanpur district). One death due to abortion was also reported in Baitaidi district.
Very recently (January 2008), one death was caused by verbal medicines used by an
Aurvedic doctor (Bajura district).
Table 4.9
Details of abortion related deaths reported in printed media
Number of abortion related women deaths during pre-legalisation period (Aug. 1997-Sept. 2002) = 10
Deaths during transitional period (Oct. 2002-Feb. 2004
SN Name
Source
Gestation age
Ethnicity
District
1
T. Thapa
15 May 2003
Not specified
Gorkha
Kantipur Daily
2
R. Rai
12 June, 2003
Not specified
Janajati
Sunsari
Spacetime Dainik
3
M. Sunuwar
24 Oct. 2003
4 months
Janajati
Kathmandu
Space time daily and Nepal
Samacharpatra
4
M. Chaudhari
17 Sept 2003
6 months
Janajati
Sunsari
Nepal Samacharpatra
Deaths after the introduction of safe abortion services ( March 2004 to 1 Jan 2008)
1
S. Tamang
May 23, 2006
3 months
Janajati
Makwanpur
Kantipur Daily
2
N. Waiwa
July 12, 2006
Not specified
Janajati
Rautahat
Annapurna Post
3
B. Gurung
Jan 25, 2007
5 months
Janajati
Kaski
Nepal Samacharpatra Daily
5
Mangala
2 March 2007
6 months
Salyan
Kantipur daily
4
P. Deramagar
July 4, 2007
Not specified
Janajati
Dailekh
Kantipur Daily
6
D. Bohara
25 Oct. 2007
Not specified
Chhetri
Salyan
Katipur Daily
7
P. Shrestha
20 Nov. 2007
Not specified
Janajati
Chitwan
Chitwan Post Daily
8
D. Rana
4 Dec, 2007
Not specified
Janajat
Kailali
Dhangadi post Daily
9
B. Chand
28 Dec. 2007
10 weeks
Chhetri
Baitadi
Paschim Nepal Daily
10 L. Saud
1 Jan. 2008
3 months
Chhetri
Bajura
Shree Nepali Times
27
4.7
Reasons for unsafe abortions in Nepal
Unsafe abortions are a continued problem in Nepal due to several reasons. The main
reasons for persisting unsafe abortion in this country even after the legalisation are- lack
of knowledge about new abortion law and availability of safe abortion practices,
inadequate access to safe abortion services, cost of services, reluctance or fear of
utilizing the services in time, growing number of unapproved abortion clinics, lack of
women's decision making power, poor supportive environment and social stigma, and
legal restriction to abortion in the past. Other factors such as low level of women's
education, ignorance, early marriage and early child bearing, declining fertility, low
contraceptive use and poor access to reproductive and sexual health information and
services are fuelling to the problems. Moreover, the act of abortion is still considered as a
sin in Nepalese society, therefore women are compelled to resort back to street abortions
which they believe to ensure confidentiality. Visiting India for the purpose of abortion is
also not uncommon especially in districts along the Indo-Nepal borders
(MoHP/WHO/CREHPA, 2006).
4.7.1
Lack of knowledge about the abortion law
Though abortion has been legalized in
Figure 4.5 Trend in awareness on legalization of
the country since 2002, most of the
abortion
people are still unaware about the law.
Although awareness about the abortion
60
law has increased from about 22 per cent
49
in 2002 to 49 per cent in 2006 among
42
40
urban public, over half of them (51%)
are still unaware of the legalization of %
26
abortion in the country. Comparatively,
20
22
a higher proportion of the adult males
(54%) than the adult females (44%)
0
were aware about the legalization of
2002
2003
2004
2006
abortion. Likewise, compared to married
Oct./Nov.
Oct./Nov.
Nov./Dec
Oct 2006
(47%), unmarried people (55%) were
(N=2613)
(N= 2652)
(N=2665)
(N = 2792)
more aware about the law. Moreover,
urban public who read newspaper regularly (66%) or are exposed to radio (56%), or TV
(53%) regularly, were more aware of legalization than those who never read newspapers
(22%) or never listen to the radio (25%) or TV (19%) (CREHPA, 2006)
The extent to which rural Nepalese men and women are aware of the abortion law was
also documented in a large scale baseline survey conducted by CREHPA during AugustOctober 2005 under a programme called "Network for advocating women's reproductive
rights in Nepal (NAWRN). The survey interviewed 1145 married women, 526 married
men, 128 unmarried men and 208 unmarried young women (15-24 years of age),
residing in the villages. The results showed that even after three years of legal reform,
only 20% of married women and 28% of married men were aware of the legalization of
abortion. Interestingly, the unmarried female and young male populations were better
informed than their married counterparts about the legalization of abortion (36-39%).
Among those who are aware of the legalization, less than a tenth were aware of at least
one of the three conditions in which abortion is permitted in the country
(MoHP/WHO/CREHPA, 2006).
28
Another study conducted by CREHPA among husbands found that only over half of the
respondents knew that abortion was legal in the country. Furthermore, only a minority
knew the major conditions for legal abortion despite the fact that most husbands reported
a regular exposure to mass media (CREHPA 2006). The same study showed that
younger (15-24 years) and older age groups (35 and above) were less likely to be aware
about the legalization of abortion. Comparatively, illiterate respondents were less likely
to be aware about the legalization of abortion than literate respondents. Among the four
study ethnicities (Brahmin/Chhetri, Newar, Yadav and Tharu), Yadav were least aware
about the legalization of abortion. Similarly, wealthier participants were more likely to
know about legalization of abortion than poor respondents (CREHPA, 2006).
Figure 4.6 Level of knowledge on approved
Even those women who seek abortion
CAC centres among married and
services from approved CAC centres are
unmarried men and women: 2005
not necessarily aware about the abortion
80
law. For example, a study conducted by
CREHPA in 2005 shows that 38 per cent
60
52
of the women seeking CAC service at
50
42
11
Paropkar Maternity and Women’s
39
11
40
6
4
Hospital, Kathmandu and Marie Stops
centres were unaware about abortion law.
41
39
36
Only 39 per cent of clients receiving safe
20
35
abortion service from government
hospitals outside Kathmandu valley were
0
aware about new abortion law. Similarly,
Women
M en
Yout h
Yout h
Female
M ale
71 per cent of the clients receiving service
from FPAN clinics were unaware about
Correct
Incorrect
abortion law. Among women who were
aware about the law only 48 percent of them had knowledge that abortion is permitted on
request during first 12 weeks of gestation. Only about a tenth of the women knew about
second condition which is the case of rape and incest whereas 12 per cent of the women
had knowledge about third condition which specifies if the pregnancy affects the health
of the mother or the foetus (MoHP/CREHPA/Ipas, 2006; MoHP/WHO/CREHPA, 2006).
4.7.2
Lack of knowledge about approved CAC centres
Lack of accurate knowledge about abortion services (where to go, who performs
abortions, the cost of an abortion, and what the procedure entails) is an important barrier
among women and couples for resorting safe abortion (CREHPA, 2005). This ignorance
can exert delays in abortion decision making and compels them to resort unsafe
procedure of termination of pregnancy. The 2006 Opinion Poll Survey of CREHPA
documented that 82 per cent of respondents believed that women go for unsafe abortion
because they are unaware about approved CAC centres (CREHPA, 2006). This
information corroborates with the result of public opinion poll of 2004 which shows that
only 43 per cent of the respondents were aware that the government hospitals or NGO
health institutions provide CAC service. Even in the metropolitan city of Kathmandu,
only about 60 per cent of the public were aware about the availability of CAC service.
In those districts where there is no approved CAC centre, respondents had a wrong
impression about the availability of safe and legal abortion service there
(MoHP/WHO/CREHPA, 2006; CREHPA, 2004).
29
The findings of the NAWRN baseline survey further corroborated with the above
mentioned results. For instance, though all the six baseline districts had at least one
approved CAC centre (some districts had more than one CAC centre), the extent of
correct knowledge of such centres was low among all the four categories of the
respondents (35-41%) (Figure 4.6). There were 9 married women in the sample who had
terminated their pregnancy in the past 12 months though after their districts had an
approved CAC centre. Of these 9 women, 3 had sought abortion from CAC approved
government hospital and 2 had visited MSI centre of their district. The remaining 4
women had resorted to unsafe abortion measures (two from pharmacist, one self induced
and one from an unqualified provider).
4.7.3
Inadequate access to safe and legal abortion services
Inadequate access to safe and legal services is another major reason for women and
couples to resort unsafe abortion procedures. Although approved CAC centres are
expanding rapidly in the country, they are still inadequate in number and are mainly
concentrated in the urban areas or district headquarters. One out of 75 districts still does
not have any approved CAC centres.
