Abortion Law Reform in Nepal: Women's Right to Life and Health

ASIA

Abortion Law Reform in Nepal: Women’s Right

to Life and Health

Ganga Shakyaa Sabitri Kishoreb Cherry Birdc Jennifer Barakd

a Reproductive Health Advisor, Family Health Division, Department of Health Services, Ministry of Health(FHD/DHS/MoH), Teku, Nepal

b Abortion Task Force Coordinator and Clinical Coordinator, Technical Committee for the Implementation ofComprehensive Abortion Services in Nepal (TCIC), FHD/DHS/MoH, Teku, Nepal

c Technical Advisor, TCIC, FHD/DHS/MoH, Teku, Nepal. E-mail: [email protected]

d Reproductive Health Advisor, GTZ Health Sector Support Programme, Kathmandu, Nepal

Abstract: In Nepal, the effects of the low social status of women and lack of access to health careand family planning have resulted in a maternal mortality ratio that is among the highest in SouthAsia. By the mid-1990s, the contribution of unsafe abortions to maternal deaths and morbiditywas acknowledged by key individuals in the Ministry of Health and Department of Health Services.Advocacy for abortion law reform over several decades culminated in the passage of a new law onabortion in 2002. The parliamentary process took almost four years from the tabling of the bill.Almost two years elapsed between the passage of the bill and approval of the Procedural Order forimplementing it. This paper describes the development of policy and programme strategies forimplementing the new law, led by the government in collaboration with NGOs, donors and otherstakeholders. During that time, documents required for implementation were prepared, training ofservice providers was begun and a model service delivery and training site was established inKathmandu Maternity Hospital. Simple systems to enable rapid expansion of services and a women-friendly approach were devised, promoting universal availability of affordable services provided byphysicians and eventually nurses, the latter particularly in remote and rural areas, where 88% ofthe population live. A 2004 Reproductive Health Matters. All rights reserved.

Keywords: unsafe abortion, abortion law and policy, advocacy and political process, abortionservices, training of service providers, Nepal

UNSAFE abortions have contributed sig-nificantly to the high maternal mortalityratio in Nepal, which the government has

been committed to reducing since 1991 underthe National Health Policy and more recently aspart of the Millennium Development Goals.Legislative change that would meet the needs ofall women and promote rapid and effectiveimplementation of ‘‘women-friendly’’ servicesbased on choice, access and quality of care, wasperceived as a necessary part of this process.

The 11th amendment of the Legal Code of Nepal(Muluki Ain) legalised abortion for a broad range

of conditions in March 2002 and received RoyalAssent in September that year. In December 2003the Procedural Order for implementation of thenew legislation was passed, enabling the provisionof services to begin. In the interim, the focus ofactivities moved from advocacy for legal changeto the development of strategies and plans forimplementing services.

Under the previous legislation, abortion wasonly allowed to save the life of thewoman, certifiedby the signature of two physicians. Nepal wasamong the few countries in the world where thelaw was being enforced, and women sent to prison

A 2004 Reproductive Health Matters. All rights reserved.Reproductive Health Matters 2004;12(24 Supplement):75–84

0968-8080/04 $ – see front matterPII: S0968-8080 (04 )24007-1

ISBN 0-9531210-2-Xwww.rhm-elsevier.com www.rhmjournal.org.uk

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G Shakya et al / Reproductive Health Matters 2004;12(24 Supplement):75–84

for having an abortion. The sentence could bethree years or more, depending on the circum-stances,1 with a possible pardon after completionof half the sentence. If the crime was deemed tobe infanticide, the sentence could be up to20 years.2 In practice, the law did not clearly dis-tinguish between abortion and infanticide, andmany poor and illiterate women received longprison sentences in court proceedings of whichthey had no understanding. Across the country,women – especially the poorest – were languishingin jail, often having been reported by their ownrelatives, sometimes even after a spontaneous

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Women in prison for abortion

