Nepal legalized abortion under certain conditions in 2002 through the 11th amendment to the Country Code, 1963. The Constitution later recognized safe motherhood and reproductive health as fundamental rights, while the Safe Motherhood and Reproductive Health Rights Act, 2018 established a broader legal framework for access to safe abortion. Despite these advances, barriers such as limited information, cost, distance, stigma, confidentiality concerns and a shortage of certified providers continue to restrict access, particularly in rural and remote areas. A 2022 study by the Family Welfare Division (FWD) and Ipas Nepal found that around 52 percent of abortions in Nepal are unsafe.
As Nepal observes the 12th National Safe Abortion Day today, Kamal Bista of Republica Daily spoke with Forum for Women, Law and Development (FWLD) Executive Director Sabin Shrestha about progress in safe abortion services, remaining barriers and reforms needed to expand access. Established in 1995, FWLD is a Nepal-based organization working on women’s rights and legal reform.
Excerpts:
More than two decades after Nepal legalized abortion, how would you assess the country’s progress in ensuring access to safe abortion?
Nepal legalized abortion under certain conditions in 2002. At that time, abortion was not recognized as a right. Rather, it was treated under criminal law as an act that would not constitute an offense under specified circumstances. Later, the Constitution recognized safe motherhood and reproductive health as fundamental rights. This was followed by the Safe Motherhood and Reproductive Health Rights Act, along with its regulations and guidelines on safe abortion.
We have also seen progress in the health system. The Family Welfare Division of the Department of Health Services lists and renews health facilities and service providers, while the Nepal Health Training Center has been training health workers. Following a Supreme Court order in 2009, arrangements were also made to provide free safe abortion services at government and community health facilities.
The expansion of medical abortion has made services more accessible, and the number of trained health workers and service sites has gradually increased. But these things did not happen immediately after legalization. It took time to establish the necessary procedures, expand services and train providers.
The bigger question now is whether these services are actually reaching everyone. According to the latest study conducted by the FWD and Ipas Nepal in 2022, around 52 percent of abortions in Nepal are unsafe, while 48 percent are considered safe or performed according to the law. This clearly shows that simply legalizing abortion does not guarantee access to safe services.
Stigma, lack of information, geographical barriers, among others still prevent many women from getting appropriate services. So, Nepal has made significant legal and institutional progress, but there is still a lot to be done to ensure that everyone has access to safe abortion.
So, putting these barriers aside, can we say that Nepal has made progress in expanding access to abortion rights and services?
Yes, definitely. There has been progress in both the availability of abortion services and the recognition of abortion as part of reproductive health. According to data from the Family Welfare Division under the Department of Health Services, more than 300,000 abortions take place in Nepal each year, and a large proportion are associated with unintended pregnancies.
But we still have significant gaps. Particularly over the past two or three years, there has been a significant unmet need for family-planning services, especially following the withdrawal of US funding. The supply of family-planning services has not been sufficient to meet demand. This increases the likelihood of unintended pregnancies and, consequently, the demand for abortion services.
At the same time, 52 percent of abortions are still unsafe. That tells us how much work remains. This figure is based on data from the 2022–23 fiscal year and a study conducted using those data.
Safe Abortion: The Unfinished Chapter of Safe Motherhood
How different is access to safe abortion between urban areas and rural or remote communities?
There is a clear difference. Since health facilities and service providers must be registered to provide safe abortion services, they are more readily available in cities and market areas than in rural communities. Services are concentrated in these areas because only registered health facilities and trained health workers can provide them.
When services are not available in rural and remote areas, some women may be pushed towards unsafe providers. Women from rural areas may also have to travel considerable distances to obtain services.
But distance is only one part of the problem. There are several other barriers as well.
What are the main barriers, and among them, which remains the most persistent and difficult to overcome?
The major barriers are stigma, lack of information, confidentiality and affordability. According to the Nepal Demographic and Health Survey, around 45 percent of women of reproductive age lack information about safe abortion services.
Misinformation can also result in unsafe practices. For example, one woman who had never smoked believed that smoking bidis could cause an abortion after hearing on radio or television that smoking is harmful during pregnancy. This shows why people need accurate information about safe abortion methods and where they can obtain services.
Affordability is another concern. Although safe abortion is supposed to be free at government and community health facilities, women may still have to pay for services such as ultrasound examinations. Private services are generally not free.