Most government hospitals reported that they are providing CAC services all week days.
which is a different situation than what was reported in the year 2006
(MoHP/WHO/CREHPA, 2006). However, few hospitals have either stopped providing
CAC services (Dhankuta hospital, Lahan hospital) or provide for just one day (Bheri
zonal hospital). Moreover, it was not uncommon to find not providing services all days
particularly in district hospitals either due to limited doctors or not giving priority to
abortion services. In comparison, all the NGO institutions (including medical colleges)
provided CAC services six days a week.
Comparatively, rural communities have lesser access to legal, safe and affordable
abortion services. The difficult geographical terrain and limited access by roads for the
vast majority of the rural population continue to hinder CAC service expansion. Very
recently, the government has expanded CAC service at primary healthcare centre (PHC)
levels and also permitted staff nurses to conduct safe abortion procedure. It should be
noted that until very recently only medical doctors have been approved for providing
CAC services . The 2006 Opinion Poll Survey conducted by CREHPA found that 69 per
cent of the respondents stated that women go for unsafe abortion as the safe services are
not accessible to all. It is evident from the NAWRN baseline survey, 2005 that unlike the
Paropkar Maternity and Women’s Hospital of Kathmandu, the district based government
hospitals in those districts were not the preferred choice for married women (37%) and
men (25%) for abortion services. Some women preferred to visit a private clinic/nursing
homes (29%) or travel to India (17%) for the abortion service. In fact, more men than
women preferred to take their spouse to India (42%) for abortion or had it done from the
private clinic/nursing home of their district (MoHP/WHO/CREHPA, 2006).
4.7.4
Low economic status and abortion fee
Accessibility of CAC service especially for women of low economic status is also
determined by the amount of fee charged for abortion and regularity of the service. Until
the end of 2006, the abortion fee charged by government hospitals are high, and ranges
from a minimum of Rs 800 (Seti Zonal Hospital, Dhangadi in Far West) to Rs. 2000
(Gorkha district Hospital and Sankhuwasabha district hospital) (MoHP/WHO/CREHPA,
30
2006). Very recently, government had decided to charge fixed fees not more than Rs.
1000 in government facilities (excluding medicines) for CAC service, which is very
commendable. However, the amount of abortion fee charged by NGOs and medical
institutions ranges from a minimum of Rs. 1,000 (FPAN clinics) to Rs. 1350 (Marie
Stopes Centres).
Table 4.10
2007)
CAC service days and service fee at selected CAC centres (as of 31 December
S.
Name of CAC facility
N.
Governmental CAC centres
1
Maternity Hospital, Kathmandu
2
Western Regional Hospital, Kaski,
Pokhara
CAC service
day
Abortion
fee (Rs)
Remarks
All week days
All week days
1000
1000
3
4
Dhading District Hospital, Dhading
Mahendra Hospital , Dang; Seti Zonal
Hospital, Kailali; Mahakali Zonal
Hospital, Kanchanpur; Makwanpur
Hospital, Makwanpur; Mahendra Adarsha
Chikitshalaya, Chitawan; Baglung Zonal
Hospital, Baglung
Koshi Zonal Hospital, Biratnagar, Morang
All week days
900
Clients loads are very high
-Excludes cost of medicines
- Service not available on
certain days like Ekadasi
Excludes cost of medicines
All week days
1000
Excludes cost of medicines
All week days
950
Excludes cost of medicines
All week days
900
Excludes cost of medicines
9
Lumbini Zonal Hospital, Butal,
Rupandehi
Bhim Hospital, Bhairahawa, Rupandehi
All week days
850
Excludes cost of medicines
10
Dhankuta District Hospital, Dhankuta
-
Listed Dr. is transferred
13
Lahan Hospital, Lahan, Siraha
Service not
available since
one year
Service is not
regular
Only Monday
All week days
1000
Excludes cost of medicines
1050
1000
Excludes cost of medicines
Include cost of medicines
All week days
1350
Including Medicines Cost
All week days
1000
Excludes cost of medicines
All week days
All week days
1250
1050
Excludes cost of medicines
Excludes cost of medicines
7
8
15 Bheri Zonal Hospital, Nepalgunj, Banke
16 Gorkha District Hospital, Gorkha
Non-governmental CAC Centers
1
MSI clinics in 47 centres located in 34
districts
5
FPAN clinics at central, Lalitpur;
Valley-Kathmandu; Pokhara, Butwal;
Itahari,Chitwan and Kavre
12 Kathmandu Medical College
13 Nepalgunj Medical College, Kohalpur,
Banke
Abortion fee in private clinics are higher than those charged by the government
hospitals. Therefore, those women who can neither afford to pay the high abortion fee
charged in private clinics nor can return to the hospital on the day specified for CAC
service has no alternative left than to opt for unsafe means of pregnancy termination.
The 2006 Public Opinion Poll Survey showed that over three-quarters of the respondents
(77%) believed that women go for unsafe abortion because of poverty as they can’t
afford the service charge (CREHPA, 2006). Another study conducted among young
couples in Nepal revealed that economic issue plays a central role in the decision making
phase, both in terms of the costs of raising a child/or the cost of an abortion. Safe
31
procedures were too expensive for some young couples which forced them to continue a
pregnancy or to seek less skilled providers or undergo a self induces procedure (Puri,
2007).
High abortion client flow in country's largest Paropkar Maternity and Women’s Hospital
at Thapathali, Kathmandu compels the providers to persuade their clients to re-visit on
another day. Moreover, about a tenth of their clients get rejected form this hospital
because of the late gestations (crossing the legal limit of 12 weeks). Apart from the
Maternity Hospital, the percentage of clients who were asked for re-visits was
considerably high in some of the medical colleges and other government managed CAC
facilities also (MoHP/WHO/CREHPA, 2006).
4.7.5
Low decision making power of women on abortion
Existing gender inequalities between women and men have a significant influence on
sexual health; male partners can play an important role in determining women’s ability to
access safe abortion services, from both social and economic standpoint
(CREHPA/PATH, 2007). Several studies have also showed that husbands play a vital
role while making decision about abortion. A study conducted by CREHPA revealed
that husbands were the main decision makers about termination of pregnancy. The study
also reveals that husbands were not only the major decision makers regarding abortion,
they also helped their wives by bringing medicines home, identifying potential service
providers, escorting them, paying the costs and providing post-abortion care (CREHPA,
2006). Therefore, if husbands are not aware about abortion law and services and women
do not have much say in the final decisions then it is likely that couples would be ended
up in using unsafe abortion procedure for pregnancy termination.
4.7.6
Poor supportive environment (husbands, family and community) and social
stigma
Poor supportive environment to women and couples for abortion is also an important
barrier for accessing safe abortion services. Studies conducted by CREHPA revealed that
supports from husbands and family is also a major a factor in deciding whether the
couple seek safe or unsafe abortion practice (CREHPA, 2006; CREHPA, 2005; Puri et
al, 2007).
Social stigma was reported as yet other barriers among women and couples for abortion.
Many women and couples still considered that abortion is against socio-cultural
expectations so that if they went for one, they would lose prestige in the community
(Puri et al, 2007; CREHPA, 2005).
32
CHAPTER 5
Efforts to prevent unsafe abortions
5.1
Efforts of the Government
The Family Health Division (FHD) under the Department of Health services (DoHS),
Ministry of Health and Population (MoHP) has played the lead role in formulating
polices, strategies, and procedural order to implement and expand safe abortion services
within the legal framework following legalization of abortion in the country.
Implementation of the abortion law in the country is guided by the National Abortion
Policy, 2002 and the Safe Abortion Services Procedure, 2003. As mentioned in the
previous chapter, The Abortion Task Force (ATF) was formed by the FHD immediately
after the legalisation of abortion (Feb 2002) to develop implementation plan the law.
The ATF assisted the FHD/DoHS in drafting and finalising the policy guidance and the
safe abortion Procedural Order. Technical Committee for Implementation of
Comprehensive Abortion Care (TCIC) headed by the Director of FHD/DoHS was
established in February 2003 to support the implementation of the CAC services. The
members of TCIC are representatives from the MOHP and Ministry of Law and Justice,
NGOs, and donor agencies to collectively assist the government in implementation of the
country's safe abortion strategy. The strategy includes training of government and NGO
health service providers to deliver CAC services from the approved CAC centres
together with increasing public awareness about the abortion law and services. The TCIC
secretariat also provides monitoring support to ensure that services comply with
international standards, including proper infection prevention procedures, counselling
and a client friendly environment. In addition, a National CAC Advisory Committee was
formed under the chairpersonship of the Director General, Department of Health
Services to review the progress of abortion law implementation and advise the
government on abortion policy reforms (MoHP/WHO/CREHPA, 2006).
Under TCIC, a behaviour change communication (BCC) working group is formed,
which advises on BCC and IEC matters related to safe abortion services. The BCC
working group has also been involved in the development of an IEC strategy, including
posters, an information leaflet and post procedure information flier for abortion clients.
