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Journal Article

Abortion Incidence and Unintended Pregnancy in Nepal

Mahesh Puri, Susheela Singh, Aparna Sundaram, Rubina Hussain, Anand Tamang and Marjorie Crowell
International Perspectives on Sexual and Reproductive Health
ternational Perspectives on Sexual and Reproductive Health (2016)
Published by: Guttmacher Institute
DOI: 10.1363/42e2116
Stable URL: http://www.jstor.org/stable/10.1363/42e2116
Page Count: 13
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Abortion Incidence and Unintended Pregnancy in Nepal

Mahesh Puri
Susheela Singh
Aparna Sundaram
Rubina Hussain
Anand Tamang
Marjorie Crowell

Mahesh Puri is associate director and Anand Tamang is director, Center for Research on Environment Health and Population Activities, Kathmandu, Nepal. Susheela Singh is vice president for international research, Aparna Sundaram is senior research scientist, Rubina Hussain is senior research associate and Marjorie Crowell is senior research assistant—all at the Guttmacher Institute, New York.

  1. Author contact:

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.

RESUMEN

Contexto: Aunque el aborto ha sido legal bajo criterios amplios en Nepal desde 2002, una proporción significativa de mujeres continúan obteniendo abortos ilegales e inseguros, y no existen estimaciones de la incidencia de los abortos seguros e inseguros a nivel nacional.

Métodos: En 2014 se recolectaron datos de una muestra representativa con cobertura nacional de 386 instituciones de salud que proveen abortos legales o atención postaborto, y de una encuesta realizada a 134 profesionales sanitarios con conocimientos sobre la provisión de servicios de aborto. Se utilizaron un número de casos provenientes de instituciones de salud, así como técnicas de estimación indirecta para calcular la incidencia nacional y regional del aborto legal e ilegal. También se estimaron los niveles nacionales y regionales relativos a las complicaciones del aborto y los embarazos no planeados.

Resultados: En 2014, las mujeres en Nepal tuvieron 323,100 abortos, de los cuales 137,000 fueron legales y 63,200 mujeres recibieron tratamiento por complicaciones del aborto. La tasa de aborto fue de 42 por 1,000 mujeres en edades de 15–49 y la razón de aborto fue de 56 por 100 nacidos vivos. La tasa de aborto en la región Central (59 por 1,000) fue sustancialmente mayor que el promedio nacional. En general, 50% de los embarazos fueron no planeados y la tasa de embarazo no planeado fue de 68 por 1,000 mujeres en edad reproductiva.

Conclusiones: A pesar de la legalización del aborto y de la expansión de servicios en Nepal, el aborto inseguro continúa siendo común e impone una pesada carga a las mujeres. Los programas y las políticas para reducir las tasas de embarazo no planeado y de aborto inseguro, para aumentar el acceso a servicios anticonceptivos de alta calidad y para expandir los servicios de aborto seguro están justificados.

RÉSUMÉ

Contexte: Bien que l'avortement soit largement légal au Népal depuis 2002, une proportion considérable de femmes recourent toujours à l'avortement clandestin non médicalisé et il n'existe aucune estimation nationale de l'incidence de l'avortement médicalisé ou non.

Méthodes: Les données ont été collectées en 2014 auprès d'un échantillon nationalement représentatif de 386 structures prestataires de l'avortement légal ou de soins après avortement, ainsi que de 134 professionnels de la santé au courant de la question de la prestation de services d'avortement. Les cas enregistrés dans les structures et les techniques d'estimation indirecte ont servi à calculer l'incidence nationale et régionale de l'avortement légal ou non. Les niveaux nationaux et régionaux de complications de l'avortement et de grossesses non désirées ont également été estimés.