But stigma remains one of the biggest barriers. Women may fear that their families or communities will find out about an unintended pregnancy or an abortion, particularly in rural areas. Because of this fear, some may avoid formal health facilities and turn to unsafe providers.
So, improving access is not simply about increasing the number of service sites. Women need accurate information, affordable and confidential services, and trained providers.
The Constitution recognizes reproductive health as a fundamental right. However, abortion remains criminalized outside specified legal conditions. How do you understand this relationship between reproductive rights and criminal law?
In my view, abortion should be fully decriminalized, and women should not be punished simply for having an abortion. But decriminalization has to go hand in hand with measures to make abortion safe and accessible.
We need to look at legal rights, health and access to services together. Although abortion is legally permitted under specified circumstances, safe services have still not reached everyone, particularly women in rural areas.
If the legal framework is expanded, the health system also needs to be strengthened so that services are safe, accessible and of good quality.
In some countries, women can use medication themselves under established procedures, which is known as self-care abortion. Nepal could also consider such a system. But before doing so, we need to assess whether the necessary systems, safeguards and support services are in place.
Are there situations in which existing gestational limits can create particular problems?
Yes. This can be a serious issue when a woman’s life or health is at risk, when a fetus is not viable, or when a pregnancy has resulted from rape or incest.
It is particularly important in cases of rape and incest. A girl may not be able to disclose what happened immediately, and families may also try to conceal the incident. Sometimes the pregnancy may only be discovered at a relatively late stage.
If services are denied simply because of a gestational limit, it can have serious consequences for the girl’s health.
So, we need clear legal provisions to deal with exceptional circumstances and ensure that women and girls can receive safe and appropriate care.
FWLD has also raised concerns about the legal distinction between abortion and miscarriage. Why is this distinction important?
A miscarriage is the natural loss of a pregnancy, while an induced abortion involves intentionally terminating a pregnancy through a procedure or intervention. The law needs to make a very clear distinction between the two.
The language of the current law is not sufficiently clear, and this creates a risk that a woman could face legal action even after experiencing a natural miscarriage. The law should clearly define abortion as the termination of a pregnancy through an act or intervention.
Greater legal clarity would help protect women who experience miscarriages from unnecessary criminal investigations or legal action.
This year’s Safe Abortion Day theme focuses on access to safe abortion during disasters. What should be done to ensure continuity of abortion services during earthquakes, pandemics, floods and other emergencies?
Pregnancy does not stop because there is a disaster, and neither does the need for safe abortion. But during disasters, abortion services often receive less attention than other reproductive health services, particularly childbirth-related services.
We saw this during COVID-19. Studies showed that disruption of health services increased the risks faced by women seeking abortion. Similar problems can arise during floods, landslides and earthquakes when roads are blocked, health facilities are damaged and health workers cannot reach affected communities.
Safe abortion services should therefore be included in disaster preparedness and response plans. We can also consider telemedicine, medical abortion and appropriate self-care options.
When physical access to health facilities is disrupted, women should still be able to obtain accurate information, counselling, medicines and referrals through appropriate mechanisms.
We need clear standards and plans to ensure that reproductive health and safe abortion services continue even during disasters.
Nepal has received international recommendations to strengthen sexual and reproductive health rights. What further legal, policy and health-system reforms are needed to make safe abortion genuinely accessible?
Nepal has received recommendations from various international mechanisms on sexual and reproductive health rights and safe abortion. The CEDAW Committee, for example, has recommended improving access to safe abortion services in rural areas and expanding information about them. During the UPR process, various countries also recommended improving access to reproductive health services and decriminalizing abortion.
The government has prepared a roadmap to implement the CEDAW recommendations and an action plan to implement recommendations from the previous UPR cycle. Since the latest recommendations are relatively recent, we have yet to see concrete progress in their implementation.
Meanwhile, the First Amendment Bill on the Right to Safe Motherhood and Reproductive Health has been registered in Parliament. The bill also incorporates recommendations made under CEDAW and the UPR.
But legal reform alone is not enough. Effective implementation is equally important. We need the necessary standards to ensure that safe abortion and reproductive health services continue during disasters.
The health system also needs to strengthen the capacity of health workers, expand services and facilities, improve the flow of reproductive health information to communities, and address the stigma and prejudice surrounding abortion.
Ultimately, legal recognition has to be matched by accessible services. Women need to know where they can obtain a safe abortion, be able to afford the service, receive confidential care and have access to trained providers, regardless of where they live.
