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Karki

The likelihood of seeking an abortion among women who had been practicing traditional methods of family planning
may reflect their mistrust for modern contraceptive methods or because they are unable to obtain modern methods that
they wished. Increasing use of traditional methods indicates not just unavailability of contraceptives but it also implies
the entrenched belief that contraceptives have side effects and may even make woman infecund. As fecundity is highly
valued, it is challenging for family planning program to persuade young women to practice modern contraceptive
methods. Women with greater wealth were more likely to obtain abortions services simply, because they have better
access to financial resource and to better health care. Women who gave one or more births were more likely to seek
abortion may be because they did not wish to have more children and wish to have space for more personal development
(Kirkman et al., 2009; World Bank, 1993). Total fertility rate in Nepal was substantially decreased down to 2.0 in 2021
from 3.9 in 2000 and 2.5 in 2010 (United Nations, 2022a). Apparently, factors other than contraceptive use and abortion,
such as socioeconomic developmental, are attributable to such fertility decline (Anderson & Kohler 2015; Caldwell et al.,
1992; and Jain & Ross, 2012). Women in Madhesh province were least likely to seek an abortion reflecting lowest human
development in the province (NPC & UNDP, 2020).
In the context of Nepal, these results may imply improvement and empowerment of women which enables them to
decide when to seek an abortion. The finding that women with one or more children ever born are likely to obtain an
abortion could be because the women who have been giving births to increasing number of children ever born are more
likely ever to have been pregnant than women who have had no birth. In the abortion model, women who had one or more
children ever born were more likely to have an abortion than those who did not give any birth. Furthermore, it could be
because women’s desired family size has become 2 or less, many women opt for permanent method of family planning
and if accessing such service is difficult, they choose to go for medical abortion which is free and relatively easy to access.
Indeed, according to the Ministry of Health of Nepal, of the total abortions in the 5 years preceding the 2016 survey, 72%
were medical abortions (MOH et al., 2017).
Nevertheless, the NDHS 2016 data show nearly half of all abortions among women aged 15 – 24 were taken place
in unauthorized facilities such as at home, which is likely higher than the world average (Shah & Ahman, 2012). This is
because Nepalese women buy medical abortion drugs from private pharmacies and use them at home and some women
get abortion service at private pharmacies not authorized by government to perform abortion (Gorkhapatra, September 5,
2019; The Himalayan Times, March 7, 2022). This proportion is alarmingly high. With the prime objective of reducing
maternal mortality, the government of Nepal legalized abortion in 2002. In 2004, the government announced a policy
of providing safe abortion services through the extensive health infrastructure existing in the country. In principle, such
private facilities are not legally allowed to sell abortion drugs, but still this takes place. Journalists report about illegal sale
of abortion drugs and as per the government law illegal sellers can be subject to 3 years imprisonment and/or charged with
fines but the situation has not improved (Gorkhapatra, October 9, 2020). However, until mid-2020, only about 1,500 health
facilities in the country had provided safe abortion service out of about 4,400 facilities (Gorkhapatra, October 7, 2020).
It is also argued that distance to a health facility is a major problem of accessing health care including abortion service in
Nepal (MOH et al., 2017). Besides, the facilities that are authorized to perform safe abortion service are not functional
all the time, because they frequently face the absence of service providers and/or the shortage of supply of necessary
drugs, and it is common that post-abortion contraceptives and equipment are interrupted. In addition, there are a number
of social, normative, economic, and distance barriers for women to access safe abortion services. Nepalese is a patriarchal
society and the NDHS 2016 data show that only 23% currently married women make decisions on their own about their
own health care (MOH et al., 2017). Last, but not least, due to cultural values and norms of son preference prevailing
in Nepal (Karki, 1988), there is also evidence that sex selective abortion is on the rise after it was legalized (Frost et al.,
2013), although there are strict laws that prohibit such a practice (MoH, 2016). All these factors could make women to
go to private unauthorized health-care facilities which are usually close by. The situation was likely worsened due to the
COVID-19 lockdown. Relatively more Nepalese women ended up with unwanted pregnancies during the lockdown,
because contraceptives were in short supply, and many service centers were closed during the lockdown period, because
abortion service providers were overwhelmed by COVID-19 pandemic, compelling women to seek abortion service from
unauthorized private facilities (The Himalayan Times, 15 July 2021).
Fortunately, the analysis of the project data shows that access to safe abortion services has been improved even during
the COVID-19 pandemic and lockdown. This is because no woman in the project was prevented from accessing safe
abortion service, while, in other parts of the country, more women were utilizing unsafe abortion and putting their life at
high risk. In the Gorkha project catchment area, there are 18 health facilities that provide safe medical abortion service.
This indicates one facility per about 1,000 women of reproductive age, which is advantageous compared to the national
rate of about 5,000 women per facility (MOH, 2021). The beauty of the project is that women in highly disadvantaged

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