Résultats: En 2014, 323 100 avortements, dont 137 000 procédures légales, ont été pratiqués au Népal et 63 200 femmes ont été traitées pour complications d'un avortement. Le taux d'avortement était de 42 pour 1 000 femmes âgées de 15 à 49 ans, avec un quotient d'avortement de 56 pour 100 naissances vivantes. Le taux enregistré dans la région centrale (59 pour 1 000) est nettement supérieur à la moyenne nationale. Dans l'ensemble, 50% des grossesses n’étaient pas planifiées et le taux de grossesse non planifiée est calculé à 68 pour mille femmes en âge de procréer.

Conclusions: Malgré la légalisation de l'avortement et l’élargissement des services au Népal, l'avortement non médicalisé reste courant et affecte lourdement les femmes. Des programmes et politiques visant à réduire les taux de grossesse non planifiée et d'avortement non médicalisé, à accroître l'accès à des soins contraceptifs de qualité et à élargir les services d'avortement médicalisés seraient utiles.

Prior to its amendment in 2002, the abortion law in Nepal was highly restrictive: Abortion was permitted only to save a woman's life.1 Moreover, unsafe abortion was common, and deaths from abortion-related complications accounted for more than half of maternal deaths that occurred in major hospitals.2 In 2002, the Country Code of Nepal (Muluki Ain) was amended to grant all women the right to terminate a pregnancy at up to 12 weeks’ gestation on demand, at up to 18 weeks’ gestation if the pregnancy resulted from rape or incest, and at any gestational age with a doctor's recommendation if the pregnancy poses a danger to the woman's life or her physical or mental health or if there is a risk of fetal abnormality or impairment.1 In addition, the revised law prohibits sex-selective abortions and abortions done without the consent of the woman.

During the past decade, the Ministry of Health has developed strategies for implementing the law and expanding access to safe and legal services. These strategies include training clinicians to perform abortions, providing them with necessary equipment, and certifying providers and health facilities3 (both of which need government approval to provide abortion services).4,5 All health facilities that have official approval to provide abortions are expected to perform first-trimester abortions. A few lower-level facilities, such as health posts, are approved only to provide medical abortion up to nine weeks’ gestation. To provide abortions after the first trimester, facilities need separate approval and are required to have staff members trained and certified to provide such abortions. Abortion legalization has led to a decrease in the number of women presenting with severe abortion complications,6,7 and it has contributed to a decline in the country's maternal mortality ratio, which fell from 580 maternal deaths per 100,000 live births in 1995 to 190 deaths per 100,000 live births in 2013.8

Nonetheless, unsafe abortions—that is, procedures carried out by an unapproved provider in an unapproved facility, potentially under unsafe conditions and using unsafe methods—remain a concern in Nepal. According to the 2011 Nepal Demographic and Health Survey (DHS), a quarter of the women who reported having had an abortion in the past five years had had postabortion complications.9 Moreover, a 2009 survey of eight districts found that abortion was the third leading cause of maternal mortality, accounting for 7% of maternal deaths.10

Barriers to women's accessing safe, legal abortion include lack of awareness of the availability and location of services, lack of transport to approved facilities, and gender norms that hinder women's decision-making ability.11,12 Moreover, abortion is considered a sin in Nepali culture, and the need to keep it secret may cause many women to go to unqualified providers.3,13 In 2009, Nepal's Supreme Court ordered the government to ensure that all women, regardless of ability to pay, have access to safe abortion services; however, the government has not yet implemented an effective mechanism through which to provide cost-free abortion services for poor and marginalized women, and fees are often prohibitively high.3,13

No national estimates of abortion incidence are available for Nepal. Data on abortion incidence are unavailable for years prior to the revision of the abortion law, and the only data available for years after 2002 are official statistics indicating the number of legal procedures reported by facilities. These statistics likely underestimate the number of abortions that occur in Nepal, given that they capture only legal abortions done in approved facilities and thus exclude illegal procedures; moreover, facility records in Nepal, as in many other countries, are often incomplete and therefore do not include even many legal abortions.14 Community-based surveys are not a good alternative to official statistics; because of the stigma associated with the procedure, women typically underreport their abortions in face-to-face interviews, a problem that may be exacerbated by women's not knowing abortion's legal status.9,11 As a result, we have used indirect methods for estimating abortion incidence.

