Barriers: Access and uptake of skilled safe abortion services
Sociocultural attitudes
Participants highlighted the impact of sociocultural attitudes, religious beliefs, cultural norms relating to sexual and reproductive health and the influence of Nepal’s patriarchal society on women’s access to and uptake of skilled safe abortion services. Stigma associated with accessing safe abortion services was stated as a key barrier to women not utilising safe abortion services.
Stigma in the community is the first barrier to women accessing safe abortion services. A woman can say that she is going to a health service for a delivery, but she can’t say she is going for abortion services. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
Negative service provider attitudes towards women seeking safe abortion services were also expressed and this impeded woman from up taking services. Several participants stated that unmarried women have further increased difficulties in accessing and use of safe abortion services due to negative cultural attitudes towards sex outside of marriage. One participant stated that this impacts women who often seek unsafe abortions.
Although abortion is legal in Nepal, many women are still getting unsafe abortions; we see less unmarried women attending safe abortion services (due to sociocultural reasons). IDI 6. Service Provider, SRH Clinic, I/NGO, Sunsari District.
Socioeconomic constraints
The complex socioeconomic disparities between women who are married and unmarried women seeking safe abortion services compound barriers to access.
Barriers exist between married and unmarried women seeking abortions…The majority of women using safe abortion services are typically from economically relatively well-off families. Poor women experience a greater financial barrier to accessing abortion services. IDI 3. SRH Research Consultant, Independent, Nepal.
The financial burden experienced by women seeking safe abortion services (including appointment and procedure fees as well as travel) was also a reoccurring theme throughout the interviews. Several participants stated that the cost of safe abortion services deters women from accessing these facilities and is a deciding factor for many women to procure unsafe abortions. The inability to afford safe abortion services is often exacerbated for women living in rural and remote regions of Nepal.
Another barrier to access and uptake of skilled safe abortion services is the abortion fee… 1000 Nepali Rupees ($9.50 USD) is a very big amount for rural women. IDI 8. Senior Officer, SRH NGO, Nepal.
Geographic isolation
The health services in Nepal are located in the Central Development Region and along the Terai belt (the low land region in Southern Nepal), to the detriment of those living in the remote hill and mountain regions.
In Nepal, approximately one in five people live in urban areas where both surgical and MA services are available. In rural areas and districts, however, access to abortion services remains problematic. In such areas, women may not have any option but to resort unsafe abortion practices that could have serious health consequences. IDI 3. SRH Research Consultant, Independent, Nepal.
Issues relating to lack of access to health care services, safe abortion services and trained medical professionals in rural and remote regions was a reoccurring theme throughout the interviews.
I come from the rural area, but I don’t choose to work in my hometown because I cannot earn as much money providing services there… Few health professionals remain in remote areas and very few I/NGOs are providing training for those professionals. IDI 2. Senior Service Provider, SRH Clinic, I/NGO, Kathmandu.
Interview participants revealed numerous inhibiting factors relating to lack of access and uptake of safe abortion services in rural and remote regions of Nepal including: lack of infrastructure, both health services as well as road and transportation issues; administrative issues relating to lack of sufficient numbers of trained staff able to provide non-judgmental safe abortion services during regular working hours; lack of training and on-going capacity building of services providers; and lack of incentives for trained personnel to work within rural and remote regions.
Translating policy into practice
Participants reported their experiences with the conflicting nature of practice versus the Ministry of Health National Safe Abortion Policy relating to effective and equitable SRH service provision in Nepal.
I think the written policy is very good, but in practice, it’s not applicable…The Government has a concrete plan of action, but they lack the knowledge and skills on where to implement and how to implement. IDI 7. Program Manager, SRH NGO, Nepal.
While current Government policy states that safe abortion services are available across Nepal, several participants stated that lack of awareness of abortion laws and available services continues to inhibit women from access and uptake of safe abortion services.
CAC services are available in all ecological areas; however, due to difficult geographical locations, women are facing difficulty in accessing services. Also, many women in these remote locations are not aware of safe abortion services. IDI 4. Senior Service Provider, CAC Unit, Public Health Facility, Kathmandu.
Geographic isolation was stated as being a deterrent for trained health care professionals, who do not want to work in remote and rural regions.
The Government has health policy that clearly states the need for doctors and medical staff in remote areas, but the incentives are very low. In public facilities, a trained medical doctor and nurse positions are allocated up to the Primary Health Care Centre (PHCC) level, but the positions are often vacant. IDI 7. Program Manager, SRH NGO, Nepal.
