(c) Mark Schlossman, Panos Pictures

In a mountainous and largely rural country like Nepal, medical abortion has the power to greatly expand access to safe abortion care  —  a leading cause of maternal death in that country.  Now, as the government moves from a centuries-old monarchy to a democratic republic, the government has announced an ambitious plan to bring medical abortion into Nepal. The move comes more than five years after abortion was legalized, and is the latest in a succession of efforts to implement that historic law.

Reaching poor, underserved women, especially those living in difficult-to-reach rural communities, is a major focus of this plan, announced April 29 at an Ipas-supported, national workshop held by the Ministry of Health and Department of Health Services. National and international partners including Gynuity Health Projects and Nepal’s Center for Research on Environmental Health and Population Activities are also committed to implementing the new government policy.

The plan will bring medical abortion to the primary health-care and community level throughout Nepal, where women are more likely to seek health care. Nepal will be the first country to introduce Medabon®, a combination of mifepristone and misoprostol specifically packaged for use in abortion care. The Nepalese government will train midlevel providers (such as nurse midwives), as well as doctors, to counsel women and provide medical abortion.

Medical abortion involves use of pharmacologic agents, such as mifepristone and misoprostol, to expel the contents of the uterus. Used together, these medications stimulate uterine contractions and cause expulsion of the pregnancy.

Medical abortion not only provides women with more choice, but it will also greatly increase access to safe services,” said Indira Basnett, director of Ipas Nepal. “Even after legalization, many women cannot reach services. Because medical abortion does not require many resources, it could be a sustainable solution for providing these women with safe abortioncare.”

The government will introduce medical abortion as a pilot project, while it develops sustainable systems in training, logistics, supply and monitoring, and develops a system for using manual vacuum aspiration (MVA) as a backup for incomplete abortion (although medical abortion is almost always successful, it is important that health-care providers be able to refer to patients in those cases when the procedure is not successful.)

“I believe that women should have the reproductive right to decide when to get pregnant, how many children they want and whether to give birth or not,” said State Minister of Health and Population and workshop leader Sashi Shrestha. “Women should also be able to choose surgical or medical methods for abortion based onthe information and benefits they see.”

Abortions in Nepal were illegal until 2002, when the government changed the law to allow qualified and authorized health workers to terminate pregnancies. The Technical Committee for the Implementation of Comprehensive Abortion Care (TCIC) was formed in February 2002 to plan the safe abortion program under the Family Health Division; Ipas serves as the technical lead to support the TCIC and its partners.

Ipas Nepal began training health-care providers in comprehensive abortion care in 2004. As a result, four years later>approximately 160,000 women have been served in public and private facilities; nearly 500 providers, including nurses, have been trained; and 74 out of 75 districts have at least one trained provider. But despite these successes, many poor, rural women still cannot access safe abortion services.

Medical abortion is a safe, effective means of terminating a pregnancy. The World Health Organization recommends the combined use of misoprostol and mifepristone as a safe, effective method for termination in the first nine weeks of pregnancy. With its low cost and ease of use, along with a government commitment to its dissemination, medical abortion has the potential to extend safe abortion care to many underserved women.

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