JENNYMATTHEW

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abortion. In 1997 a nationwide survey estimatedthat 20% of the women in Nepali jails hadbeen convicted on charges of abortion or infanti-cide.1 In April 2004, after legalisation of abortion,31 women were still held in prisons across thecountry on charges of infanticide. By November2004, 18 of them had been released (Personal com-munication, Binda Magar, Forum for Women, Lawand Development, November 2004). Mostly poorand illiterate, they were kept in miserable con-ditions, unable to afford legal assistance or evento understand what had happened to them.Significantly, only women were imprisoned, their

, Kathmandu, Nepal, 2004


male partners and the abortion providers were notheld accountable. By contrast, middle- and upper-class women were able to access services fromprivate practitioners, paying for both medicaland legal safety. Many better-off women alsotravelled across the border to India for services(Personal communication, Jyotsna Tamang, Centrefor Research on Environment, Health and Popula-tion Activities, October 2004).

In contrast, the new law represents a huge stepforward.Abortion is allowed up to 12weeks for anywoman with her consent; up to 18 weeks if thepregnancy is the result of rape or incest, and at anytime during the pregnancy on the advice of amedical practitioner if the life, or physical ormentalhealth of the woman are at risk, or the fetus isdeformed or has a condition incompatible with life.The consent of the husband or guardian is notrequired for women over 16 years of age, and forthose under 16, the ‘‘guardian’’ can include anyadult friend or family member.

This paper describes the development of policyand programme strategies for implementing thenew abortion law in the context of a poor, mostlyrural, country with limited health care resources,which took place during the almost two yearsbetween the passage of the bill and approval ofthe Procedural Order for implementing it.

Women’s health and status in NepalPublic health services in Nepal are constrainedby resource and staff shortages, particularly inrural areas, where 88% of the population live,and 44% of households subsist below the pov-erty line.3 In many remote areas governmenthealth services are virtually non-existent, withhealth posts infrequently staffed and medi-cines unavailable or out of date. In such circum-stances, people continue to use traditional healersand remedies, and many do not have access to orknowledge about modern family planning. Thus,despite 40 years of family planning initiatives,only an estimated 59% of the demand is beingmet, and contraceptive use among marriedwomen of reproductive age is only 39%.4

The position of women in traditional commu-nities is physically and socially harsh, with girlchildren systematically discriminated against,receiving less food,5 doing more work from anearlier age and less likely to attend school thantheir brothers. The average literacy rate for women

(35%) is only half that of men.4 A daughter will bemarried at the earliest opportunity, frequently inher early teens. Living with her husband’s family,she will occupy the lowest position, her treatmentdirectly related to her ability to produce sons andwork hard.6 Any decisions related to her life andhealth will be taken by her husband and his family.Thus, although women carry all the social respon-sibility for producing and bringing up a healthyfamily with more sons, they have no decision-making power. They are blamed for unwantedpregnancy – whether from rape or incest or justtoomany children.Without the permission of theirhusband and family, however, they are unable touse family planning. Women in rural areas suffermost, as traditions are more closely adhered to,and in desperation they are often forced into thehands of unscrupulous local ‘‘quacks’’, who usea variety of unsafe methods to induce abortion.When complications arise, women are usuallyafraid to seek medical help until it is too late.In urban areas, private practitioners have offeredabortion services for many years, using theloophole provided by the wording of the law,which allowed abortion on health groundswith thesignature of two physicians. However, the cost isbeyond the reach of most poor women, and thecheaper options carry greater risks, so that thepoorest women are the most vulnerable.

The combined effect of the low social statusof women and lack of access to health care andfamily planning resulted in a maternal mortalityratio that is among the highest in South Asia,at 539 to 100,000 live births.7 Complicationsfrom unsafe abortions have contributed signifi-cantly to this. It has been estimated that 53.7%of gynaecological and obstetric hospital admis-sions were due to induced abortion complica-tions,8 and 20% of the maternal deaths in healthfacilities.9 This does not account for the manywomen dying at home, either because they weretoo far from a hospital or afraid to risk goingto a public institution because of the illegalstatus of abortion. One community study in 1994estimated the total abortion rate to be 117 per1,000 women of reproductive age per year.10