Participants reported that monitoring and evaluation mechanisms of safe abortion services to maintain quality of care and ensuring CAC service data is accurately recorded and reported, are inconsistent across public, I/NGO and private services.
The main cause of inconsistency is the lack of a monitoring mechanism… There are no regular monitoring visits in some NGOs as well as in the public sector. Monitoring is very weak. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
Effective and consistent monitoring and evaluation processes of I/NGO safe abortion services in Nepal was reported to be currently undertaken within I/NGO SRH clinics. However, lack of trained professionals to conduct monitoring and evaluation of safe abortion services provided by public and private facilities was sighted as being the key component of inconsistent services provision, impacting women’s ability to access and utilize safe, effective and comprehensive abortion services.
Here (Government Office) we are only two staff members, one doctor and one Public Health Nurse (PHN), we can’t go to every district to monitor sites so (SRHR I/NGO) is supporting the Government with monitoring. In the districts, we have a PHN as a focal person who should monitor the district hospital and other private clinics. She should go from time to time (to monitor services), but in some districts, it is lacking. It depends on how active PHN is. IDI 9. Senior Officer, Ministry of Health, GON, Nepal.
Current translation of policy into practice and monitoring of safe abortion services in Nepal are intrinsically linked and have a substantial impact on access to safe abortion services with trained and culturally sensitive health professionals. Increasingly, the Government is establishing a memorandum of understanding (MoU) with I/NGOs to overcome the lack of resources and expertise they lack for monitoring and evaluation of safe abortion services. While the vast majority of participants shared their positive perceptions of Government SRH and Safe Abortion Policy in Nepal, lack of effective monitoring inhibits the translation of policy into practice.
It’s not so much the policy, rather the implementation that must be looked at. Implementation of the guidelines needs to be monitored… The Government needs to have a regulating body to assess, evaluate and monitor the standard of abortion provision services. IDI 3. SRH Research Consultant, Independent, Nepal.
Barriers: Access and uptake of post-abortion family planning services
Misconceptions and cultural barriers
In Nepal, contraception is free of charge and consequently, socioeconomic issues relating to access and uptake of post-abortion contraception did not emerge in our interviews. However, sociocultural factors impacting post-abortion contraception decision making were a prominent theme discussed by all participants. Prevailing misconceptions relating to the use of modern contraception was a critical factor in women deciding not to use post-abortion contraception.
There are many misconceptions regarding the use of contraception like excessive bleeding will occur, weight gain will happen, or they will get cancer through the use of contraceptive methods. IDI 6. Service Provider, SRH Clinic, I/NGO, Sunsari District.
Effective provision of post-abortion SRH information and contraceptive education through counselling was stated as an important component of increasing uptake of post-abortion contraception. However, challenges were reported.
Good counsellors have key role to play in reducing the misconceptions around contraception. If a counsellor is well trained and knowledgeable, they will motivate the client to use contraception and provide comprehensive information. Half information leads to misconception. IDI 7. Program Manager, SRH NGO, Nepal.
The difficulty of discussing post-abortion contraception support and services with husbands and mothers-in-law is a cultural barrier.
Cultural and social barriers are the most common barriers for women accessing post-abortion contraception….in some cases, women still cannot share their SRH related problems with their husbands. IDI 1. Service Provider, SRH Clinic, I/NGO, Kathmandu.
While our participants shared many examples of barriers to uptake of post-abortion contraception and SRH information, the most frequently cited inhibiting factor to the uptake of post-abortion family planning services was the large number of women whose husbands work outside of Nepal or away from their home districts.
In our country, mostly the males (husbands) are migrant workers, who occasionally come home to visit their wives. That is one of the main reasons for women not accepting contraception (post-abortion). IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
All participants shared their thoughts relating to the ever-increasing male migrant worker population and the impact it is having on women using contraception and post-abortion contraception.
Geographic remoteness
Issues with timely procurement and supply of contraceptives was also a barrier to women receiving a broad choice of contraceptive options post-abortion. Reported contraceptive supply chain challenges include lack of trained logistical staff and insufficient human resources; lack of adequate storage and timely transportation from district centres to peripheral health facilities; and an absence of accountability mechanisms for stockouts and commodity delays. Along with a lack of supply, geographical isolation also impacted the availability of trained safe abortion service providers able to provide women with comprehensive post-abortion family planning services and SRH information.
