Poverty and lack of awareness and access forcing many to resort to unsafe abortionEven 19 years after legalisation, women’s struggle for safe abortion continues. As a result, they put their health at risk and are unable to exercise their rights, experts say.
For months last year, Mina waited for the Covid-19 induced lockdown to end with bated breath.
When the government finally eased months of lockdown in July, Mina, whose name has been changed to protect her identity, was all set to run away from her home.
Mina had her own simple reason—she did not want to have the child she was carrying.
“Both of us were unemployed,” said Mina, who had got married a few months before the country went into the lockdown. “What would we eat if we added another member to our family? But my husband told me that I could not throw his baby. We fought terribly over what to do with the baby in my womb. Running away was the only option I could see.”
When Mina, an underage girl from Sindhuli, discovered her unwanted pregnancy, she quickly went for the abortion pills on her sister’s advice. But they didn’t work.
So she had to visit the hospital—not an easy thing to do.
The bus stop was a two-hour walk from her home. Then it was another few hours to the district headquarters where the hospital is. The journey was an arduous one, both physically and mentally. All she had with her was Rs1,000.
“I understand my husband did not have the money to take me to hospital. But he could have just supported me. But he was not willing to listen to me,” said Mina. “I had to borrow some money with my sister.”
Mina ran away from her husband and the family. She has not returned since then.
It’s 19 years since abortion was legalised in the country. But for many women in rural areas, the process of abortion still costs a lot. Sometimes even conjugal life.
Poverty and not having a medical facility nearby adds complications to the plans of aborting and women and girls resort to unhealthy and unsafe practices.
Many may end up taking abortion medication without even consulting with the doctor which can lead to various health complications like bleeding, bladder injury, bowel injury and uterine perforation which might result in injury to major blood vessels in future.
Mina also experienced such complications.
“I had a bleeding problem, which doctor said was because of the abortion kit, a pill that can abort a pregnancy after nine weeks,” she said. “I have been staying at my sister’s home since then. I have not completely recovered and I am taking medicines. I had an abortion to reduce my husband’s burden, but I do not have him with me now.”
Mina is also left with a loan to pay.
“I don’t know how I will pay that,” she said.
With fraught emotions and suffering in silence, women are still struggling to reach health centres to consult with trained workers and get proper counselling on abortion.
Clause 3 (5) of the The Right to Safe Motherhood and Reproductive Health Act, 2018 says, “Every woman shall have the right to obtain abortion” and Clause 3 (2) says “Every person shall have the right to obtain service, counselling and information relating to reproductive health.”
Nepal legalised abortion in 2002 from various facilities registered with the Health Ministry. Until 2002 abortion in Nepal was prohibited even when pregnancies resulted from rape.
Following a 2009 order of the Supreme Court to make abortion services accessible to all women, the government expanded the services extensively.
“Abortions are free at governmnet clinics, which have helped hundreds of women for safe abortions,” said Dr Punya Poudel, chief of Safe Motherhood Programme at the Family Welfare Division under the Department of Health Services.
The Ministry of Health and Population could not provide data on the number of abortions that take place in the country every year.
Estimates from different sources vary widely.
According to the Guttmacher Institute, a research and policy organisation committed to advancing sexual and reproductive health and rights based in the United States, an estimated 323,000 abortions were performed in Nepal in 2014.
Similarly, according to Centre for Research on Environment Health and Population Activities, a Kathmandu-based non-governmental organisation, between 2002 and 2017, almost 1 million women received safe abortion services.
As per The Right to Safe Motherhood and Reproductive Health Act, 2018, abortion is permitted up to 12 weeks of gestational age on the request of the pregnant women, up to 18 weeks of gestational age in the case of rape or incest and at any gestational age if the pregnancy is detrimental to the woman’s health and life or if there is foetal impairment.
But in most of Nepal, women still consider abortion illegal and end up having unsafe abortions.
According to the Demographic and Health Survey-2016, only four in ten women are aware abortion is legal in Nepal.
Social stigma and lack of awareness remain the main reasons behind unsafe abortions, according to Hima Mishra, a helpline manager at the Meri Saathi Contact Centre, a call centre opreated to provide reproductive health related information by Marie Stopes Nepal, an international charity that specialises in safe abortion services, contraception and family planning services across Nepal. Headquartered in London, Marie Stopes works in 37 countries and has 27 centres in 23 districts of Nepal.
