How Nepal reduced maternal mortality by legalizing abortion

When Dr. Sudha Sharma was just starting out as a young obstetrician gynecologist in Nepal in the 1990s, she and her colleagues saw, on a daily basis, the impact of their country’s ban on abortions. At Katmandu’s Maternity Hospital and smaller hospitals across the country, women staggered into emergency rooms near death. Some had sticks in their wombs. Others had perforated uteruses or had contracted sepsis. Each was the result of a botched, illegal abortion.

“Women were dying,” said Dr. Sharma, who went on to serve as director of the Maternity Hospital, the country's largest, and later as secretary of the Ministry of Health and Population. “Women were being penalized. If they didn’t die, they were put in jail and their older children were left at home.”

Researchers estimated that during this time, up to one-fifth of all incarcerated women in Nepal were imprisoned for abortion-related crimes. Aiding an abortion was also the third leading cause of men’s imprisonment. Government data from 1998 indicated that more than half of all gynecological and obstetric hospital admissions were related to botched abortions. And data from one hospital-based study published in 1992 found that more than half of all maternal deaths were related to complications from illegal abortions.

“We had committed and were working towards achieving the Millennium Development Goals,” said Dr. Sharma. “At the same time, we knew that illegal abortions were contributing tremendously to maternal deaths.”

Outraged doctors, civil society leaders, and Ministry of Health officials worked together to make abortion services legal in 2002 – setting the stage for the transformation of health outcomes for women. In 1996, Nepal’s maternal mortality rate was 750 per 100,000 live births, among the highest in the world. By 2017, the last year for which figures are available, it was one third that level – 250 per 100,000 live births.

The story of how Nepal came close to meeting its MDG targets and saved untold women’s lives includes both the legalization of abortion policies and funding to make those rights accessible. It also involves ambitious programs to help women gain access to modern family planning services, improved antenatal care, skilled birth attendants, and safe delivery in a health facility.

At a time when leaders in Poland and the United States are restricting access to abortion, while other countries, such as Colombia and Argentina, have recently legalized the procedure, Nepal’s experience is informative and timely.

Nepal demonstrates that legalization isn’t just a switch that you flip on, said Loveday Penn-Kekana of the London School of Hygiene & Tropical Medicine. “Yes, the law changed in 2002. But then, the country needed to be very thoughtful about its implementation. First piloting, then expanding. All of this takes time… the drugs have to be included on the list of essential drugs. The funding has to be made available.” 

Nepal's health ministry started by training doctors to perform vacuum aspirations, just one type of abortion service and aftercare, in one health facility. That allowed them to begin offering abortion services in one hospital by March 2004. Then, they trained doctors on that one procedure and aftercare in 60 health facilities across 30 districts. By 2008, the government had expanded trainings to nurses and, a year later, added medical abortions to the trainings. It wasn’t until 2010 that all 75 districts had at least one qualified abortion provider.

More recently, the government expanded training to other abortion procedures and expanded the number of qualified providers by training midwives. It also began collaborating with the private sector to expand institutional providers. 

It was a slow, deliberate, and strategic rollout, said Penn-Kekana. Still, there are areas of the country where both family planning services and abortion remain challenging to access.

The decline in the country’s maternal mortality rate reflects this slow and steady increase in access to care and demonstrates a broad truism in global health, said Oona Campbell, a professor of epidemiology and reproductive health at the London School of Hygiene & Tropical Medicine: “Generally, the more permissive a country’s abortion laws, the lower its maternal mortality rate.”

Campbell added: “What we see in Nepal is more women going to health facilities over the last two decades. And each time they go, they get more services and better-quality services. And that is impacting their health.”

The legalization of abortion in Nepal, which was followed over the next two decades by policies and funding to make that right accessible and safe for women throughout the country, was just one step in transforming health outcomes for women and children.

Exemplars in Global Health research on how Nepal reduced its stunting rate by half, from the world’s highest rate of 68 percent in 1995 to 36 percent in 2016, as well as EGH research on the country's reduction of under-five mortality, captures some of this story.

It involves Nepal investing heavily in health infrastructure. From 2000 to 2015, Nepal’s health expenditure doubled as it built hospitals, clinics, and birthing centers, and trained tens of thousands of health workers. To connect national systems with women living in remote villages, the government also launched its Female Community Health Volunteers program, which trained more than 50,000 village women to provide essential health care, including contraception, to rural women.

The volunteers, notably, helped double contraceptive use. For example, married couples increased their use of contraceptives from 24 percent in 1990 to 49.6 percent in 2014. Allowing parents to space out and reduce the number of their children meant healthier mothers and healthier children.

To further bridge the gap between rural women and health facilities, the country launched the Aama (“mother” in Nepali) program, which provides cash incentives to mothers, to encourage prenatal care and delivery at a health center. The cash incentives, which could be used by poor women to arrange transportation to a clinic, were highly effective. In 2001, just 28 percent of pregnant women received any prenatal care from a skilled provider. By 2016, that figure was 84 percent. Likewise, the percentage of women benefiting from skilled birth attendants also increased from just 11 percent in 2001 to 58 percent in 2016.

“Today in Nepal, more women know about contraception. More women are accessing health care including contraception. And more women are using effective, and long-lasting contraception,” said Campbell. “And women can increasingly access safe abortion.”

“We see a lot things changing for women in Nepal over the last two decades,” Campbell added. “The average age of marriage has gone up. Education has gone up. Fertility rates have declined. Women’s aspirations have gone up. Abortion access is part of the story of what has changed for women in Nepal.”