Unsafe abortion practices posing high risk to rural women
By Gita Sapkota
Kathmandu, Oct. 29: Til Kumari Rai, 39, a resident of Khotang and mother of seven children, died at the Khotang district hospital a month-and-a-half ago due to complications during an abortion. Rai had aborted her ninth pregnancy at the district hospital on August 31.
Doctors called her for a re-abortion the next day due to incompleteness. The following day, however, doctors referred her to Kathmandu for further treatment as she suffered from peritonitis, a hole in the uterine, in the course of the process. Unfortunately, she breathed her last on September 4 at the hospital.
Similarly, Yam Kumari Gaha, died at the mid-western regional hospital in Birendranagar due to excessive bleeding as a result of rampant use of abortion medication.
Such incidents are not new in the country as dozens of young women in the remote and far-flung areas of the nation die annually due to complications related to unsafe abortion practice or in the absence of post-abortion care.
Safe abortion practices are still rare in the remote districts. As there is a lack of proper medical facilities for safe abortion, many pregnant women go for unsafe abortion even if the risk to their lives is high.
Safe abortion became legal in Nepal in 2002, and services have been available in the maternity hospitals since 2004.
According to the Health Ministry, about 900,000 women have benefitted from safe abortion services so far since then. This has saved many lives of women. This year alone, 80,000 women benefited from safe abortion services.
According to a national study, 25 per cent of the pregnancies are still unplanned in Nepal, and only 38 per cent women know that abortion is now legal. Knowledge that it is legal is very low among illiterates and rural denizens.
A total of 809 health facilities across the country, including government, NGO and private run institutions, have been listed for safe abortion.
As per the abortion law, only trained doctors, nurses and health workers can provide abortion services at the approved and listed health facilities with the consent of the pregnant women.
About 700,000 Nepalese women get pregnant every year. About 200,000 of these pregnancies are termed unplanned, unintended and unwanted.
In Nepal, the reasons behind unintended pregnancies and low use of contraception are fear of side effects, lack of access to preferred methods, failure of contraceptives, restraint by the husband and family, sexual inequality in some cultures and the lack of women’s autonomy, says Prabhakar Shrestha senior advocacy and training officer at the CREPHA.
Dr. Silu Aryal of the Maternity Hospital said that although women were afraid to use contraceptives, they went more readily for an abortion.
Sharing her experience she said she had come across many women who had come to terminate their pregnancies even seven or more times in her clinic.
Of the total, about 80,000 women go to approved health facilities or clinics for an abortion. This means about two-thirds of the needy women still go to the non-listed clinics and terminate their pregnancies unsafely, said Pramish Thapa, director of the Safe Abortion Programme at the Family Planning Association.
Thapa said the government should list more clinics in the remote areas to ensure safe abortion services (SAS) to the needy people.
Human Rights Committees, CEDAW and Rights of the Child committees have declared unsafe abortion as a violation of women’s rights to health and life.
As Nepal is a signatory country to different international declarations on fulfilling the reproductive rights of women, and the Constitution of Nepal has provisioned reproductive health rights as a fundamental human right, the health system must train and equip health service providers and take other measures to ensure that abortion is safe and accessible, Thapa said.
Challenges for SAS in Nepal are said to be high abortion fees, unskilled clandestine providers within and across the border that continue to exploit ignorant women, SAS delivery schedules, especially at the government facilities, not being women-centred, and frequent transfer of doctors and trained SAS providers.
"One had to pay Rs. 1,000 for the service in the listed health facilities. However, from this year, the government has made the services totally free," said Dr. Jhalak Sharma, chief of the Safe Abortion Programme under the Department of Family Health Division.
The government is also planning to provide training to more health workers, he said.
As there is a lack of listed sites in the remote areas of the nation, the government should reach those who are excluded by the services, he said.
An estimated 22 million unsafe abortions occur every year worldwide. Nearly all unsafe abortions - 98 per cent - occur in the developing countries. About 13
per cent of the pregnancy-related deaths are due to complications of unsafe abortion, according to a report of WHO in 2012.
Before abortion was made legal in Nepal, about 54 per cent of gynecological and obstetric admissions in hospitals were for complications during abortion, and 20 per cent of the maternal deaths in the health facilities resulted from complications of abortion.