Nepal has come a long way in the past decade. Nepal went from having one of the world's highest maternal mortality ratios to having a ratio comparable to other countries in the region.  However, reducing women’s risk of death and injury from unsafe abortion remains an important priority.  While pregnancy-related deaths have virtually been eradicated in the developed world, one woman perishes from such causes every four hours in Nepal.

Many factors contributed to Nepal’s historically high maternal-death rate: an abortion ban that lasted until 2002, persistent poverty, low rates of contraceptive use and a high percentage of deliveries occurring without a skilled birth attendant.  Health-care coverage was and still is hindered by a lack of physicians and other health-care personnel to serve a majority of the population living in rural and remote areas.  In 2004, government statistics estimated only one doctor was available per 19,695 Nepalis.

For much of its modern history, terminating a pregnancy was illegal in Nepal, the world’s only Hindu state. The law that banned abortion turned neighbors into informers, health-care facilities into temporary holding cells, and miscarriages or pregnancy-related illnesses into suspicions of clandestine abortions. In cases like Shanti’s, such suspicions could mean serving a life sentence in an overcrowded jail, and women incarcerated under the ban still remain in prison.

Though Nepal was one of the few countries worldwide to jail women for ending pregnancies, the ban didn’t deter women from seeking unsafe abortions from unskilled providers or self-inducing abortion using drugs, herbal potions and foreign objects inserted into the uterus. Unsafe abortion was and continues to be a significant factor in maternal deaths and injuries; as many as half of all maternal deaths in Nepali hospitals may result from complications of unsafe abortion.

But in 2002, the Nepali House of Representatives passed an amendment to its country code that, once approved by the monarch, legalized abortion and expanded women’s rights in other areas, including divorce, property ownership and education. Abortions can be performed on demand up to 12 weeks gestation, or 18 weeks in cases of rape or incest, or when the woman’s life is endangered or the fetus has a severe deformity.

With such a recent reversal of the ban, many Nepalis don’t know that abortion is now legal. Uninformed about their right to terminate pregnancy or unable to afford legal abortion, women who might otherwise use the safe, government-sponsored services may still go elsewhere for unsafe abortions.
 
As Nepal continues on the path to making abortion accessible and safe for every woman, Ipas is a partner in the Support to the Safe Motherhood program and collaborates with His Majesty’s Government and the Technical Committee for Implementation of Comprehensive Abortion Care (TCIC).

As a key member of Nepal’s safe abortion program, Ipas works to address the need for public awareness, training and education of current and future abortion providers, and making services available throughout the country.  

• Launching the first safe abortion clinic in Nepal at Kathmandu Maternity Hospital in March 2004;
• Providing more than 72,000 women with comprehensive abortion care (CAC) services through Ipas and partner interventions between March 2004 and September 2006;
• Assisting in creating standards and guidelines for implementing CAC;
• Helping devise a system for approving abortion-providing facilities and then certifying almost 140 non governmental organization (NGO) and private sites ;
• Training more than 270 CAC providers from government and nongovernment facilities;
• Ensuring 95 percent of districts and public-sector hospitals have skilled providers;
• Supporting NGO work to educate lawyers about reproductive health and gathering national data about use of abortion services and impact of the law change.

• Strengthening the monitoring system to ensure high-quality services;
• Developing a CAC training curriculum for doctors and nurses;
• Addressing the shortage of physicians by training midlevel providers;
• Scaling up communication efforts that encourage behavior change, including women’s discussion groups; radio programming; and information, education and communication materials ;
• Implementing medication abortion as an effective method of reaching women underserved by health-care providers.

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