At rural and remote sites (safe abortion services), contraceptive commodity and trained human resources are not always available. If a woman comes to the service site and wants an Implant, due to lack of trained human resources and commodity she can’t get an Implant. That gap of commodity and trained staff means women are not getting contraceptive method of their choice and the counselling will be biased in that case. The service provider will counsel on those methods which are available at the site. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
Policy, practice and monitoring
Participants spoke of the juxtaposition between Government policy that requires clinics to have five different methods of contraception available to clients and the reality of the limited choice, perhaps only two or three contraceptive methods, available at many public clinics.
According to Government Policy, at the Health Post level, there must always be the availability of five contraceptive methods (condom, pills, Depo (injectable), IUD and implant). But, there are not all five methods available at all the government Health Posts in Nepal. IDI 9. Senior Officer, Ministry of Health, GON, Nepal.
While the current Government policy states all SRH facilities should follow the same guidelines, service provision continues to vary due to poor contraceptive supply, lack of trained service providers and a high level of staff turnover resulting in clinic closures. This lack of comprehensive education and knowledge provision among health professionals across facilities was reported to be a key inhibitor of post-abortion contraception uptake and continuation.
Women need to be informed and educated so they can make an informed decision…Most abortion clinics offer contraception in an almost a ritual way… Through counselling and discussion, the service provider must ensure that the women’s individual contraceptive needs are met… Counsellors should really focus on the women’s fertility goals and desires and see what the best way for her to achieve that is. IDI 3. SRH Research Consultant, Independent, Nepal.
Although current Government SRH and Safe Abortion Policy addresses the SRHR needs of Nepali women on paper, it was emphasized there is ineffective translation and application of policy into practice.
In Nepal, implementation of policy into action leaves a lot to be desired. IDI 3. SRH Research Consultant, Independent, Nepal.
Concerns about medical abortion provision through pharmacies
The evolution of unsafe (less and least safe) abortion and medical abortion
All interviewees commented on the increasing trend of women accessing both registered (Government approved) and unregistered brands of mifepristone and misoprostol (MA pills) illegally through pharmacies, sometimes referred to as chemists or medical shops. Respondents also raised concerns that not only are registered and unregistered MA tablets sold through pharmacies, but potentially drugs of unknown chemical composition are also being provided to induce abortion. One participant elucidated the evolution of unsafe abortion in Nepal and its impact on negative health outcomes for women.
Before the legalization of abortion, women practised harmful abortion methods such as taking herbs and extensive massage which could cause complication and the need for hospital admission. Now, because of the availability of abortion pills, women go to pharmacies, take the pills, have incomplete abortion or complications and need to go to the hospital. IDI 8. Senior Officer, SRH NGO, Nepal.
Several participants reported that a high number of women accessed safe abortion services after experiencing an incomplete abortion as a result of accessing MA illegally through pharmacies.
Most of our incomplete abortion cases come from medical shops. IDI 4. Senior Service Provider, CAC Unit, Public Health Facility, Kathmandu.
The participants shared the reality of women accessing MA through pharmacies and the lack of SRH information relating to the administration of MA as well as the lack of post-abortion care and post-abortion family planning.
Pharmacy staff are not aware of the eligibility criteria for the provision of abortion services, what is the route of administration, what is the expected outcome and side effects, what are adverse side effects. They are just selling medical abortion pills. IDI 8. Senior Officer, SRH NGO, Nepal.
Several reasons for women choosing to access abortion through pharmacies instead of going to health facilities for safe abortion services were cited during the interviews. Negative sociocultural attitudes towards abortion and privacy issues relating to accessing abortion were reported to be a key reason why women chose pharmacies.
Abortion is very stigmatized in Nepali culture, so they scared of losing their privacy… in chemist shop they don’t have to give any answers regarding the abortion they can get pills very easily. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
Obstacles to safe abortion services
Geographical isolation and the health service provision implications were also reported as key influences in women choosing to access MA through pharmacies. Participants shared that women will often seek MA through pharmacies as there is no health facility that provides safe abortion service located near them or there are no trained safe abortion service providers in their local community.
The reason for women choosing medical shops over safe abortion services (from registered clinics) may be due to the lack of abortion services in government health facilities in their area. IDI 8. Senior Officer, SRH NGO, Nepal.