The financial implications were also serious.The estimated cost of managing abortion com-plications ranges from US$20–133,10 dependingon severity, technique used and socio-economicfactors. Post-abortion care services were intro-duced in 1995 and are now available in 45 of

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the 72 major public hospitals across the country(records from the Department of Health Services),with a number of development programmes,mainly funded through USAID, providing sup-port for upgrading of facilities and training ofphysicians and nurses.*

Although the availability of post-abortioncare represented a major step forward, savingthe lives of many women and helping themto access family planning services, it did notaddress the fundamental problem of complica-tions and deaths stemming from the illegalstatus of abortion.

Small beginnings: a perceived needfor changeFrom small beginnings in the 1980s, and increas-ingly throughout the 1990s, a number of influ-ences were simultaneously working towardschange, based on a public health perspective(with a focus on maternal mortality), legal andhuman rights issues (women in prison), andinternational influences (including the experi-ences of neighbouring countries). In differentways, each of these began to affect public aware-ness and opinion, gradually wearing awayentrenched, traditional views about abortion. Acritical factor was the presence of strong advo-cates in key positions, who were able to movethings forward and to forge links between thedifferent stakeholders.

Around 1980 an obstetrician–gynaecologistworking at the Maternity Hospital in Kath-mandu noted the number of women sufferingand dying from the medical and social conse-quences of abortion-related complications. Hisobservations convinced him that abortion shouldbe legalised, and he submitted articles to anumber of daily newspapers outlining his views.

78

*No research updating this figure could be found. How-

ever, the charge for post-abortion care services at public

hospitals is currently Rs.500 (US$7) plus the cost of any

additional drugs needed. In cases of severe infection, the

total cost can be as high as Rs.1,500 (US$21), which is

borne by the woman unless she is very poor, in which case

the hospital might subsidise her. The establishment of

post-abortion care services has made care of women with

complications less expensive, so we consider the estimate

from 1994 still valid for the purposes of this paper.

This generated national discussion, eventuallyresulting in an interview aired on BBC Sri Lankaand BBC UK, giving the issue internationalattention.11 In 1990, the same physician tookpart in a public debate on legalisation of abor-tion on Nepal Television and challenged anti-abortion views, stating that he intended toperform abortions. In 1992 he began workingwith the Family Planning Association of Nepal,performing mini-laparotomy sterilisations andmenstrual regulation.

While touring the country’s jails in 1993–95,the Secretary of the Home Ministry noted thenumber of women imprisoned on abortioncharges and their poor conditions and lack ofrights, and determined to address the issue.Working with the Chairman of the FamilyPlanning Association of Nepal, also a memberof the Upper House of Parliament, he draftedabortion legislation for submission to the UpperHouse as a private bill in 1996. Despite thesupport of a number of parliamentarians it wasrejected, and failed again in 1997, when pre-sented as part of the Women’s Property RightsBill. At this stage the issue did not have a highnational profile, as the energies of women’sreform groups concentrated on women’s prop-erty rights rather than abortion.

By the end of the 1990s, the contribution ofunsafe abortions to the high levels of maternalmortality and morbidity, highlighted by theNational Maternal Mortality and MorbidityStudy,8 was widely acknowledged, with keyindividuals within the Ministry of Health andthe Department of Health Services recognisingthe need for change.

NGO-led advocacy effortsDuring the mid-1990s, the Center for Research onEnvironment, Health and Population Activities(CREHPA), a non-governmental organisation(NGO) specialising in research and advocacy,became involved in the abortion issue, carryingout a number of studies on the effects of the ille-gal status of abortion on women’s rights andwelfare, particularly poor women. These studiescomplemented a World Health Organization(WHO) funded longitudinal study carried out in1992–9412 on the types of abortions women wereundergoing in Nepal, and the resulting deaths andcosts of the post-abortion treatment provided at


three large Kathmandu hospitals. In 1996, CREHPAconducted an opinion poll on abortion13 to ascer-tain public views on abortion and its legalisation,which indicated that most sectors of Nepali societywere broadly in favour of legalisation.

