This report is published in partnership with the Center for Research on Environment, Health and Population Activities (CREHPA).
Advocacy Case Study: Ensuring Safe Abortion Provision at the Local Level—Madhesh Province, Nepal
This report is published in partnership with the Center for Research on Environment, Health and Population Activities (CREHPA).
Nepal is well known for having moved from completely prohibiting abortion to allowing it on request, in 2002,1 something that no other country in Southern Asia has done in a single amendment. As with any expansion of legal grounds, changing the law is not enough, and the country is also notable for enshrining into law women’s right to abortion free of charge in public institutions.2 Enabling all women throughout the country to exercise that right, however, remains a challenge.3
The federalization of all government services, which was required by Nepal’s 2015 constitution,4 led to the need to clarify the distinct roles and responsibilities for providing safe abortion services in each of three government tiers—federal, provincial and local (i.e., municipality). In 2022, guidelines for the implementation of safe abortion services were drafted for Sudurpashchim Province;5 these then served as the basis for developing these guidelines for another Nepali province, Madhesh Province.
|Selected reproductive health indicators for women aged 15–49, Nepal and Madhesh Province
|No. of women (2021)
|Maternal mortality ratio (2021)
|% of married women with unmet need for modern contraceptive methods (2022)
|Overall pregnancy rate (2017)
|Unintended pregnancy rate (2017)
|Abortion rate (2017)
|% of pregnancies unintended (2017)
|% of unintended pregnancies ending in abortion* (2017)
|% of unintended pregnancies ending in unplanned births* (2017)
|*% of unintended pregnancies ending in miscarriage not shown. Notes: Ratio is the number of maternal deaths per 100,000 live births. Rates are the number of events each year per 1,000 women. Year is most recent for which data are available, except for abortions and pregnancies. These indicators rely on less-recent data from a methodology that avoids directly questioning women, who vastly underreport their abortions and related unintended pregnancies. Sources: References 6 and 7. Population numbers for 2021 come from: National Statistics Office, National Population and Housing Census 2021, Vol. 1, Kathmandu, Nepal: Government of Nepal, 2023, https://censusnepal.cbs.gov.np/results/downloads/national. Maternal mortality data come from: Ministry of Health and Population and the National Statistics Office, National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021, Kathmandu, Nepal: Ministry of Health and Population and National Statistics Office, 2022, https://mohp.gov.np/uploads/Resources/Nepal%20Maternal%20Mortality%20Report%202021.pdf.
Selecting the Province
Of Nepal’s seven provinces, Madhesh Province stands out on several reproductive health indicators. For example, women there have the most children—and the largest wanted family size—of women in any other province,6 facts that are consistent with women there starting childbearing the soonest and having the highest annual pregnancy rate (181 pregnancies per 1,000 women aged 15–49 vs. 114–146 in the six other provinces).7 Despite married women’s stated desires for large families, residents of Madhesh Province are likeliest among those of all provinces to feel pressured into pregnancy (16% vs. 6–8%).6 The province’s estimated abortion rate is somewhat higher than that for Nepal overall (50 abortions per 1,000 women vs. 42).7 Although the proportion of abortions provided by government-certified staff in approved facilities is unavailable, it is important to fully implement local guidelines for safe abortion services to ensure that all who need to can access safe and legal care.
Holding the Workshops
Nepal’s leading research organization in sexual and reproductive health and rights, the Center for Research on Environment, Health and Population Activities (CREHPA), organized a series of interactive workshops to widely share and discuss the final draft of Madhesh Province safe abortion implementation guidelines. They met with elected municipality officials and health care providers in seven Madhesh Province municipalities: Baudhimai, Bindabaseni, Golbazar, Harion, Khadak, Pokhariya and Sabaila. Over nearly two weeks in April 2023, a total of 194 participants attended one of seven workshops; participants included mayors, deputy mayors, ward chairs, municipality health coordinators and municipality-level health care providers.
At these workshops, CREHPA first presented information on recent achievements in, and ongoing challenges to, providing safe abortions, and then introduced to stakeholders the recently finalized safe abortion implementation guidelines for Madhesh Province. CREHPA facilitated the open and far-ranging discussions with stakeholders that followed.
From the very beginning, it was clear that participants had doubts and misconceptions on a wide range of issues. Several officials and providers admitted being uninformed about the provisions for legal abortion in Nepal. Issues raised by stakeholders pertinent to delivering services included: how facilities and providers would get accredited to provide safe abortion care; how providers would get reimbursed for supplying medication abortion pills so that women would not have to pay; how to procure adequate supplies of these pills; and how to provide infection management and other related services. Specifically, the following issues arose from the workshops:
Officials and providers were unaware of the site accreditation process for municipality-level facilities. Participants (e.g., in Golbazar, Harion and Pokhariya) were unclear about how to obtain accreditation for facilities and staff.
