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KATHMANDU, Sep 9 2006 (IPS) - As the 21st century began, more women were dying during childbirth in Nepal than in almost any other country and it was estimated that half of maternal deaths in hospitals were caused by unsafe abortions.
Today, 59,000 Nepali women have had safe abortions, performed by 260 trained doctors at 133 approved centres, and if plans hold, trained nurses will soon be providing the service.
But for every positive number there are many more that reveal the challenges ahead for the Safe Abortion Programme.
“Well over 50,000 women have received safe abortion services through this suction (MVA or manual vacuum aspiration) method,” says Cherry Bird, director of the Support to the Safe Motherhood Programme. “It’s not scraping or cutting or anything else. Women get up off the table a half-hour later: it’s amazing.”
But “it’s going to take 20 years to end unsafe abortions”, she added in an interview Thursday after a meeting to review the work of the growing number of facilities providing comprehensive abortion care (CAC).
The government decriminalised abortion in 2002 after years of a sustained campaign by activists and researchers. Today, abortion is available on demand up to 12 weeks, until 18 weeks if the pregnancy resulted from rape or incest and any time, with a doctor’s consent, if the women’s health is in danger or the foetus is severely deformed.
Lack of awareness, uneven supply of services, poverty and social taboos are just some of the barriers that women with unwanted pregnancies face.
For example, 13 percent of women who sought abortions at 22 facilities from January to March this year were rejected because they were more than 12 weeks pregnant, according to a study released at Thursday’s meeting.
The report also found that some government centres were refusing to provide abortions if patients were nine weeks pregnant or more, despite the law permitting abortion on demand up to 12 weeks.
“Such a practice has deprived clients of their rights to safe and legal abortion up to 12 weeks of gestation from any government approved facility of her choice,” says the ‘National Facility-based Abortion Baseline Study’ by the Centre for Research on Environment Health and Population Activities (CREHPA).
The research also revealed that only 50 percent of CAC clients were aware that abortion is now legal. The number was even lower in rural areas: 45 percent.
“Many people don’t know that abortion services are legal,” confirmed Kasturi Malla, director of Kathmandu’s Maternity Hospital, at Thursday’s meeting. “This really has to be disseminated at the community level.”
Others agree. “A big challenge is educating women (and men) of their rights to safe abortion and what is safe abortion (when they had to do it clandestinely for years),” says Wendy Darby of Ipas, a US-based NGO that has given considerable financial and technical support to Nepal’s programme.
Despite those rights, obstacles to abortion mean women are still resorting to unsafe methods. CREHPA’s study found that of 1,560 cases treated at the post-abortion care unit at Maternity Hospital from April 2004 to April 2005, 138 were for complications caused by induced abortion.
One-quarter of those clients had sought an abortion from a private unlisted clinic, about one-sixth from an unskilled provider and one in eight tried to abort using unapproved drugs. The remaining one-fifth had used herbs, “unidentified substances or other measures” to end their pregnancies.
“Oral intake of medicines not revealed by clients and insertion of sticks are the common clandestine methods used,” a group of doctors told CREHPA researchers in interviews in 2005.
While statistics show that 68 of Nepal’s 75 districts now have at least one trained service provider, “23 of them are not yet providing services, for a variety of reasons”, Darby told IPS via e-mail from the United States.
According to Bird, “There are still a lot of service providers who see CAC services as a luxury. Sure I can understand that in the districts, where they are alone and have to treat everything from broken legs to internal injuries, but not in the cities,” added the former manager of the Ministry of Health’s Technical Committee for the Implementation of Comprehensive Abortion Care (TCIC).
Added a representative of an international non-governmental organisation (INGO): “At one district hospital the doctor didn’t agree with the incentive (30 percent of the total fee) being offered so he decided that he would perform CAC services only one day a week”.
Such infrequent service is one way in which rural women are being deprived of their abortion rights, according to Lokhari Bashyal of the Forum for Women Law and Development (FWLD). “Sometimes women pass the legal deadline for an abortion (12 weeks) for lack of knowledge. Or, if there is an authorised hospital or clinic, sometimes the doctor is not there,” he told IPS.
One woman who went to her district hospital for an abortion did not have the money to pay the fee (which averages 1,000 rupees – 13.61 U.S. dollars û in government hospitals versus 1,350 rupees in NGO clinics.) She returned home and months later reported that her baby had been stillborn.
A district court sentenced her to 10 years for homicide but an appellate court reduced that to three years. “The court realised that because of a woman’s right to abortion, it should use its discretion and sentence her to a lesser amount,” said Bashyal.
Surprisingly, such understanding is lacking in some places where you would expect to find support for women seeking abortions. Nearly half (44 percent) of women who went to government hospitals for CAC services were told that they first had to agree to start using birth control after the procedure, a pre-condition “which is against human rights”, reported CREHPA.
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