These IEC materials are being distributed through the National Health Education
Information and Communication Centre (NHEICC). The National Health Training
Centre works closely with FHD and TCIC. The NHEICC is responsible for public
information dissemination and NHTC is responsible for training procedures. The MoHP
provide guidance at policy and procedural level and the Ministry of Law and Justice
provide advice on legal aspects of the reform (FHD/MoHP/ CREHPA/
FWLD/Ipas/PATH, 2005)
Currently, the government is promoting Manual Vacuum Aspiration (MVA) for safe
abortion through CAC approved centres. MVA technique is not only safe for first
trimester abortions but also complies with usual gestation limits of 12 weeks for legal
abortion in the country (MoHP/WHO/CREHPA, 2006). Until July 2005, the Paropkar
Maternity and Women’s Hospital, Thapathali, was the only government approved CAC
training centre in the country. Now there are four CAC training centres (two government
and 2 NGOs) in the country. In addition to Maternity Hospital, Lumbini zonal hospital,
33
Butwal (Western region) was approved by government as CAC training centre. In
August, 2005, the Marie Stopes Centre at Saatdobato, Lalitpur was established as the
first NGO-run CAC training centre with the government approval. Recently, the FPAN
clinic at Itahari, Sunsari district (Eastern region) is also approved by the government as
CAC training centre. Efforts are underway to establish additional training centre in Seti
Zonal hospital in Dhangadi (Kailali district).
Table 5.1
services
Progress made in CAC service expansion and the number of clients receiving the
Fiscal year
Government
Sites
2060-61
(Mar-June, 04)
2061-62
(July 04-June, 05)
2062-63
(July 05-June, 06
2063-064
((July 06-June, 07
2064(July 07-Oct,
07)
Grand Total
% share of the
total approved sites
and clients served
SPN/MSI
Sites
Clients
served
1
-
Non-governmental
FPAN
Other private
Sites Clients Sites Clients
served
served
1
2
-
Total
clients
served
8
Clients
served
719
38
5,255
9
3,076
6
1,846
5
384
10,561
29
7,658
24
34,518
1
3,666
8
1,609
47,451
13
9,445
11
57,625
5
6,433
6
3,732
77,235
3
2,229
-
16,218
1
2,443
5
1,333
22,223
92
2,5306
47
111,437
14
14,388
28
7,058
158,189
50.8
16.0
26.0
70.4
7.7
719
9.1
15.4
4.5
Source: TCIC/FHD/MoHP, 2008
As of mid-May 2008, 508 (482 doctors and 26 Nurses) were trained for providing CAC
service. Among these trained providers, 323 were from the government and 185 were
from private/NGOs. Training on second trimester abortion was also organised by
FHD/MoHP in June 2007 in Maternity hospital. A total of 16 (9 gynaecologists and 7
Nurses) participated in the training. The government has approved 206 sites-98
government affiliated and 108 non-government affiliated CAC sites in 74 districts out of
the total 75 districts of the country. Only one district – Salyan still do not have any listed
CAC Centre.
According to the recommendation of CAC Advisory Board, the government has already
standardised the abortion fee at all the government hospitals and revoked the existing
policy that had allowed the respective hospital management committees to set their own
abortion fee. The government provided pilot training to four experienced staff nurse as
CAC providers and so far 26 nurses have received training. This is an important step in
enabling women in remote areas, where there are shortage of doctors and no NGO
clinics, to access safe abortion services.
In view of large number of caseloads of patients seeking treatment of abortion related
complications including incomplete spontaneous abortions, the Ministry of Health with
the technical assistance from USAID, JHPIEGO, Engender Health and FHI, established
a Post Abortion Care (PAC) Unit in Paropkar Maternity and Women’s Hospital in 1995.
The aim of the PAC service was to provide a comprehensive post abortion care service
which consists of emergency management, uterine evacuation of incomplete abortion
with manual vacuum aspiration (MVA), provision of family planning counselling and
service and other health care needs of such women.
34
Paropkar Maternity and Women’s hospital is the only national training centre for PAC
programme in the country. This training is coordinated by NHTC of Ministry of Health.
As of the year 2006, PAC training programme of the hospital had successfully provided
competency based skill training to 159 doctors, 135 nurses and 199 assistants
(Bajracharya et. al., 2007). PAC is one of the important components of Basic Emergency
Obstetric Care (BEOC) given to the women. PAC services are provided at the 78 centres
located in 51 districts. As of 2006-07, PAC service sites are established in 48
government hospitals and 22 primary health care centres and 8 teaching and Army and
NGOs health institutions covering 51 districts of the country (NFHP, 2007).
5.2
Efforts of the NGOs
5.2.1
Centre for Research on Environment Health and Population Activities
(CREHPA)
Centre for Research on Environment Health and Population Activities (CREHPA), is a
leading research-based NGO with substantial programmatic experiences in the areas of
unsafe abortion and abortion rights of Nepalese women. It was established in 1994 under
Society's Act 2034, as a non-governmental organisation.
CREHPA has played an active role through research, dissemination and advocacy to
decriminalise abortion and support the liberalization of abortion law in Nepal CREHPA
had networked with 43 district-based NGOs of Nepal from 1990 -2002 for implementing
its public Education and Advocacy Project (PEAP) aiming to prevent unsafe abortion
practices, create conducive environment for abortion legalisation and save women's
lives. CREHPA refused to sign the Mexico City Policy (Global Gag Rule) in the year
2000.
CREHPA has initiated a new programme called "Sumarga" (Right path) in partnership
with its district-based NGOs to create enabling environment for women to make
informed reproductive decisions and options. It supports the MoHP in developing
IEC/advocacy and behaviour change communications (BCC) strategies to address unsafe
abortion in the country. CREHPA represents the NGOs in the National Safe Abortion
Advisory Committee of the government (MoHP/WHO/CREHPA, 2006).
CREHPA has been conducting abortion related research studies and opinion polls on
abortion since its establishment. Encouraged by favourable public opinion pool on
abortion rights for women (CREHPA, 1996; 2002; 2003; 2004), the organisation
initiated Public Education and Advocacy Programme against unsafe abortion in the
eastern development region covering 16 districts of the country in 1999 with grant
support from the Ford Foundation. This programme aimed at empowering women to
make conscious and timely decision about their fertility and advocacy for legal reforms
(MoHP/WHO/CREHPA, 2006). In view of the growing concern on sex selection
abortion in Nepal, CREHPA has recently conducted a study on "Prenatal Sex Selection
in Nepal" with funding support from UNFPA, Nepal.
CREHPA with support form Planned Parenthood Federation of America-International
(PPFA-I), implemented a one year pilot project entitled "Access to legal and safe
abortion services through networks of private paramedics and chemists (PPC) and
community based health care providers and volunteers" in six districts. It was the first
public-private partnership initiatives aimed at preventing illegal and unsafe abortion
35
practices and increasing women's access to safe abortion service in the country. The key
project interventions included empowerment of the district based NGOs for project
intervention and monitoring, training and enrolment of private paramedics and chemist
in the initiatives, establishment of referral networks between PPC members and CAC
centres in the district and monitoring of the project performance and implementation.
This public private partnership concept has been replicated by CREHPA under the
PPFAI-International supported "Network for addressing women's Reproductive rights in
Nepal (NAWRN)" programme in 16 districts (MoHP/WHO/CREHPA, 2006).
CREHPA with support from Safe Abortion Access Fund (SAAF Fund, IPPF) has
launched another two years project entitled "Advocacy and Behaviour Change
Intervention (ABCI) Project: Enabling rural and marginalized women to access safe
abortion care in Nepal" in 15 districts of Nepal. The overall objectives of the project is
to create supportive and enabling environment for rural women to access safe, legal and
affordable abortion services without fear through advocacy and lobbying, community
education, networking and group formations. Under the project an operational research
study is also being conducted to test the effectiveness of male involvement in community
level education and advocacy in overcoming existing social barriers in utilizing safe and
timely abortion services by marginalized rural women and couples in two districts (Dang
and Palpa).
5.2.2
Family Planning Association of Nepal (FPAN)
The Family Planning Association of Nepal (FPAN) founded in 1959 became an associate
member of the Planned Parenthood Federation (IPPF) in 1960 and full-fledged member
in 1969. Family planning services in Nepal were started by the FPAN immediately after
its establishment. The family planning program in the government sector gained
momentum only after the establishment of the Maternal and Child Health Division at the
Ministry of Health in 1965 and the launching of the National Family Planning and
Maternal and Child Health Project in 1969 (FPAN, 2007). The family planning services
in 1960s were limited to distribution of condoms, pills and insertion of loops. All
activities were implemented by volunteers because there were no staff members to assist
their work. Since the only electronic media reaching the general public was radio, FPAN
initiated a weekly radio program on family planning in 1968 (FPAN, 2007).