In 1995, the Forum for Women, Law andDevelopment (FWLD), a national NGO advocatinglegal reform and human rights, began workingwith women imprisoned on abortion-relatedcharges. They published a number of newspaperarticIes on their work, claiming that the illegalstatus of abortion constituted a violation of humanrights, and in 2003 produced an updated studyon women in prison.14

From the mid-1990s, advocacy work by indi-viduals and organisations stimulated the interestof activist women’s groups, and the issue gainednational profile and momentum. CREHPA madeextensive use of the press, stressing the publichealth consequences of maternal deaths and theburden on public hospitals caused by admissionsfor abortion complications. Meanwhile, FWLDconcentrated on lobbying key decision-makersand members of parliament, building coalitionswith women’s groups and other NGOs, focusingon legal issues related to women in prison andthe lack of differentiation between induced andspontaneous abortion.

In 1999, CREHPA began working with othersto design an advocacy strategy, developingposters about the prevention of unsafe abor-tion. In 1999 and 2000 they submitted two policymemoranda to Parliament, explaining the casefor legalisation of abortion, and in 2001 theyworked with the Family Health Division ofthe Department of Health Services on an advo-cacy paper. FWLD also worked closely withthe Centre for Reproductive Law and Policyin New York to draft legislation amending allgender discriminatory laws in the Legal Code,including the prohibition of abortion. They con-tinued to document the plight of women inprison on abortion-related crimes, publishing apaper in 2002.2 The movement for change wasgrowing, as advocacy to reduce unsafe abortionwas also a major item on the agenda of the 1999Cairo+5 conference, and many other positivechanges internationally.

Around 2000, various influencing factors gath-ered momentum; of particular importance wasthe growing support of the Ministry of Healthand Department of Health Services, which played

leading roles in the later stages of the process ofchanging the law.

During the mid-1990s, the Director of theFamily Health Division, through his position asVice-Chairman of the Family Planning Associ-ation of Nepal, arranged discussions with differentinfluential groups, including women parliamen-tarians, the Nepal Medical Association, lawyersand youth groups. In November 2000, as FamilyHealth Division Director, he raised the issue at anational level Reproductive Health Steering Com-mittee meeting, at which the Secretaries of sevenkey Ministries were present. With the support ofdonor agency representatives, he succeeded inpersuading these influential Secretaries to supportthe submission of a proposal to amend the abor-tion law to parliament, based on the high prior-ity accorded by the health sector to reducing thenational maternal mortality ratio. The proposalwas accepted, and the Ministry of Healthrequested Family Health Division to draft an abor-tion section for inclusion in the 11th amendment tothe Legal Code, scheduled for parliamentarydebate. This amendment also included reformsin other areas of women’s rights, particularlyproperty rights.15

Meanwhile, with the help of CREHPA andFWLD, leaflets were developed on the preven-tion of unsafe abortion and distributed to allparliamentarians and Ministry Secretaries. TheSecretary of the Ministry for Women and SocialWelfare presented the 11th amendment to Par-liament, and the debate focused mainly on theethical, religious and social aspects of accessiblelegal abortion. After several months of discussion,the principle of safe abortion was agreed upon,and in March 2002 the amendment was passed.

Government-led preparations forimplementing the new law

In February 2002, when passage of the amend-ment appeared imminent, the Family HealthDivision formed an Abortion Task Force todraft the Procedural Order for implementationof the amendment and the Policy and Strategydocuments. Royal Assent was given in Septem-ber 2002, and the Procedural Order submitted tothe Cabinet. However, changes in the governmentdelayed approval until December 2003, almosttwo years after the new law was passed, creatinga frustrating grey period during which abortion

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was technically no longer illegal, but publicservices could not be provided.

The Abortion Task Force was chaired by FamilyHealth Division, with membership drawn fromthe Nepal Society for Obstetricians and Gyne-cologists, the Nepal Safer Motherhood Project(funded by DFID UK), German Technical Assis-tance (GTZ) Health Sector Support Programmeand CREHPA. GTZ, DFID and Ipas provided tech-nical and financial support. Much of its work wascentred on developing key documents (Box 1).

