Despite the fact that abortion has been legalized in Nepal since 2002, the number of unsafe and illegal procedures remains dreadfully high. The main reasons being: a lack of awareness and an unfamous cultural shame. For a country that has 50% unwanted pregnancies, this is a large scale sanitary crisis.

“We [Nepali] have different mentalities about health care. We never think about tomorrow which is really bad. We all need to think about it now and act.” A Volunteer from awareness programs in remote areas.

Good News travels Slow

Marie Stopes Nurse

“Abortion legalization [in Nepal] has contributed to a sharp decline in maternal mortality, which fell from 580 maternal deaths per 100,000 live births in 1995 to 190 per 100,000 in 2013.” World Health Organization (WHO) in 2014.

More recent statistics delivered by Marie Stopes International NGO, reveal that adverted Maternal deaths keep positively increasing in Nepal. Especially between 2015 and 2017, during which the annual number of women saved from a deadly pregnancy outcome went from 295 to 315.

Nowadays, the previous progression of these life-threatening situations is slowing down, not by lack of efforts, but illustrating the strong effectiveness advancements in prevention operations have.

Indeed, according to the NGO’s numbers, in 2017, 174 000 Unintended pregnancies, and 135 000 unsafe abortions were avoided thanks to better guidance and patients monitoring.

The NGO Marie Stopes has thirty-six clinics and on-field facilities distributed in thirty-two districts of Nepal with programs such as MS Ladies and LARC Team. And there are not the only ones dispatched across seventy-seven total dividing the country. A handful of other NGOs also settled themselves in Nepal to fight back the alarming phenomenon of unsafe and illegal abortions. UNFPA is among the few that can be listed.

All of them, use numerous means and deploy lots of efforts in order to take action against unawareness, and offer a legal and safe treatment to every woman having to go through an abortion protocol.

Yet, many factors of complication lead to a remaining dangerously high number of unsafe and illegal procedures (somewhere around 45 and 50% of abortions are not done “properly”).

In this article, we will try and understand why interrupting an early pregnancy is still a national health issue and what solutions are already available for the public.

“It’s legal but it’s illegal”

Nepal Snehi Kaakha. In this article, the black line used on pictures of women from care centers is used to protect the identity of persons not mentally or physically capable of giving consent to the use of their own image.

When I asked a Nepali social worker woman about the legal status of abortion, the previous titling quote “it’s legal but it’s illegal” is what she replied to me.

What she meant by that statement, is that there are two forms of laws in deeply traditionally influenced modern cultures: The State’s present juridical measures, and the historical local usages.

Even in a modern democratic country like Nepal, some ancient beliefs still overcome the most logical, ethical, and universal rules of human conduct put in place to ensure equality and safety to all its citizens.

In pursuance of answers to my delicate following questions:

Why, in our present time and age, women are still scared, harmed, and dying on such a shockingly high scale when having to turn towards an abortion protocol? 

and,

Why do women find it so hard to go through safe and legal procedures?

I directly went to the main supporting actors of this crisis: NGO’s.

These very important and powerful players are in a particular position giving them a broader view on the general aspect of our subject, along with a deeper knowledge of the facts and numbers used to describe it. Their sole purpose is to take over on a local level global humanitarian problems and development programs, where government left them after failing to answer or simply ignoring them.

External Relations Teams (ERT) Satyajit Pradhan and Ursula Utsaha Singh, gave me the following enlightenment to share :

“The overview of the market is quite simple. [First, there are all] the barriers a woman has to go through: There is the gender bias, the social bias, the cultural bias, the family pressure, the age bias, the marital status bias… (5)”

“Now, somehow, she finds herself pregnant. Married, unmarried, it doesn’t matter, the age bias doesn’t matter [at this point]. Maybe, she and her partner didn’t want to get pregnant, and she decides it is unwanted. The option she now has is to get an abortion.” (ERT)

But before the abortion,

• First, She may or may not know about the legality status (1).
• Second, she may not know how to get the abortion product (4).
• The last factors are affordability (2) and the importance of confidentiality (3).

Let us explore more thoroughly these different obstacles (1,2,3,4,5) a woman has to overcome before having access to a safe and legal procedure in Nepal.

Picture took in a care center offering shelter to women in need. Most of them were victims of unsafe abortions, or unwanted pregnancies, which resulted in horrible outcomes for them and their lost, taken from them or abandoned children. Only a few still have direct contact with them. Children also become victims. Recently, in that center, a 2-month baby was saved after being found in a dumpster.

1- Not knowing its legal

Many Women, mostly in remote rural areas, are still not aware the law is on their side.

