Situational Analysis
Of
Unsafe Abortion in Nepal
Nepal Country Team:
Family health Division, Govt. of Nepal( FHD)
Nepal Society of Obstetricians and Gynaecologists (NESOG)
Family Planning Association of Nepal (FPAN)
UNFPA, Nepal country office
TCIC/Ipas,Nepal
Centre for Research on Environment Health and Population Activities(CREHPA)
Paropakar Maternity and women’s Hospital ( PMWH)
Marie Stopes International/Sunaulo PariwarNepal ( MSI//SPN)
Forum of Women, Law, and Development(FWLD)
Safe Motherhood Network Federation ( SMNF)
Situational Analysis
Of
Unsafe Abortion in Nepal
Dr. Mahesh Puri and Dr. Pushpa Chaudhary
Nepal Society of Obstetricians and Gynaecologists (NESOG)
August, 2008
*This document is developed by Nepal Society of Obstetricians and Gynaecologists (NESOG) in close collaboration with Family Planning Association of Nepal(FPAN) and Centre for Research on Environment Health and Population Activities (CREHPA), Nepal incorporating valuable inputs from members of core working group -the FHD, DoHS, Govt. of Nepal; UNFPA country office, Nepal; Ipas, Nepal , Paropakar Maternity and Women’s Hospital, Thapathali; Sunaulo Pariwar Nepal/Marie Stopes International; Forum of Women, Law, and Development(FWLD, Nepal and Safe Motherhood Network Federation, Nepal(SMNF).
**Funding for developing this document is provided by UNFPA, Nepal Country office and publication is fundedby IPPF.
Acknowledgments
We express our sincere thanks and gratefulness toMrs Shashi Shrestha, the honarable State Minister of Health &Population and other representatives of the Govt. of Nepal including Dr. Govind Ojha, The Director General,( DoHS), Dr. Bal Krishna Suvedi, Director, Family Health Division, Mr. Arjun Bahadur Singh, Director, National Health Training Centre, and Dr. Meera Ojha, Ministry of Health for their support to this assessment study and commitment to implement plan of action based on this study.
We express our sincere gratitude to Dr. Dorothy Shaw, the President of FIGO, Dr. Annibal Faundes, Chief coordinator, FIGO initiative on Unsafe Abortion and Dr. Shahida Zaidi, the regional coordinator, FIGO initiativeon Unsafe Abortion for their noble effort to reduce the burden of unsafe abortion in the developing world.
Prof. Pramila Pradhan, the president of NESOG and Mr. KP Bista , Director, Family Planning Association of Nepal deserve special acknowledgement for their valuable guidance and support in every step of developing this document. We also extend our thanks to Prof. Sudha Sharma, Director, Paropakar Maternity and Women's Hospital for her input and suggestions. Our heartiest thanks goes to Dr. Indira Basnet, country director, IpasNepalfor her extra ordinary guidance and support in the whole process.
We also wish to express gratitude to all FIGO initiative Core Working Group members including Dr. Shilu Aryal, Senior Obstetrician and Gynaecologist, Family Health Division; Dr. Prasanna Gunasekara, UNFPA;Mr. Anand Tamang, Director, CREHPA;Dr. Lata Bajracharya, Paropakar Maternity and Women's Hospital;Dr. Durga Manandhar, Marie Stopes International/Sunaulo Parwar- Nepal (MSI/SPN); Mr. Lok Hari Basyal, Forum for Women, Law and Development (FWLD);and Mr. Sambhu Jang Rana, Safe Motherhood Network Federation(SMNF). We would also thank Ms. Sapana Malla Pradhan, FWLD and Dr. Giridhar Sharma Paudel, FPANfor theircontribution in preparation of this report.
We extend our heartfelt thanks to Dr. Pushpa Chaudhary, Focal person for FIGO initiative and Secretary General, NESOG and Dr. Deeb Shreshtha Dangol ,NESOG member, Focal point and coordinator from FPAN and congratulate them for their excellent coordination and commitment throughout this process. Similarly, Mr Ganesh Shrestha, Member of core working group from IpasNepal, deserve special thanks for his extra effort and contribution.
Our heartiest thanks goes to Dr. Mahesh Puri of CREHPA for his excellent consultancy for gathering information from published and unpublished reports and documents and preparing the draft report on “ Situational Analysis of Unsafe Abortion in Nepal”.We acknowledge the valuable contribution of Elena Preda of AGI who reviewed this document and approved it on behalf of FIGO.