The international literature was reviewed tolearn from the experiences of other countrieswhere abortion had been legalised. These coun-tries included India, where many barriers hadarisen as a result of complex regulations and lackof health service infrastructure in rural areas,South Africa and Guyana, both of which hadsought through their laws, with varying success,to minimise barriers.16 Many of the recom-mendations contained in the WHO guidance,17

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available in draft at the time, were also incor-porated. Based on global lessons learned, theamended law, policies and procedures developedwere very liberal, in order to make implemen-tation as widespread and straightforward aspossible and to minimise barriers to womenneeding services.

Principles and priorities for implementingthe new lawIn June 2002, a policy support paper submitted tothe Family Health Division,18 based on theliterature review, highlighted three cross-cuttingprinciples which apply to successful implemen-tation of abortion law reform:

� Advocacy does not end with the passage of aliberal law. In other countries, continued advo-cacy has been needed to ensure anti-abortionforces do not overturn or curtail hard-won legalreforms, that health care providers are on boardand willing to provide safe services and thatwomen are aware of their rights and able toaccess services.

� A progressive law that cannot be fully imple-mented is not enough of an improvement,although it may prevent women being harassedand imprisoned. In addition, policies and pro-cedural guidelines must be sufficiently flexibleto allow rapid implementation of services withlimited resources, without compromising safetyor standards.

� Strengthened family planning services mustbecome an integral part of comprehensiveabortion care, in order to reduce unwantedpregnancy and achieve a significant reductionin maternal mortality.

Based on these three principles, 35 detailedrecommendations were made, grouped underten major headings, which included: the needfor changes in social attitudes towards abortion,meeting women’s needs, policy and standards,health system barriers, funding, health policyframework, cross-sector linkages and partner-ships, and monitoring and evaluation.

The priorities for meeting women’s needswere summarised as the five Cs:

� Convenience and accessibility of services.� Confidentiality – relating to both the physical

layout of facilities and service providers’attitudes.


� Caring and comfort – including service pro-viders’ attitudes and pain control techniques.

� Cost – ensuring that no woman is denied ser-vices because of inability to pay.

� Contraception – effective counselling and avail-ability of appropriate methods.

In the resource-poor context of Nepal, servingthe needs of all women, including the poor andilliterate, poses a major challenge. Two key deci-sions were, first, to train nurse providers, asthat would facilitate the availability of services atsmall district hospitals and primary health carecentres, and second to focus on certification ofservice providers after satisfactory completion ofcompetency-based training, keeping criteria forapproved facilities to the minimum compatiblewith safe services. Manual vacuum aspiration(MVA) was chosen as the recommended abortionmethod, using the experience gained from post-abortion care services, for which MVA is theaccepted technique, and so that nurses could alsobe trained as service providers.

A two-day workshop19 was held in November2002, to begin the process of developing animplementation plan. Representatives attendedfrom all the major stakeholders, including thegovernment, donors, national and internationalNGOs. The objectives were to reach a commonunderstanding of what comprehensive abortionservices involved, reach consensus on the goalsand purpose of the national safe abortion plan,and formulate a two-year plan for the introduc-tion of services.

As it had completed its tasks,19 the AbortionTask Force was dissolved. A new body, the Tech-nical Committee for the Implementation of Com-prehensive Abortion Services (TCIC), was formedto assist the government with planning andimplementation of the law and new terms ofreference were drafted. The four working groupsremained, continuing the work they had begununder the Task Force.

The TCIC has a clinical coordinator, an admin-istrator, and input from a consultant technicaladvisor, with funding and technical support pro-vided by DFID, Ipas and PATH. The full commit-tee, around 30 representatives from national andinternational NGOs and government departments,meets approximately four times a year. A coregroup, consisting of representatives from FamilyHealth Division, DFID, GTZ and the secretariat,

meet more often, as required. The working groupsmeet separately, reporting back to the core groupand the main committee.