Despite what surroundings say, it is crucial for ladies to understand and keep in mind the following truth:

No one can force a woman to have or don’t have a procedure. Legal ways are numerous, affordable, and at reach, if needed.

Ignoring these facts often result in the following actions:

“She might try and go in The Back Alleys, thinking its illegal. And she is compromising her health for it.” (ERT)

The back alleys is a figure of speech to describe the black market trafficking of fake tomorrow pills, illegal treatments, and fake doctors chirurgical interventions. Some women go to these extremes because they are afraid they might be jailed for just wanting to have an abortion, thus, wrongly thinking its illegal.

Ironic isn’t it? Doing something illegal because of not knowing it isn’t in the first place.

There are more than 26 illegal (mostly Indian) abortion products on the black market.

Dangerous drugs that come with no World Health Organizations or the National Department of Health approval. But also, no notice on how to perform the treatment by yourself.

Consequently, the use of this drug often results in failed abortion or complications that can lead to lethal consequences.

Clandestine procedures provided by untrained or unapproved providers, or induced by the pregnant woman herself, were still more popular than the legal procedures in 2014, as  58% of abortions were done this way.

If we add up and summarize all the data cited since the beginning of this investigation, we discover that these last years more than 25% of pregnancies in Nepal result in unsafe and illegal abortion.

That is 6 Nepali people out of 1 000 per year, who are directly concerned.

2- The price range :

Statue of a woman made out of pills in Marie Stopes International offices.

“Most of the unsafe providers charge more than any of us in the legal business would do.” (ERT)

On the Black market, an abortion pill can sometimes up to 25 000 rupees.

“This drug probably accounts for 40% of the market. Second rate medicines sold for premium prices 10, 20 thousand rupees. It’s money made on desperation.” (ERT)

On the contrary, the affordability of legal procedures offered by NGOs is calculated to be in reach for any financial background.

It is difficult to share a proper description of the price range suggested by the organizations, as it depends on numerous factors according to the steps required by one’s procedure. However, I can ensure it remains cheaper, safer and more effective than illegal methods.

“There is still 27 restricted drugs that are on the market, mainly coming from India. Coming in through backpacks and questionable storage units, no quality control.” (ERT)

3-  The aspect of confidentiality:

“If I go here no one will ever know”.

“Places like Marie Stopes, a woman might wrongly think people will question her: It is an international NGO they might sell my information. They might call me back. Which is false” (ERT)

Confidentiality is the most important promise made by NGOs.

A safe environment for women to feel safe is their number one priority to invert the numbers of unsafe abortion techniques. Also, confidentiality is a decisive aspect due to the shame or disapproval surrounding the practice. Some women have to travel for days across the country to find a place where nobody can recognize her face and spread the rumor.

But we will dig deeper into the subject shortly (5).

4- What abortion options do a woman have?

“Her options are a medical or a chirurgical abortion”

This needs to be explained properly because time is the variable.

Before 8 weeks of pregnancy, it is acceptable to give medication or go through surgery. It can be argued for up to twelve weeks. And passed the issue date, “they will most likely go in the back alleys”.

“Most of the time, only knowing this, women will not go to a clinic but a pharmacy to do it themselves.” (ERT)

Which also represents a risk if the pharmacist doesn’t explain to you properly the procedure.

Not knowing about or how to take the product

“We (Marie Stopes) go through a lot of pain to ensure the information for the proper intake of the drug is there. Because it’s a timed process, and it works better in certain ways.

“There are some complications you have to accept as well. Some women panic because there is blood when its just part of the process.”

“I don’t have a problem with women going to the pharmacy and doing it themselves. I have a problem with the fact the pharmacy may overcharge them, may not provide them with proper counseling. They may take the drug the wrong way, it usually resolves in a failed abortion. So we have to deal with complications at our end. (hospitals, government). In Nepal, there are 4 legal [products] that are authorized.  We have Medabon, MTP kit, preggo kit, and Mariprist which is our own brand.”

“All of these things go through strict quality regulation. When it fails, its when the pharmacist takes it out the package and just hands it to the women, which is what the woman wants, as far as the confidentiality goes. and then the women don’t know how to take it.”

“So studies show it not about the drug but how she takes it.” (ERT)

5- So, what does unsafe abortion techniques means and why turn towards them?

“There are many unsafe abortion techniques. In many rural areas, there are herbal treatments, such as papaya leaves, that don’t necessarily work and can cause a lot of harm. Quack doctors that actually perform the abortion themselves. ” (ERT)

A remote and therefore undocumented issue. But at least are there police investigations?