In this study, we estimate the incidence of abortion in Nepal in 2014 using a modified version of the Abortion Incidence Complications Methodology (AICM). This approach, which has proven useful in settings where abortion is highly legally restricted, has been used to estimate the incidence of induced abortion in more than 20 countries,1518 and can be modified for settings, such as Nepal, where abortion is legal and yet often done illegally by untrained or unapproved providers.

In addition, we present estimates of the abortion ratio and key indicators of unintended pregnancy. We also estimate the proportion of abortions that were illegal, the proportion that ended in complications requiring care in health facilities, the proportion that did not end in complications, and the treatment rate for abortion complications.

METHODS

As per the AICM, we calculated abortion incidence primarily using data from two sources: a survey of facilities potentially able to provide abortion-related care, called the Health Facilities Survey (HFS), and a survey of experts on abortion in Nepal, called the Health Professionals Survey (HPS). Both were conducted from August to November 2014 and were approved by the Nepal Health Research Council. Below we describe the two surveys, as well as the other data sources we drew upon and the method we used to compute abortion incidence.

Health Facilities Survey

The HFS was a multistage, stratified probability survey of 386 facilities that had the capacity to provide safe abortion services, postabortion care or both. The sample was drawn from 27 of Nepal's 75 districts, and was representative of facilities in the country as a whole as well as in its three geographic zones and five development regions. Public, private and nongovernmental organization (NGO) facilities were included.

We identified eligible facilities using a list obtained from the Health Management Information System of the Nepal Ministry of Health and Population. A total of 2,226 facilities were eligible for the HFS (Table 1). Seventy-three percent were public facilities: large tertiary hospitals (i.e., national, regional, subregional and zonal hospitals), district hospitals, public medical colleges, primary health care centers, health posts and sub–health posts with birthing centers. From the private sector, which accounted for 23% of eligible facilities, we included hospitals, medical colleges and clinics. Last, we selected NGO facilities providing abortion, postabortion care or both, which accounted for 4% of eligible facilities.

TABLE 1.
Number of eligible facilities, percentage and number of facilities sampled, and response rate, Health Facilities Survey, Nepal, 2014
Sector/facility
type
No. of
facilities
% of
facilities
sampled
No. of
facilities
sampled
No. of
participating
facilities
Response
rate
All
districts
Sample
districts
All 2,226 929 46 430 386 90
Public 1,628 528 54 285 283 99
Tertiary hospital 20 12 100 20* 20 100
District hospital 68 26 100 26 26 100
Medical college 3 2 100 2 2 100
Primary health care center 194 83 63 52 52 100
Health post 819 256 43 110 108 98
Sub–health post 524 149 50 75 75 100
Private 504 357 36 130 88 68
Hospital 222 147 32 47 43 91
Medical college 15 10 100 10 9 90
Clinic 267 200 37 73 36 49
NGO† 94 44 34 15 15 100
MSI 43 19 37 7 7 100
FPAN 37 16 25 4 4 100
Other 14 9 44 4 4 100

We sampled a fraction of each type of facility; the proportion sampled varied according to the likelihood that facilities of that type provided abortion services and to the number of such facilities (Table 1). Because district hospitals and public and private medical colleges were few in number and had some of the largest caseloads of both legal abortions and postabortion care, we included in the HFS sample 100% of these facilities in the sampled districts. The sampling fractions were smaller for primary health care centers (63%), health posts (43%), sub–health posts with birth centers (50%), private hospitals (32%), private clinics (37%) and NGO facilities (34%). Of the 927 facilities in the sample districts, 430 were selected for the HFS and 386 participated, for a response rate of 90%.

For each participating facility, a senior staff member knowledgeable about the facility's provision of abortions and postabortion care was interviewed in person. A key purpose of the HFS was to determine the number of women who obtain care for postabortion complications at each facility (i.e., caseloads). In the survey, postabortion complications referred not only to extremely serious conditions, such as sepsis or a perforated uterus, but also to less severe conditions, such as incomplete abortion with heavy bleeding, that require facility-based treatment.

