Level of awareness about legalization of abortion in Nepal: a study at Nepal Medical College Teaching Hospital.

Abstract

World Health Organization (WHO) estimates that about 25.0% of all pregnancies worldwide end in induced abortion, approximately 50 million each year. More than half of these abortions are performed under unsafe conditions resulting in high maternal mortality ratio specially in developing countries like Nepal. Abortion was legalized under specified conditions in March 2002 in Nepal. But still a large proportion of population are unaware of the legalization and the conditions under which it is permitted. Legal reform alone cannot reduce abortion related deaths in our country. This study was undertaken with the main objective to study the level of awareness about legalization of abortion in women attending gyne out patients department of Nepal Medical College Teaching Hospital (NMCTH), which will give a baseline knowledge for further dissemination and advocacy about abortion law. Total 200 women participated in the study. Overall 133 (66.5%) women said they were aware of legalization of abortion in Nepal. Women of age group 20-34 years, urban residents, service holders, Brahmin/Chhetri caste and with higher education were more aware about it. Majority (92.0%) of the women received information from the media. Detail knowledge about legal conditions under which abortion can be performed specially in second trimester was found to be poor. Large proportion (71.0%) of the women were still unaware of the availability of comprehensive abortion care services at our hospital, which is being provided since last seven years. Public education and advocacy campaigns are crucial to create awareness about the new legislation and availability of services. Unless the advocacy and awareness campaign reaches women, they are not likely to benefit from the legal reform and services.

Full text

Page 1

76
Level of awareness about legalization of abortion in Nepal: A study at
Nepal Medical College Teaching Hospital
H Tuladhar and A Risal
Department of obs/gyne, Nepal Medical College Teaching Hospital, Jorpati, Kathmandu, Nepal
Corresponding author: Dr. Heera Tuladhar, Associate Professor, Department of obs/gyne, Nepal Medical College Teaching Hospital,
Jorpati, Kathmandu, Nepal
ABSTRACT
World Health Organization (WHO) estimates that about 25.0% of all pregnancies worldwide end in induced
abortion, approximately 50 million each year. More than half of these abortions are performed under unsafe
conditions resulting in high maternal mortality ratio specially in developing countries like Nepal. Abortion was
legalized under specified conditions in March 2002 in Nepal. But still a large proportion of population are
unaware of the legalization and the conditions under which it is permitted. Legal reform alone cannot reduce
abortion related deaths in our country. This study was undertaken with the main objective to study the level of
awareness about legalization of abortion in women attending gyne out patients department of Nepal Medical
College Teaching Hospital (NMCTH), which will give a baseline knowledge for further dissemination and
advocacy about abortion law. Total 200 women participated in the study. Overall 133 (66.5%) women said they
were aware of legalization of abortion in Nepal. Women of age group 20-34 years, urban residents, service
holders, Brahmin/Chhetri caste and with higher education were more aware about it. Majority (92.0%) of the
women received information from the media. Detail knowledge about legal conditions under which abortion
can be performed specially in second trimester was found to be poor. Large proportion (71.0%) of the women
were still unaware of the availability of comprehensive abortion care services at our hospital, which is being
provided since last seven years. Public education and advocacy campaigns are crucial to create awareness
about the new legislation and availability of services. Unless the advocacy and awareness campaign reaches
women, they are not likely to benefit from the legal reform and services.
Keywords : Abortion, maternal mortality, legalization, awareness.
INTRODUCTION
More than 100,000 unwanted pregnancies each day, or
about 36 to 53 million each year, ends in induced abortion.
Estimates suggest that more than half of these abortions
are performed under unsafe conditions and result in more
than 70,000 deaths per year, almost all in developing
countries.1 The legal status of abortion is a key determinant
of access to safe abortion. Women will normally obtain
abortion also in countries where abortions are against the
law, the more affluent women obtaining relatively safe
procedures, whereas the poor women usually suffer the
severe consequences, adolescents being particularly
vulnerable. In 1998, according to a study in Nepal, it was
estimated that more than half of gynecological and
obstetric hospital admissions were due to abortion related
complications.2In Romania, after legalization of abortion
in 1989, maternal deaths related to abortions fell from
around 130 per 100,000 live births in the years before to
around 60 per 100,000 live births in the year after abortion
was legalized.3
Although the exact proportion is not known, unsafe
abortions are believed to contribute significantly to
Nepal’s high maternal mortality ratio. In order to address
this, abortion was legalized under specified conditions
in March 2002. The bill received Royal Assent in
September 2002 with the Procedural Order enabling the
implementation of the new law receiving approval in
December 2003. Government of Nepal, through Ministry
of Health, has prioritized the national safe abortion
program, working with many partners, including
government departments at central, regional and district
level, non-government organizations, public and private
sector service providers and international development
partners, to implement the new law as quickly as possible
and save maternal lives. Under the new law, which is
liberal by any standards, abortion is permitted up to 12
weeks’ gestation for any woman above 16 years on her
request. For women under 16 years the permission of a
guardian is required, but this is not strictly defined and
may be any adult relative or friend. Abortion is also
permitted up to 18 weeks’ gestation if the pregnancy is
the result of rape or incest, and at any time on the advice
of a medical practitioner if the life or health of the woman
is in danger or the fetus is seriously deformed or has a
condition that is incompatible with life.4
Original Article Nepal Med Coll J 2010; 12(2): 76-80