FPAN started advocacy for liberalization of abortion policy in early 1970s. FPAN made
numerous efforts, primarily through organizing national and international workshops,
lobbying to the legislators, to develop a conducive environment and legalization of safe
abortion. FPAN organized a national level conference for policy makers and legislators
in 1974, on "Unsafe Abortion and Its Consequences in Nepal". Many seminars were
organized and materials published between 1974-1994. Safeguarding safe and legalized
abortion as a basic human right of Nepalese women, was again expedited by FPAN after
the ICPD Conference held in Cairo in 1994. FPAN made numerous efforts between
1994-2002 for the provision of safe and legalized abortion in Nepal. In order to create
pressure, to the national government to legalize abortion, five regional workshops:
"Population and Development", were organized in each development region included
were heads of the local governments (mainly, District Development Committee
Chairpersons and Mayors of Municipalities). An "ICPD, Follow up Workshop", was
organized for parliamentarians, senior government officials and advocates.
36
FPAN started more target-oriented and focused programs in the 1970s. A Family
Planning Welfare Project was implemented in ten wards of Kathmandu valley in 1972,
which started providing sterilization services on request with the assistance of USAID.
FPAN programs were expanded from three districts in the 1960s to 15 districts in the
1970s and 32 districts in 2004 (FPAN, 2007). The program focus of FPAN has been
changing gradually to adjust its program thrust and activities with contemporary demand
for FP services by the people. In the 1960s and 1970s, it adopted an integrated approach
of amalgamating community development and family planning programs. Consequently,
the emphasis was given to disseminate FP messages and service delivery since 1992 to
meet the unmet demand for family planning and reproductive health services.
Community development programs were curtailed substantially and new programs,
including STI/HIV/AIDS, counselling and services, sexual and reproductive health
education and services to adolescent and youths, maternity services and strong advocacy
on safe abortion were added in the 1990s. FPAN contributes 25-30 percent to the
national family planning programs and its program activities are ever expanding meeting
the unmet needs of family planning, including STI/HIV/AIDS prevention, control and
management (FPAN, 2007)
FPAN started safe abortion services in selected clinics in 2004. To date, the government
has approved 14 sites for safe abortion services including a training centre. As of
October 2007, 14,388 women received safe abortion services from these clinics. FPAN
trains service providers in safe abortion techniques, provides CAC services including
post-abortion contraception and emergency contraception, educates social mobilizers on
safe abortion services and supports the established “Nepal Safe Abortion (public and
private) Providers Network”. FPAN adopting IPPF's new Strategic Plan beginning in
2005 has focussed on five thematic areas including Advocacy, Access, Adolescent,
Abortion, and AIDS. It aims to establish centre of excellence in the country as well as n
South Asia region on safe abortion.
5.2.3
Forum for Women, Law and Development (FWLD)
Forum for Women, Law and Development (FWLD) is an autonomous, non-profit, nongovernmental organization established in 1995 to work for the protection and promotion
and of women's human rights. The Forum uses law as an instrument for establishing
social justice and ensures women's, children's and minority's rights. In order to eliminate
all forms of discrimination, the Forum uses international human rights instruments such
as CEDAW, CRC, ICERD and other human right instruments.
The Forum has been working on the various issues related to the women's human rights
such as: right to property, right to sexuality, child right, right to health, right to
citizenship, minority rights etc. Women's reproductive right is a key concern area of the
organization. The Forum had conducted the advocacy program among the key
stakeholders and parliamentarians to legalize the abortion in collaboration with various
other stakeholders. A research was done to find out the impact of abortion
criminalization which was quite useful tools for advocacy for legalization of abortion.
Legal services were also provided to women who were in prison in charge of procuring
abortion. Forum filed a writ petition for the issuance of safe abortion procedure when
safe abortion procedure was not issued for almost a year after legalization of abortion
right.
37
Forum has been working on the areas of ensuring women's safe abortion right under the
NAWRN programs with the support of PPFA-I. Under the NAWRN program, the Forum
mainly focuses on creating awareness relating to the abortion law among law enforcers,
services providers and others key stakeholders in sixteen districts and also conducted the
monitoring program on implementation status of abortion law in six districts (Jhapa,
Sunsari, Kaski, Tanahun, Baglung and Dadeldhura). Under the monitoring program, the
organisation is observing the role of various stakeholders to implement the abortion law
such as: District court, CAC centres, jail, police office, media activities in relation with
abortion right. Existing abortion law has been dealt under the homicide Chapter of
Country Code, 1963. The human right activist and other concerned stakeholders raised
the concern to enact a comprehensive safe abortion law. Forum has drafted a safe
abortion law in 2007 and it will be finalized in 2008. The Forum has also developed and
printed various IEC materials to create the public awareness for ensuring safe
terminating of the unwanted pregnancy.
The Reproductive Rights Litigation Unit (RRU) was established by FWLD with support
from the CRR in December, 2005. The objective of the unit is to provide legal services
and counselling to women who are deprived of exercising their reproductive rights, and
legal counselling to the service providers in case of complication while providing CAC
services in accordance with the existing law. The unit also makes immediate intervention
on unsafe abortion incidents and also makes the fact finding on severe violation of
reproductive rights. The litigation unit filed a writ petition at Supreme Court to ensure
access to women on abortion right in February, 2007. The litigation unit collected the
data of women who were in the prison in charge of abortion or abortion related offences.
It was found that 16 women and 2 men were in the prison in charge of abortion or
abortion related offences in 2006.
The Forum also conducted a meeting with drafting committee of interim constitution
2063. The objective of the meeting was to ensure the women's reproductive right as
fundamental right in the constitution. As a result of this meeting, reproductive right has
been recognized as fundamental right of women. Recently, FWLD have published the
IEC materials in relation with reproductive right and it has been mentioned as a model
fundamental reproductive right in upcoming constitution.
5.2.4
Sunaulo Parivar Nepal/ Marie Stopes International (SPN/MSI)
Marie Stopes International (MSI) is a global Sexual and Reproductive Health (SRH)
service providing organization registered in 1973 in the United Kingdom. It works in
close partnership with local NGOs in different countries, providing technical and
managerial support to the partners. MSI, at present, has partnership with over 38
countries in Asia, Africa, Europe and Latin America, following the
National/International guidelines for increasing access and utilization of quality FP/SRH
services with a mission of enabling people to have “children by choice not by chance.”
Sunaulo Parivar Nepal (SPN), a non-government organization established in 1994, is a
local partner of MSI in Nepal. it has been working in partnership with MSI to meet the
SRH needs of the men, women and young people of Nepal by increasing awareness and
understanding of SRH and increasing access to quality and affordable services. The
overall goal of MSI/SPN is to support the government in meeting national FP/RH needs
by establishing sustainable FP/SRH program.
38
Starting with one static centre named as Marie Stopes centre in Morang, SPN now runs
53 static centres in 39 districts of Nepal (9 centres are within Kathmandu Valley). It
provides a wide range of FP/RH services including permanent sterilization for male and
female, temporary FP methods- condoms, pills, IUD, Depoprovera, Norplant and
emergency contraception, antenatal/postnatal checkups, treatment of RTI and STI, child
immunization, general health checkups and comprehensive abortion care. In addition,
SPN also runs various need based FP/SRH programs like mobile sterilization camps,
contraceptive social marketing, and youth friendly information centre.
SPN provides safe abortion services through its 47 listed centres located in 34 districts of
the country with technical and financial support from MSI-UK. As of October 2007,
SPN has provided CAC services to 111 thousands women (70% of the total clients
served in last four years) demonstrating an important safe abortion service provider in
the country.
SPN also runs a Reproductive Health Training Centre at Satdobato, Lalitpur. This is the
first CAC training centre run by a non-governmental organization in the country and
recognised by the government to serve as the CAC Training Centre. The main purpose
of this training centre is to support government of Nepal in meeting unmet demand of
quality FP/RH service providers, through producing competent human resource of health
trained by qualified trainers The centre provides trainings on infection prevention and
management, quality of care, minilap tubectomy, vasectomy, IUCD, Norplant, FP
counselling, youth friendly service delivery, RTI/STI case
management and
comprehensive abortion care.
5.2.5 Nepal Society of Obstetricians and Gynaecologists (NESOG)
Nepal Society of Obstetricians and Gynaecologists (NESOG) is an independent non
profit making professional organization of Obstetricians and Gynaecologists in Nepal
established in 1988 A.D. with commitment of highly motivated gynaecologists Prof.
Dibya Shree Malla, Prof. Sanu Maiyan Dali and Dr. Bhola Rijal in the country and
support of friends and well wishers of NESOG abroad including Prof. Hiroaki Soma
from Japan, Visiting Consultant at Prasuti Griha and Visiting Prof. at Institute of
Medicine and Late Emeritus Prof. Shan S.Ratnam, the Secretary General of Asia
Oceania Federation of Obstetrics and Gynaecology (.Dali ,2006 ).
In the very short time period, NESOG has been established as a leading organization
working for improving women’s health in the country and has strong liaison with other
federations as an affiliated member such as South Asia Federation of Ob. /Gyn.
