Dr. Shyam P Lohani

Although many countries have some severe restrictions or penalties to control unsafe abortions, such abortions are being carried out unabated. This shows that laws alone cannot help end unsafe abortions. Every day almost 70,000 unsafe abortions are carried out globally, mainly in countries with strict laws. Every woman has the rights to good reproductive care and safer pregnancy. Good public health policy supported by ethical medical practice is critical for a safer pregnancy and contributes to decreasing mortality and morbidity rates resulting from unsafe pregnancies in countries where they remain high.
Unplanned and unwanted pregnancies are a global public health concern. Parallel to the decline of the fertility rate, the desire to control and space births have increased faster than contraceptive use. Once a couple decides they want fewer children, they use a combination of approaches that include modern or traditional methods of contraception and abortion. Induced abortion also has contributed to fertility decline along with increased prevalence of contraceptive use over the last couple of decades.
Situation
The effectiveness of methods of contraception and the extent of its use definitely have influences on abortion rates. However, every contraceptive method has limitations even with consistent and correct use. Nowadays, there is a longer duration for a woman to have unwanted pregnancy due to earlier menarche and age at marriage. The rate of abortions, thus, greatly depends on the access to quality family planning services for reproductive-age women, particularly single and young ones.
Between 2015 and 2019, 73.3 million induced abortions, both safe and unsafe, occurred every year throughout the world. Of abortions carried out between 2010 and 2014, almost 45 per cent (25 million) were unsafe and majorities (97 per cent) were carried out in developing countries (WHO, 2020). Similarly, estimates show that up to 13 per cent of all maternal mortality is attributed to unsafe abortions. However, in some countries, the mortality rate due to unsafe abortions is much higher but unplanned pregnancies and abortions occur even in those countries where contraceptive prevalence is very high.
In 2014, more than 300,000 abortions were performed in Nepal. Of them, about 60 per cent were carried mainly by untrained or unregistered providers or self-induced and considered unsafe (Puri et. al, 2016). Medically unsafe abortion procedures, lack of trained abortion providers, restrictive abortion-related laws, and high mortality and morbidity from abortion tend to occur together and cause millions of preventable deaths worldwide every year.
Nepal has legalised abortions since 2002. Now safe abortion is available in government-approved public and private health facilities throughout the country. Nevertheless, significant proportions of women still find difficulties in obtaining legal abortion services, and unsafe abortions are rampant across the country. The unsafe abortions are carried out not only by untrained providers but also in unsanitary conditions.
In Nepal, safe abortions are available up to 12 weeks' gestation on the consent of pregnant women, up to 28 weeks' gestation in cases of rape or incest, as per the consent of pregnant women, and after the opinion of the licensed practitioner that there may be a danger in the life of the pregnant woman or her physical or mental health may deteriorate or disabled infant may be born in case the abortion is not performed (The Rights to Safe Motherhood and Reproductive Health Act, 2018).
It is both safe for women’s health and less complicated for the provider if abortion takes place earlier, preferably in the first trimester. Hence, regulations that tend to delay the safe abortion procedure should be avoided on public health grounds. Regulations such as putting the abortion decision into the hands of people other than the pregnant woman herself, and the waiting period in between obtaining permission and performing an abortion delay safe abortion.
In countries where safe abortions are the normal costume, a large majority (90 per cent) of women have abortions in the first trimester of pregnancy. Still, early marriage, poor education, an inadequate number of trained providers, and unavailability of services are barriers to safe abortion practices in developing countries. About 10 per cent of abortions worldwide take place at or after 13 weeks of gestation. Lack of access to early care, late recognition of symptoms of pregnancy, adolescence, and poverty, lack of awareness of abortion laws, substance use, and fear of stigma, fetal anomalies, and maternal medical status are risk factors for a second-trimester abortion.
Requirements mandated by the Government of Nepal for facilities providing second-trimester abortions have contributed to the slow scale-up. These regulations call for certain resources to be made available that includes 24 hours of comprehensive emergency obstetric and neonatal care, a functional operating room, blood transfusion services, and obstetric providers capable of providing cesarean sections. On the contrary, international safe abortion guidelines state that second-trimester abortions can be safely provided in both hospital and outpatient clinic settings provided these facilities are properly equipped and have clear referral mechanisms in case of emergencies. So, there is need to update the requirements urgently.
The introduction of second-trimester abortions has raised concerns around sex-selective abortion. The reasons for sex-selective abortion are multifaceted. Gender discrimination deeply rooted in society mingled with religious beliefs that value men more than women are drivers for sex-selective abortions in developing countries.
Additionally, the dowry system in Nepal forces economic hardships on parents who have daughters. In Nepal, the law unequivocally prohibits abortion with sex selection and restricts the use of technology to determine fetal sex. However, this law is poorly enforced due to increased access to ultrasound services and a higher prevalence of routine ultrasonography during antenatal care.

Massive awareness
Higher abortion rates may be the result of increased use of condoms instead of more efficacious contraceptive methods by people who need double protection from sexually transmitted diseases and unwanted pregnancy. Therefore, a massive countrywide advocacy and awareness campaign on more effective contraceptive use and safe sex, rights to safe abortion, and campaign against dowry system should be planned and implemented.

(A Professor, Lohani is the founder and academic director at Nobel College. lohanis@gmail.com)