Statement from the Peace Foundation, Pakistan
“We have been hearing so many sweet coded words that now with legal abortion women will be free, have access to reproductive justice. Legislation regarding abortion is often proved meaningless, however, because wherever abortion is legal, barriers are still posing threats for safe abortion seekers, providers and advocates. The law on abortion is highly restrictive in Pakistan. But the situation for many women is not different in Nepal or India. Laws permitting safe abortion are present in those and other countries, but control over women and barriers are present everywhere. A question arises: those who disobey traffic laws are charged on the spot; when safe abortion is legal but not provided to women, and only unsafe abortions are available, why are those who fail to implement the law not charged? Why are they allowed to break the law without punishment? Even where abortion is forbidden by both law and religion, punishment is highly dependent on the social status of the woman who had the abortion. Women belonging to rich families have so many resources to terminate their pregnancies, but punitive social norms are applied to poor women.”
One woman’s experience: Nepal
“A woman aged 45 with 3 children, told me she was two months pregnant and wanted an abortion. I referred her to a safe abortion clinic but she went to a local pharmacy instead and took 10 pills of medical abortifacients thinking the pregnancy would come out soon. Later on she suffered excessive bleeding and came to me seeking help. I immediately sent her to a health center through an ambulance for proper management. After a couple of days she shared with me that she felt guilty for ignoring my advice to go to a safe abortion site and also thanked me for helping her.”
This woman’s story was shared by Nepal Community Health Volunteer (FCHV) Sarada Paudel during the sensitization programme “Talking about abortion with Nepal’s Female Community Health Volunteers”, 29 December 2015, by Asia Safe Abortion Partnership. Read the full blog post.
Effects of being denied abortion in Nepal
Center for Research on Environment, Health and Population Activities (CREHPA)Reproductive Health Research Policy Brief No.20, November 2015Full report of the study: “I need to terminate this pregnancy even if it will take my life”: a qualitative study of the effect of being denied legal abortion on women’s lives in Nepal. by Mahesh Puri, Divya Vohra, Caitlin Gerdts, Diana Greene Foster. BMC Women’s Health 2015. 15:85.Many women who are denied legal abortion care go on to seek unsafe alternatives: further study could help identify strategies to improve access to safe abortion services in NepalBackground Access to safe abortion services and to post-abortion care are critical to women’s ability to control their fertility, protect their health, and ensure the wellbeing of their families [1-3]. Researchers have hypothesized that women who are denied abortions may go on to seek illegal abortions elsewhere [4-7]. The experiences of women denied abortion services and the health consequences of seeking alternative, and potentially unsafe, services are not fully documented [7].In 2002, abortion was legalized in Nepal and made widely available. Abortion is permitted up to 12 weeks gestation on request and up to 18 weeks in cases of rape, incest, and health risks to the woman or fetus [8]. Abortion services were established at most government hospitals, designated private hospitals, and non-governmental organization (NGO) clinics. The government of Nepal has taken important steps to include abortion as a component of women’s reproductive health services, enabling nearly 800,000 women to obtain safe, legal services between 2004 and 2014. The government has recently announced that abortion services will be made available free of cost in the public facilities but this will take time to implement.Methodology We conducted in-depth qualitative interviews with 25 women who were denied abortion services due to high gestational age (>12 weeks) from two health facilities, in September and October 2013. The study sites included a reproductive health non-governmental organization clinic in Eastern Nepal and a major tertiary government hospital in Kathmandu. Participants were eligible if they were women between 18 and 49 years old, seeking abortion services, and denied services due to advanced gestational age on the day of recruitment. Researchers completed a case report and obtained informed consent at recruitment, then contacted women two months later for an open-ended in-depth qualitative interview about their experiences seeking and being denied legal abortion services.Denial of legal abortion is commonMany Nepali women are still unable to access abortion services, especially the poorest, most marginalized and geographically isolated women. A total of 311 women sought abortion services from the two sampled facilities. Of these, about 26% (80 women) did not receive the abortion services they were seeking; 14% were turned away for high gestational age and 12% were turned away for other reasons including lack of availability of abortion medications at the facility, undetectable pregnancy and medical contraindications. Some women were unaware of why they were turned away, but most thought that gestational age must have played a role.Actions and emotions upon being turned away variedWomen found it difficult to express their feelings upon being denied care. Some women were frustrated, angry, upset, or desperate. In contrast, women who received abortions typically reported being happy, relieved, and satisfied with the services they had received. Some women reported being treated poorly at the private clinics where they received their abortions, because they were stigmatized by providers.
“I got really angry as the doctor had said all this and later what would become of me when I had to give birth. The only thing that I keep thinking of is, how will I give birth to the baby later?”
