Many Nepali women are in unsafe hands, as evidenced by the death of a 35-year-old woman while seeking an abortion at a local clinic in Dhangadi. No sooner had she died than people found out that the clinic was operating illegally. Every year, around 100,000 women have abortions in Nepal at legally-authorised clinics and health facilities; however, the actual number could be much higher, as many abortions are swept under the rug. Many illicit clinics could be running and taking women’s lives far from the government’s gaze.

The country legalised abortion in 2002, allowing women to terminate up to 12 weeks of pregnancy without any reason being sought, and up to 28 weeks in cases of rape, incest and health complications. Free first-trimester and second-trimester abortion practices were also initiated. The Health Ministry’s Safe Abortion Service Guideline doesn’t recognise private sector auxiliary nurse midwives as authorised persons to provide medical abortions as they are not trained as skilled birth attendants. Nepal allows trained auxiliary nurse midwives (ANMs) to provide medical abortion care up to 10 weeks gestation, even in rural health care centres. Staff nurses can do both manual vacuum aspiration (MVA) and medical abortion up to 10 weeks gestation, while MBBS doctors can perform MVA up to 12 weeks. But only obstetrician-gynaecologists and general practitioners are permitted to do second-trimester abortions (13-28 weeks).

But despite these provisions, unsafe abortions continue to add to the maternal mortality rate, which, according to a recent census, is 151 per 100,000 live births. Six percent of the total maternal deaths (37 women) had undergone abortions or suffered a miscarriage. What’s more, according to a 2016 study titled Abortion Incidence and Unintended Pregnancy in Nepal that used indirect estimation methods, more than 300,000 abortions were performed in Nepal in 2014, of which nearly 60 percent were illegal. The number is expected to have increased since.

The biggest hurdle to doing away with illegal abortions is lack of regulation and monitoring of such unlawful clinics. This calls for the government to investigate the mushrooming business of illegal abortion clinics, shutting and punishing them while also ensuring that healthcare centres, whether rural or urban, have adequate abortion facilities. Additionally, the local governments should keep an eye on established clinics in their areas. But lack of awareness remains a critical barrier to mitigating illegal abortion in Nepal. According to the country’s 2016 Demographic and Health Survey, only four in 10 women knew abortion is legal. So, legal awareness programmes on abortion law and how and where to get safe services are as important.

The World Health Organization recognises abortion as safe when carried out with care. Still, when women with unwanted pregnancies face barriers like lack of access to abortion services, awareness as well as social stigma associated with abortion, they fall prey to illegal clinics and unsafe abortion. Dhangadi’s harrowing incident is a reminder that Nepal’s fight against unsafe abortion is far from won, impeding the country’s progress towards securing abortion rights and achieving the target under the UN Sustainable Development Goals of reducing the maternal mortality rate to 75 deaths per 100,000 births by 2030. Abortion is every woman’s reproductive right, and making it safe is the state’s duty in a democratic and progressive society.