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Background: In a historic move to ensure comprehensive abortion care, India amended the 1971 Medical Termination of Pregnancy (MTP) Act in 2021, creating an unprecedented opportunity for accelerating safe, respectful, and rights-based abortion services. The Federation of Obstetric and Gynecological Societies of India (FOGSI), together with World Health Organization (WHO) India and the Ministry of Health and Family Welfare, set up a flagship initiative "Respectful Abortion Care" (RAC) to provide training to obstetricians and gynecologists on the new Act, and also address their values and biases., Methods: Virtual training sessions were organized during the COVID-19 pandemic to disseminate the amendments made under the MTP Act and address provider values and biases. The primary focus was on private providers as they account for more than half of all abortion services in India (52.9%). The RAC modules were systematically designed and delivered by 690 Master Trainers, trained by FOGSI and WHO., Results: A total of 9051 FOGSI members (22%, with 50% from private clinics) completed the RAC trainings. Pretests and post-tests were conducted for impact assessment. Significant improvement was seen on knowledge of criteria for termination of pregnancy for significant birth defects (52%-83%). The post-training survey showed a high level of commitment to promote RAC: >95% were strongly motivated to perform or assist in abortion; 89% reported that the WHO value clarification exercises were helpful in facilitating open discussions on sensitive topics in a comfortable manner; 96% expressed a strong commitment to addressing the issue of respect and confidentiality in abortion care., Conclusion: RAC was a unique initiative around the MTP Act amendment 2021 in India, which demonstrated that collaboration and leadership by professional associations can help motivate providers and lead to improved knowledge and commitment from public and private sector providers., (© 2024 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Despite the legalization of abortion in 2002 and the concerted efforts of the Ministry of Health and Population, abortion services remain inaccessible for many Nepali women. In 2017, the United States government enacted the Protecting Life in Global Health Assistance (PLGHA) policy, which prohibited international non-governmental organizations (INGOs) from receiving United States global health assistance from providing abortion services or referrals or engaging in advocacy on liberalizing abortion laws that may have had an impact on abortion services. Though this policy was revoked in January 2021, there is a need to assess its impacts in Nepal and mitigate its lingering effects, if any., Methods: We conducted in-depth interviews with 21 national-level stakeholders selected purposively on the basis of their experiences and expertise in sexual and reproductive health and rights (SRHR) in Nepal. Interviews were conducted two times: first between August and November 2020 when PLGHA was in place, and then between July and August 2021 after PLGHA was revoked. Interviews were digitally recorded, transcribed, translated and analysed thematically., Results: Most participants reported that the implementation of PLGHA created gaps in SRHR services, affecting marginalized and underserved populations in Nepal. Participants reported that this policy has compromised the work of INGOs and civil society organizations (CSOs), posing additional risk to the sustainability of SRHR program achievements made so far. Beyond funding loss, participants also mentioned that PLGHA curtailed their freedom, with limited working areas and partnerships for CSOs leading to low or no utilization of services. Most participants welcomed the revocation of PLGHA and hoped it would have positive impacts on SRHR services by permanently repealing PLGHA. Most participants believed that the revocation of PLGHA opened opportunities for new funding and could re-establish partnerships and collaboration, though immediate results had not yet been seen., Conclusions: PLGHA had negative impacts on access to and quality of SRHR services. The Nepal government and other donor agencies need to bridge the funding gap created by the policy. The revocation of the policy has created the hope of bringing positive impacts in SRHR sector; however, the implementation of revocation at the ground level and impacts made on SRHR programs in Nepal remains to be explored., (© 2023. The Author(s).)