Abortion services are coordinated by the Depart-ment of Health Services Reproductive Health Coor-dination Committee, with central responsibilityfor listing of service providers resting with theDepartment. At local level, District Health Officesare responsible for implementation and super-vision of services, including listing of service pro-viders and facilities. The process associated withlisting has successfully been kept simple.

Training and service deliveryTo facilitate rapid implementation of servicesacross the country, a cascade approach was usedand both the public and private sector involved.Activities began with a three-day orientation forsenior gynaecologists, including an update onclinical procedures, infection prevention andcounselling. In view of their experience, thiswas considered sufficient for their being listedas competent practitioners. The second stagehas been training of trainers. As of June 2004,20 participants from zonal public hospitalsacross the country, medical colleges (to promoteinclusion of abortion in pre-service training),and private institutions had received training.Ultimately these facilities will be developed astraining sites. The nine-day course includesclinical skills, counselling, infection prevention,orientation on the law and training skills. Thethird stage, training of service providers, hasbegun in Kathmandu and will later be extendedto training sites at zonal hospitals outside thecapital. As of December 2004, 99 physicianservice providers had been trained and 53 nursecounsellors/assistants. There are plans to begintraining nurses as service providers within thenext year.

The first service and training site was deve-loped as a model centre at the Maternity Hospitalin Kathmandu, with excellent facilities to caterfor a high caseload. At smaller hospitals andhealth centres it is anticipated that, where pos-sible, training and services will be integratedinto existing facilities, or modest renovations willbe undertaken to provide space. Basic equipmentsuch as MVA and sterilisation equipment andspecula will be distributed to service providerson completion of their training. The guidelines

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also allow for private hospitals and NGOs toserve as training centres, once trainers and faci-lities receive government approval.

Information disseminationPlans for disseminating information are still atthe planning stage, since it would be irrespon-sible to create demand before services can meetit. Energies have initially focused on dissemi-nating information about the legal changes tolaw enforcement authorities, tomake them awarethat women should no longer be arrested orimprisonedonabortioncharges.However, despitethese efforts arrests of women have continued.14

Advocacy NGOs have been carrying out district-level awareness-raising and orientation on thenew law, and using the media to disseminateinformation at national level. At the same time,the government and NGOs have begun develop-ing messages about the new law, availability ofservices and avoidance of unsafe abortions, fordissemination through the media. Representa-tives from Family Health Division have begunvisiting districts where the first service pro-viders have been trained, to orientate hospitalstaff, the District Health Office and local offi-cials about the details of the law. With technicalassistance from PATH, work has also begun ondrafting a broader Behaviour Change Commu-nication Strategy, to address current attitudesand practices related to abortion, based on for-mative research carried out by CREHPA.

Monitoring and evaluation of services will bethe responsibility of District Health Offices andFamily Health Division, and tools for this purpose,including registration and listing forms, havebeen drafted. Evaluation of training is the respon-sibility of the TCIC, including follow-up to assessthe competency of trained providers and provideadvice on the establishment of services.

Challenges for the futureMuch has been achieved of which the country canbe proud, although many challenges remain onthe road to universal availability of safe, accessibleabortion services for women in Nepal. Not leastamong the challenges is the prevailing socialstigma, which associates abortion with ‘‘loose,immoral behaviour’’. The status of women remainslow, particularly in rural areas, making it difficult

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for them to access information andmake decisionsabout obtaining services at a sufficiently earlystage to remainwithin the law (which only permitsabortion up to 12 weeks under normal circum-stances). Although the government is proceedingwith training of service providers and listing ofservice sites as rapidly as possible, there are stillmany areas where services and information arenot yet available. Even where they are available,many women are not familiar with the concept ofgestation dates, and thus are presenting at clinicswhen they are already beyond the legally speci-fied limit of 12 weeks (Personal communication,Sabitri Kishore, Maternity Hospital, Kathmandu,October 2004).

Of immediate importance is the need to ensurethat information about the changes in the law isfully disseminated, and to get local authorities tostop imprisoning women on abortion charges,particularly in remote rural areas. The 13 womenremaining in prison must also be released at theearliest possible date.