(SAFOG), Asia Oceania Federation of Ob. /Gyn. (AOFOG) and recently Federation of
International Society of Gyn. / Ob. (FIGO). NESOG has adopted the Ethical FIGO Code
of Human Rights based Ethics.
The overall objectives of the society is to serve the people by rendering fully educational,
scientific and public health oriented services of high standards in the field of Obstetrics
and Women diseases ( Constitution of NESOG,2000). Specific activities of this
organization are focused to organizing Continuing Medical Education for NESOG
members and other heath care providers related to this specialty including organizing
annual conferences/ Seminars and Symposia on various key theme topics addressing
vital health needs of Nepalese women. This organization works in close collaboration
with the Government together with other stakeholders in different areas such as policy
39
formation, developing guidelines and training manuals, implementation program
including trainings in all reproductive health services. It also organizes awareness
campaigns not for its members but also for the general public and promotes and
facilitates research in women’s health issues.
NESOG has played crucial role together with other key stakeholders in making abortion
safer for Nepalese women and saving their lives and disabilities by reducing the burden
of unsafe abortion. Highly committed members of this organization have not been only
involved as technical experts in service delivery and provide training in safe abortion
services but have been strong advocates for raising voice against criminalization of
abortion and violation of human rights of Nepalese women for more than two decades
NESOG has been key stakeholder for advocacy effort and actively involved in battle for
legalization of abortion in Nepal. Around 1980s , One of the past presidents of NESOG,
raised his voice for making abortion legal when he noticed while working in Prasuti
Griha ( now named as Paropkar Maternity and Women’s Hospital) that many lives of
Nepalese women are simply lost because they could not avail provision of safe and legal
abortion services. He published articles related to this issue in various newspapers and
helped activate a national environment for discussion and gained international attention
through interview broadcasted by BBC Sri Lanka and BBC London (G. Shakya et al.,
2004). In 1990, he participated in public debate on legalization of abortion on Nepal TV
and challenged anti abortion views, and clearly announced that he is willing to provide
safe abortion services to women.
After legalization, NESOG was a member of Abortion Task Force Committee formed by
Family Health Division to draft the procedural order for implementation of the
amendment and the Policy and Strategy document. Technical input from NESOG was
incorporated in all legal and technical documents related to comprehensive abortion
services including procedural order, Abortion policy and strategy, implementation plan
and reference and training manual. NESOG members are not only key providers but are
involved extensively for training of not only specialists but also medical doctors and
nurses. NESOG strongly supported training of mid level providers (nurses) to increase
access to services in districts and lower level facilities where there is paucity of
gynaecologists. Apart from training, NESOG has also been involved in monitoring and
evaluation program and members are also supporting research activities related to
abortion in various hospital.
Eighth national conference of NESOG was on theme topic “Preventing women from
unsafe abortion” in 2004 when program implementation was just started and post
conference workshop was organized on safe abortion services with the support of Ipas.
Making abortion safer has also been a very much discussed topics among members and
various CMEs are conducted on this issue in last few years.
Currently, NESOG has been a member of CAC advisory committee and supporting very
much the Govt. in all orientation and training activities of CAC services. With support of
Ipas/FHD/MSI it has organized short comprehensive CAC training course for all its
members to facilitate their listing as legal providers and their service delivery site as
listed sites. NESOG is also supporting recently launched Medical Abortion pilot project
in six selected districts by FHD/Ipas to help Nepalese women get a choice of abortion
methods.
40
5.3
Contribution of INGOs
5.3.1
Ipas
Ipas is an international organization that works around the world to increase women's
ability to exercise their sexual and reproductive rights, and to reduce abortion-related
deaths and injuries. Ipas believes that women everywhere must have the opportunity to
determine their future, care for their families and manage their fertility. Ipas global and
country programmes include training, monitoring, research, advocacy, and promotion of
evidence based technology in order that all health facilities are providing high quality of
reproductive health care.
In 2002 Ipas and other donor agencies (such as National Safe Motherhood Programme
(NSMP), Department for International Development (DFID/Options, Germany’s
Gesellschaft Fur Technische Zusammenarbeit (GTZ) supported planning and
implementation of the safe abortion programme. Ipas in coordination with other
international organizations (SSMP/DFID/Options, SIDA, GTZ, PPFA-I & PATH)
provides technical assistance to government through the TCIC (Technical committee to
implement comprehensive abortion care) in developing standards, guidelines for training
and as well as provides support for strengthening quality of care. As a partner of SSMP,
Ipas has been supporting the safe abortion program since 2004 and focusing on full
implementation of abortion law in Nepal.
5.3.2
Planned Parenthood Federation of America- International (PPFA-I)
The Planned Parenthood Federation of America (PPFA)- International Division works
with local organizations in the developing world to provide reproductive health services
to women and men who often have no other access because of location or age or as a
result of crisis. Since 1971, PPFA-I has been working with pioneering NGOs throughout
the world to bring high-quality, prevention-based reproductive health services to women,
men, and adolescents in many of the world’s most impoverished settings.
PPFA-I has been working in Nepal since early 2002, supporting the movement of Nepali
NGOs to legalize abortion. Since legalization of abortion was achieved in late 2002,
PPFA has continued to support partner NGOs working to increase awareness of the new
law and access to safe abortion services. In 2005, PPFA launched a three-year
countrywide program called ‘Network for Addressing Women’s Reproductive Rights in
Nepal (NAWRN)” which works in 16 districts through the concentrated efforts of the
four multidisciplinary NGOs namely, CREHPA, FPAN, FLWD and the Safe
Motherhood Network Federation. The objective of the NAWRN program is to increase
access to and utilization of affordable, quality CAC services for Nepal’s most vulnerable
communities. In NAWRN project, CREHPA focuses on educating PPC on abortion
issues including the abortion law. The trained PPCs in turn educate women and refer
them to registered CAC centers through a well-established referral system. The FPAN
trains service providers in safe abortion techniques, provides quality CAC services
including post-abortion contraception and emergency contraception, educates social
mobilizers on safe abortion services and supports the established “Nepal Safe Abortion
(public and private) Providers Network”. The FWLD develops education materials to
advocate for women’s reproductive rights and reduction of stigma surrounding abortion,
identifies and files cases of violation of reproductive rights in the court, develops
strategies for legal reformation, educates law enforcement officials regarding the new
41
abortion law and monitors the effective implementation of the abortion law and The Safe
Motherhood Network Federation builds the capacities of partner NGOs, educates
community-based service providers on safe abortion issues including the abortion law.
The trained providers in turn educate women and refer them to registered CAC centers
through a well-established referral system. The project also conducts grass root
awareness activities to educate the community.
5.3.3
Programme for Appropriate Technology for Health (PATH)
PATH is an international, nonprofit organization that creates sustainable, culturally
relevant solutions, enabling communities worldwide to break longstanding cycles of poor
health. By collaborating with diverse public- and private-sector partners, PATH helps
provide appropriate health technologies and vital strategies that change the way people
think and act. Over the past 25 years, PATH has lead projects in more than 20 countries,
improving the lives of millions of people worldwide.
In 2004 PATH began to work in Nepal. The goal of PATH's work in this country is to
increase women's power to choose and access safe and legal abortion. After discussions
with an array of organizations working in Nepal to address issues related to safe abortion
policy, advocacy, and clinical service delivery, PATH determined that it could best
contribute to their efforts by developing a behaviour change communications (BCC)
strategy for Nepal—an approach and tools to implement it—that would help
communities accept and access the newly available safe abortion services (PATH, 2007).
The strategy includes the use of dialogue groups to encourage critical reflection and
experience sharing. These groups are complemented by awareness-raising events for
community members, radio programming, and posters and leaflets, all of which
communicate successful behaviour change stories. In 2005, with the support of PATH,
the FPAN and NAMUNA Integrated Development Council launched a nine-month pilot
project to gauge the effectiveness of the Dialogues for Life strategy. PATH developed a
training curriculum that prepares facilitators to lead community dialogue groups, capture
personal behaviour change stories, and facilitate referrals for reproductive health
services. PATH supported CREHPA to conduct two studies: A formative needs
assessment on BCC strategy development for accessing safe abortion care in Nepal and
the influence of male partners in pregnancy decision making and pregnancy outcomes in
Nepal. The study results were useful in identifying appropriate information and
communication channels those are needed to reduce the social, familial, attitudinal, and
knowledge barriers that women face with accessing safe abortion services in Nepal
PATH, 2007).
PATH, in cooperation with partners, produced an interagency report, entitled Women’s
Right to Choose: Partnerships for Safe Abortion in Nepal that documents the significant
progress made in the first 18 months after the new abortion law was enacted PATH,
2007).
5.3.4
Center for Reproductive Rights (CRR)
The Centre for Reproductive Rights (formerly the Centre for Reproductive Law and
Policy) founded in 1992, is a US based non-profit legal advocacy organization dedicated
to promote and protect women's reproductive rights worldwide. Using international
human rights law to advance the reproductive freedom of women, the Centre has
42
strengthened reproductive health laws and policies across the globe by working with
more than 100 organizations in 45 nations including countries in Africa, Asia, East
Central Europe, and Latin America and the Caribbean.
