Striving toward safe abortion services in Nepal: A review of barriers and facilitators

Abstract Background and Aims Despite the decriminalization of abortion in Nepal in 2002, unsafe abortion is still a significant contributor to maternal morbidity and mortality. Nepal has witnessed a significant drop in abortion‐related severe complications and maternal deaths owing to the legalization of abortion laws, lowered financial costs, and wider accessibility of safe abortion services (SAS). However, various factors such as sociocultural beliefs, financial constraints, geographical difficulties, and stigma act as barriers to the liberal accessibility of SAS. This review aimed to determine key barriers obstructing women's access to lawful, safe abortion care and identify facilitators that have improved access to and quality of abortion services. Methods A systematic search strategy utilizing the databases PubMed, CINAHL, Scopus, and Embase was used to include studies on the accessibility and safety of abortion services in Nepal. Data were extracted from included studies through close reading. Barriers and facilitators were then categorized into various themes and analyzed. Results Of 223 studies, 112 were duplicates, 73 did not meet the inclusion criteria, and 18 did not align with the research question; thus, 20 studies were included in the review. Various barriers to SAS in Nepal were categorized as economic, geographic, societal, legal/policy, socio‐cultural, health systems, and other factors. Facilitators improving access were categorized as economic/geographic/societal, legal/policy, socio‐cultural, and health systems factors. The patterns and trends of barriers and facilitators were analyzed, grouping them under legal/policy, socio‐cultural, geographic/accessibility, and health systems factors. Conclusion The review identifies financial constraints, unfavorable geography, lack of infrastructure, and social stigmatization as major barriers to SAS. Economics and geography, legalization, improved access, reduced cost and active involvement of auxiliary nurse‐midwives and community health volunteers are key facilitators.


| INTRODUCTION
Terminating a pregnancy before full term is reached is known as abortion.When the reasons for having an abortion do not align with legal justifications, it often results in women resorting to secret and unsafe abortions.In Nepal, unsafe abortion is considered a significant contributor to maternal morbidity and mortality.This can lead to serious complications such as injuries, hemorrhage, and sepsis, that can have a long-term detrimental effect on the mother's health.
2][3][4] Abortion was illegal in Nepal until 2002.6][7][8][9] Despite strict laws, a large number of unsafe abortions occur each year, reflected by the fact that one-third of all imprisoned women and half of all hospitalized women were due to the consequences of illegal termination of pregnancies. 10,113][14] Under current law, a woman has the right to an abortion for any reason within the first 12 weeks of pregnancy, and up to 18 weeks in cases of sexual assault. 15ditionally, abortion at any gestational age is legally permitted if a doctor certifies that continued pregnancy endangers pregnant woman's physical and/or mental health; or that the fetus is deformed. 5,15In 2018, a new law known as the Safe Motherhood and Reproductive Health Rights Act (SMRHR) was enacted by Parliament to increase women's access to safe and legal abortion. 16 Nepal, safe abortion services (SAS) are available at the federal, provincial, and municipal levels, as well as through outreach programs. 17Public sector health facilities in the country offer free abortion care to the client and receive reimbursement ranging from 800 to 3000 Nepalese rupees from their respective provincial governments based on the service provided. 17These multiple efforts to encourage SAS across have resulted in a significant decline in maternal mortality ratio, that is, from 539 maternal deaths per 100,000 live births in 1996 18 to 151 per 100,000 live births in 2022. 19During the period from 2007 to 2010, a notable trend emerged: a significant reduction in the severity of complications caused by unsafe abortions. 7study conducted in Nepal in 2014 analyzed the distribution of legal abortions across sectors and found that, approximately 37% occurred in public facilities, 34% in nongovernmental facilities, and the remaining 29% in private clinics. 9Interestingly, these statistics are influenced by the fact that unsafe abortion is the third most common cause of maternal mortality in Nepal. 9cording to the data from the Ministry of Health and Population, in the fiscal year 2020/21, 79,952 women in Nepal utilized SAS.This represents a slight decrease from 87,869 women who used SAS in the previous fiscal year 2019/20; overall, SAS has shown a downward trend since a peak of 98,640 women accessing services in 2017/18. 17e global gag rule (GGR) prohibits non-US-based nongovernmental organizations (NGOs) from providing, referring, or counseling abortion services that receive US global health assistance.
It also prohibits advocating for abortion law reforms. 20GGR has fragmented sexual and reproductive health (SRH) service delivery in many countries, including Nepal. 20The broad scope of this policy affects funding allocation, posing challenges even for NGOs without direct US government funding.This disruption is consistent with preexisting barriers to legal abortion, such as limited knowledge, stigma, cost, and limited access to services.In addition to abortion, GGR contributes to reducing contraceptive use, increases induced abortion, and has a chilling effect on advocacy efforts. 21is review aimed to identify barriers and facilitators affecting access to SAS in Nepal, focusing on major obstacles hindering women's access and identifying improvements in quality and accessibility.