Page 2

77
group, area of residence, educational status, occupation
and level of awareness about legalization of abortion in
Nepal, source of information, awareness about different
conditions for legal abortion and knowledge about
availability of comprehensive abortion care (CAC)
service at NMCTH.
RESULTS
Total 200 women participated in the study. Overall 133
(66.5%) women said they were aware of legalization of
abortion in Nepal. The level of awareness varied
according to the age group, area of residence, occupation,
ethnic group and educational status of the women as
shown in Table-1.
Adolescents, laborers, rural, uneducated and Magar
women were less aware about legalization of abortion,
whereas women of age group 20-34 years, urban
residents, service holders, Brahmin/Chhetri caste and
higher educated women were more aware about it.
Majority of the women received information from the
media, and health personnel were the least common
source of information.
Although two thirds of total women were aware about
legalization of abortion in the country detail knowledge
about legal conditions under which abortion can be
performed specially in second trimester, was found to
be poor.
A large proportion of the women were still unaware of
the availability of abortion services at our hospital, which
is being provided since last seven years. Majority (84%)
of the women were also not using any contraceptive
methods.
Thirteen women (6.5%) already had an experience of
induced abortion in the past, two among them were
unaware about legalization. They were also not aware
about legal conditions for abortion specially that in the
second trimester.
DISCUSSION
WHO estimates that about 25.0% of all pregnancies
worldwide end in induced abortion, approximately 50
million each year. Of these abortions, 20 million are
being performed under dangerous conditions, either by
untrained providers or using unsafe procedures, or both.
Deaths as a result of unsafe abortions in developing
countries are estimated at 80000 annually, i.e. 400 deaths
per 100 000 abortions. Although over the past 10 years
there have been improvements in the safety of the
abortion procedures used and access to treatment for
complications for some women in developing countries,
the number of women requiring treatment for serious
The government is committed to enabling women across
Nepal, regardless of their socio-economic status, to
exercise their legal right to access safe abortion services
if they have an unwanted pregnancy.
From a country with one of the most restrictive and
strictly enforced abortion laws in the world, where many
women received lengthy prison sentences for abortion-
related ‘crimes’,Nepal has become a model for change
globally.5 One of the main post-legalization challenges
for Nepal is “ how to make legal and safe abortion
services accessible to all women without fear of
stigmatization and as women’s reproductive rights”.
Public Opinion Poll conducted by CREHPA in October
2002 revealed that just 22.0% of the urban adult
population was aware that abortion has been legalized
in Nepal.6
Legal reform alone cannot reduce abortion related deaths
in our country. Public education and advocacy
campaigns are crucial to create awareness about the new
legislation, modify society’s attitude towards abortion,
prevent unsafe and illegal practices, inform about legal
and safe abortion care services and create enabling
environment for women and couples to make informed
decisions on their unintended pregnancies. Unless the
advocacy and awareness campaign reaches women, they
are not likely to benefit from the legal reform and
services. This study was undertaken with the main
objective to study the level of awareness about
legalization of abortion in women attending gyne out
patients department of Nepal Medical College Teaching
Hospital (NMCTH), which will give a baseline
knowledge for further dissemination and advocacy about
abortion law.
MATERIALS AND METHODS
This is a hospital based prospective study conducted in
Nepal Medical College Teaching Hospital which is a
700 bedded tertiary care hospital and medical college
situated at Jorpati, a suburban area of Kathmandu. The
area mainly consists of population of lower
socioeconomic class, most of them working as laborers
especially in carpet factories. The study period extended
from 1st July ‘09 to last August ‘09, total duration being
two months. The study group consisted of 200 women
of reproductive age (15-49 years) who attended obs/gyne
outpatient department. The women were enrolled in the
study irrespective of their complaints and diagnosis.
These women represent a sample of typical suburban
female population of Nepal. The purpose of the study
was explained and informed verbal consent was
obtained. A partially structured questionnaire was filled
up by interviewing all those cases. The questionnaire
included information regarding the age, parity, ethnic
H Tuladhar et al