In 2001, CRR in collaboration with FWLD conducted a fact findings mission to
document violations experienced by women imprisoned for abortion and related offences
in Nepal. The findings were published in a report entitled “Abortion in Nepal: Women
Imprisoned” which extensively analyzed Nepal’s restrictive abortion law and
documented the human rights violations of women imprisoned for abortion. An
executive summary containing key findings and legal arguments in support of
decriminalization was distributed to policymakers at the historic national conference on
gender organized by FWLD right before the final vote on the 11th amendment bill in
2002. CRR in collaboration with FWLD drafted and submitted, a shadow letter to the
Committee on Economic, Social and Cultural Rights (CESCR), the international body
that monitors the implementation of the International Covenant on Economic, Social and
Cultural Rights (ICESCR) in 2001, which recommended the issuance of concluding
observations by the Committee asking the Nepal government to decriminalize abortion.
In 2001, CRR developed an abortion kit including testimonies from key government
officials in support of abortion law reform This kit was adapted into Nepali by FWLD
and distributed nationwide to be used for lobbying policymakers. In 2002, the CRR
launched a public advocacy campaign for the release of women in prison. CRR provided
technical and financial support to FWLD at the local level. Between 2001-2004, the
Center provided pertinent information about the situation in Nepal to international
humans rights bodies including the Committee on Economic, Social and Cultural Rights,
the Committee on the Eliminations of Discrimination Against Women and the Human
Rights Commission to create international pressure on the government to decriminalise
abortion, release women imprisoned for abortion related offences and to speed up the
implantation of the newly amended law.
In 2005, CRR has begun to focus on law enforcement, law reform and legal
accountability. Building on the success of is work over the years, CRR helped FWLD
establish a Reproductive Rights Unit which will provide legal assistance to women who
are denied access to safe abortion services and legal counselling to medical providers
about the scope of their rights and obligations under the amended law and new protocols.
In collaboration with PPFA-International, FWLD, CREHPA, SMNF, and FPAN, CRR
formed a National Network for the Reproductive Rights of Women in Nepal in 2005. In
2006, the CRR in collaboration with PPFA-International and local members of the
network is gathering information about issues surrounding access to abortion to craft
recommendations for abortion law and policy reform, in order to improve access to
services and establish better formal protections and mechanisms for the protection of
their right to safe abortion services. CRR worked with FWLD and the other NAWRN
partners to develop questionnaires for gathering information. In 2007, CRR sponsored
and led a consultation on abortion law reform and engaged a broad range of stakeholders
including key governments officials in a discussion about gaps in the existing legal
regime and the need for a comprehensive abortion law to ensure the accessibility,
availability, affordability and quality of abortion services and to prevent the occurrence
of unsafe abortions by unlicensed providers. Over the years, the Center has also been a
vocal critic of the Global Gag Rule, which continues to undermine abortion access in
Nepal.
43
CHAPTER 6
Issues and challenges of current abortion care services
Legalisation of abortion has been the key step to reduce abortion related maternal
mortality and morbidity rates as well as a milestone in ensuring women's reproductive
health and rights. It has certainly created a new paradigm requiring the framing of rightbased polices and programmes by the government to be implemented in collaboration
with non-governmental organisations and donor agencies. Universal access to
information and safe abortion services has the potential to significantly reduce the
country's maternal mortality ratio. However, there are many obstacles that must be
overcome before Nepalese women will be able to exercise their rights to safe and legal
abortion services on affordable costs and protect themselves from consequences of death
and disabilities related to unsafe abortion. Unsafe abortion continues to prevail in the
country despite the four years of safe abortion service expansion. One of the main postlegalization challenges for Nepal is to increase access to legal and safe abortion services
by women without fear within the framework of right based approach.
Lack of awareness about the law and services: Evidences show that rural women are
unaware of the abortion law that supports women's rights to control over and decide on
their unintended pregnancies. They are also unaware about place where they can seek
safe and legal abortion. Majority of the married men and about two-fifths of the
unmarried men and youths in rural areas were not in favour of women's absolute right to
abortion. Moreover, fewer married men and unmarried boys favoured abortion rights for
unmarried women (NAWRN baseline survey 2005). Therefore, challenges are to create
community awareness of provision of safe abortion within legal framework and modify
the risk taking behaviour of abortion seekers. Unskilled/clandestine providers within the
country and across the border continue to exploit ignorant women and put their life into
risk. Therefore, there is strong need to develop a comprehensive strategic intervention to
uproot illegal abortion practices including public vigilance and monitoring of the illegal
sales of banned drugs used for abortion and punitive measures to discourage unskilled
abortion providers to continue these practices.
Inadequate services and unequal distribution of CAC centres: Although CAC
centres are expanding rapidly over the years, most of the centres are located in urban and
semi-urban areas and district headquarters. CAC service delivery schedules especially at
the government CAC centres are not women friendly especially for women who live in
remote areas and cannot access such services if not available six days a week.
Efforts to expand CAC services at peripheral (PHC) levels and hospitals in remote
districts continue to pose challenges because of the unwillingness of the doctors and
other skilled health care providers to serve at such locations. Moreover, problem of
frequent transfer of doctors and trained CAC providers from one health facility to
another and the delays in providing suitable replacements remain as a major challenge in
ensuring sustained CAC services. In addition, poor referral network mechanisms
between different levels of service providers affect continuity of abortion care. The
recent decision made by the government to train and involve experienced staff nurses as
CAC providers is a good step to minimise the service access gaps for rural women. In the
meantime, community-based health providers and volunteers should be involved to
44
educate the communities about the health implications of unsafe abortions and establish
referral linkages between women and approved CAC service providers.
Until very recently, the government policy has been to concentrate on imparting CAC
skills to doctors for handling first trimester (within 12 weeks) abortions only. The
government has recently provided training to 16 providers to deal with abortions up to 18
weeks in case of rape or incest which is legally allowed. Strengthening the capacity of
the specialists to manage beyond 12 weeks gestational cases presenting at the referral
hospitals and establishment of effective referral networks are paramount important. The
most crucial intervention in the community is to have provision of early detection of
pregnancy using pregnancy detection kits with the help of Female Community Health
Volunteers and Community Health Workers for timely access to safe first trimester
abortion services.
Unaffordable service charges: High cost may limit access even though service is
geographically accessible. The recent decision taken by the government to standardize
abortion fee in all government hospitals (NRs, 1000 including the cost of medicines
approx.USD15) based on the recommendations of the National Safe Abortion Advisory
Committee is a major achievement towards this step. These are extremely important
decisions which can increase affordability and accessibility of safe abortion service to
every woman. There should be safety net for poor women to avail free services in all
CAC centres. Fees for abortion services charged by some private institutions remain high
and unregulated. In addition, increasing number of unapproved abortion service
providers and service sites should be monitored and discouraged from such a practice.
Choice to women and couples on abortion methods: The country’s Safe Abortion
Procedure, clearly specifies a range of safe abortion technologies to be adopted by a
listed CAC provider or an institution for an abortion within 12 weeks of gestations.
These are MVA, EVA, pharmacological and traditional D&C. Currently, only MVA as a
surgical method of abortion is being promoted by the government. However, in view of
the high demand for medical abortion and its proven effectiveness throughout the world
including Nepal, the government is introducing pharmacological or medical abortion
technology in the country as a pilot project in six districts so as to provide Nepalese
women with an alternative safe technological option and be responsive to women's need.
Recent decisions made by the Department of Drug Administration (DDA) to add
Mifepristone and Misoprostol to its list of essential medicines and the government's
approval of these two medicines for terminating first as well as second trimester
pregnancy, are commendable (personal communication). However, it is equally
important for the government to bridge the gaps and challenges such as women’s access
to relatively safer and non-evacuation procedures of pregnancy termination to minimize
the risk of exposure to abortion related complications.
Involvement of husbands: Husbands play crucial role in abortion decision-making
including choice of abortion providers. Majority of the rural men are not supportive to
women’s absolute rights to abortion as guaranteed by the law. It was also discouraging to
find certain segment of societies not in favour of providing abortion services to an
unmarried woman. Therefore, there is a need that all IEC materials and behaviour change
communication programme should target men in creating positive attitude towards
women’s abortion rights. Programme that involve husband in creating enabling
environment to women in accessing safe abortion services including pre-post abortion
contraceptive counselling and discourage unsafe abortion practices in the villages are
45
highly required in the country. In addition, involving male partners and encouraging their
contraceptive use and cooperation may help increase the use of modern contraceptive
methods and consequently contribute to reduce abortion rate (both safe and unsafe).
Social transformation: One of the major challenges is social transformation of
legalisation of abortion and to change prejudice mindset. For example, a group of
lawyers have filed a case to the court challenging the law saying that the abortion law
has curtailed the rights of father. Similarly, social stigma attached to abortion still not
only posing challenges to women in accessing safe abortion services but also
discouraging women to disclose their abortion need.