| Research design
We utilized a systematic search strategy to identify relevant studies investigating the accessibility and safety of abortion services in Nepal.

| Research question
The research question guiding the review was: "What are the barriers and facilitators for accessing safe abortion services in Nepal?"

| Inclusion criteria
The studies included in this review satisfied the following requirements: (i) they were conducted in Nepal, (ii) they offered insights into abortion accessibility and safety, and (iii) they were published in peerreviewed journals or recognized sources in the English language.

| Exclusion criteria
To ensure the accuracy of our analysis, we specifically chose to include only studies written in English that reported original research

Key points
• The legalization of abortion in Nepal has not ensured universal access to safe services.
• Stigma, lack of awareness, and negative attitude of providers hamper access.
• Rural, low-income women face additional obstacles such as distance, cost and lack of confidentiality.
findings and published before March 31, 2023.Additionally, we excluded studies such as reviews, commentaries, editorials, and letters that did not meet our inclusion criteria.

| Database searched
To systematically search for literature on abortion access and saftey in Nepal, a syntax was created combining the following keywords: abortion, access, safety, Nepal.
(("abortion" OR "terminat*" OR "miscarriage*") AND ("access*" OR "availability" OR "utilization") AND ("safety" OR "complication*" OR "risk*") AND ("Nepal" OR "Nepali")) We then systematically searched four databases: PubMed, Embase, CINAHL, and Scopus.In addition to these databases, a search of the grey literature was also conducted, which included difficult-to-find sources such as conference proceedings, government reports, and dissertations.This search was carried out using the World Health Organization Global Health Library as well as other sources such as Nepalese medical journals and databases including the Nepal Journal of Obstetrics and Gynecology and Nepal Journals Online (NepJoL).

| Data extraction
Identified studies underwent title/abstract and full-text screening for eligibility.Data were extracted from included studies through close reading.Barriers and facilitators were categorized into themes.Patterns and trends were analyzed across themes to synthesize insights on factors impacting abortion safety and accessibility in Nepal.

| Ethical clearance
Ethical clearence is not applicaple as this study reviewed published studies.
We identified various barriers to SAS in Nepal, categorized as: economic, geographic, societal; legal/policy; sociocultural; healthcare systems; and other factors (Table 1).In the category of "economic, geographic, and social barriers," major factors that barred access to SAS included financial constraints, high cost of abortion services in private clinics, limited availability of resources and infrastructure in rural areas, distance and transportation barriers, and lack of availability and accessibility to abortion services.The legal and policy barriers included a lack of knowledge about the law and SAS, fear of legal consequences, and legal restrictions.Other barriers include societal norms that stigmatize and discriminate against this form of healthcare, negative attitudes from healthcare providers, and cultural beliefs that perpetuate gender-based power imbalances.Furthermore, inadequate knowledge and training of providers, limited privacy and confidentiality, and insufficient resources also contribute to hindering access to medical abortion.
Facilitators improving access were categorized as: economic/ geographic/societal; legal/policy; sociocultural; and healthcare systems factors (Table 2).The economic and geographical factors were the primary drivers in promoting accessibility to abortion services.We analyzed the patterns and trends of barriers and facilitators, grouping them under legal/policy, sociocultural, geographic/accessibility, and healthcare systems factors (Table 3).