“The main reason for unsafe abortion is stigma and lack of awareness. Hundreds of people from poor backgrounds visit Marie Stopes for abortion,” said Mishra. “But, in most cases, they come after taking pills and practising unsafe methods. That worries us sometimes.”
While the situation might seem worse for poor, underaged and newly married ones like Mina, it is not any easier for women who have been married for a long time.
Gita, 37, who wanted a pseudonym to be used, has her own struggles to recount.
Gita, from a rural area of Sindhuli, wanted abortion after her husband had left for foreign employment. Working as a maid, she faced difficulties feeding her four children. She didn’t want to add another child in her life.
“I decided to have an abortion, but I couldn’t do it on time,” said Gita. “When I visited the health post nearby, they couldn’t help me and I couldn’t leave my children and visit the district hospital as I was advised.”
Bindeshor Shah, in charge of the health post that Gita visited, said the health facility did not have any medication to help those like her.
“About 40 percent of women who visit us come with various reproductive health related problems and most of them with abortion issues,” said Shah. “We ask them to visit the district hospital or Marie Stopes in Lahan.”
According to Shah, women come to the health post asking for abortion when it’s already too late.
Mishra, the helpline manager, says they receive more than 3,000 calls per month and nearly 16 percent are inquiries related to abortions.
Of total calls, Meri Saathi receives,53 percent are youths and adolescents.
On the other side of the phone calls are mostly scared voices, reflecting the unease and fear of even discussing the matter.
“When they call they sound hesitant and scared as if others will hear about abortions. At such moments we counsel them saying that it's not a crime to have an abortion,” said Mishra. “We assure them that it’s legal and they can talk freely. Then they react strangely and ask us questions. This clearly shows that despite 19 years of legalisation, people are still not aware of these things.”
According to the Nepal Demographic and Health Survey-2016, common barriers to accessing safe abortions are getting permission to go to the doctors, getting money for advice or treatment, distance to a health facility and not wanting to go alone.
To mitigate the problem, the government in 2016 announced free safe abortion services from government health insitutions along with with free family planning services.
“The government has been conducting policy dialogue with the health agencies at the provincial level to reduce all those maternal health related problems,” said Paudel of the government’s Safe Motherhood Programme.
But the government schemes on promoting safe abortions seem not to be working on the ground.
“Patients from various rural areas visit hospitals in critical conditions with internal injuries,” Dr Shresyashi Aryal, assistant professor of obstetrics and gynaecology at Lumbini Medical College in Palpa, told the Post over the phone.
Aryal recalled a case she had recently dealt with.
A few months back, a 19-year-old from Gulmi, who underwent an abortion at a small hospital in Gulmi, reached her with injuries in uterus and the intestines.
“We had to perform a major surgery on both organs. She was referred on time therefore she could be safe. But this cannot happen most of the time due to difficulties of transportation services,” said Aryal. “Such things happen when patients have a little knowledge about abortions and try to use various abortion kits on their own.”
A study conducted by the Centre for Research on Environment Health and Population Activities in 2014 found that that only 42 percent of the women who had abortions chose safe abortions while the rest went to unregistered health institutions and health workers.
Experts in the field promoting safer abortions emphasise making girls and women aware of abortions and contraceptions so that they do not have to go through an ordeal which can even cost their lives.
“Only awareness and collaboration among different agencies for promoting safer abortions can reduce this problem. We are still lagging behind in providing them with a clear education regarding abortion and all the kind of reproductive health issues,” said Mishra. “It is good to have abortion for unwanted pregnancies, but it’s better to be aware of contraception beforehand, which people lack.”
According to Meera Dhungana, president of Forum for Women, Law and Development, a non-government organisation advocating the rights of women, even if abortion is legal, the barriers to accessing safe abortions exist at many levels.
"The law ensures that women have the right to abortion, but this cannot always happen due to socio-economic conditions, lack of general awareness as many women in Nepal still hesitate to come out and exercise their rights," Dhungana said.
Meanwhile, Mina, who thought abortion was illegal and everyone would ostracise her for having an abortion, does not regret the decision.
“Despite losing my husband and everything, I am happy that I did what I had to do in the right time despite the pressure of the loan I have to pay now,” she said.
Meri Saathi free helpline number: 1143 from 7:00 am to 12:00 pm.