In July, a 28-year-old woman from Kavrepalanchok was rushed to Thapathali-based Paropakar Maternity and Women’s Hospital after she suffered a septic shock, a life-threatening condition that occurs when blood pressure drops to a critically low level after an infection.

Doctors who attended the patient said that the woman was bleeding profusely due to the misuse of a ‘medical abortion kit’—a series of pills that abort a pregnancy within nine weeks.

The woman was five-month pregnant and had taken medical abortion kit without consulting a doctor, according to Dr Shanti Shrestha, a consultant gynaecologist who attended the patient. “When she started to feel the movement of the fetus in her womb, her husband bought over-the-counter abortion pills,” Shrestha said.

Incidents like this are common among many Nepali women who use over-the-counter medical abortion pills and reach the stage of shock due to excessive bleeding and other health complications.

Abortions were legalised in Nepal in 2002, in a milestone for women’s reproductive rights, their empowerment, and their right to bodily autonomy. With legalisation, persecution and jail terms for women who terminated unwanted pregnancies stopped and unsafe abortions decreased dramatically.

Between 1996 and 2016, the maternal mortality rate fell from 539 to 239 per 100,000 live births, with the country achieving the Millennium Development Goal—a feat for which the legalisation of abortions played a significant role, doctors say.

Since then, however, the decline in rate has become stagnant, with conditions like sepsis shock posing serious challenges towards ensuring maternal health.

One of the major reasons behind that stasis in progress is misuse of abortion abortion pills, doctors say.

According to Shrestha, neither did the woman’s husband consulted the pharmacist about the right way to use abortion pills nor did the pharmacist think it necessary to inform him.

The woman continued to ingest one pill every day for five days, which, doctors say, is the wrong way to take it.

A 2021 study on ‘medical abortion kit dispensing practices of community pharmacies in Pokhara’ shows that pharmacy workers provide limited knowledge about the medicines to their clients.

Doctors say that for medical abortion, a pregnant woman has to take a pill called mifepristone first. Pregnancy needs a hormone called progesterone to grow normally. Mifepristone blocks the body’s own progesterone, thereby stopping the fetus from growing.

Then the woman has to use four tablets of the second medicine called misoprostol at once, either right away or up to 48 hours later. This medicine causes cramping and bleeding to empty the uterus. It’s kind of like having a really heavy, crampy period, and the process is very similar to an early miscarriage.

Due to the use of abortion pills in late pregnancy, the woman from Kavrepalanchok suffered from uterine rupture, which caused excessive bleeding. The woman was admitted to the hospital’s intensive care unit for seven days, transfused several pints of blood and treated in the general ward for another week.

“One must know that abortion pills can be used only for up to nine weeks of pregnancy,” Dr Jageshwor Gautam, an obstetrician and gyanaecologist, said. “The said medicine should be used under the supervision of trained health workers. Its misuse can be deadly.”

Doctors at the Maternity Hospital said that the woman from Kavrepalanchok already had three children and had used birth control shots in the past.

But when she suffered from some side effects of the shots, she stopped using it and her husband too did not think it necessary to use other means of contraception.

According to a recent UNFPA report on the “neglected crisis of unintended pregnancy”, half of the 1.2 million pregnancies in Nepal in 2017 were unintended and nearly 359,000 were aborted.

“Unintended pregnancy is a reality for millions each year, accounting for nearly half of all pregnancies,” the report reads. “Sixty percent of these unintended pregnancies will end in abortion.”

The report further stated that “the toll of these pregnancies is—and has long been—unseen.”

Nepal has to reduce maternal deaths to 116 per 100,000 births by 2022 to meet one of the UN Sustainable Development Goals. The country has already missed its own 2020 target to reduce maternal mortality to 125 per 100,000 births.

The health target under the SDGs is to reduce the maternal mortality rate to 75 for every 100,000 births by 2030.

Even as safe medical abortions are being contested globally as emblematic of women’s rights to reproductive health and bodily autonomy, doctors say some men are increasingly refusing to use other means of contraception and forcing their partners to undergo abortions.

“Despite the fact that over-the-counter medical abortion kits are illegal, authorities concerned have not bothered to regulate the trade and prevent their misuse,” Gautam said. “Due to the authorities’ indifference, the said medicine has been used as contraception, which is alarming.”

The UN agency report states that many unintended pregnancies occur because a woman has lost, or never had, autonomy over her own body. “Together, these numbers point unequivocally to persistent levels of gender discrimination and to deficits in human rights and development,” the report says. “These must be addressed to achieve the Sustainable Development Goals.”

Meanwhile, the Paropakar Maternity and Women’s Hospital said that it has been training auxiliary nurses midwives and staff nurses about the proper use of medical abortion kits.

Dr Amir Babu Shrestha, director at the Hospital, said, “In direction of the Ministry of Health and Population, we have been providing training to auxiliary nurse midwives and staff nurses about the proper use of medical abortion kits.”