A key issue will be ensuring that safe abortionservices are combined with increased access toeffective family planning services, and strength-ening links with the health care system, so thatwomen are able to avoid repeat abortions.

The geographical and resource constraints ofNepal pose a major challenge to country-wideimplementation of programme plans, with poorroads and communications, and staff shortagesmaking it difficult to maintain high standards.The situation is further exacerbated by the cur-rent armed conflict and harassment of localpeople, which is widely affecting travel in ruralareas, causing fear, including among healthworkers, and making planning difficult. For thisreason, a key issue will be the training of nursesto provide safe services where doctors are oftennot available, and to reach poor women in remoteareas, who aremost at risk from unsafe abortions.

As safe abortion becomes more available, theneed for post-abortion care for dealing withcomplications will be reduced. However, certaindonor countries only allow the use of govern-ment funding for post-abortion care, not forsafe abortions. Since post-abortion care will stillbe needed for women suffering from incompletespontaneous abortions, the government is not ina position to compromise this funding, and sothe natural combination of the two services isunlikely to happen in the near future.


ConclusionsThe changes in the law were largely based on theneed to address the high maternal mortality ratiofrom unsafe abortions, treating the needs andrights of women as paramount. Despite the tra-ditionally conservative social attitudes of thecountry, those in authority became convincedthat legalisation of abortion and the provisionof safe, accessible services would prevent com-plications and deaths. Interestingly, despite thestrongly religious nature of Nepali society, therehave been no major public objections to thereforms. The delay of almost two years betweenthe passing of the reform bill and the ProceduralOrder approving the new law created a greyperiod during which abortion was no longerillegal, but public services could not be provided.Perseverance was needed to keep up the momen-tum for change and to plan for immediate actionwhen approval was achieved.

Services began at the Maternity Hospitalin Kathmandu in March 2004, with demandbuilding quickly. As of December 2004, around2,000 women had had legal abortions there. Afurther 22 sites (public and private) have alsobegun providing services, although the caseloadhas been slower to build up. Forty-three sites(26 public and 17 private) across the country have

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et al. Women in Prison in Nepalfor Abortion. Kathmandu7Centre for Reproductive Lawand Policy and CREHPA, 2000.

2. Centre for Research onEnvironment, Health andPopulation Activities and Forumfor Women Law andDevelopment. Abortion inNepal: Women Imprisoned.Kathmandu7 CREPHA andFWLD, 2002.

3. Central Bureau of Statistics,Nepal Living Standard Survey.Kathmandu7 CBS, 1996.

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completed the listing process and are ready tobegin services. There are now trained physicianservice providers in 30 of the 75 districts of thecountry. Plans for a second training site outsideKathmandu are underway.

The central lessons learnt are that from theearly stages of the process, key members of thegovernment have played a leading role in facili-tating change and guiding policy development,and that effective collaboration and partnershipswith a wide and diverse group of stakeholders tosupport the government in achieving the requiredchanges have been essential.

AcknowledgementsSpecial recognition goes to Dr YashovardhanPradhan (Department of Health Services,Nepal), Ms Anne Erpelding (GTZ Cambodia),Ms Susan Clapham (DFID Nepal), Ms MaryLuke (Ipas USA) and Ms Bela Ganatra (IpasIndia) for their technical advice and support. Wewould also like to acknowledge Dr Laxmi RajPathak (MoH Nepal), Mr Anand Tamang(CREHPA Nepal), Dr Bhola Rijal (Ob–Gyn),and Ms Binda Magar (FWLD Nepal) whoplayed significant roles in the abortion lawreform process and gave invaluable input tothis paper.

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12. Tamang AK, Shrestha N,Sharma K. Determinants ofabortion and subsequentreproductive behaviour amongwomen of three urban districtsof Nepal. In: Mundigo Al,Infriso C, editors. Abortion inthe Developing World. NewDelhi7 Vistaar Publications,1999. p.167–90.

