Safe abortion: a strategy that saves women's lives in Nepal

Wednesday, March 14, 2012

Champions of Nepal's abortion law reform and implementation were honored at a reception marking the 10th anniversary of the law.

On the 10th anniversary of the law that legalized abortion in Nepal, Ipas Nepal Director Dr. Indira Basnett sends her reflections on the impact the law has had for women and health in her country.

It was not so long ago in Nepal that a woman suspected of having an abortion could be arrested and thrown in prison, and that half of gynecological admissions in hospital were the result of back street abortions. But in 2002, the government, with a coalition of health, women’s and human rights advocates, took bold action to reduce maternal mortality by legalizing abortion.

On the 10th anniversary of this crucial vote in parliament, and the March for Gender Equality, it seems appropriate to take stock of what has been achieved: investment in safe abortion alongside a number of other safe motherhood strategies helped Nepal nearly halve the rate at which women die from pregnancy-related complications.

So how did we get here?

Before the law was changed, unsafe abortion had an extremely detrimental impact on the wellbeing of women and families. A UNICEF/government study estimated that 20 percent of all pregnancy deaths in 2000 were a result of unsafe abortion (the global average is 13 percent). Unsafe abortion caused more than half of all gynecological admissions in hospitals. And as if the health consequences weren’t sufficiently alarming, a 1997 survey found that 20 percent of all women in Nepal’s prisons were there on charges of abortion or infanticide. Clearly, illegal, unsafe abortions were tearing families apart.

In determining how to address this public health crisis, and then how to implement policy changes, the government has relied on public health evidence, human rights documents and the insights of experts from within government, and other national and international development partners. This collaboration not only led to a revolutionary new law (where women may seek abortion upon request for up to 12 weeks gestation, and under certain medical and legal conditions thereafter), but identified the best way to implement the law to have the most efficient and maximum effect for women.

For example, the Ministry of Health established a technical coalition to be a center for collaboration and discussion around abortion care, led by Family Health Division/Department of Health Services (DoHS) and technical assistance provided by Ipas, with the government setting standards and providing oversight. This has been the basis for development of a successful public-private partnership approach, engaging all stakeholders working for safe abortion, including public, private and NGO service providers, training institutions, communications experts and researchers. It also ensures that whether they seek service through a private doctor, or a government clinic, women should be receiving consistent quality of care.

As a result of these efforts, comprehensive abortion care — often including medical abortion (abortion with pills) — is available in all 75 districts throughout the country. The Ministry of Health has established more than 500 public and private sites throughout the country where women can go for safe abortion care. Thousands of doctors and nurses have been trained in safe abortion care by the training centers approved by the DoHS, and thousands of female health volunteers have been oriented to provide information and referrals for women needing reproductive health care including safe abortion at the village level. Approximately 500,000 women have received safe, legal abortion services, with few complications, contributing to a significant decrease in pregnancy-related deaths and injuries nationwide.

The commitment of the government to these efforts, and their successful outcome, is recognized in the international community as well: In 2010, was recognized by the United Nations for its commitment to and progress towards meeting Millennium Development Goal Five, reducing maternal mortality by 75 percent by 2015. 

The world can learn a great deal from Nepal’s experience. Recent research by Ipas has shown in countries where abortion law reform is followed by the implementation of safe abortion services with other reproductive health interventions, drops in unsafe abortion and related deaths should follow. While significant challenges remain in ensuring that all Nepali women can readily exercise their legal right to abortion, Nepal’s experience making high-quality abortion care widely accessible in a short period of time offers important lessons for other countries seeking to reduce maternal mortality and morbidity from unsafe abortion.