We are most grateful to Mr. Prabin Shakya, MSI/SPN, Ms MadhabiBajrachjarya and Ms. Mukta Shah, TCIC/Ipas, Dr. Asha Pun, Nepal Family Health Project, Dr Chanda Kakri, Dr. Neera Singh Shrestha, Dr. Suman Risal and Tika Parajuli, all from Kathmandu Medical College for their support in providing invaluable information and support to this work. Our special thanks goes to Ms. Melissa Upreti, Center for Reproductive Rights, USA, Ms. Sona Sethi, Planned Parenthood Federation of America, Inc. Bangkok, Thailand and Ms. Lorelei Goodyear, PATH for providing invaluable information about their institution's activities in Nepal.
Nepal Society of Obstetricians and Gynaecologists express gratitude to UNFPA, IPPF and Ipas, Nepal funding for accomplishing the first phase of the FIGO initiative on Unsafe Abortion - Situational Analysis of Unsafe Abortion in Nepal.
Foreword
Prof. Pramila Pradhan
President, NESOG
Unsafe abortion has substantial detrimental consequences for society, negatively, affecting woman and their families, public health system and ultimately economic productivity.
Data shows that around 19 million abortion take place globally every year. The absolute number of unsafe abortion is highest in Asia at 10 million and 13 % maternal mortality is due to unsafe abortion and as high as 54% hospital admission are due to induced abortion complications (MOH 1998). Legalization of abortion in September 2002 has been the first step in the breakthrough of reproductive rights of the women in Nepal. Many national NGOs including professional organizations such as Nepal Medical Association and Nepal Society of Obstetricians and Gynaecologists (NESOG) played an important role in the advocacy for the legal reform in the late nineties. Centre for Research for Environment Health and population activities (CREHPA) , Forum for Women, Law and Development (FWLD) and family planning association of Nepal (FPAN) were the key players in the movement. Their advocacy work and that of other individual and organizations with support from INGOs stimulated interest of women’s activist group and the issue of abortion gained national profile and momentum (2006).
The family health division under the department of health services, ministry of Health and population has played the lead role in formulating policies, strategies and procedural order to implement and expand safe abortion services in the country. The first comprehensive abortion care service in the country was started at the government run Paropakar Maternity and Women’s hospital in Kathmandu from March 2004
As of midwifery 2008, 508 /482 physicians and 26 nurses were trained for providing CAC services. The government has approved 206 sites for CAC services in 74 districts out of 75 districts of the country and total of 212000 women had received the CAC services a remarkable achievement in reducing maternal mortality and morbidity.
In spite of such good work, there are many challenges like lack of awareness about the CAC centres, inadequate and unequal distribution of transformation, sex selective abortion. We need to overcome these as obstacles before Nepalese women will be able to exercise their rights .
Foreword
Dr. Pushpa Chaudhary
Focal person for FIGO initiative on Unsafe Abortion, NESOG
The International Federation of Gynaecology and Obstetrics (FIGO), created a Working Group (WG) on “The Prevention of Unsafe Abortion” and its complications, including representatives of Obstetrics and Gynaecology Societies and partners from other organizations with similar area of interest such as IPPF, ICM, UNFPA, WHO and Ipas, and othersin order to reduce maternal mortality and morbidity due to unsafe abortion and its consequences. The FIGO Executive Board called for a situational analysis of unsafe abortion in each country or territory with FIGO affiliated societies where burden of the unsafe abortion is significant to have a basis for preparing a country specific plan of action.
In Nepal, Nepal Society of Obstetricians & Gynaecologists (NESOG) was entrusted to prepare this Situations Analysis on Unsafe Abortion in Nepal in close collaboration with FPAN, the Government and other key stakeholders. The purpose of this Situational Analysis on Unsafe Abortion in Nepal is to gather and analyze information on the current level of unwanted pregnancy and its determinants, situation of unsafe abortion in the country, document the progress made so far in the preventions and management of unsafe abortions, highlight issues and challenges and suggest areas of activities to address unsafe abortion in Nepal.
Information for this Situational Analysis has been collected from the published and unpublished reports and journal articles related to unintended pregnancy and unsafe abortion. Information was also obtained from the Nepal Demographic Health Surveys reports, and abortion related studies and reports. Key experts within country and abroad were contacted via email or telephone and requested for any information they have had on this issue. Feedback was received from the Core Working Group (WG) for FIGO Initiative in Nepal and incorporated in this report.
I would like to acknowledge UNFPA, Country office, Nepal for providing Funding support todevelop this document and IPPF forsupporting the dissemination workshop of this situational analysis as well as publication of this document. I would also extend thanks to IpasNepal,core working group members, participants of group work and the facilitator, Mr. Parimal Jha forcontributing and supporting the dissemination workshop. My special thanks go to Dr. Deeb Shrestha and Mr. Ganesh Shrestha for playing vital role in the whole process.
I am optimistic that this information will be an asset for all stakeholders and help develop a realistic and focussed plan of action to reduce the burden of the problem of unsafeabortion in Nepal.