Few or no sites were accredited to provide safe abortion services. Some municipalities (e.g., Bindabaseni and Sabaila) lacked even a single site accredited to provide safe abortion. Bindabaseni residents’ only option was to travel to another municipality or seek illegal, potentially unsafe abortions, either locally or in India.
Few sites were accredited to offer medication abortion. Many Nepali women prefer medication over procedural abortion,8 and method choice is guaranteed in the federal-level Comprehensive Safe Abortion Guidelines.9 But in Sabaila, just a single site provided medication abortion, and women not living nearby have had to travel long distances to buy pills either elsewhere in Nepal or over the border in India. In Baudhimai municipality, which is adjacent to India, women can obtain unregulated abortion pills across the border in Indian pharmacies. Similarly, in Pokhariya, the use of abortion pills bought over the counter in India is widespread, with at least some pills likely to be counterfeit and thus ineffective.10
Many existing accredited sites were not operational. Officials in multiple municipalities explained that many accredited sites were nonfunctional because they could not hire trained staff. This was the reason given for why none of three listed sites were functional in Khadak and just one was functional in Baudhimai.
Unaccredited sites were widespread throughout the municipalities. Numerous abortions take place in unaccredited private clinics and through the use of abortion pills purchased without a prescription in pharmacies. Participants noted that private clinics were prevalent in urban areas in Golbazar; and in the one predominantly urban municipality of the seven that participated, Harion, the only functioning site offering abortion care was an unaccredited private clinic. Participants stressed that in rural areas throughout all seven municipalities, women tended to seek abortions from traditional providers who use folk methods, which are especially likely to result in complications.
Monitoring of sites was lacking. Officials and providers from several municipalities—e.g., Baudhimai, Harion and Sabaila—cited confusion over how to monitor compliance with accreditation requirements. Because stakeholders had no clear guidelines on how rogue clinics were to be controlled, they were unsure how to close unaccredited private clinics.
Budgeting for abortion services was problematic. One of the most commonly mentioned barriers to meeting the demand for safe abortion services was a lack of funds. This included municipalities not budgeting for abortion care, having a severely limited budget and restricting funding to training only specific health care personnel.
Stigma and taboos persist. Abortion is highly stigmatized in many communities, especially those in rural areas. Participants in Khadak and Sabaila noted that this real fear of being ostracized and judged led many women to deliberately avoid formal services, only to later get an unsafe abortion from an unaccredited provider, often across the border in India.
Sex-selective abortion remains common. Officials and providers also mentioned the disturbingly high prevalence of sex-selective abortions, which have been illegal in Nepal since 2002.1 Some women who can afford it pay first for prenatal testing to determine the sex of a fetus in a big city in Madhesh Province and then obtain an abortion if they are carrying a girl. Residents in the border municipalities of Baudhimai and Bindabaseni often clandestinely seek these services in India.
Commitments for Progress
Following the stakeholder meetings, CREHPA hosted a similarly interactive meeting with the media so that members of the press could be informed about the Madhesh Province guidelines and the substance of the discussions. The timing of the media event likely added to the momentum of the finalization of the Madhesh guidelines: Just two weeks later, the Madhesh Ministry of Health and Population approved them, bringing women and girls in that province closer to realizing their reproductive autonomy, as promised in the country’s laws.
The specific commitments made by participants in the workshops fall into three major areas of abortion services in the province:
Funding provider training. Participants’ assertions that the absence of trained providers reduced the availability of safe abortion services are supported by the data: Just over half of the 15 abortion care training centers in Madhesh Province were nonfunctional as of 2022.11 To restore or expand safe abortion services, officials pledged to fund more training of abortion care providers. Training nursing staff was a top priority to getting sites accredited to provide medication abortions in rural areas.
Monitoring abortion services sites. Several municipalities pledged to form committees in the deputy mayors’ offices or through other local enforcement mechanisms to monitor how closely sites adhere to service provision guidelines. These committees would aim to deter private clinics from offering illegal, potentially unsafe abortions.
Educating communities. If many elected officials and providers have little practical knowledge about the specifics of legal abortion, the general public likely has even less. Municipality officials agreed to conduct awareness campaigns—through mothers’ groups, volunteer community health workers and many other community organizations—to make sure that all women were fully informed of their legal options.
Recommendations for Success
That so many providers and officials lacked accurate information highlights the importance of focused advocacy in the jurisdictions tasked with implementing safe abortion services guidelines. Directly engaging municipality officials through in-person workshops is a highly effective way to move policy from paper to practice. It is also easily replicable in most settings.