Objective: To evaluate whether conducting a bimanual examination prior to medication abortion (MAB) provision results in meaningful changes in gestational age (GA) assessment after patient-reported last menstrual period (LMP) in Nepal., Study Design: Women ages 16-45 (n=660) seeking MAB at twelve participating pharmacies and government health facilities, between October 2014 and September 2015, self-reported LMP. Trained auxiliary nurse midwives assessed GA using a bimanual exam after recording LMP. We compared GA assessments as measured via patient-reported LMP alone versus via LMP plus bimanual exam., Results: Overall, 660 women (326 at pharmacies, 334 at health facilities) presented for MAB, and 95% were able to provide an LMP. Overall agreement between LMP alone and LMP with bimanual exam was 99.3%. If LMP alone had been used without bimanual exam, fewer than one in 200 women would have been given MAB beyond the legal gestational limit. Among the three women who were ≤63 days by LMP but >63 days by bimanual exam, only one would have received MAB beyond 70 days gestation. Fewer than one in 600 women would not have received MAB care when eligible by adding a bimanual exam., Conclusion: There was high agreement between LMP alone and LMP plus bimanual exam. Routine bimanual exam may not be essential for safe and effective MAB care for women who are able to report an LMP. Removing the bimanual exam requirement could decrease barriers to provision outside of currently approved clinical settings and allow for expanded abortion access through provision by providers without bimanual exam training or facilities., Implications: Routine bimanual exams may not be essential for safe medication abortion provision by trained clinicians in pharmacies and health facilities in low resource settings like Nepal., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Context: Medication abortion has the potential to transform the provision of safe abortion care in low- and middle-income countries, and can be provided with minimal clinical skills and equipment. In Nepal, first-trimester abortion using mifepristone and misoprostol is legally available at government-certified health facilities, but little is known about pharmacy workers' perspectives regarding pharmacy-based provision., Methods: In-depth interviews were conducted in 2015 with 19 pharmacy owners and auxiliary nurse-midwives in two districts of Nepal to examine respondents' views on medication abortion and on potential legal provision of medication abortion from pharmacies. Two coders independently reviewed interview transcripts, and coded and analyzed them using a thematic approach., Results: Participants were confident that they could provide safe medication abortion and felt that they filled an important niche by providing affordable, convenient and confidential services to women in their communities. They saw benefits of integrating pharmacies into legal abortion networks in Nepal, such as improved access to medication abortion and greater privacy. Participants also felt that the quality of the care they provided could be improved through ongoing training of pharmacy-based providers and formal incorporation of such providers into existing networks of abortion provision to streamline referrals., Conclusions: Integration of pharmacies into the legal abortion provision system could aid in regulation and training. Consideration of pharmacy workers' perspectives can help to ensure the sustainability and success of safe abortion programs.

Objectives: To examine the treatment efficacy, safety and satisfaction of women using medical abortion (MA) pills provided by pharmacists following an education intervention based on a harm reduction approach., Study Design: This was an operations research study over a six-month period in 2015, using a non-inferiority design. We provided training to dispense MA pills, based on a harm reduction approach, to a group of pharmacy workers in Makwanpur district (GROUP 2). We compared selected outcomes with women who bought the pills from pharmacy workers in Chitwan district (GROUP 1), who had received similar training in 2010. The primary endpoint measured in 992 women in both districts was complete abortion within 30 days of using the pills. We assessed the efficacy of MA (self-reported complete abortion) and safety (no reported adverse event). To determine complete abortion, we asked women about passage of the products of conception, cessation of abdominal cramps, vaginal bleeding, need for manual vacuum aspiration or repeated doses of misoprostol. We used a four-point Lickert Scale to determine level of satisfaction with MA use. Pearson Chi-Square test was used to examine any differences in proportion of complete abortions between women who were served by the two groups of pharmacy workers., Results: The difference in the rate of complete abortions between the two groups of women, 96.9% and 98.8%, was not statistically significant. The women reported no serious complications, and there was little difference in their satisfaction levels., Conclusions: Trained pharmacy workers dispensed MA safely and effectively to the satisfaction of almost all women clients, and the positive results of training had continued several years later., Implications: The role of pharmacy workers as providers of correct and complete information on safe and effective use of MA needs to be recognized and policies formulated to allow them to provide MA drugs for first trimester use., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal., Methods: Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 μg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression., Results: Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%])., Conclusions: Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.