Challenges of monitoring unsafe (less and least safe) medical abortion
Participants spoke of numerous challenges when trying to stop the sale of MAs through pharmacies in Nepal.
In current Government policy, it is stated that medical abortion should not be provided through chemist shops, it should be provided through permitted (registered) clinics only. But the demand is very high…The clients don’t care about World Health Organization (WHO) standards and protocol, they just want prompt service. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
The difficulties the Government Drug Administration Department faces trying to monitor and halt the flow of MA pills through pharmacies was reiterated throughout the interviews. Human resource capacity was cited as being a major barrier to the effective monitoring of MA drugs within the market.
Medical abortion obtained from medical shop should stop. We have approached the Department of Drug Administration but they can’t control it, and this is a great concern. IDI 9. Senior Officer, Ministry of Health, GON, Nepal.
Several spoke of collaboration between Government, I/NGOs and the private sector to establish a committee to implement monitoring of pharmacies. However, this has proven challenging with inconsistent results seen across areas of implementation. While MA can only legally be prescribed by a safe abortion service provider in the first trimester in Nepal, it was suggested that women might have a sex-selective MA through pharmacies after the first trimester.
There are currently no regulatory body on sex-selection issues in Nepal. Technology (ultrasound) has made it easier for couples to test for the sex of their child… It needs to be audited and evaluated; sex-selection is emerging as a big concern with the increase of accessibility to medical abortion as well. The MoH (Ministry of Health) needs to set up an independent body to ensure that ultrasound is not used for sex-selective abortion in the country. IDI 3. SRH Research Consultant, Independent, Nepal.
One participant stated that within the context of sociocultural practices and beliefs, the motivation behind sex-selection abortion and the legalization of safe abortion (both surgical and medical), should be not be viewed as mutually dependent. They commented that the legalization of abortion in Nepal is not the causation factor of sex-selection abortion practices but is a component of entrenched cultural beliefs.
Sex selection is related to the social, economic and patriarchal pattern of society. It has been done for many years prior to the legalisation of abortion. Linking the legalisation of abortion services and sex selection is wrong. If we educate the community people on the value of the girl child, if boys and girl are equally valued, sex selection abortion will decrease, it takes time, it won’t change overnight. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
Interviewees shared their views on the current state of MA provision in Nepal and on how unsafe provision of MA can decrease.
Medical abortion has left the clinic, left the doctors. Technology has outpaced everything, so we have to find a way to engage the non-conventional facilities. Medical shops are increasing medical abortion provision; however, they are just dispensing the drugs and are not counselling the women… Medical shops are evolving their role in Nepal. Globally, the function of medical shops has enlarged and is recognized by the World Health Organization (WHO) as well. IDI 3. SRH Research Consultant, Independent, Nepal.
While one research participant stated that MA pills should only be administered by professionals that are able to perform pelvic or vaginal examinations, several participants shared their views of a more harm reduction approach through education and training of safe MA provision to pharmacy staff.
For medical shops that don’t have medical professionals, we should provide at least basic harm reduction training. IDI 7. Program Manager, SRH NGO, Nepal.
Several participants highlighted the need for Government policymakers to carefully consider the role pharmacies currently play in the provision of MA and how current policy must be revised to reflect this.
(The Government of Nepal) should revise policy as we can’t stop chemist shop from selling the pills (medical abortion). If more restrictions are made, they will, of course, sell the pills under the table… Rather than stopping chemist shops and stopping women visiting chemist shops we should give information on the right dose and right time or complete information of taking pills in case of abortion. IDI 5. Safe Abortion Policy Advisor, I/NGO, Nepal.
Pharmacy specific harm reduction strategies such as training of non-medical staff, as well as the potential for qualified pharmacy staff receiving further education on MA provision through pharmacies, was noted as a potential governmental approach to increase access to safe MA as well as theoretically reducing the incidence of complications resulting from unsafe MA provision.
Through training, medical abortion services can be expanded, and those who are eligible to provide medical abortion could provide services. For those who don’t meet the edibility, their business selling medical abortion will decrease, and therefore complications of medical abortion will be reduced. IDI 8. Senior Officer, SRH NGO, Nepal.
The certainty that pharmacy staff will continue to sell MA tablets regardless of illegality was reiterated by research participants. The majority of participants also stated the need to review and revise current government policy relating to MA provision through pharmacies to help reduce mortality and morbidity associated with the practice.