Shreejana Bajracharya, ASAP Youth Champion, Nepal

The International Day for the Eradication of Poverty falls on the 17th of October every year. On this ocassion, Sreejana reflects on whether poverty is the only factor that influences access to safe abortions for women in Nepal. 

“It’s a culture.” I tell one of the freelance journalists. “When you have a headache or something you don’t rush to the hospital. You go directly to the pharmacist.”

This article talks about the clandestine procedures that are still common in Nepal even though abortion is legal. The abortion law in Nepal does not permit pharmacies to sell abortion pills without a prescription. However, thousands of women are easily accessing Medical Abortion (MA) pills via medical shops/pharmacies nearby.

Even if it is mentioned strictly that abortion should be performed within a standard health protocol by authorized/certified health facilities and by trained medical professionals, women continue to access services through unregistered medical shops and untrained medical professionals. A study done by the Center for Research on Environment, Health & Population (CREHPA) shows that nationwide, fewer than half (42%) of all abortions were provided legally in government-approved facilities. The remainder (58%) were clandestine procedures provided by untrained or unapproved providers, or induced by the pregnant woman herself. While it is true that when taken correctly, self-inducing abortions using misoprostol and mifepristone can safely terminate a pregnancy, beyond a certain gestational period, the woman may need medical support in case of bleeding or any other complication.

Studies have also shown that women prefer visiting pharmacies rather than any Government authorized health facilities for abortion service. Nepal’s pharmaceutical industry is difficult to regulate. Only four brands of misoprostol and mifepristone abortion kits are legal in the country, but at least 20 different brands are smuggled across its porous border with India. The pharmacists have a high incentive to sell them since they can pocket hundreds of rupees each time they sell medical abortion kits.

If women are willing to pay high amounts then clearly cost is not the only barrier that keeps them away from facilities?

I had casually discussed with them the reasons behind accessing MA pills in pharmacies rather than authorized health facilities with the women who used self-administrated drugs. Most of them shared that pharmacies are convenient as they do not have to go through paperwork; no forms, no personal information needs to be provided, and the guarantee of privacy.

In the meanwhile, an estimated 80,000 women were treated in health facilities in 2014 for complications related to unsafe abortion and miscarriage. Sixty-eight percent of these women had complications that resulted from a clandestine abortion. Forty-four percent of women receiving post-abortion care were treated in private facilities, 41% in public facilities and 15% in NGO facilities.

Various organizations like Marie Stopes Nepal and PSI Nepal have recognized that working in partnership with pharmacies could result in women being provided with accurate information and instructions to reduce complications while self-administering drugs. Marie Stopes Nepal has been closely working with pharmacists and orienting them about their mobile health program “Mero Swastha Mero Haath ma”.

How does this work?

• The pharmacists provide stickers and wallet cards to the client accessing medical abortion pills.
• The client registers on a mobile health platform; types MA and sends it to 35565, and they receive SMSes free of cost.
• It has clear stepwise instructions on how to use medical abortion pills.
• It discusses the expected results and instructions on what to do in case of any complications.
• The SMS also provides information on Contact Centre numbers for emergency and complications
• It SMS also has information on post-abortion family planning and information on Marie Stopes’ clinics.

Recently Government of Nepal has provided free abortion service in Government health facilities- District Hospitals, Primary Health Care and via Health/sub-health posts. This is indeed great progress while recognizing women’s health and prioritizing abortion to be safe, legal and accessible. However, to measure the impact of the provision of free safe abortion services the number of women accessing abortion without stigma in health facilities resulting in a reduction in clandestine abortion should be performed.

What else can we recommend to the Government of Nepal?

• Take into account the fact that pharmacies are more accessible for women than health facilities.
• Reform its policy; either resulting in stricter punishment for pharmacies selling unauthorized medical abortion pills (besides the four registered MA drugs),
• Or work in coordination with Druggists and Chemists Association to regulate the drugs and make abortion pills accessible to women all over Nepal with clear instructions, at a reasonable price.
• Increase the awareness around the legality of safe abortion
• Actively conduct stigma reduction programmes in the community and through the media to ensure that the women in Nepal can benefit from the legal safe abortion services.

So, the next time a woman goes to the pharmacist to get a medical abortion pill, she will get one which is safe and effective, price controlled and with a set of instructions which will ensure that she understands the complications and has access to a service centre if she needs one!