Adequate access to contraception and sexual and reproductive health (SRH) information post-abortion: A case study from Nepal

Abstract

Of the 55.7 million abortions that occur worldwide each year, 30.6 million (54.9%) are safe, and 25.1 million (45.1%) are considered unsafe. Of the unsafe abortions occurring annually, 24.3 million (97%) occur in developing countries. Since the legalisation of abortion in Nepal in 2002 and the availability of medical abortion in 2009, Nepal has demonstrated significant progress in the expansion of safe abortion and family planning services. However, a significant number of women continue to access unsafe abortions in the country. An estimated 60% of all abortions performed in 2014 were unsafe, with unsafe abortion continuing to be a leading contributor to maternal mortality. Despite medical abortion access being solely permitted through government accredited safe abortion services, medical abortion pills are readily available for illegal purchase at pharmacies throughout the country.

Efficient and equitable access to high quality safe abortion services as well as effective and culturally appropriate post-abortion care is essential for positive health outcomes for women and for the prevention of future unintended pregnancies. However, in Nepal, women accessing medical abortion through pharmacies do not systematically receive any form of abortion care or support such as: adequate information regarding the administration of medical abortion pills, sexual and reproductive health (SRH) information, family planning and contraceptive counselling, post-abortion contraception; or effective and timely health care referral.

This qualitative, exploratory study conducted 29 in-depth open-ended interviews in the Kathmandu Valley and Sunsari District of Nepal to explore and examine the post-abortion experiences of Nepali women, and access and uptake of safe abortion services; unsafe abortion; post-abortion contraception; and sexual and reproductive health information. Research participants included a cross-section of Sexual and Reproductive Health and Rights (SRHR) professionals; women who accessed medical abortion through an accredited safe abortion service; and women who accessed illegal and unsafe medical abortion through pharmacies.

This study utilised an Assets Focused Rapid Participatory Appraisal research methodology underpinned by a health information pyramid conceptual framework, referred to as an Assets Focused Rapid Participatory Assessment Cycle. The research design was grounded in the desire to utilise community recognised assets to support outcomes and recommendations as well as to base the research within a positive and participatory context that ensured culturally sensitive and contextually rich data collection.

Thematic content analysis revealed emerging themes relating to barriers to access and uptake of high quality safe abortion services, comprehensive family planning counselling and post-abortion contraception as well as the decision-making when seeking safe or unsafe medical abortion. Findings emphasised the interconnectivity of sexual and reproductive health and rights; gender discrimination; reproductive coercion; education; poverty; geographical isolation; spousal separation; and women’s personal, social and economic empowerment.

Effective and ongoing sector-wide monitoring and evaluation of safe abortion services and their staff is essential if women in Nepal are to have adequate access to safe abortion services and post-abortion care as well as to ensure countrywide adherence to the current Safe Abortion Policy. While barriers to safe abortion services persist, so will the continued demand for medical abortion provision through pharmacies. Innovative and effective harm reduction implementation combined with medical abortion access and information expansion strategies offer the potential to increase access to safe medical abortion while decreasing adverse health outcomes for women.

Associated Publications

Rogers, C., Sapkota, S., Tako, A., & Dantas, J.A.R. (2019). Post-abortion care in Nepal: perspectives of a cross-section of sexual and reproductive health and rights professionals. BMC Women’s Health doi:10.1186/s12905-019-0734-1

Rogers, C., & Dantas, J.A.R. (2017). Access to contraception and sexual and reproductive health information post-abortion: a systematic review of literature from low- and middle-income countries. Journal of Family Planning and Reproductive Health Care doi:10.1136/jfprhc-2016-101469

Rogers, C., Sapkota, S., Paudel, R., & Dantas, J.A.R. (under peer review). Medical abortion in Nepal: a qualitative study on women’s experiences at safe abortion services and pharmacies.

Rogers, C., Sapkota, S., & Dantas, J.A.R. (under peer review). Conducting qualitative sexual and reproductive health and rights (SRHR) research in resource poor settings: experiences from Nepal.

Rogers, C. (under examination). Adequate Access to Contraception and Sexual and Reproductive Health (SRH) Information Post-Abortion: A Case Study from Nepal. Unpublished PhD Thesis, Curtin University.

Research conducted for the attainment of the degree: Doctor of Philosophy (International Health), Curtin University, Australia