The survey asked for caseloads for all instances of post-abortion care, regardless of whether the complication was from a miscarriage or an induced abortion, both because symptoms of one are often difficult to distinguish from those of the other and because providers may be reluctant to identify cases of illegal abortion. The AICM adjusts for this in the abortion incidence calculations by subtracting the number of cases resulting from miscarriage. We collected the caseload information for postabortion care separately for inpatients and for outpatients, and for two reference periods: the average or typical month, and the month prior to the interview. Obtaining estimates for these two periods increased the likelihood of accurate recall and allowed us to capture variation in caseloads over the course of a year.

Given that abortion is legal in Nepal, a second key goal of the HFS was to collect data on the number of women who obtain legal abortions in approved facilities. As we did for postabortion services, we collected this caseload data for both the past month and the average month. Because most of these procedures are done on an outpatient basis during the first trimester, we did not collect data separately for inpatients and outpatients.

Health Professionals Survey

The HPS was administered to a purposive sample of health professionals with broad knowledge about the conditions under which women in Nepal obtain abortions—whether the procedures are legal or illegal; safe or unsafe; and performed by trained providers, by untrained providers or by the women themselves (self-induced). Because no list of potential key informants existed, the study team compiled one using a snowball sample approach. First, we identified individuals and organizations known to focus on abortion issues in each sampled district. We then contacted these organizations and individuals and added suitable persons to the list; we also asked them to provide names of other potential key informants in their district. Finally, we selected informants from the list and contacted them for an interview. In selecting potential participants, we intentionally avoided including anyone who had participated in the HFS.

The list included both people with medical training and those without it, and it spanned a wide range of professions, including public health experts, managers of reproductive health programs, obstetrician-gynecologists, public health nurses, other clinicians (e.g., medical officers, senior nurses), policymakers, advocates and researchers (Table 2). The diversity of experience was important, because some AICM studies have found that estimates from professionals with medical backgrounds may differ substantially from those of experts with other backgrounds. We expected that including a range of perspectives would improve the reliability and representativeness of our estimates.15 Almost all key informants selected for the HPS (95%) participated in the study.

TABLE 2.
Number of health professionals interviewed, by primary profession, according to development region, Health Professionals Survey, Nepal, 2014
Profession Eastern Central Western Mid-Western Far-Western Total
All 29 58 19 10 18 134
Manager of reproductive health program 10 17 4 3 5 39
Obstetrician-gynecologist 3 13 3 1 2 22
Public health nurse 5 4 3 2 1 15
Policymaker/advocate 1 10 1 0 0 12
Other clinician 10 9 8 4 9 40
Researcher 0 5 0 0 1 6

 

All HPS interviews were conducted in person by trained interviewers using a structured questionnaire. Altogether, 134 health professionals, representing all five development regions, were interviewed. More than three-quarters of participants had worked in rural areas in the past five years; about half currently worked in the government sector, and the remainder in the private sector or for NGOs.

The key purpose of the HPS was to obtain information that would allow us to calculate the proportion of illegal abortions that resulted in complications that were treated in health facilities, a key measure for estimating abortion incidence. From the literature, the study team created a list of categories of approved and unapproved providers,* and HPS respondents were asked to estimate the proportion of abortions in their district performed by each type of provider. They were also asked to estimate the proportion of women who would likely experience complications requiring care at a health facility after obtaining an abortion from each type of provider, as well as the proportion of those with complications who would obtain care at a facility.

Because the conditions under which abortions are performed vary by women's socioeconomic status and place of residence, the above information was obtained for each of four socioeconomic subgroups of women: poor urban, nonpoor urban, poor rural and nonpoor rural.