ResumeAu Nepal, le statut social peu eleve des femmeset leur manque d’acces aux soins de sante et ala planification familiale expliquent le taux demortalite maternelle parmi les plus hauts d’Asie duSud. A la moitie des annees 90, des fonctionnairescles du Ministere de la sante et du Departementdes services de sante ont reconnu l’impact desavortements non medicalises sur la mortalite et lamorbidite maternelles. Le plaidoyer pour unereforme de la loi sur l’avortement a culmine dansl’adoption d’une nouvelle legislation en 2002. Leprocessus parlementaire a pris quatre ans depuisle depot du projet de loi. Deux autres annees sesont ecoulees avant la publication du decretd’application. L’article decrit la preparation depolitiques et de strategies pour mettre en Kuvre lanouvelle loi, sous la direction du gouvernementavec des ONG, des donateurs et d’autres acteurs.Pendant cette periode, les autorites ont redigeles documents d’application, commence a formerles prestataires de services et cree un site pilotede formation et de services a la Maternite deKatmandou. Des systemes simples qui permettentune expansion rapide des services et uneapproche conviviale ont ete con9us, favorisantune disponibilite generalisee de services abordablesassures par des medecins ou, dans les zonesrurales isolees ou reside 88% de la population, par

ResumenEn Nepal, el bajo nivel social de las mujeres y lafalta de acceso a los servicios de salud y deplanificacion familiar ocasionan uno de los masaltos ındices de mortalidad materna en Asiameridional. Para mediados de los noventa,funcionarios clave del Ministerio de Salud y elDepartamento de Servicios de Salud reconocieronel aporte del aborto inseguro a la morbimortalidadmaterna. La defensa de reformas en la ley de abortoculmino en la aprobacion de una nueva ley en2002. El proceso parlamentario duro casi cuatroanos desde la presentacion del proyecto de ley. Casidos anos mas transcurrieron antes de la aprobacionde la Orden Procesal para aplicarla. Este artıculodescribe la formulacion de estrategias de polıticasy programas para dar cumplimiento a la nueva ley,dirigidos por el gobierno en colaboracion con lasONG, los donantes y otras partes interesadas.Durante ese tiempo, se prepararon los documentosnecesarios para su cumplimiento, se inicio lacapacitacion de los profesionales de la salud y seestablecio un lugar modelo para la prestacion deservicios y la capacitacion en el Hospital deMaternidad de Katmandu. Se idearon sistemassencillos para permitir la rapida ampliacion de losservicios y un enfoque centrado en la mujer, lo cualpromovio la disponibilidad universal de losservicios a precios asequibles prestados pormedicosy, con el tiempo, por enfermeras, estas ultimasparticularmente en las zonas remotas y ruralesdonde reside el 88% de la poblacion.

13. Centre for Research onEnvironment, Health andPopulation Activities. OpinionPoll Survey on Abortion Rightsfor Women. August 1996.

14. Forum for Women, Law andDevelopment, Center forReproductive Rights, Ipas.According to the findings of thedistrict prison visit by FWLD,CRLP and Ipas, June 2003.(Unpublished report)

15. Forum for Women, Law andDevelopment. Country Code

Eleventh Amendment Billand Woman’s Rights No.45.Kathmandu: FWLD, 2001.

16. Ministry of Health and FamilyWelfare, Government of India.Report on a NationalConference on Making EarlyAbortion Safe and Accessible.Agra, India. 11–13 October 2000.

17. World Health Organization.Safe Abortion: Technical andPolicy Guidance for HealthSystems. Geneva: WHO, 2003. 7

18. McCall M. Policy Support

Paper: A Review of GlobalLessons Learned andRecommendations to HisMajesty’s Government of Nepalon the Implementation ofAbortion Services. Kathmandu,2002. (Unpublished report)

19. Ministry of Health, Departmentof Health Services, FamilyHealth Division. NationalImplementation Plan forComprehensive AbortionServices: Workshop Report.Kathmandu, 2002.


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Abortion Law Reform in Nepal: Women's Right to Life and Health

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