Sex selective abortion: A recently completed study on sex imbalance revealed that sex
selective abortion is not yet issue of major concern in Nepal (UNFPA/CREHPA, 2007).
However, in light of the legalisation of abortion, easy availability of prenatal sexdetermination technologies and abortion clinics, as well as the religious and socioeconomic value given to sons, the demand for sex selective abortion could increase in the
coming years. In addition, the declining fertility levels and the pressure to couples to
balance the sex composition of their children may contribute to further demand for prenatal sex selection. It is unlikely that legal sanctions alone can prevent such practices. On
the contrary, any harsher legal measures can results in making the services more
clandestine and expensive. Experiences in India and China indicates that until and unless
women are empowered to make the sole decisions on the number of children
(irrespective of sex composition) they want and the society gives equal value to
daughters, the demand for sons will continue to prevail in all societies and the
consequent effect on women's health and lives. Therefore, there is a need of constant
vigilance and advocacy activities to reform the existing discriminatory laws, and public
dialogue on the ethics of sex selection.
Maintaining abortion-related record: The existing record keeping system on abortion
related morbidities particularly on PAC admissions, both at government and private
health facilities pose a great challenge to monitor the trends of unsafe abortion in the
country. As mentioned earlier, almost all the government and private health institutions
do not separate out induced abortion cases from their PAC clients. As a result, the
number of unsafe abortions seeking PAC services from these hospitals cannot be
ascertained. In order to establish a post-legalization baseline database on unsafe abortion
which can be used for future comparison and to document the impact of abortion
legalisation, it is essential to segregate the records on unsafe abortions from the PAC
client's registers. Recently, the Government has introduced a modified record system in
HMIS that segregates records of induced abortion separately.
Finally, prevention of unsafe abortion practices in the country and creating enabling
environment for women and couples to access legal and safe abortion services as
outlined in the Comprehensive abortion service Procedure 2003 are daunting task and
requires strategic interventions that would help to achieve: 1) Awareness about the legal
reform and positive attitudes towards abortion as reproductive rights of Nepalese
women, 2) Informed decisions among women's and couples on their pregnancies and
choice of abortion procedures 3) Enabling environment for women to access safe and
legal abortion service without fear of stigmatization by the society and 4) Increased
access to affordable CAC services for all. The programme should be focussed to
enhance women's knowledge about the law and abortion rights, create enabling
environment for them to access timely CAC services without the fear of social sanctions,
46
encourage husbands to accompany them for receiving post abortion contraceptive
counselling and acceptance and discourage unsafe abortion practices in the villages
including cross-border abortion. The prevention of unwanted pregnancies must always
be given the highest priority and every attempt should be made to reduce the need for
abortion. Currently, the family planning services have become an integral part of the
government health services. Access to family planning services including emergency
contraceptive should be improved, especially by expanding the services towards health
post and sub health posts. Further research on reasons for unsafe abortion in legalised
context and identifying strategy to create conducive environment for safe abortion to all
women are required. All these activities cannot be accomplished in a short span of time
and by the government sector alone. The active participation of the private sectors
including NGOs, INGOs and donor community is imperative in this respect.
47
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51
Annex. 1.
Summary of the Main Recommendations
1. Limited Awareness
Scale up radio program to create awareness among rural population on the legal
condition of abortion
 Local context (targeted approach, language, social practices) needs to be
considered while developing materials for the radio
 Develop the capacity of FCHVs for early detection of pregnancy (urine test for
confirming pregnancy) and empower women for making timely decision - for
antenatal care or safe abortion service
 Develop simple messages for women, as well as develop a standard protocol for
providing services for the third condition of law that says:
 ''At any time during pregnancy, with the advice - if the life, physical or
mental health of the pregnant woman are at risk or if the fetus is deformed of a listed medical provider and the consent of the pregnant woman as
well''.
 Intensify awareness programs for women/families
 Include sexual and reproductive health related information in high school and
secondary school curriculum, and work on teachers' attitudes
 Behavior change communication on:
 do not use harmful practices
 detect early pregnancy and make timely decision
 Contact FCHVs/health care providers as early as possible
 Seek safe abortion site
 Unsafe abortion can kill women.







2. Unmet Need for Family Planning
All health facilities (SHP/HP/PHCs/Hospital) should be offering contraceptive
methods of women's and men's choices (short and long acting methods) backed
up with good counselling and follow up
Provision and awareness of Emergency Contraception
Behavioral research on why there is a big gap between Knowledge and Practice
Targeted approach to be considered for increased utilization
All RH related services (CAC/PAC/FP) and training are integrated at all levels.
Myths and rumours are counteracted with improved IPCs (interpersonal
communication skills) of FCHVS, and providers.
3. Increasing Access and Quality of Services
o Include Safe Abortion Service in essential health care package
o Include WHO approved technology (MVA, Mifepristone and Misoporostol) in
essential drug list
o Provide Pregnancy test kit (for early detection of pregnancy) in essential drug
list
o Approve and implement the national strategy on medical abortion
o Provide a safety net for poor women even in the private sector
52
o Expand mid-level providers to increase outreach for safe abortion services
o Make services as client friendly as possible (time, privacy, confidentiality,
affordability).
4. Social Stigma

Intensive advocacy with mothers-in-law, religious leaders, and community
leaders with the message that ''pregnancy can kill women'‘ and this is to save
the women from unwanted pregnancy
5. Reporting and Monitoring
 Due to the tireless efforts of the FHD Director, monitoring of safe abortion is
now included in the national HMIS
 DHOs/RHD should be delegated authority as well accountability for
listing/delisting of SAS sites in their district
 All (public-private) sector need to be encouraged to implement SAS
monitoring system and take appropriate actions to address issues related to
unsafe abortion.
53
Annex 2: List of core working group members (FIGO Initiative of Unsafe Abortion)










NESOG- Dr . Pushpa Chaudhary
FPAN- Dr . Deeb Shrestha Dangol
FHD- Dr. Shilu Aryal
UNFPA- Dr. Prasanna Gunasekara
CREHPA- Mr. Anand Tamang
Ipas , Nepal- Mr. Ganesh Shrestha
Paropkar Maternity and Women’s Hospital- Dr. Lata Bajracharya
SMN/MSI- Dr. Durga Manandhar
FWLD- Mr. Lok Hari Basyal
SMNF- Mr. Shambhu Jang Rana
54
Annex. 3: List of Participants of dissemination workshop
S.N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Name
Dr. Shanti Joshi
Ms. Gyanu Shrestha
Dr. Aruna Karki
Dr. Heera Tuladhar
Mr. Ganesh Shrestha
Dr. Mahesh Puri
Dr. Durga Pd. Manandhar
Shambhu J. Rana
Sarah Stucke
Dr. Pushpa Chaudhary
Dr. Deeb Shrestha
Paban S. Shrestha
Dr. Lata Bajracharya
Mukta Shah
Dr. Paban Sharma
Dr. Achala Vaidya
Dr. Naresh P.
Dr. Prayaschit
FL
Matron Mara Devi
Dr. Giridhari Sharma
Beena Mahat
Dr. Anu Kushawa
Sharada Sharma
Dr. L.N Shrestha
Dr. I.P Prajapati
Bashu Dev Neupane
Prakash Bohora
Deepak B.