| DISCUSSION
Our comprehensive review of barriers and facilitators revealed four predominant factors impacting access to safe and legal abortion services in Nepal.These interrelated factors span across multiple spheres and require coordinated strategies.

| Legal and policy factors
In various studies, a common barrier that was consistently found was a lack of understanding of abortion laws and service availability. 7,8,23,25,32,34,37,38This leaves women unaware of their rights and options, 8 which ultimately leads to uncertainty, fear of legal repercussions, and stigma.Additionally, the spread of misinformation exacerbates misconceptions. 7,8rict legal restrictions pose significant challenges, making it very difficult for women to freely make choices about their own bodies and reproductive health. 24,34,37Particularly, in lower-income settings such as Nepal, restrictive legal status increases disparities in accessing safe abortion care. 35Thankfully, the policy landscape has changed over the past two decades as abortion laws have become more liberal. 25,38This has led to a significant shift toward recognizing women's reproductive health and that abortion is their fundamental right.
Despite these advances in the legal framework, barriers to access to abortion care remain.The policy requiring women who live far from healthcare facilities to obtain physician approval for medical abortion is an example of barriers that disproportionately affect rural populations. 28This restriction may increase inequalities.However, its recent amendment allows community healthcare workers to provide medical abortion, a promising policy change to expand access. 17 Flowchart of the review procedure.
It is critical to comprehensively address the complex legal and policy barriers to protect and uphold women's reproductive health and rights.To achieve equitable and safe access to abortion, it is important that strategies not only address ongoing restrictions, but also tackle existing awareness gaps and inequities.This requires coordinated efforts across sectors to establish an enabling environment for all individuals to exercise their right to abortion. 33y facilitators such as legalizing abortion were transformative in decriminalizing the procedure and acknowledging women's autonomy. 25,38Government-NGO partnerships have successfully increased awareness and availability of services. 33Better education on abortion laws and services also empowers women by giving them accurate information about their rights and options. 26

| Social and cultural factors
][33][34]38 This stigma originates from deeply ingrained patriarchal beliefs of women's morals and sexuality, which makes abortion taboo in our culture. 34It manifests itself through social isolation, verbal abuse, denial of services, and community disapproval of women seeking abortion. 23,24yond emotional distress, stigma deters timely care-seeking, compels unsafe procedures, and hinders women's ability to reach/afford services. 32,33,38rsistent gender inequities and limited control over reproductive decisions act as catalysts for perpetuation of stigma. 34As a result, women are left with few options and often resort to unsafe and secretive methods of abortion. 34Adding to this cycle, healthcare providers perpetuate stigma through their discriminatory actions and refusal to offer essential services. 8,30Women encounter multilayered T A B L E 1 Barriers and their categories.

Barriers
Economic, geographic, and societal factors Scarcity of resources and infrastructure in rural areas 8,9,25,32 Distance and transportation hindering access to service providers 30,33 Financial constraints 8,34 Limited availability and accessibility of service in rural areas 7,24 High cost of abortion services in private clinics 7,[23][24][25]30,33 Legal and policy factors Lack of knowledge of the law and availability of SAS 8 Fear of legal consequences or social stigma for seeking an abortion 7,8 Legal restrictions 24,34,37 Restricted legal status of abortion where access to safe care is limited 35 A policy that bars women living more than 2 h from a health facility from using medical abortion 28 Challenges in obtaining necessary documents and approvals 38 Social and cultural factors Stigma and discrimination against women seeking abortion 8, 25,30 Stigma surrounding abortion 32,33,38 Negative attitudes from providers 28,29 Sociocultural factors such as cultural beliefs 34 Sociocultural factors such as gender-based power dynamics and lack of decision-making power for women 34 Fear of judgment or discrimination from healthcare providers or others in the community 23,24 Healthcare system factors Lack of knowledge about abortion and available services 8,22,33 Lack of trained providers 8,34 Inadequate knowledge and experience about the services required 23 Lack of confidentiality and privacy in healthcare settings 7,23,35 Inadequate capacity to meet the needs of the population 26 Inadequate training and resources for healthcare providers 22,25 Limited availability of trained providers and facilities 8,30,38 Lack of service providers and physician oversight 31 Challenges in accessing effective postabortion contraception 34 Inadequate or inaccurate information and unsafe medications provided by untrained pharmacy workers, and the lack of a formal referral mechanism 26,35 Other factors Lack of awareness of abortion laws and services 7,29,32,34 Lack of knowledge about contraception and social norms regarding sons 22,27 Women resorting to covert and unsafe traditional procedures or selfinduced abortion 22,37 T A B L E 1 (Continued)

