Abstract
Unsafe abortion's significant contribution to maternal mortality and morbidity was a critical factor leading to liberalization of Nepal's restrictive abortion law in 2002. Careful, comprehensive planning among a range of multisectoral stakeholders, led by Nepal's Ministry of Health and Population, enabled the country subsequently to introduce and scale up safe abortion services in a remarkably short timeframe. This paper examines factors that contributed to rapid, successful implementation of legal abortion in this mountainous republic, including deliberate attention to the key areas of policy, health system capacity, equipment and supplies, and information dissemination. Important elements of this successful model of scaling up safe legal abortion include: the pre-existence of postabortion care services, through which health-care providers were already familiar with the main clinical technique for safe abortion; government leadership in coordinating complementary contributions from a wide range of public- and private-sector actors; reliance on public-health evidence in formulating policies governing abortion provision, which led to the embrace of medical abortion and authorization of midlevel providers as key strategies for decentralizing care; and integration of abortion care into existing Safe Motherhood and the broader health system. While challenges remain in ensuring that all Nepali women can readily exercise their legal right to early pregnancy termination, the national safe abortion program has already yielded strong positive results. Nepal's experience making high-quality abortion care widely accessible in a short period of time offers important lessons for other countries seeking to reduce maternal mortality and morbidity from unsafe abortion and to achieve Millennium Development Goals.
Highlights
Nepal is a poor country whose rugged terrain and political unrest exacerbate the significant challenges of providing health care to its population of about 28 million
This paper examines factors that contributed to rapid, successful implementation of legal abortion in this mountainous republic, including deliberate attention to the key areas of policy, health system capacity, equipment and supplies, and information dissemination
Important elements of this successful model of scaling up safe legal abortion include: the preexistence of postabortion care services, through which health-care providers were already familiar with the main clinical technique for safe abortion; government leadership in coordinating complementary contributions from a wide range of public- and private-sector actors; reliance on public-health evidence in formulating policies governing abortion provision, which led to the embrace of medical abortion and authorization of midlevel providers as key strategies for decentralizing care; and integration of abortion care into existing Safe Motherhood and the broader health system
Summary
Nepal is a poor country whose rugged terrain and political unrest exacerbate the significant challenges of providing health care to its population of about 28 million. In the case of minors (< 16 yrs of age) or mental incompetence, a legal guardian must give consent This significant policy change followed an intensive period of advocacy and rigorous planning for implementation of safe legal abortion services. This article highlights key elements of planning and implementation of safe abortion care in Nepal to suggest lessons related to both successes and challenges that can be applied in other contexts to reduce maternal deaths and injuries from unsafe abortion. Perhaps the element most critical to the successful roll-out of safe legal abortion in Nepal is reliance on public-health evidence as a basis for policy, which led to the embrace of medical abortion technology and the involvement of midlevel providers as key strategies for making safe abortion care widely accessible to women. The authors hope that sharing the successful experience of safe abortion service implementation in Nepal can lead to improvement in women’s health and contribute to achievement of health-related Millennium Development Goals in a variety of settings
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