Other Data Sources

We used the data from the HFS and the HPS in conjunction with information from several other sources. Data on population size and number of births, nationally and by development region, were obtained from the Ministry of Health and Population and the Central Bureau of Statistics.19,20 The 2011 Nepal DHS9 was our source of data on the distribution of women by wealth and place of residence. Finally, the two largest NGO service providers, Marie Stopes International and the Family Planning Association of Nepal, supplied statistics on the number of legal abortions and postabortion services that their affiliated clinics provided in 2014. Although service provision records from public- and private-sector facilities are generally of poor quality, we considered the data from these two NGOs to be of high quality, because the relevant clinics are part of large international organizations that have a uniform and well-established system for documenting services provided and clients served. Thus, we used the caseload data from these NGOs in our estimates. Caseload data for other NGOs were obtained using the HFS.

Steps in Estimating Abortion Incidence

Estimating the number of legal abortions.* To estimate the number of legal abortions, we first estimated the annual caseload at each facility by taking the mean of the number of abortions in the two reference periods—the average month and the past month—and multiplying by 12 to yield annual values. The caseload numbers were summed and then weighted at the regional level using sample weights. Adding the regional estimates to the caseload numbers from the two large NGO networks yielded the total number of legal abortions in Nepal.

Estimating the number of postabortion care patients. Estimating the number of illegal abortions is a complex task that requires a range of information and assumptions. The first step is to determine the number of women receiving postabortion care. For each facility, we estimated the annual postabortion care caseload to be the mean of the caseloads for the two reference periods—the average month and the past month—multiplied by 12. Because we collected data separately for inpatient and outpatient care, we performed these calculations for each and added the results to obtain the total number of cases. As we did in the legal abortion calculations, we then weighted the caseloads to the regional level. The results were added to the number of cases treated by the two large NGO networks to yield the total number of postabortion care patients treated in each region and in Nepal as a whole.

Estimating the number of women treated for complications of illegal abortion. The postabortion care caseloads computed above include not only women treated for complications of illegal abortion, but also those treated for complications from miscarriage and legal abortion. Therefore, we made adjustments to subtract the number of women in the last two groups.

First, we estimated the number of women treated for complications of miscarriage. Clinical research has identified a biological pattern of spontaneous pregnancy loss,21,22 and the proportion of pregnancies ending in miscarriage and the distribution of these miscarriages by gestational age are thought to be fairly constant across populations. We assumed that only late miscarriages (those occurring at 13–21 completed weeks’ gestation) were likely to be accompanied by complications requiring care in health facilities, and that women did not obtain care for first-trimester miscarriages. In accordance with these assumptions, and with evidence from clinical studies, we estimated that the number of miscarriages requiring care was equivalent to 3.4% of the number of live births (577,718),20 which yields an estimate of 19,700 late miscarriages.

However, because it is likely that not all of these women received care, we made a further simplifying assumption: that the proportion of women with late miscarriages who obtained care at a facility was equal to the proportion of women whose most recent delivery took place at a facility or who did not have their delivery at a facility for reasons other than poor access (e.g., because they did not consider it necessary). By applying this proportion (88%)9 to the 19,700 cases of miscarriage complications requiring care, we estimated that 17,300 women received care for complications from late miscarriage. We performed this calculation for each development region and subtracted the number of patients treated for late miscarriage from the total post-abortion care caseload in the region.

One final adjustment was needed to account for women whose complications resulted from legal abortions. HPS data provided estimates of the proportion of women having legal abortions who had complications, and the proportion of women with complications from legal abortions who received care in a health facility; these estimates were available for each of the four socioeconomic subgroups (poor rural, nonpoor rural, poor urban and nonpoor urban women). By weighting these proportions according to the relative size of the four subgroups (obtained from the 2011 DHS), we estimated that 6% of women who had legal abortions were treated in a facility for complications. We applied this proportion to the total number of legal abortions, and subtracted the result from the number of women treated for complications of any abortion to arrive at an estimate of the number of women treated in facilities for complications from illegal abortions.

Estimating the number of illegal abortions. The number of women who had illegal abortions includes not only the number treated for complications of such abortions, but also the number who did not receive treatment or did not have complications. To account for the last two groups, we calculated a multiplier—an adjustment factor that is applied to the number of women treated at a facility for complications of illegal abortion—to yield an estimate of the total number of illegal abortions.