Barriers
Abortions being performed for the wrong reasons 26 Misuse of services, particularly by women not using family planning methods 26 Sex-selective abortions and abortions used as a family planning method 26 Limited access to trained providers and equipment, particularly in remote areas 34,35,37 Women's lack of knowledge about their legal rights 30 Lack of counselors 28 Lack of formal referral networks for women who have been denied abortion services elsewhere 29 Lack of awareness of medical abortifacients among healthcare providers, prescription of varieties of allopathic and indigenous medicines by private providers and chemists for inducing abortion 36 stigma originating from communities and the healthcare system. 23,24dressing stigma requires comprehensive strategies that span sociocultural, legal, health systems, and geographic spheres.
Increased awareness, community engagement, improved provider training, and more robust legal frameworks can slowly transform social attitudes and norms. 7,24,25,33Including parents in communicating about SRH with adolescents fosters supportive family environments. 23Adolescent-friendly healthcare services meet the needs of young women by providing a welcoming space for information and care. 23Confidential, nonjudgmental care from trained staff mitigates stigma and makes women more likely to seek timely, appropriate care. 32Positive attitudes among healthcare staff toward abortion laws create an atmosphere of empathy and understanding that encourages care-seeking. 26

| Geographic and accessibility factors
Nepal's diverse terrain creates geographic barriers that, along with economic and social factors, challenge access to SAS and underscore disparities. 8,9,25,32Rural areas suffer from scarce facilities and trained providers, obstructing services. 8,9,25,32Rugged topography poses transportation obstacles, with remote regions especially affected. 30,33Many women struggle to afford travel and clinic fees, creating financial barriers. 8,34Rural populations have limited access to SAS availability in general. 7,2430,33 These intertwined geographic, economic, and social barriers hinder timely and appropriate care.
However, some facilitators show promise in improving access.
Reducing service costs alleviates financial limitations. 24Expanding availability beyond cities helps address geographic disparities in rural areas. 7,24Leveraging local auxiliary nurses, midwives, and volunteers facilitates community-level care. 33

| Healthcare system factors
35]38 A major challenge is the lack of knowledge about abortion and available services T A B L E 2 Facilitators and their categories.

Economic, geographic, and societal factors
Reduction in the cost of abortion services 24 Improving access to SAS in rural areas 7 Improved access to SAS in rural areas 7,24 Participation of auxiliary nurse midwives, and community health volunteers in rural areas 33 Legal and policy factors Legalization of abortion 25,38 Government efforts to increase access to SAS 33 Partnerships between government and NGOs to increase awareness and access to SAS 33 Improved awareness and education about abortion laws and services 26 Social and cultural factors Increased awareness and education about SAS 7,24,25,33 Parental involvement in communication about SRH with adolescents 23 Availability of adolescent-friendly health services 23 Confidential and nonjudgmental care provided by trained staff 23 Supportive partners, friends, or family members, and the availability of information 32 Positive views of healthcare staff and abortion service providers toward the new abortion law and practice 26 Healthcare system factors Providing information and counseling to women seeking abortion care 24 Training female community health volunteers to provide information and referrals 28 Increased availability of medical abortion pills 25,33,38 Pharmacy provision of medical abortion 9,33,35 Training and support for nonphysician clinicians 33,35 Expansion of SAS and provider training 7,25 Established referral networks for women who have been denied abortion services elsewhere 29 Consistent access to medication for abortion 29 Improved training for providers 29 Increased confidentiality and privacy in healthcare settings 7,24 Reduced stigma surrounding abortion 7 Support from local and international organizations to improve access to SAS 25 Training and mobilization of mid-level health workers, such as auxiliary nurse midwives 31 T A B L E 2 (Continued)

