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In 2002, Nepal changed its civil code to legally permit abortion, largely in response to deaths and injuries from unsafe abortion. The first comprehensive abortion care service was offered in Kathmandu, in 2004 and now comprehensive abortion care is available in all 75 districts through 331 listed safe abortion sites throughout the country.
Despite remarkable progress and the availability of legal and safe abortion services, unsafe abortion remains an issue. Safe abortion services are mainly confined to cities and district headquarters, so women in rural and remote areas face myriad barriers — physical, informational and financial. According to the Nepal Maternal Mortality and Morbidity Study 2008/09, abortion (induced and spontaneous) is the third highest direct cause of maternal mortality, constituting nearly 14 percent of hospital deaths.
A unique program seeks to remove the barriers to safe abortion for rural women, using well-respected female community health volunteers (FCHVs). The Nepali government began training health extension workers decades ago. Now there are more than 48,000 FCHVs working all over the country. The volunteers support a number of health outreach programs, including immunization, prenatal and neonatal care. FCHVs “are of the community, they know the languages,” says Rishi Parajuli, Ipas Nepal medical abortion manager. “Why not train them in giving information about safe abortion care?” he and others at Ipas asked.
In January 2009, the idea became reality. With the purpose of early identification of pregnancy, Ipas and the Family Health Division of the Nepal Ministry of Health developed a two-day orientation for more than 1,500 FCHVs in six districts (Jhapa, Tanahun, Dhading, Surkhet, Kailali and Chitwan). The program consists of several important topics, including:
- The legal conditions for safe abortion service
- Consequences of unsafe abortion
- How to refer for reproductive health-care services (mainly for antenatal care, family planning and safe abortion services)
- Names and locations of comprehensive abortion care (CAC) sites
- Cost for CAC services
- Techniques for performing urine pregnancy tests (UPT)
- Available contraceptive methods (condom, oral pills, injectables, Norplant, IUCDs and sterilization)
- Introduction to emergency contraception
“Based on women’s needs and desires, the FCHVs refer for various reproductive health services, including safe abortion,” says Parajuli.
According to an initial evaluation of the program released last month, the results are encouraging. Training given to the FCHVs in the six pilot districts increased the access to and use of reproductive health services. FCHVs developed the capacity to test for early pregnancy, and women were able to make timely and informed decisions based on their reproductive needs.
According to one FCHV in Kailali: “After this training, our village women are taking safe abortion service from the government-approved sites. Earlier, they used to abort clandestinely, risking their life and health and spending a lot of money. Now they know many things about it. They go and take safe abortion services at listed sites and also advise others for the same.”
“After the orientation to the FCHVs on reproductive health referrals, the number of referred cases coming to our center has increased. In my experience, the FCHVs have provided good counseling to the referred cases, on both the options of abortion; medical and surgical,” reports a staff person at a Marie Stopes clinic in Gajuri, Dhading.
Part of the program’s success comes from the respect for FCHVs in communities. “These women are very trusted and are chosen by the women of their communities,” says Parajuli. “They don’t get paid but their motivation is to help women, teach them skills and increase their knowledge. They really empower other women in the community,” he adds.
For more information, contact media@ipas.org