Context: Although abortion has been legal under broad criteria in Nepal since 2002, a significant proportion of women continue to obtain illegal, unsafe abortions, and no national estimates exist of the incidence of safe and unsafe abortions., Methods: Data were collected in 2014 from a nationally representative sample of 386 facilities that provide legal abortions or postabortion care and a survey of 134 health professionals knowledgeable about abortion service provision. Facility caseloads and indirect estimation techniques were used to calculate the national and regional incidence of legal and illegal abortion. National and regional levels of abortion complications and unintended pregnancy were also estimated., Results: In 2014, women in Nepal had 323,100 abortions, of which 137,000 were legal, and 63,200 women were treated for abortion complications. The abortion rate was 42 per 1,000 women aged 15-49, and the abortion ratio was 56 per 100 live births. The abortion rate in the Central region (59 per 1,000) was substantially higher than the national average. Overall, 50% of pregnancies were unintended, and the unintended pregnancy rate was 68 per 1,000 women of reproductive age., Conclusions: Despite legalization of abortion and expansion of services in Nepal, unsafe abortion is still common and exacts a heavy toll on women. Programs and policies to reduce rates of unintended pregnancy and unsafe abortion, increase access to high-quality contraceptive care and expand safe abortion services are warranted.

Background: Although abortion was legalized in Nepal in 2002, many women are not able to obtain legal services. Using qualitative data from women who were denied legal abortion services, we examined reasons for seeking an abortion, options considered and pursued after being denied an abortion, reasons for delaying seeking care, as well as complications experienced among women who were denied legal abortion., Methods: After obtaining authorization from two health facilities in Nepal, we requested informed consent from all women who were seeking abortion services to complete a case report form to determine their eligibility for the study. We then recruited all eligible and interested women in to the study. Two months after recruitment, we conducted in-depth interviews with 25 women who were denied abortion services from the two recruitment facilities due to advanced gestational age (>12 weeks). Interviews were translated and transcribed, and the transcripts were analyzed through an iterative process grounded in thematic analysis, involving both a priori and emergent codes., Results: Eleven women were recruited from the government hospital and 14 from an NGO facility. The majority of women (15 women or 60 %) were living rural settings, ranged in age from 18 to 40 years and had an average of 2 children. None had completed any post-secondary education. Women most commonly cited financial concerns and health concerns as reasons for seeking termination. Not recognizing pregnancy, uncertainty about how to proceed, needing time to coordinate the trip to the facility or raise money, and waiting to know the sex of fetus were the commonly cited delays. Among the women interviewed, 12 decided to continue their pregnancies following denial, 12 terminated their pregnancies elsewhere, and one self-induced using medication. At least two women experienced significant complications after obtaining an abortion. Most women who continued their pregnancies anticipated negative consequences for their health, family relationships, and wellbeing., Conclusions: Barriers to seeking early abortion need to be addressed in order to reduce utilization of abortion services that may be unsafe and to improve women's health and wellbeing in Nepal.