“No, they are cases where woman have died because of unsafe abortion, but they don’t even document or report it. We advocate for the government to do more about it” (ERT)

Nepali Culture and the taboo subject of Abortion

Women and children celebrating the new year in a remote village, Center of Nepal.

The federal democratic republic of Nepal is a country of diversity. Numerous languages, traditions, and religion are dispatched in the challenging landscapes it has to offer. But the Hindu belief is clearly the most popular among its inhabitants, as no less than 87% of the population follow its guidance and sacred practices.

Why am I reminding you of this fact? For the simple reason, that cultural bias plays an important role in illegal and unsafe abortion. As much as it makes it a taboo.

In 3 different classic Hindu texts, it is compared to the murder of a priest, a parent, and can also lead to a cast ban.  In remote villages, religion is a form of education more spread than basic biology. It is also the reason a lot of women try and hide by any means their unwanted pregnancy.

However, it is also said in these holy writings, that all life is sacred, and preserving life is a priority. So, putting a life at risk for an illegal procedure is by definition worst according to Hinduism than doing it in a safe environment. An observation made by many blogs on the subject.

Finally, religions evolve as societies do. Sex-selective abortion, guided by the desire to have a son, is not only illegal (Because knowing the sex of the child means it is too late for a procedure) but a very popular practice in Hindu countries. Why would a woman feel ashamed for doing a legal, safe, early, costless, abortion, and another feel none for doing the opposite? In here lies the fine line beliefs draw between right and wrong

At this point, the family and especially the husband intervenes. Because above religion, culture, and law, there is the opinion of relatives.

For example, I was told a story that took place in Kathmandu. A man, so afraid his girlfriend would get pregnant, fed here with “emergency contraceptive pills” after every sexual intercourse they had. Because he didn’t want to protect himself and at the same time never wanted to go through the shame of abortion.

More than 2 of these pills in a lifetime can have disastrous effects on a body. And she was forced to take so much she couldn’t even count them. Sometimes, even without knowing. Her husband would mix it in her tea. They both discovered the awful result of his unconscious actions the day they wanted to have a child. It was already too late. She couldn’t carry one anymore.

This story illustrates the cultural shame, the man’s patriarchal uneducated decisions, and of course the irreversible effects of unsafe family planning. Recurring factors in remote places.

The bottom line of the story is: the best way to respect your faith, your family, and culture, is by staying alive and healthy. So don’t put that at risk because of fear. A legal and safe procedure will provide you with all the safety and discretion you need.

6- The solutions: Awareness, and contraception methods.

“We [Nepali] have different mentalities about health care. We never think about tomorrow which is really bad. We all need to think about it now and act towards it.” A Hygiene Volunteer in outreach programs (not from NGO).

The primary reasons responsible for unwanted pregnancy in Nepal, and therefore abortion, are irresponsible unprotected sexual relationships. Or what is called ” family planning failures”.

Women in remote areas “the poorest of the poor” are the first concerned by the issue. Then, the urban mother comes second, as she usually already have children and doesn’t want more responsibility.

In general, it is married mothers suffering the most from withdrawals, and are forced into the use of traditional dangerous useless techniques because their husband doesn’t want to wear condoms.

“We have centers, and outreach programs focused on prevention. Sometimes its the performance of vasectomy. other time IUD implant, all the other family planning methods, pills, and condoms.” (ERT)

“A Contact center provides family planning and safe abortion to women and men who seek our services. The Contact Centre Agent is responsible for providing information and counseling to inbound calls from existing and potential clients on Marie Stopes Nepal’s range of services including but not limited to: Family Planning, Safe Abortion, Post Abortion Family Planning and Sexual and Reproductive Health issues as well as the referral of callers to other Marie Stopes Nepal service delivery points (i.e. the Centers of Excellence, Outreach & MS Ladies). The other functions will include managing inquiries, referring the clients to Marie Stopes Nepal’s services, proactive follow-ups (outbound), as well as marketing support. Strong customer service skills, politeness, empathy and the passion to provide correct information are integral personal values that are required for this role.” Job description for Contact Centre, Call Centre Agents.

NGO’s are strongly developing their preventions programs. Because the best way to fight a problem is by making sure it doesn’t exist in the first place.

“Reach youth is our biggest challenge !” (ERT)

Ambassador programs are being put in place, so that youth representatives, who a better positioned to come through to their fellow classmates, can expose what is often mocked, or ditched by teachers.

Awareness is by definition an investment in the future. And who better to carry its premises of progress than the younger generations?