Dr. Prabin Shakya

The 28th of September is marked as International Safe Abortion Day. The day was first celebrated in 2015 when Nepal also started celebrating the National Safe Abortion Day on September 26.
The abortion law in Nepal grants the right to a legal abortion up to 12 weeks of gestation for any woman; up to 18 weeks of gestation in case of rape or incest; and 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 fetus is deformed and incompatible with life.

Services
Since the legalization of abortion, there has been significant progress in increasing access to safe abortion in the country. Comprehensive abortion care (manual vacuum aspiration-MVA) has been made available in all district hospitals and majority of primary healthcare centres. Additionally, second trimester abortion services have been made available in big hospitals where comprehensive emergency obstetrical and neonatal care services are also available, and medical abortion services are being expanded in majority of health posts. Moreover, the number of non-governmental and private hospitals is increasing to provide safe abortion services.

A total of 912 sites for MA, 604 sites for both MA and MVA and 22 sites for abortion in/after second trimester were listed in the country to provide safe abortion services till 2076/77 B.S. In 2076/77 B.S., about 88,000 women have received safe abortion services while nearly 96,000 women in 2075/76 and 99,000 in 2074/75 had received this service. This indicates that the reported number of safe abortions has decreased notably during the last two years. This could be largely due to COVID-19, resulting in national and local lockdowns, quarantine, travel bans and limited access to safe abortion services. Abortion is time dependent. Delayed access to safe abortion can p ose a risk to life and health. Therefore, it is more likely that there could be increase in both unsafe abortion and unwanted births during the ongoing pandemic. With the increased access to medical abortion services, there has been notable shift in choice of abortion service from surgical to medical. The use of medical abortion among the total safe abortion users is in increasing trend while the proportion of surgical abortion is showing a falling tendency.

Studies conducted at home and abroad show that many women face unwanted pregnancy due to limited access to family planning information and services. Nearly one-fourth of women of reproductive age reported to have unmet need of modern family planning services. Moreover, in 2076/77, more than 2,000 women and girls experienced rape who might seek for safe abortion services. In Nepal, abortion rate among women of reproductive age (15-49 years) is 42 per 1000 women. The Family Welfare Division of the Ministry of Health and Population estimated that more than half of the women who seek abortion services are going for clandestine abortion.

Those women who seek for safe abortion service, if cannot access this service in a timely way, are at a high risk of unsafe abortions clandestinely and abortion related complications, or in the worst case, suicide due to social pressure. Yet, unsafe abortion contributes to a significant proportion of maternal mortality and morbidity in Nepal. Nowadays, Nepal government is showing attention towards ensuring sexual and reproductive rights of women and young people, increasing access to sexual and reproductive health education, information and services for better health and wellbeing of them. Although 15 years have passed since the legalisation of abortion in the country, many women of reproductive age are still unaware of the legal provision for abortion.
Abortion services are safe when they are carried out by a skilled healthcare worker in a safe environment. Thus the obtainability of safe abortion upsurges the wellbeing and survival of women. Studies have shown that social cost of having abortion service is still high in Nepal because of its socio-cultural context. Stigmatisation of abortion exists at all levels from individual to community level, and service providers to policy makers. This has contributed to limiting the use of safe abortion practices. It is also reported that the use of abortion service is increasing for sex selective abortion and family planning.

Need of awareness
With abortion pills easily available, men are refusing to use condoms. Therefore, there is a need to control the misuse of abortion service for sex selective abortion and family planning. It is important to raise awareness on prevention of unwanted pregnancy; and to make safe abortion services available, accessible, and affordable to all women with unwanted pregnancies, to ensure better utilisation of safe abortion service for their better health and wellbeing. Repeated abortion can be harmful, increasing health and economic consequences, and obstructing career development opportunities and wellbeing. To avoid repeated safe abortion, it is vital to provide counselling on post-abortion contraceptive methods. Increased awareness on family planning and access to family planning services reduces the unwanted pregnancy. Therefore, it is essential to make both family planning and abortion services qualitative and effective across the country.

Safe abortion should be recognised as essential healthcare without any discrimination and stigmatisation, respecting sexual and reproductive rights of women. Once the safe abortion is easily accessible to all women and girls, there would be no more clandestine abortions.