Page 3

78
complications of unsafe abortion remains very high and
many women never receive care at all.7-14 A range of
positive steps has been taken to reduce deaths and
morbidity from abortion in a growing number of
countries over the past 15 years. Since 1980, abortion
laws have been liberalized in some form. Making
abortion legal is an essential prerequisite for making it
safe. Safety is not only a question of safe medical
procedures being used by individual providers, it is also
about removing the risk of exposure and the fear of
imprisonment and other punitive measures for both
women and providers. Since the legalization of abortion
in Nepal, there have been few studies regarding public
awareness. One such study done by Singh and Jha15
among 150 participants from health background 87.0%
knew abortion was legalized in Nepal. Regarding the
site of abortion service, only 27.4% said government
hospital and 72.6% identified private clinic as the main
source for abortion service.
Our study showed the awareness about legalization of
abortion to be 66.5%. Study done by CREHPA in 2000
Table-1: Socio-demographic characteristics of the study population with awareness of legalization of abortion
Characteristics No.%Aware of legalization of abortion
Age group(in years) No.%
Adolescents(<19)8 4.02 25.0
20-34 16884.0 11669.0
>35 24 12.0 1562.5
Mean age: 26.01 years
Range: 18-47years
Area of residence
Rural 13165.58564.9
Urban 6934.5 48 69.6
Occupation
Housewife155 77.59863.2
Laborer6 3.02 33.3
Service 22 11.0 2090.9
Business147.0 1178.6=
Student31.52 66.7
Ethnic group
Brahmin/Chhetri
8542.568 80.0
Lama/Sherpa/Tamang
4723.5 22 46.8
Newar
3517.52262.8
Magar
10 5.03 30.0
Others23 11.5 1878.3
Educational status
Illiterate4924.5 2448.9
Primary 2814.09 32.1
Secondary71 35.5 5678.9
Intermediate and above 52 26.0 4484.6
Nepal Medical College Journal

