Lamichhane P, Harken T, Puri M, Darney, Blum M, Harper CC, Henderson JT: Sex-selective abortion in Nepal: a qualitative study of health workers` perspectives. Health problems for women. 2011, 3 (Supp): S37-S41. Policymakers` confidence in public health evidence – both from other countries and in Nepal itself – has helped Nepalese women benefit as much as possible from scientific advances and ensure that legal abortion services meet the highest international standards. Examples include the introduction of medical abortion and modern techniques for second-trimester abortion. The evidence-based inclusion of nurses and auxiliary nurse midwives as first-trimester abortion care providers has been particularly important in making care widely available, unlike environments like India, where even first-trimester abortion has fallen under the responsibility of a small number of highly qualified doctors. Nepal`s more inclusive approach has significantly increased the scope of services in terms of the number of trained providers and geographical coverage. Maintaining confidence in public health evidence will be critical to the continued success of the program. Careful planning and coordination by the above-mentioned groups ensured that legal and safe abortion services in Nepal began immediately after the approval of the procedure order, followed by gradual expansion. National scaling has paid attention to critical elements of policy, health system capacity, equipment and care, and information. Nepal has enjoyed considerable success in the 15 years since abortion was legalized, but many challenges remain. In many parts of the country, women still do not have access to safe abortion services, especially second-trimester services.
Given the significant geographical barriers within the country, it will be crucial to continue to prioritize the decentralization of services and to increase the number of health posts and under-health sub-posts capable of performing medical abortions in the first trimester. Further efforts are needed to safely increase the supply of abortions in the second trimester. Decentralization must be accompanied by investments in technical assistance to providers in rural areas and, where appropriate, in transfer networks to tertiary centres. Early implementation successes provide valuable insights into the importance of evidence-based strategies and the integration of abortion services into existing health care to ensure high-quality and responsive care. It will be important for policymakers and health officials to build on these past successes to strengthen surveillance systems, respond to data and continue to innovate. We would like to express our gratitude to the Nepalese Ministry of Health for its continued efforts to improve access to safe reproductive health care and promote reproductive rights throughout Nepal. We would also like to thank the individuals and institutions in nepal`s health sector who continue to work for reproductive rights and access to safe abortion throughout the country. Another important basis for success has been the integration of abortion care with the National Initiative for Safe Motherhood and with the wider health care system. The inclusion of nurses and NNIs as service providers and FHCV for information and referral has facilitated efforts to integrate safe abortions into the existing health system network, including the use of existing HMIS to support monitoring and evaluation efforts. The expansion of safe abortion services has been hampered by continuing education and staffing issues. For example, the number of training centres is not sufficient to meet the high demand for trained providers, and many providers, especially in public institutions in underserved areas, find it difficult to obtain a work permit to participate in the training. Hospitals and clinics that act as training centres are also burdened by the dual requirement of training and regular service provision.
In addition, high staff turnover, especially in remote facilities, leads to significant gaps in care services for the most vulnerable women. The lack of trained providers and licensed clinics in some areas can lead to serious delays for women and prevent some from using services at a later stage of pregnancy within the legal deadlines. Abortion was partially legalized in Nepal in 2002 after advocacy highlighted the high maternal mortality due to unsafe abortion. A study published in Plos ONE in 2013, covering the years 2002-2010, found that legislative reform had led to a reduction in the most serious complications of unsafe abortion.