Background: Factors such as poverty, stigma, lack of knowledge about the legal status of abortion, and geographical distance from a provider may prevent women from accessing safe abortion services, even where abortion is legal. Data on the consequences of abortion denial outside of the US, however, are scarce., Methods: In this article we present data from studies among women seeking legal abortion services in four countries (Colombia, Nepal, South Africa and Tunisia) to assess sociodemographic characteristics of legal abortion seekers, as well as the frequency and reasons that women are denied abortion care., Results: The proportion of women denied abortion services and the reasons for which they were denied varied widely by country. In Colombia, 2% of women surveyed did not receive the abortions they were seeking; in South Africa, 45% of women did not receive abortions on the day they were seeking abortion services. In both Tunisia and Nepal, 26% of women were denied their wanted abortions., Conclusions: The denial of legal abortion services may have serious consequences for women's health and wellbeing. Additional evidence on the risk factors for presenting later in pregnancy, predictors of seeking unsafe illegal abortion, and the health consequences of illegal abortion and childbirth after an unwanted pregnancy is needed. Such data would assist the development of programmes and policies aimed at increasing access to and utilisation of safe abortion services where abortion is legal, and harm reduction models for women who are unable to access legal abortion services., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To examine postabortion contraceptive discontinuation and pregnancy in Nepal, where abortion was decriminalized in 2002., Study Design: We conducted an observational cohort study of 654 women obtaining abortions from four public and nongovernmental facilities in 2011. Patients completed questionnaires at their abortion visit and 6 and 12 months later. We used Cox proportional hazards models to assess contraceptive discontinuation and pregnancy by method initiated postabortion and other sociodemographic and reproductive factors., Results: Among the 78% (508/654) of women who initiated a modern contraceptive method within 3 months postabortion, the 1-year contraceptive discontinuation rate was 62 per 100 person-years. Discontinuation was far lower among the 5% of women using long-acting reversible methods (21/100 person-years) than among those using condoms (74/100 person-years), pills (61/100 person-years) and the injectable [64/100 person-years; adjusted hazard ratio (aHR)=0.32 (0.15-0.68)]. Unmarried women and those not living with their husband experienced higher contraceptive discontinuation [aHR=2.16 (1.47-3.17)]. The 1-year pregnancy rate for all women was 9/100 person-years. Pregnancy was highest among those who initiated no modern method postabortion (13/100 person-years) and condoms (12/100 person-years), and pregnancy was lowest among users of long-acting reversible methods (3/100 person-years). The poorest women were at increased pregnancy risk [aHR=2.31 (1.32-4.10)]., Conclusion: Women using intrauterine devices and implants experienced greatly reduced contraceptive discontinuation and pregnancy within a year postabortion, although initiation of these long-acting methods was low. Increased availability of long-acting methods in Nepal and similar settings may help to prevent unwanted pregnancy and attendant maternal mortality and morbidities., Implications: Initiation of modern contraception was high postabortion; however, 1-year discontinuation was high for the condom, pill and injectable, the methods most commonly used. Rates for intrauterine devices and implants were low. Results support efforts to facilitate patient knowledge and access to the full range of contraceptives, including long-acting reversible methods., (Copyright © 2015 Elsevier Inc. All rights reserved.)

In Nepal, despite policy restrictions, both registered and unregistered brands of mifepristone and misoprostol can easily be obtained at pharmacies. Since many women visit pharmacies for abortion information, ensuring that they receive effective care from pharmacy workers remains an important challenge. We conducted an operations research study to examine whether trained pharmacy workers can correctly provide information on safe use of mifepristone and misoprostol for early first trimester medical abortion. Pharmacy workers in one district were given orientation and training using a harm-reduction approach, and compared with a non-equivalent comparison group in the second district. Overall, trained pharmacy workers' knowledge increased substantially, but no increase was found in the comparison group. Compared to the baseline (65%), 97% of trained pharmacy workers knew up to what stage of pregnancy and how women should use mifepristone and misoprostol. A higher percentage of pharmacy workers in the intervention group (77%) compared to the comparison group (49%) were knowledgeable at follow-up about determining whether an abortion was successful, implying a need for improving this aspect of training. As many mid-level health providers run their own pharmacies and offer medical abortion pills, it is important for the government to consider training these providers and registering their pharmacies as safe medical abortion service outlets., (Copyright © 2015 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.)

Medical abortion was introduced in Nepal in 2009, but rural women's access to medical abortion services remained limited. We conducted a district-level operations research study to assess the effectiveness of training 13 auxiliary nurse-midwives as medical abortion providers, and 120 female community health volunteers as communicators and referral agents for expanding access to medical abortion for rural women. Interviews with service providers and women who received medical abortion were undertaken and service statistics were analysed. Compared to a neighbouring district with no intervention, there was a significant increase in the intervention area in community health volunteers' knowledge of the legal conditions for abortion, the advantages and disadvantages of medical abortion, safe places for an abortion, medical abortion drugs, correct gestational age for home use of medical abortion, and carrying out a urine pregnancy test. In a one-year period in 2011-12, the community health volunteers did pregnancy tests for 584 women and referred 114 women to the auxiliary nurse-midwives for abortion; 307 women in the intervention area received medical abortion services from auxiliary nurse-midwives. There were no complications that required referral to a higher-level facility except for one incomplete abortion. Almost all women who opted for medical abortion were happy with the services provided. The study demonstrated that auxiliary nurse-midwives can independently and confidently provide medical abortion safely and effectively at the sub-health post level, and community health volunteers are effective change agents in informing women about medical abortion., (Copyright © 2015 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.)