Some of the recommendations that came directly from the workshops include: fully implement the new province-level guidelines for Madhesh; prepare municipality-level action plans; allocate adequate local resources to safe abortion services; increase monitoring to ensure continued accreditation and quality of abortion care; run education campaigns to inform the public about the law and the dangers of unsafe abortion; and combat sex-selective abortion by fully complying with the National Strategy for Ending Gender-Biased Sex Selection.12
The recently approved abortion care guidelines for Madhesh Province must be fully disseminated and implemented. Closely following them is key to addressing many of the practical issues that emerged in the workshops. Similar province- and municipality-level advocacy events are needed throughout the entire country so Nepal’s remaining provinces can develop their own guidelines to improve safe abortion care.
1. Government of Nepal, 11th Amendment to the Muluki Ain (National Code) of Nepal, 1959 (2020 BS), 2002, https://nepal.ohchr.org/en/resources/Documents/English/other/2009/March%2009/1.Country%20Code%20amendment.pdf.
2. Nepal Law Commission and Government of Nepal, The Right to Safe Motherhood and Reproductive Health Act, 2018 (2075 BS), Act No. 9, 2018, https://www.lawcommission.gov.np/en/wp-content/uploads/2019/07/The-Right-to-Safe-Motherhood-and-Reproductive-Health-Act-2075-2018.pdf.
3. Puri M, Tamang A and Singh S, Addressing Gaps in Safe Abortion Services in Nepal, New York: Guttmacher Institute; Kathmandu, Nepal: Center for Research on Environment, Health and Population Activities (CREHPA), 2022, https://www.guttmacher.org/article/2022/06/addressing-gaps-safe-abortion-services-nepal.
4. Government of Nepal, Constitution of Nepal, 2015, https://constituteproject.org/countries/Asia/Nepal?lang=en.
5. Puri M et al., Advocacy Case Study: Addressing the Challenges of Delivering Safe Abortion Services at Province and Local Levels in Nepal, New York: Guttmacher Institute; Kathmandu, Nepal: CREHPA, 2023, https://www.guttmacher.org/report/advocacy-case-study-abortion-services-nepal.
6. Ministry of Health and Population, New ERA and ICF International, Nepal Demographic and Health Survey 2022, Kathmandu, Nepal: Ministry of Health and Population, 2022, https://dhsprogram.com/pubs/pdf/FR379/FR379.pdf.
7. Sundaram A et al., Adding It Up: Costs and Benefits of Meeting the Contraceptive and Maternal and Newborn Health Needs of Women in Nepal, New York: Guttmacher Institute, 2019, https://www.guttmacher.org/report/adding-it-up-meeting-contraceptive-mnh-needs-nepal.
8. Tamang A et al., Factors associated with choice of medical or surgical abortion among women in Nepal, International Journal of Gynecology & Obstetrics, 2012, 118:S52–S56, doi:10.1016/j.ijgo.2012.05.011.
9. National Health Training Centre, Department of Health Services and Ministry of Health and Population, Comprehensive Abortion Care (CAC): Integrated Reference Manual, 3rd Ed., Kathmandu, Nepal: Ministry of Health and Population, 2015.
10. Bower J et al., Quality testing of mifepristone and misoprostol in 11 countries, International Journal of Gynecology & Obstetrics, 2023, 00:1–11, doi:10.1002/ijgo.15148.
11. Ministry of Health and Population of Madhesh Pradesh, Monitoring Report of Health Directorate, Madhesh Province, 2078/79, Janakpurdham, Nepal: Ministry of Health and Population of Madhesh Pradesh, 2022.
12. Ministry of Health and Population, National Strategy on Ending Gender-Biased Sex Selection, Kathmandu, Nepal: Ministry of Health and Population, 2021, https://mohp.gov.np/uploads/Resources/National%20Strategy%20on%20Gender%20Biased%20Sex%20selection.pdf. [in Nepali]
Puri M et al., Advocacy Case Study: Ensuring Safe Abortion Provision at the Local Level—Madhesh Province, Nepal, New York: Guttmacher Institute; Kathmandu, Nepal: Center for Research on Environment, Health and Population Activities, 2023, https://www.guttmacher.org/report/advocacy-case-study-safe-abortion-provision-nepal.
This advocacy case study was written by Mahesh Puri and Anand Tamang, both of the Center for Research on Environment, Health and Population Activities; and by Susheela Singh and Lisa Remez, both of the Guttmacher Institute.
This advocacy case study was made possible by grants from the Norwegian Agency for Development Cooperation and the Swedish International Development Cooperation Agency. The findings and conclusions contained within are those of the authors and do not necessarily reflect the positions or policies of the donors. The authors thank Ashley C. Little, Guttmacher Institute, for her invaluable fact-checking.