Unsafe, Illegal Abortion Persists in Nepal Despite Legalization

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KATHMANDU, NEPAL - Kalpana Rai, 20, lies in bed No. 301 on the fourth floor of Prasuti Griha Government Maternity Hospital, Nepal's lone maternity hospital. She was brought to the hospital in Kathmandu, Nepal's capital, because of excessive bleeding after obtaining an unsafe abortion in an illegal clinic. "I didn't know where to go for an abortion," says Rai, who has studied up until 10th grade but wasn't aware abortion was legal in Nepal. "I did it in a rush and am suffering now." A dirty, green blanket covers her in the hospital bed, where she receives IV therapy. The loss of blood has left her face pale, and sweat is dripping from her forehead. Her husband, Toran Bahadur Kumal, sits beside her. The couple met while they were working in Kuwait when Rai was 17. Two years after coming back to Kathmandu, they got married. But their families didn't accept it because it was an intercaste marriage. Six months after their wedding, Rai got pregnant. But with no support from their families and a dwindling business, they thought it wasn't a good time to have a child. The couple decided to have an abortion but didn't know that they could obtain a safe and legal one in a government-approved clinic. The only information they had was that it was a sin and so they kept it a secret. They found a place named Samrat Polyclinic while walking the streets of a busy neighborhood in the capital. The chemist said the procedure only takes 10 minutes to perform, which Rai says she was elated to hear. She bargained the price down from 2,500 rupees ($32) to 2,200 rupees ($28). Rai recalls entering a small room and feeling scared. The procedure took 30 minutes - not the promised 10 - and Rai says she was in unbearable pain. The chemist then gave her medicine and told her the procedure was over. But when she got home, the bleeding wouldn't stop. She thought this was normal until she started to periodically lose consciousness. The couple waited for a week, then finally went back to the same polyclinic. The person there examined Rai and said "something" had been left inside her. So he put his hands inside Rai's vagina and "cleaned" it, Kumal says. Armed with more medicine, the couple went home. But Rai says she started having more pain and bleeding, leading to periods of unconsciousness. Her neighbors found out and told her to go to the maternity hospital. "She almost died," Kumal says. "But after bringing her to the hospital, she seems to be fine." Tripti Neupane, a nurse at the hospital, says Rai is out of danger. But she tells the couple that they can't have a child for the next two years or sexual intercourse for six months. A decade after the Nepali government legalized abortion, educated women in Nepal still report risking their lives for illegal and unsafe abortions. Medical professionals cite various causes for this disconnect, from lack of awareness of the law and reproductive health to social stigma. Traditional views of contraceptives in Nepali society and traditional abortion practices in rural areas also contribute to illegal and unsafe abortions. The Nepali government legalized abortion in 2002. Legal abortion services are now offered in nearly 500 governmental, nongovernmental and private centers in all of Nepal's 75 districts, according to the Family Health Division of the Ministry of Health and Population. With the consent of the pregnant women, fetuses up to 12 weeks old can be aborted. In case of rape or incest, the legal abortion period is 18 weeks. Pregnancies of any duration can be aborted if an authorized medical practitioner determines that a mother's life or mental or physical health is in danger or the fetus is deformed. Since abortion gained its legal status, nearly 50,000 women have undergone safe abortion in Nepal, according to the Family Health Division. Still, the division attributes 7 percent of maternal deaths to unsafe abortion. Nepal has pledged to improve maternal health under goal five of the Millennium Development Goals, a U.N. anti-poverty initiative. The country posted one of the highest mortality rates in the world, with 1,500 maternal deaths per every 100,000 live births in 1990, according to the MDG Monitor. In 2005, it has nearly halved deaths to 830. Like Rai, Mita Sapkota, also 20, endangered her life by seeking an unsafe abortion. Sapkota is thin and has deep, sunken eyes. She is weak, and her veins are visible in her hands and feet. Two years ago, her parents arranged her marriage to Ujjwal Sapkota from the neighboring village in Dhading, a district in central Nepal. A month after their marriage, she says she was shocked to find out she was pregnant. The couple hadn't know about any forms of contraceptives. Sapkota says she feared the community would talk about her for being pregnant so soon after marriage. "I thought it would be embarrassing to be pregnant so early, and people would talk about it," she says. She then started brainstorming ways to abort her child herself. She tried various methods she had heard of: stuffing her hair into her mouth to induce excessive vomiting, eating a lot of papaya, honey and blue Hokkaido pumpkin or squash and inserting the latex of a cactus plant into her vagina. "But nothing worked," she says. Three months pregnant, she started pressing her now-visible womb. and inserting her hands into it to try to abort the child. Sapkota says she started having lower abdominal pain and also bleeding. At first, she says she was happy because she thought she was menstruating and had successfully aborted the child. But the bleeding and pain worsened until she was bedridden and the neighbors urged her husband to take her to the maternity hospital in Kathmandu. With treatment there, Sapkota recovered. But five months later, she returned to the hospital. She was pregnant again and wanted an abortion. But the hospital turned them down, saying it was illegal to abort a 