Facilitators
Human resources (trained ANM) and contraceptive supplies 22 Ongoing monitoring and evaluation of SAS to ensure that they are effective and equitable 9 Abbreviations: ANM, auxiliary nurse-midwives; NGO, nongovernmental organization; SAS, safe abortion services; SRH, sexual and reproductive health.
among women. 8,33Being uninformed hinders their ability to make appropriate decisions, potentially delaying care or leading to unsafe practices.The shortage of trained healthcare providers equipped to offer SAS results in inadequate counseling and care. 34The absence of a safe and confidential environment can deter women from seeking SAS, perpetuating unsafe abortions. 7,23,37The scarcity of trained providers and facilities, especially in certain regions, forces women to endure logistical hurdles to access care far from home. 8,30,38This underscores the urgency of expanding the reach of services to remote areas.Failure to provide effective postabortion contraception contributes to repeat unintended pregnancies and unsafe practices. 34e provision of inaccurate information and unsafe medications provided by untrained pharmacy staff further endangers women's health and lacks a proper referral system. 26,35spite these challenges, numerous facilitators show promise in improving SAS in Nepal.Providing women with comprehensive counseling and information promotes informed choices and timely, safe care. 24Training female CHV to offer referrals bridges the access gap, particularly in rural areas. 28Widening availability of medical abortion pills enables convenient, safe termination of early pregnancies. 25,33,38armacies can serve as accessible points to obtain these medications privately. 9,33,35Training non-clinicians in abortion care enhance access in underserved regions. 29,33,35Expanding the number of trained providers and facilities ensures that the services are within reach for more women. 7,25Referral networks prevent denial of care and resorting to unsafe means. 29Fostering confidential, nonjudgmental settings encourages care-seeking. 7,24Reducing stigma creates a supportive environment. 7Collaborations with organizations provide resources to strengthen SAS delivery. 25Training mid-level health providers such as ANM brings care closer to the communities. 31Ongoing monitoring and evaluation maintain quality and equity. 9

| Strengths and limitations
The factors that were found to aid in the success of abortion services were the lowered cost, greater availability of SAS in rural communities, and the crucial roles played by auxiliary nurse-midwives (ANM) and community health volunteers (CHV) in rural areas.The legal and policy facilitators included the legalization of abortion, government efforts to increase access to SAS, partnerships between government and NGOs, and increased awareness and education about abortion laws and services.Social and cultural facilitators included increased awareness and education about SAS, parental involvement in communication about sexual and reproductive health (SRH) with adolescents, availability of adolescent-friendly healthcare services, confidential and nonjudgmental care provided by trained staff, supportive partners, friends, or family members, and the availability of information about SAS.The facilitators of the healthcare system included providing information and counseling to women seeking abortion care, training women CHV, increasing availability of medical abortion pills, pharmacy provision of abortion medications, training and support for non-clinicians, expansion of SAS, training of providers, and established referral networks for women who have been denied abortion services elsewhere.
Summary table showing the patterns and trends of barriers and facilitators for safe abortion services in Nepal.
There was minimal data directly linking identified factors to abortion morbidity/mortality.Few studies evaluated interventions or policies to improve access.While valuable insights emerged, higher-quality longitudinal and interventional studies are required to strengthen the knowledge base on improving the safe provision of abortion in Nepal.T A B L E 3