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

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.

The medico-legal death investigation system in Nepal

In Nepal, police inquests have several limitations. When they receive information about a death, the police visit the crime scene and write an inquest report. Then, they arrange for the body to be autopsied. However, most autopsies are performed by medical officers in government hospitals who lack specialised training in conducting autopsies. Although all Nepalese medical schools teach forensic medicine to undergraduate students and require them to witness some autopsies, most private institutions are not authorised to perform them. Autopsies performed without expertise can be subpar and, even when trained personnel are available, these facilities are inadequately equipped. In addition, there is a lack of sufficient manpower to provide expert medico-legal services. The Honourable Judges and District Attorneys of all district courts believe that the medico-legal reports prepared by the doctors are inappropriate, incomplete and inadequate for use as evidence in court. Moreover, the police are more concerned with establishing criminality than other aspects of medico-legal death investigation, such as autopsies. Therefore, the quality of medico-legal investigations, including death investigations, will not improve until government stakeholders recognise the importance of forensic medicine in the judiciary and for the resolution of crimes.