Page 4

79
showed that between 20.0-60.0% of the obstetric and
gyne patients in major government hospitals of the
country are cases of abortion complication.16Majority
of the urban public are still ignorant about legalization,
only 42.0% of the urban public mentioned that abortion
is now legal in the country. There has been a remarkable
increase in awareness level about the legal reform. For
example, in 2002, only 22.0% were aware about
legalization, this percentage increased only marginally
in 2003 (26.0%) and increased by approximately one
and a half times in 2004 (42.0%). Knowledge about the
three legal conditions for abortion is still very low.
Among the urban public who were aware of legalization,
only a third of them (37.0%) were aware that abortion is
permitted on request during first 12 weeks of pregnancy.
Very few respondents (7.0%) were aware that abortion
is permitted up to 18 weeks in case of rape or incest and
just one fifth (20.0%) were aware that it is permitted if
pregnancy affects the health of mother or the fetus. Over
a half of the respondents were unaware about CAC
services. In districts having government approved CAC
centers, more than half of the urban public (except
Kathmandu; 72.0%) were still unaware about their
district hospitals having approved safe abortion service
centers. Even in districts not having CAC centers, a
considerable proportion (25.0-49%) of the urban public
have the misconceptions that their district hospitals
provide safe abortion services. Though there is a
remarkable increase on awareness about the legalization,
more public awareness efforts are essential to impart
correct knowledge about abortion rights, legal provision
and safe abortion (CAC) services.17-19
Although abortion has been legal in India since 1972,
study done by Gupte et al of 67 women in rural
Maharashtra in 1997 found that only 18.0% knew that,
while 64.0% thought it was not legal, and the remainder
were unsure.20 Azize-Vargas et al has also reported that,
although abortion has been legal in Puerto Rico for 20
years, there is still a widespread perception that abortion
remains illegal, public information about abortion
service site is also very limited and even the medical
students know very little about the law.21
In Sri Lanka where induced abortion is a criminal offence
except to save the life of the mother, Abeyasinghe et al
studied the awareness and views of the law on abortion
among 313 women seeking abortion,22 65.8% of the
respondents stated they knew the current law, 25.6%
Table-2: Awareness among women with history of induced
abortion (n=13)
Awareness on legalizationNo.
Aware
Upto 12 weeks for any women
Upto 18 weeks if pregnancy results from
rape or incest
Life or physical or mental condition of a
pregnant woman is at risk or if the fetus is
deformed or incompatible with life
11
9
2
0
Fig. 2. Knowledge about three legal conditions in abortion law
Fig.1. Source of information
Friends 6%
Health personnel 2%
Media 92%
H Tuladhar et al