Background: Identifying unsafe abortion among the major causes of maternal deaths and respecting the rights to health of women, in 2002, the Nepali parliament liberalized abortion up to 12 weeks of pregnancy on request. However, enhancing women's awareness on and access to safe and legal abortion services, particularly in rural areas, remains a challenge in Nepal despite a decade of the initiation of safe abortion services., Methods: Between January 2011 and December 2012, an operations research study was carried out using quasi-experimental design to determine the effectiveness of engaging female community health volunteers, auxiliary nurse midwives, and nurses to provide medical abortion services from outreach health facilities to increase the accessibility and acceptability of women to medical abortion. This paper describes key components of the operations research study, key research findings, and follow-up actions that contributed to create a conducive environment and evidence in scaling up medical abortion services in rural areas of Nepal., Results: It was found that careful planning and implementation, continuous advocacy, and engagement of key stakeholders, including key government officials, from the planning stage of study is not only crucial for successful completion of the project but also instrumental for translating research results into action and policy change. While challenges remained at different levels, medical abortion services delivered by nurses and auxiliary nurse midwives working at rural outreach health facilities without oversight of physicians was perceived to be accessible, effective, and of good quality by the service providers and the women who received medical abortion services from these rural health facilities., Conclusions: This research provided further evidence and a road-map for expanding medical abortion services to rural areas by mid-level service providers in minimum clinical settings without the oversight of physicians, thus reducing complications and deaths due to unsafe abortion.

Background: Sex-selective abortion is expressly prohibited in Nepal, but limited evidence suggests that it occurs nevertheless. Providers' perspectives on sex-selective abortion were examined as part of a larger study on legal abortion in the public sector in Nepal., Methods: In-depth interviews were conducted with health care providers and administrators providing abortion services at four major hospitals (n = 35), two in the Kathmandu Valley and two in outlying rural areas. A grounded theory approach was used to code interview transcripts and to identify themes in the data., Results: Most providers were aware of the ban on sex-selective abortion and, despite overall positive views of abortion legalization, saw sex selection as an increasing problem. Greater availability of abortion and ultrasonography, along with the high value placed on sons, were seen as contributing factors. Providers wanted to perform abortions for legal indications, but described challenges identifying sex-selection cases. Providers also believed that illegal sex-selective procedures contribute to serious abortion complications., Conclusion: Sex-selective abortion complicates the provision of legal abortion services. In addition to the difficulty of determining which patients are seeking abortion for sex selection, health workers are aware of the pressures women face to bear sons and know they may seek unsafe services elsewhere when unable to obtain abortions in public hospitals. Legislative, advocacy, and social efforts aimed at promoting gender equality and women's human rights are needed to reduce the cultural and economic pressures for sex-selective abortion, because providers alone cannot prevent the practice., (Copyright © 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore, using both survey data and case studies, factors that are associated with abortion decisions among young couples in the context of recently legalized abortion in Nepal., Methods: This article draws primarily on data collected in detailed case histories of 30 participants selected from a sample of the respondents to a survey of 997 married women aged 15 to 24 years and 499 men aged 15 to 27 years collected in 2003. Bivariate analyses of the survey data are presented in summary form to provide some general contextual background, with the key themes that emerged from analysis of the case histories being described., Results: Almost half of the young women in the survey reported that they had ever experienced an unintended pregnancy. A considerable proportion of these couples thought about abortion but the majority of them did not take any action. Some of them had attempted abortion but only few had succeeded. Multiple factors, including socio-cultural beliefs, affect the decision-making phase, making the process dynamic and situation-specific. Husbands and health service providers play a major role in the decision-making process., Conclusions: The study highlights the need to scale up family planning and abortion services to young couples, and emphasizes the importance of involving men and service providers in public education and advocacy campaigns against unsafe abortion. It also points to the need for wider education in the community about family planning and legal abortion services, as well as for the transparent pricing of services and greater efforts to enhance women's decision-making capacities and control over their reproductive options.