5-month-old fetus, as well as unsafe. So the couple went to a private polyclinic, where they were told that it would be an expensive procedure to abort a fetus older than 12 weeks. Sapkota she paid 12,000 rupees ($150) for the abortion, compared with the government cap of 1,000 rupees ($13) at legal clinics. Still, they went ahead with it. But after the procedure, Sapkota started bleeding constantly, having pain in her lower abdomin and back and leaking urine. She went to the hospital, where doctors reported that the device used for the abortion had hurt her internal organs. Sapkota underwent surgery and recovered. But she says she is worried that she will never be able to have children again. "I've given my body a lot of torture," says Sapkota, who never told her family about her abortions. Despite the legalization of abortion in Nepal, medical professionals say that a lack of awareness and proper information regarding the law and reproductive health continues to drive women to obtain unsafe and illegal abortions. Private clinics looking to earn money by performing abortions they don't have the staff or facilities for leave women vulnerable to many health complications. "It's due to low literacy and lack of information on maternal and reproductive health as well health infrastructures clustered in cities that women are suffering," says Dr. Ganesh Dangal, senior consultant obstetrician and gynecologist at Kathmandu Model Hospital. Prabina Joshi, coordinator at the Marie Stopes International registered clinic in Kathmandu, says women come for abortions at the government-approved clinic for various reasons, ranging from family pressure to rape and incest. Others are unwilling to have a child because they see it as a risk to their employment, studies or opportunities to travel abroad. Dr. Shilu Aryal, a consultant obstetrician and gynecologist in the Family Health Division says that almost 10 percent of women who seek legal abortions at government-rapproved facilities are denied because they are past the 12-week period, citing a study by the division. She says that these women, who usually lack the knowledge of their pregnancies or financial capabilities to come earlier, then choose unauthorized places for abortions. "All the abortions done outside the places designated by the government are illegal," says Aryal, who adds that data is limited because the government only learns of illegal cases when women seek care for botched abortions. Dangal says women also prefer illegal clinics because of the privacy, as abortion is still considered taboo despite its legality. Lama says she wanted her abortion to be private. She doesn't know the name of the person who aborted her child or have any record of it. Sapkota says she was too embarrassed to talk about sex and thus didn't want to tell anyone about her pregnancy or abortion. Dangal also cites poor government implementation of the law, minimal publicity and promotion of the issue, lack of awareness among women and the social structure itself as causes for persistent illegal and unsafe abortions. In government-appointed centers and hospitals, the queues are also often long and services delayed and irregular, Dangal says. Outside the capital, there are only limited days and time that these services are carried out. Dr. Sarita K.C. from the maternity hospital in Kathmandu attributes the plethora of problems that unsafe abortion invites - from bacterial infection to excessive bleeding to uterus problems - to unsafe procedures. She says that the only approved and safest method is manual vacuum aspiration. Because of these complications, the government recently introduced medication that can induce abortions of fetuses up to nine weeks. However, such medicine, which must be used under the supervision of a medical professional, is being sold illegally in the market, K.C. says. After abortion became legal in Nepal, many teenagers as well as educated, married couples began viewing abortion as an alternative to contraceptives. A master's student in sociology who declined to be named to protect her privacy is married and has a daughter. She says she doesn't want another child because of financial reasons but that her husband doesn't use condoms when they have sexual intercourse. She is hesitant to use female contraceptives because she has heard of side effects ranging from weight problems to constant periods. "My husband tells me to abort [rather] than him using a condom," she says. "He doesn't understand of the physical and mental stress I'd have if I become pregnant." Teenagers and young people are having sex, departing from traditional views in the predominantly Hindu society that sex before marriage is immoral, the sociology student says. Yet traditional views condemning contraceptives hasn't changed as quickly. "Educated women like me haven't been able to convince my husband," she says. "What'll happen to teenage girls?" An employee at Kathmandu's Om Hospital and Research Centre, who declined to be named, says that on an average, five girls come to the government-approved facility for abortions every day. Traditional views toward abortion in rural areas are also contributing to unsafe practices, despite the female community health volunteers deployed there by the government to spread awareness about safe and legal abortion. Shiva Maya Subedi, 46, of Dhading is a mother of seven children. She says she doesn't know anything about contraceptives or legal abortion services. So when she became pregnant with her eighth child two years ago, she resorted to traditional practices recommended by her mother-in-law to abort the baby herself. She says her husband helped her abort the fetus at home. She says that menopause should enable her to avoid future pregnancies. "Now I've stopped menstruating," she says. "Now I don't think I'll be pregnant." But Aryal warns of various consequences from such practices. "Traditional approaches as such might have some serious implications on women's health," Aryal says.