1
Abbreviations and Acronyms
ATF / Abortion Task ForceBCC / Behaviour Change Communications
CAC / Comprehensive Abortion Care
CREHPA / Centre for Research on Environment and Population Activities
FIGO / Federation of Gynaecology and Obstetrics
FP / Family Planning
FPAN
GoN / Family Planning Association Nepal
Government of Nepal
IEC / Information, Education and Communication
INGO / International Non-governmental Organization
IPPF / International Planned Parenthood Federation
IUD / Intra-uterine Device
MMR / Maternal Mortality Ratio
MTP / Medical Termination of Pregnancy
NESOG / Nepal Society of Obstetricians & Gynaecologists
NGO / Non-governmental Organization
PAC / Post-abortion Care
PEAP / Public Education and Advocacy Project
PHC / Primary Health Care Centre
PMO / Private Medical Outlets
RH / Reproductive Health
RTI / Reproductive Tract Infection
SRH / Sexual and Reproductive Health
TCIC / Technical Committee for Implementation of Comprehensive Abortion Care
UNFPA / United Nations Population Fund
WFS / World Fertility Survey
WHO / World Health Organisation
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Table of Contents
Page No
CHAPTER 1: Introduction
CHAPTER 2: Extent and determinants of unintended pregnancy...... 4
2.1Extent of unintended pregnancy...... 4
2.2Determinants of unintended pregnancy...... 4
2.3Fertility preference...... 6
2.4Causes of unintended pregnancy...... 7
CHAPTER 3: Legal framework of abortion...... 9
3.1Abortion law: Global context...... 9
3.2Aabortion law in Nepalbefore 2002
3.3 Efforts to legalise abortion in Nepal
3.4 The current status of lagal framework of abortion in Nepal and its implementation 15
CHAPTER 4: Unsafe abortion
4.1Magnitude of the problem: Worldwide
4.2Unsafe abortion in Nepal before legalization...... 18
4.3Unsafe abortion procedures used in pre-legalisation era...... 20
4.4Unsafe abortion after legalization of abortion...... 21
4.5Unsafe abortion procedures after legalization of abortion...... 25
4.6Abortion related death reported in printed media...... 26
4.7Reasons for unsafe abortions in Nepal...... 28
CHAPTER 5: Efforts to prevent unsafe abortions......
5.1Efforts of the Government
5.2Efforts of the national organizations
5.3Contribution of INGOs...... 41
CHAPTER 6: Issues and challenges of current abortion care services
References 48-51
Annexes 52 - 61
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List of Tables
Page No.
Table 2.1 Knowledge of specific contraceptive methods among currently married
Women age 15-49 and men age 15-59…………………………………………..7
Table 3.1Abortion law in South Asia……………………………………………………10
Table 4.1Induced abortion in Nepal during pre-legalisation era ……………………….19
Table 4.2Literacy status of women and their spouses receiving abortion service from untrained and trained personnel ………………………………………………..21
Table 4.3 Facility-wise annual caseloads of PAC clients in selected health facilities outside KathmanduValley …………………………………………………..22
Table 4.4Trend in PAC clients and percentage of induced abortions complications
Among PAC clients in MaternityHospital (2058-2063) ……………………….23
Table 4.5 Number of seriously complicated induced abortion out of the total
induced abortion case to total PAC clients in MaternityHospital…………….23
Table 4.6 Procedure used for abortion resulting into complication/incomplete abortion
and subsequent admission at PAC units …………………………………….24
Table 4.7Unsafe abortion procedure used in Nepal……………………………………...25
Table 4.8 Persons assisting the abortion procedure resulting into complication/
incomplete abortion and subsequent admission at PAC units….………………25
Table4.9Details of abortion related deaths reported in printed media ………………….27
Table 4.10CAC service days and service fee at selected CAC centres…………………31
Table 5.1Progress made in CAC service expansion and the number of clients
Receiving the services ….…………………………………………………….34
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List of Figures
Page No.