Page 5

80
stated they did not and 8.3% were unsure. On detailed
analysis of each respondent’s knowledge regarding the
situations where abortion is legalized only 11.2% had
an accurate knowledge.
So, the findings of our study are more or less comparable
to other studies in various countries with different status
of legalization of abortion. Overall a highly satisfactory
proportion (66.5%) of the respondents were aware about
legalization of abortion in Nepal, as compared to 49%
in the most recent survey conducted by CREHPA in
2006,23but the in depth knowledge about the conditions
when abortion is permitted under the law seemed still
lacking. So, from this study we can conclude that
advocacy and awareness campaigns about abortion law
and against unsafe abortion practices are strongly needed
in our country.
As seen from the study, media was the most common
source of information for the public, widespread utilization
of electronic and print media is required for creating
awareness about the new abortion law, the safety net or
gestation period for legal abortion, pre- and post abortion
counseling and risk of unsafe abortions. Conducting
district and village level advocacy workshops and talk
programs on above issues should be considered involving
frontline health workers such as VHWs (village health
workers), FCHVs (female community health volunteers)
and TBAs (traditional birth attendants) for awareness and
education campaigns among communities. Hence,
widespread public awareness is an important component
in making abortion safe where it has previously been
unsafe; women need to know that safe abortions are not
only permitted but also available.
REFERENCES
1. WHO, Abortion. A Tabulation of Available Data on the Frequency
and Mortality of Unsafe Abortion .Geneva, (ed. 2nd), 1993.
2. Ministry of Health, Nepal. National Maternal Mortality and
Morbidity Study. Kathmandu, Nepal: Ministry of Health; 1998.
3. AbouZahr C, Åhman E. Unsafe abortion and ectopic
pregnancy. In: Murray CJL, Lopez AD, eds. Health
Dimensions of Sex and Reproduction. Global Burden of
Disease and Injury Series Volume III. WHO, Harvard School
of Public Health and the World Bank, Harvard University
Press, 1998: 267-96.
4. Thapa S. Abortion Law in Nepal: The Road to Reform.
Reproductive Health Matters 2004; 12 (24 Supplement):
85-94.
5. Center for Reproductive Law and Policy (CRLP), FWLD.
Abortion in Nepal: Women Imprisoned. Kathmandu, Nepal:
CRLP and FWLD; 2002.
6. Public Opinion Poll on Abortion and Abortion Law 2002
Reproductive Health Research Policy Brief Number 5,
January 2003.
7. Unsafe abortion: global and regional estimates of incidence
and mortality due to unsafe abortion. Geneva, WHO 1998.
8. Alan Guttmacher Institute. Sharing responsibility: women,
society and abortion worldwide. The Alan Guttmacher
Institute, New York and Washington DC, 1999: 35.
9. Alan Guttmacher Institute. Sharing responsibility: women,
society and abortion worldwide. The Alan Guttmacher
Institute, New York and Washington DC, 1999: 36.
10. Wulf D, Jones H. Health professionals’ perceptions about
induced abortion in South Central and Southeast Asia. Int’l
Family Planning Perspectives 1997; 23: 59-67.
11. Rodriguez K, Strickler J. Clandestine abortion in Latin
America: provider perspectives. Women Health
1999; 28: 59-75.
12. Ahmed S, Islam A, Khanum PA, Barkat K. Induced abortion:
what’s happening in rural Bangladesh. Reprod Health Matters
1999; 7: 19-29.
13. Makinwa-Adebusoye P, Singh S, Audam S. Nigerian health
professionals’ perceptions about abortion. Int’l Family
Planning Perspectives, 1997, 23: 148-54.
14. Mahomed K. Improved treatment of abortion complications
and post-abortion family planning in Zimbabwe. Paper
presented at: 120th Annual Meeting, American Public Health
Association, Washington, DC, 8-12 November 1992.
15. Singh M, Jha R. Abortion legalized: Challenges ahead.
Kathmandu Univ Med J 2007; 17: 95-7.
16. CREHPA. Need to strengthen hospital resources for
management on complications of abortions in Nepal.
Reproductive Health Res Policy Brief No. 2, 2000
17. CREHPA. Public Opinion Poll on Abortion and Abortion
Law –I. Reproductive Health Res Policy Brief No.5, 2002.
18. CREHPA. Public Opinion Poll on Abortion Law and Rights-
II, News Release 2003
19. CREHPA. Public Opinion Poll on Abortion Law and
Service – III. Reproductive Health Res Policy Brief
No. 9, 2004.
20. Gupte M, Bandewar S, Pisal H. Abortion needs of women in
India: a case study of rural Maharashtra. Reprod Health
Matters 1997; 5: 77–86.
21. Azize-Vargas Y, Avilés LA. Abortion in Puerto Rico: the limits
of colonial legality.
1997; 5: 56-65.
22. Abeyasinghe NL, Weerasundera BJ, Jayawardene PA,
Somarathna SD. Awareness and views of the law on
termination of pregnancy and reasons for resorting to an
abortion among a group of women attending a clinic in
Colombo, Sri Lanka. J Forensic Legal Med 2009; 16: 134-7.
23. CREHPA. Public Opinion Poll Survey on Abortion 2006.
Reprod Health Res Policy Brief No. 10, 2006.
Reprod Health Matters
Fig.3. Knowledge about availability of CAC service at
NMCTH
Nepal Medical College Journal