To compute the multiplier, we used estimates from the HPS of the proportion of women who obtained abortions from each of the various types of illegal providers, the proportion of abortions performed by each type of provider that would be expected to result in complications, and the proportion of women with complications who obtained treatment. HPS respondents were asked to estimate each of these proportions separately for the four socioeconomic subgroups.

The product of the three proportions yields the estimated proportion of women in each subgroup who obtained treatment for complications of an illegal abortion performed by each provider type. These calculations were done for each region of Nepal. Using data obtained from the 2011 DHS, we then weighted the estimates by the size of the four population subgroups within each region and summed the results to obtain the proportion of all illegal abortions that resulted in women receiving treatment for complications.

The multiplier for each region is the inverse of this overall proportion.* To obtain the total number of illegal abortions in each region, we multiplied the estimated number of women treated in health facilities for complications from illegal abortions in the region (estimated as described above) by the region's multiplier. The resulting estimate includes not only women who obtained treatment for complications of illegal abortion, but also those who had such an abortion but either did not have complications or did not receive needed care (and may even have died).

The regional multipliers ranged from 2.72 in the Western region to 3.83 in the Central region. In general, a lower multiplier implies a higher probability of complications from illegal abortions, greater access to medical care or a combination of the two factors, whereas a higher multiplier implies a lower probability of complications, less access to care or both.

Estimating the total number of abortions. We summed the number of legal abortions and illegal abortions for each region to obtain the total number of abortions in that region in 2014. The regional results were summed to produce national estimates.

For each region and for Nepal as a whole, we calculated the abortion rate (the number of abortions per 1,000 women aged 15–49) and the abortion ratio (the number of abortions per 100 live births). Since these rates and ratios are derived from data from a sample of health facilities, they are subject to sampling error. To account for the resulting uncertainty, we provide not only main or “medium” estimates, but also “low” and “high” estimates derived using estimates of the number of legal abortions and the number of postabortion care cases that are two standard deviations below and above our main estimates.

Estimating Unintended and Intended Pregnancies

We calculated the number of unintended pregnancies, for each region and for Nepal as a whole, by summing the numbers of induced abortions, unplanned births, and miscarriages resulting from unintended pregnancies. To compute the number of unintended pregnancies ending in miscarriage, we used a model-based approach, derived from clinical studies on pregnancy loss, that estimates the number to be 20% of the number of live births resulting from unintended pregnancies plus 10% of the number of induced abortions.21,22 We estimated the number of unplanned births by multiplying the number of births by the proportion of all births that were unplanned (mistimed or unwanted at the time of conception), using data from the 2011 DHS on the planning status of births in the previous three years. The number of planned pregnancies was calculated by summing the number of planned births and the number of miscarriages from intended pregnancies (estimated to be 20% of the number of planned births). The sum of all live births, abortions and miscarriages (from intended and unintended pregnancies) yielded the total number of pregnancies.

RESULTS

Abortion Service Provision in Nepal

Of the 386 surveyed facilities, 63% offered legal abortion, postabortion care or both (Table 3). Provision of one or both services was nearly universal (88–100%) among large facilities, such as tertiary, district and private hospitals. In contrast, the proportion that provided either service was lower among small facilities, such as health posts (46%), sub–health posts (27%) and private clinics (56%). Nationally, a weighted total of 1,112 facilities provided one or both services.