Figure 2.1 Fertility planning status……………………………………………………4
Figure 2.2 Fertility planning by mother's age at birth……………………………………...5
Figure 2.3 Fertility planning by birth order ………………………………………………..5
Figure 2.4 Percentage of currently married women age 15-49 who want no
more children, by residence and education…………………………………….6
Figure 2.5 Percentage of currently married women age 15-49 with unmet need
for family planning……………………………………………………………..7
Figure 2.6 Percentage of currently married women age 15-49 using
a contraceptive method………………………………………………………8
Figure 2.7 CPR and unmet need for FP……………………………………………………..8
Figure 3.1 Grounds on which abortion is permitted (percentage of countries)………….9
Figure 4.1Percentage distribution of unsafe abortion by age group in
the different regions………………………………………………………….17
Figure 4.2The Causes of Maternal Mortality: Global Estimates……………………….17
Figure 4.3 Number of deaths due to unsafe abortion per 100000 unsafe abortions, by sub region, 2003 …………………………………………………………………18
Figure 4.4 Abortion cases as percentage of total obstetric & gynaecological admissions in selected major hospitals ……………………………………………………..20
Figure 4.5 Trend in awareness on legalization of abortion………………………………..28
Figure 4.6 Level of knowledge on approved CAC centres among married and unmarried men and women: 2005 ………………………………………………29
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CHAPTER 1
Introduction
Each year approximately 205 million women become pregnant worldwide, as reported in the year 2003of which around 30 million pregnancies end in spontaneous abortion or still births and some 130 million women go on to deliver live born infants (Sedgh, et al, 2007). Worldwide, an estimated 36 per cent of pregnancies are unplanned and some 16 per cent of births are thought to be 'unwanted' or mistimed. Unintended pregnancies are common in both developing and developed countries. In developed countries, of the 23 million pregnancies occurring every year, an estimated 44 per cent are unintended. In developing countries, of the 182 million pregnancies occurring every year, an estimated 35 per cent are unintended(AGI, 1999; Sedgh, et al, 2007; UN, 2005 ).
An estimated 42 million pregnancies around the world that were terminated through induced abortion in the year 2003, about 19 million of them were performed outside the legal system. Most of these illegal abortions are considered unsafe because they are often performed by unskilled providers or under unhygienic conditions or both. Of these women, 35 million live in developing countries, and 6.6 million in developed countries. Globally, about58 per cent of all women having abortions live in Asia,11 per cent in Africa, and 9 per cent in Latin America and the Caribbean. The remainders live in Europe (17 per cent) and elsewhere in the developed world. The prevalence of unsafe abortions remain maximum in the 82 countries with the most restrictive legislations, as high as 23 unsafe abortions per 1000 women aged 15–49 years. By contrast, 52 countries that allow abortion on request have a median unsafe abortion rate as low as 2 per 1000 women of reproductive age (Berer, 2004).
Approximately one in four women having an unsafe abortion is likely to face complications, including life threatening complication and will seek hospital care, putting extra constraint on scarce resources(WHO, 2007). Moreover, in developing countries, the risk of death following complications of unsafe abortion procedures is several times higher than that of an abortion performed safely by skilled professionals (WHO, 2003)
Country context
Nepal is a predominately hilly and mountainous small land-locked country bordering with the People’s Republic of China in the north and India in the east, south and west. The country has diverse cultures, climates, traditions and languages. A large percentage of the population live in rural areas, with limited access to basic infrastructure or services. The country is divided intothree geographic regions: the terai (plains belt), the hills, and the mountains. As one moves from the terai upto the mountains, living conditions and access to health care become increasingly constrainedresulting in wide discrepancies in health services in different regions.
Total area of the country is 147,181 square kilometres. The population is about 28 millions with 781, 686 live births occurring every year (CBS, 2002).The population has more than doubled in the last 30 years. Life expectancy is one of the lowest in the world: 60.7 years for women and 60.1 years for men(NDHS, 2006). The country is one of the poorest and least developed countriesin the world with almost one-third of its population living below the poverty line (Ministry of Finance, 2006). Development is largely hindered by topography, marked caste and class distinction and unequal distribution of power and resources, as well as by severe gender discrimination in spheres of public and private life.Women’s access to education, property, and economic resources is often limited, particularly in rural areas, where approximately 86 per cent of Nepalese Population live.
Nepal Demographic Health Survey, 2006 showed a remarkable decline in Maternal Mortality Ratio (MMR) from 539 deaths (CI 392-686) for the period 1989-1995 to 281 deaths (CI:178-384) per 100,000 live births for the period 1999-2005 (NDHS, 2006).In contrast, estimation made by WHO/UNICEF/UNFPA/World Bank (based on reviews of all data available for Nepal and adjusted for under registration and misclassification) showed much higher MMR of 830 per 100,000 live births (WHO/UNICEF/UNFPA/World Bank, 2005). However, it has been argued that this estimation was consequently high due to the useof old data on proportion of births attended by skilled personnel in estimation process (Pant et. al, 2008). Nevertheless, Nepalstill falls in those countries with the highest maternal deaths in the world. It is estimated that up to 50 percent of all maternal deaths in Nepal's hospitals, are attributable to complications of unsafe abortion (Thapa et.al., 1992) Beside unsafe abortions, Nepal’s high maternal mortality and morbidity rates are associated with a number of other factors, such as early, closely spaced, and repeated pregnancies; poor health and nutritional status of women; insufficient facilities of essential obstetric care; inaccessibility of health services; low utilization of health services; harmful traditional beliefs and practices and the low status of women.