ACCESS AND BARRIERS TO ABORTION IN NEPAL: PROVIDERS PERSPECTIVE
Written by : Roshna Poudel
Abortion was legalized in September 2002 A.D with a goal to reduce the country’s high maternal mortality ratio and prevent abortion related morbidity among girls and women. Since then, Nepal has been praised for the victorious achievement regarding implementation and expansion of safe abortion services.
Fifteen years after legalization, safe abortion services are present in all 75 districts. Currently, there are over 2,000 trained providers, and between 2011 and 2016, over 400,000 abortions were performed at legal, safe abortion sites.1
Things wouldn’t have been possible without the collaborative work among the government, reproductive health right working group, NGO’S and INGO’S which are active in Nepal. The laws have been created, services have been expanded and policies are made such that people can have access to safe abortion at ease and even free of cost.
But despite of this effort why do women still seek unsafe abortion? This is a big question today arising in the entire health care delivery system.
Numerous studies have highlighted various barriers to the effective implementation of the services. The crucial ones among them were knowledge barriers, service delivery barriers, cost barriers, policy4 whereas gaps in equity, quality also threaten the realization of reproductive rights 5.
Let me share some of my my perspective as a health service provider on what I have strongly felt regarding some of the barriers at the service providing levels. For past 4yrs now, I have been working closely in the reproductive, maternal and child health department under ministry of health.
“Within my experiences I have seen women and adolescents who were in constant fear, stress, threat and pain just because of unwanted pregnancy. To gather the courage and finally walk out of their houses to the service provider’s door is like crossing a distance of an infinite ocean. There is a self-stigma, feeling of guilt, a blaming society, and stereotypical myths to overcome.”
The major barriers where these women have to face which leads to unsafe practices despite of legalization are:
POOR INFRASTRUCTURE OF THE HEALTH CARE SYSTEM:
I vividly remember one incident last year during my posting in primary health care center in eastern Teari, when women in her 20’s came for medical abortion. She was very shy in seeking service. Due to lack of separate rooms for counseling for abortion services, I asked her to wait couple of minutes before the Maternal and Child health room was free. In response to which she said she will be back but then never came again.
This is a common scenario in our health care delivery system where there might be a trained service provider, the service might also be free of cost but many of the setting has seen to provide all the services in the maternal and child health clinics where there is a continuous flow of antenatal women’s, clients requiring family planning, children’s coming to receive vaccination and so on. The infrastructures are made in such a way that there are not enough rooms for the expansion of any services.
In our society, where a woman is implied different stigmas and myths about abortion, we can just imagine how much hurdles she has to pass on before she finally approaches a health facility. And if this “she” is an unmarried female client, in the absence of separate Abortion service room makes it very difficult to access the services particularly to young unmarried program.
BREACH IN CONFIDENTIALITY:
When women come to access services, the only hope she has is with service provider where she truly believes that the service provider will be empathetic and the entire process will be highly confidential. Every woman has the right to confidentiality and it is the responsibility of the service provider to maintain it. Even in the incident that I shared earlier, the reason she turned away from the service was because she felt threat to her confidentiality. I am not criticizing all the service providers here, because there are some role models who follow the code of ethics strictly and a true source of inspiration. However, still there are some who do not leave a single chance to mimic, criticize, taunt and hurt the client. Some of our fellow workers are busy gossiping about the details of the client, her various circumstances or her character. The girls and women are left with no choice but turn back and pursue unsafe abortion secretly rather than being victimized again.
JUDGMENTAL ATTITUDE OF PROVIDERS
There are ample of incidents where I remember where providers taunt service seekers particularly young women for being irresponsible in their sexual activity and blame them for the unwanted pregnancy when they come to access the services. This is the major barrier for effective service deliveries as providers can act as the gatekeepers of the services. We might have trained personnel in the techniques but their personal values and beliefs might conflict with that of providing abortion. This is because providers are also the product of patriarchal society where abortion is stigmatized.
Every judgmental provider increases the chances of unsafe abortion particularly in young women. The medical and nursing curriculum should have an understanding of gender, patriarchy and values clarification to create sensitized provider.
While the world is still grieving with the deaths occurring due to unsafe abortion, let’s not make this situation even worse. As, providers let’s take an oath today to perform our duty with ethics placing our personal values, judgments and sentiments apart. Also, policy makers and supporting organization should focus on developing infrastructures at every level and also sensitize providers through training like Youth Advocacy Institute and value clarification sessions. As, youth champions, I have realized the utmost importance of such training and refreshers. Let’s ensure from today that every woman counts and no women would be discouraged and turned back from our door!! Let’s not force any women to place her life and health in danger. Let’s debunk the myth that health care provider are against safe abortion. But prove those health care providers are the leading advocate for access to safe abortion.
1) Government of Nepal, Ministry of Health, Department of Health Services, Abortion utilization data 2011–2016 (Kathmandu: Department of Health Services, 2016). Available at http://dohs.gov.np/publications.
2) World Health Organization, Maternal mortality in 1990–2015 (Geneva: World Health Organization, 2015)
3) J. Henerson, M. Puri, M. Blum, et al., “Effects of abortion legalization in Nepal, 2001–2010,” PLoS ONE (2013), p. e64775.
4) CREHPA, Reproductive health research policy brief no. 16, “Expanding safe abortion access: concerted efforts needed to overcome existing barriers “, April 2011.
5) Wan JU WU, Maru, Kiran Regmi and Indira Basnet, Health and Human Rights Journal, “Abortion care in Nepal, 15 years after legalization: Gaps in Acess, Equity and Quality”, June 6, 2017 vol 19, No. 1
Edited by: Smriti Thapa