Getting an abortion after being turned away is not always easy
“I felt very scared when the doctor told me it wasn’t possible. When they said ‘no’, I felt like, where am I going to go and how would I survive in this state? I felt like crying and I cried too. I told her I needed to terminate this pregnancy even if it will take my life.”
Many women continue their pregnancies after denial. Others, however, seek care at other facilities, obtain illegal abortions, or take self-induction medications, which can result in incomplete abortion or complications. Twelve out of 25 women (48%) successfully obtained abortions at facilities for a cost after being turned away. Women commonly paid between 10,000 and 15,000 Nepali rupees for abortion, and many received multiple referrals and visited several private health facilities before finding one willing to perform the procedure at an affordable price. One woman paid 26,000 Nepali Rupees. All of the women who obtained abortions after denial did so at facilities that were unlikely to have been certified to legally provide abortion.
“It was really difficult to make that decision… I thought like if I gave birth to that baby then the other kids would face problems for their whole life. …how could I deliver that kid as I already have sons and daughter!”
Women lack knowledge about abortion law and legality of servicesThe vast majority of women who were interviewed reported that they had no knowledge of abortion-related laws in Nepal. Many knew that facilities typically didn’t provide abortion after 12 weeks gestation, but women did not necessarily recognize this as a legal restriction. Some women said they believed abortion is illegal in Nepal. All of the women who obtained abortions after denial from recruitment sites were beyond the legal gestational age limit for abortion on request, yet women rarely knew whether abortions were ever legal, or under what circumstances they could be considered legal.
“I didn’t have much money for abortion, without money it wasn’t possible for me. …so I worked for a whole month and collected money for abortion.”“They disposed of the fetus and told me not to tell about it to anyone as it was illegal. …They kept it undercover regardless of who came…”
Conclusions
- Delays, such as financial and logistical barriers and difficulty recognizing pregnancy, prevent many women from receiving legal abortion services within the first 12 weeks of pregnancy
- Women and providers do not fully understand the scope of the abortion law
- Denial of legal services may increase the likelihood that women seek illegal, potentially unsafe, abortions
Recommendations for improving women’s access to legal care:1. Minimize delays women face in seeking abortion care
- Improve awareness of pregnancy risk and availability of services
- Increase access to pregnancy tests at low costs
- Reduce stigma of abortion
2. Train more providers at all levels to provide abortion and to refer appropriately
- Support women at the moment of turn-away, regardless of the reason for denial
- Inform women about legal indications for abortion according to the law
- Provide counseling to women and refer them to other facilities where they can get service
- Discuss the dangers of self-induction and unsafe abortion
3. Increase provider empathy for women with unintended pregnancy
- Implement recently announced policy of free abortion services, as many women face financial hardships
- Discuss psychological effects of unplanned pregnancy with women
4. Monitor the prevalence of illegal abortion and its impact on women’s health
- Conduct additional qualitative research on women’s experiences with unsafe and/or illegal abortion providers
- Conduct further research on providers’ perspectives of abortion denial
- Implement a longitudinal study on the impact of denial of abortion services on women’s health and wellbeing
AcknowledgementsThis policy brief is based on research funded by the Society for Family Planning and the Packard Foundation and coordinated by the University of California, San Francisco. We are very grateful to our additional international collaborators, from Bangladesh, South Africa, Tunisia, and Colombia. Most importantly, we are immensely grateful to the participants of this study including the women who have given their time and responded to questions on personal matters.References1. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE et al. Unsafe abortion: the preventable pandemic. Lancet. 2006; 368(9550):1908-19.2. Rasch V. Unsafe abortion and postabortion care – an overview. Acta Obstet Gynecol Scand. 2011; 90(7):692-700.3. Shah I, Ahman E. Unsafe abortion in 2008: global and regional levels and trends. Reprod Health Matters. 2010; 18(36):90-101.4. Fetters t, Vonthanak S, Picardo C, Rathavy T. Abortion-related complications in Cambodia. BJOG. 2008;115(8):957-68.5. Gebreselassie H, Fetters T, Singh S, Abdella A, Gebrehiwot Y, Tesfaye S et al. Caring for women with abortion complications in Ethiopia: national estimates and future implications. Int Perspect Sex Reprod Health. 2010;36(1):6-15.6. Harries J, Gerdts C, Momberg M, Greene Foster D. An exploratory study of what happens to women who are denied abortions in Cape Town, South Africa. Reprod Health. 2015; 12:21.7. Upadhyay UD, Weitz TA, Jone RK, Barar RE, Foster DG. Denial of abortion because of provider gestational age limits in the United States. Am J Public Health. 2014;104(9):1687-94.8. MoHP; National Safe Abortion Policy. In Kathmandu Ministry of Health and Population 2002.