Madhavi Bajracharya
Anuja Singh
Dr. Prasanna
Dr. Tara Shakya
Dr. Jyoti Sharma
Dr. Chanda Shrivastava
Dr. Sarita Upadhyay
Dr. Pramila Pradhan
Dr. Bimala Lakhey
Kunj Joshi
A Tamang
Dr. B.K Suvedi
Dr. Amita Pradhan Thapa
Nadia Shamdudin
Dr. V. Shrivastava
Shanti Manandhar
Dr. Geetha Rana
Address
NESOG
UNFPA
NESOG
NMCTH
TCIC/FHD
CREPHA
MSN
SMNF
TCIC/FHD
NESOG
FPAN
FPAN
Maternity Hospital
TCIC
Patan Hospital
Maternity Hospital
ERHD- Dhnakuta
Bhim Hospital
ATU
Capital Hospital
FPAN
FPAN
FPAN
IPPF/ SARO
Maternity Hospital
Bhaktapur Hospital
Putalisadak
Kupondole
Ipas
TCIC/Ipas
TCIC
UNFPA
PHECT-Nepal
TUTH
NESOG
UNFPA
NESOG
NHEICC
CREHPA
FHD
UNFPA
Ipas
NESOG
Shtree Shakti
UNICEF (ROSA)
55
Contact no
9841698937
4326119
9851042579
9841227475
9851002231
9851089910
9841297343
stuckes@ipas.org
9851052755
9841409274
01-5524440
4260405
4215265
9851097844
9851033017
9851042824
9857020310
9841581496
9841243928
5524440
5524440
5524440
9851030962
9841332383
9841259071
9841705557
9841700095
9841231809
9841248800
9803317641
4261595
9851061900
9841276275
9851027558
9841730453
9841392794
4262155
shamsuddin@ipas.org
9851043013
4423054
4417082
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
Dr. Archana Amatya
Dr. Hira Dangol
Dr. Ganga Shakya
Dr. Chanda Karki
Dr. Kusum Thapa
Dr. Shreedhar Acharya
Dr. S.B
Janaki Singh
Rameshwor sapkota
K.P Bista
Babita Thapa
Dr. Rita Gajurel
Dr. Bhola Rijal
Dr. L.R. Pathak
Dr. D.S. Malla
Aneeta Shah
Anup Acharya
65
66
67
68
69
70
71
72
73
74
75
76
77
78
Dr. Surya K. Shrestha
Meena Shrestha
Dr. Kathryn Anderson
Dr. Kundu Yanzom
Dr. Tumla Lacoul
Dr. Tara Pokharel
Laxmi Rana
Prof. S.M. Padhye
Lindsay Carathiri
Dr. Nafisha Malla
Meera Dhungana
Sarala KC
Dr. Indira Basnett
Mr. Ganesh Shrestha
TUTH
NESOG
SSMP
NESOG
Maternity Hospital
LZH Butwal
SNC
Avenues Television
Agra Nikash
FPAn
FPAN
MSI
OM Hospital
NHRC
Maternity Hospital
Babarmahal
Associated News
Agency
SMNF
TCIC/Ipas
Ipas
Patan Hospital
NFCC
MMH
NHEICC
KMCTH
Ipas
Phect-Nepal
FWLD
NAN
TCIC
TCIC
56
5522025
4220662
9851026793
9841555740
9857021374
9851042711
4227222
02141436
9851102682
5524440
9841694713
4482677
4770890
4271878
4262628
9841371901
9851048995
4215265
9841549666
9851030024
9841566111
9841525134
9841263703
carattinit@ipas.org
4332160
4242683
4421738
9851019268
9851002231
Annex 4: Plan of Action Proposed by Groups
1.
Awareness and Social Stigma
Strategies and Actions
Responsibility
(Lead/Supportive) *
NHEICC/ INGOs (Ipas,
IPPF, PPFA)
Wide-scale information
dissemination/orientation:
 Information (IEC/BCC) about and in
SAS Centers
 Use of displays, audio-visual media,
street drama, local events, media
coverage and IEC print materials
 Information display boards in health
facilities
Social Mobilization:
NGOs (FWLD,
 Community mobilization and
CREPHA, SMNF, FPAN,
orientation
MSI, CBOs)
 Awareness about early pregnancy
detection
 Availability of pregnancy kits on-site
Orientation to FCHVs and all levels of
FHD/ SSMP, UNFPA,
health workers:
TCIC, DPHO
 Advocacy campaigns, workshops,
interaction programs
 Study/analyze IEC needs - KAPs
 Developing teaching/learning
materials and IEC packages and kits
 Establishment of Information Centers
Ensure safety, privacy and confidentiality FHD/ NESOG
in SAS Centers:
 IECs during mobile healthy camps
 Incorporate SAS/IEC in RH/IEC
Committees
 Incorporate SAS/IEC indicators in
GON plans
Intensify advocacy/awareness programs:
DPHO, DDC, HMC,
 Influence and use
SMC, TCIC/FHD
unskilled/clandestine providers as
change agents
 Involve males/mother-in-law/elder
sisters
 Create awareness among adolescents,
couples, sex workers, teachers, etc.
 Educate women about calculation of
LMP
 Carry out advocacy targeting media,
influential persons, CA members,
policy and decision makers
* Those mentioned in bold have the lead responsibility.
57
Time Line
Within 4-6
months
ASAP
In 2008
In 2008
Initiate
ASAP
2.
Unmet Needs of Family Planning
Strategies and Actions
Responsibility
(Lead/Supportive) *
Make facilities accessible, affordable and FHD, TCIC, NHTC, MSI,
staffed with trained providers:
MSI, FPAN, NFCC,
 Ensure adequate supplies at all times NESOG, Other INGOs
 Provide need-based training to all
levels of providers
 Make rationale selection of sites to
ensure easy accessibility for the
target groups
Re-start/rejuvenate non-functioning
FHD (with support from
existing facilities:
NGOs, INGOs)
 Carry out monitoring visits to
identify the issues
 Design and implement appropriate
interventions
 Conduct regular supervision visits to
provide backstopping and other
support for these facilities to be
effectively providing services
Intensify awareness campaigns to dispel DHO, MOE, NHTC,
myths, fear of side-effects and other
FCHVs, FPAN, MSI,
barriers (shyness, issues of
NGOs, INGOs
privacy/confidentiality etc.):
 Carry out door-to-door visits
 Use media to intensify campaigns
 Review and update curricula
 Provide training/refresher for
counselors
 Ensure proper infrastructure for
privacy/confidentiality
Motivate and empower service providers FHD, DHO (with support
for quality service:
from NGOs, INGOs)
 Provide incentives and basic supplies
and facilities
 Upgrade infrastructure
 Carry out continuous training and
upgrading of their skills/knowledge
Facilitate services as per client’s choice: DHO
 Be open to and provide services as
per clients’ needs/choice
Ensure meeting needs of special target
FHD (with support from
groups:
NGOs, INGOs)
 Conduct research to identify
problems of unmet needs of special
groups
 Establish “adolescent corners” in all
facilities
58
Time Line
In 3 months
On-going
Within 3-6
months
In 6 months
3 months
6 months

3.
Provide need-based services to
clients for disadvantaged and
marginalized groups
Access and Quality of Services
Strategies and Actions
Continue to use the terminology (CACSAS):
 CAC terminology should be
continued, and safe abortion service
terminology needs to be used for
program purpose and IEC
messages, while the nature of care
is comprehensive and it covers not
only abortion but also provides care
for other existing reproductive
health needs such as for RTI, HIV,
FP.
Include safe abortion in the essential
health care package to waive cost
barrier (drugs and service charge) in the
government supported health facilities:
 Address cost barrier for women to
access safe abortion services
 Provide incentives to providers to
provide quality care
 Make arrangements for the
provision of safety net for poor
women even in the private health
sector
Review and formalize/approve the Safe
Abortion Policy:
 Components/aspects to be included
o Surgical abortion up to PHC
o Medical abortion up to SHP,
with functioning referral network
To ensure availability of services, allow
for
o Methods of choice
o Proper distribution of sites (DHO
to decide on distribution of
private sites together with private
partners)
o Provision of services 7
days/week
Include relevant drugs (MVA,
Mifepristone and Misoporostol) in
Responsibility
(Lead/Supportive) *
FHD
MOHP (Planning
Division), LMD,
Management Division,
EDPs
Time Line
Immediate
Within 6
months
Hospital Management
MOHP (Planning
Division)
Within 3
months
FHD
FHD, LMD
59
Within 3-6
months
essential drug list:
 Make arrangements for supply of
drugs (including those listed above)
and equipment though the health
system
Capacity building of FCHVs to inform DHO
women about CAC service availability
and cost:
 Create awareness on the availability
of services (time, cost, day etc.)
Make available skilled providers:
FHD, NHTC, DHO
 Provide regular updating and
refresher courses for providers
 Train ANMs for medical abortion
(MA)
Ensure client-friendly facilities:
Hospital Management
 Ensure facilities are functioning
(clean, privacy and confidentiality)
 Make sure that all components of
CAC are available
 Regularize recording and reporting
and referral system
 Authorize DHO to list/de-list sites
based on regular monitoring
4.
ASAP
3-6 months for
MA
On-going
Starting
immediately
Monitoring, Recording, and Reporting
Strategies and Actions
Strengthen monitoring of unsafe
abortions (facility and community
levels):
 Simplify listing process
 Support in expansion of listed sites
 Provide on-going training to
service providers
 Have regular communications
with social organizations
 Strengthen tracing of abortion
complications
 Conduct verbal autopsy about due
to unsafe abortion
 Review with media people
Implement mechanism for monitoring
of listed sites and providers:
 Create monitoring team to review
services of own site
 Conduct regular reviews using
external team (skill and logistics)
Responsibility
(Lead/Supportive) *
FHD, DHS, SOG, NHTC
Time Line
On-going
process
DHO, DPHO, RHCC,
Mothers’ Groups,
Women’s Cell (Police)
Starting
September
2008 regular
quarterly
reviews
Focal Person in individual Quarterly
institutions
DHO, FHD, Technical
Every 6
consultants
months
DHO and media persons
60
 Monitor service charges
Create and implement mechanism for
regular recording and reporting:
 Emphasize to staff on the
importance of proper recording for
HMIS
 Motivate staff to report regularly
 Conduct periodic review and
analysis
Individual Facility, FHD
DHO, HMIS
61
Quarterly