As those of us in the public health field know, deaths and injuries due to unsafe abortion are a leading cause of maternal death around the world and they are entirely preventable. But Nepal is an example of what can happen when three things align: a law that promotes women's health and rights (including expanding access to safe abortion care), a supportive health infrastructure to make good on the law, and the resources (financial and technical) to bring to the table.
Since Nepal reformed its abortion laws in 2002, 105,000 safe abortions have been performed and experts in Nepal see this as contributing to the significant reduction in maternal mortality that has taken place over the past decade.
That Nepal has taken such strides is all the more remarkable given the political climate in the country. Take the case of Sindhupalchowk, a remote district in Nepal that borders Tibet. It is home to about 327,610 people, most of whom survive on less than U.S. $1 per day. In 2006, the Technical Committee for Comprehensive Abortion Care (or TCIC, the Department of Health Services body responsible for implementing the new abortion law) trained physicians working in this district and set up a clinic in the government-run hospital.
However, during civil unrest in the past few years, the hospital found itself caught between the army and rebels. Riddled with bullets, it was shuttered, once again cutting off the district's residents from essential health care. But in January 2007, TCIC trained two private physicians working in the neighboring Dolakha district, set up a new clinic in Guarishanker hospital and engaged them to provide safe abortion care for Sindhupalchowk's citizens.
The doctors left their families in Kathmandu in order to offer high-quality obstetrical care to the poorest of the poor. As these health-care professionals provided abortion care and managed complications from pregnancy and delivery, they gained the trust of the community, and women are increasingly choosing to seek safe abortions through this hospital rather than from unsafe providers. TCIC monitoring suggests that the Gaurishanker hospital is among the best of the 165 approved sites that provide comprehensive abortion services in the country.
As part of a national Safe Motherhood program, Ipas works with the Nepali government and the TCIC to make comprehensive abortion care (a model that includes pre- and post-abortion counseling, as well as family planning services to prevent repeat unwanted pregnancies) available throughout the country.
While Nepal is still a work in progress, it is clearly improving. Furthermore, it is not alone. We see similar progress in South Africa, where deaths due to unsafe abortion fell by 91 percent after abortion was legalized and made accessible to women in 1997. We hope to see similar progress in Ethiopia and Mexico City, where recent changes in legislation are being followed-up with efforts by Ipas and our partners to ensure health services are available.
Safe abortion care and the decrease in maternal deaths in Nepal would not have been possible without legal change. But legal change alone will not ensure that women have the care they need, when and where they need it. Well functioning health systems, trained providers, on-site monitoring and support, and a steady supply of medical equipment are four of the basics that are also needed. And we have not even touched on the long list of other items that are needed to truly transform women's lives: education, economic opportunities and a life free of violence, to name a few. The unfolding story in Nepal is deeply gratifying to those of us who have watched women suffer and die needlessly. At long last, a success story.