TABLE 3.
Measures of facility survey participation and service provision, by type of facility, Health Facilities Survey, Nepal, 2014
Sector/facility
type
No. of
participating
facilities
No. of
facilities
providing
abortion
or PAC
% of
facilities
providing
abortion
or PAC
Weighted
no. of
facilities
providing
abortion
or PAC
No. of
abortions
% of
abortions
provided
No. of
PAC
cases
% of
PAC
provided
All 386 242 63 1,112 136,951 100.0 80,469 100.0
Public 283 160 57 774 50,509 36.9 33,089 41.1
Tertiary hospital 20 18 90 18 7,904 5.8 8,754 10.9
District hospital 26 26 100 68 13,441 9.8 11,960 14.9
Public medical college 2 2 100 3 4,380 3.2 2,940 3.7
Primary health care center 52 44 85 168 11,930 8.7 4,630 5.8
Health post 108 50 46 372 10,329 7.5 3,086 3.8
Sub–health post 75 20 27 145 2,525 1.8 1,718 2.1
Private 88 67 76 268 40,281 29.4 35,698 44.4
Hospital 43 38 88 181 32,496 23.7 28,128 35.0
Medical college 9 9 100 14 2,460 1.8 5,106 6.3
Clinic 36 20 56 73 5,325 3.9 2,464 3.1
NGO* 15 15 100 70 46,161 33.7 11,683 14.5
MSI 7 7 100 43 31,563 23.0 2,083 2.6
FPAN 4 4 100 15 13,128 9.6 594 0.7
Other 4 4 100 12 1,470 1.1 9,006 11.2

About 137,000 legal abortions were provided in Nepal in 2014. Thirty-seven percent were performed by public facilities, 29% by private facilities and 34% by NGO facilities.

Overall, an estimated 80,500 women were treated in health facilities for complications of miscarriage or induced abortion in 2014. Private facilities provided the largest share of postabortion care, accounting for 44% of the national caseload. Forty-one percent of cases were treated at public facilities and 15% at NGO facilities.

Service Provision by Region and Sector

Forty percent of legal abortions in Nepal were provided in the Central region, which includes the capital city of Kathmandu (Table 4). Twenty-two percent were provided in the Western region, 19% in the Eastern region and 10% each in the Mid-Western and Far-Western regions.

TABLE 4.
Number and percentage distribution of legal abortions and postabortion care cases, by type of facility, according to development region
Development
region
Legal
abortions
Postabortion
care
cases*
No. %
distribution
by
region
%
distribution
by
facility
type
No. %
distribution
by
region
%
distribution
by
facility
type
All Public Private NGO Public Private NGO Total All Public Private NGO Public Private NGO Total
All 136,951 50,509 40,281 46,161 100 37 29 34 100 80,469 33,089 35,699 11,683 100 41 44 15 100
Eastern 25,755 12,041 2,358 11,356 19 47 9 44 100 19,012 5,243 5,321 8,449 24 28 28 44 100
Central 54,274 12,168 31,122 10,984 40 22 57 20 100 36,867 11,351 24,715 801 46 31 67 2 100
Western 29,838 11,475 3,749 14,614 22 38 13 49 100 13,206 6,772 4,405 2,029 16 51 33 15 100
Mid-Western 13,768 7,257 957 5,554 10 53 7 40 100 8,062 6,931 891 241 10 86 11 3 100
Far-Western 13,316 7,568 2,095 3,653 10 57 16 27 100 3,322 2,792 367 163 4 84 11 5 100

The Central region also provided the largest share of postabortion care (46%). About 24% was provided in the Eastern region, 16% in the Western region and smaller proportions in the Mid-Western (10%) and Far-Western (4%) regions.

The contribution of each sector to provision of abortion and postabortion care varied by region. Close to or slightly more than half (47–57%) of legal abortions in the Eastern, Mid-Western and Far-Western regions were provided by the public sector, whereas this sector provided a smaller proportion in the Western (38%) and Central (22%) regions. The private sector accounted for more than half of legal abortions in the Central region (57%), a much larger share than in other regions (7–16%). In the Eastern, Western and Mid-Western regions, a large proportion of abortions were provided by the NGO sector (40%–49%).

More than 80% of women who received postabortion care in the Mid-Western and Far-Western regions were treated in public facilities, while in the Central region the private sector dominated, accounting for 67% of the caseload. The domination of a single sector was less extreme in the Western and Eastern regions; in the former, the public sector accounted for the largest share of cases (51%), while in the latter NGOs were the most common providers (44%).

Incidence and Rates of Postabortion Care and Abortion

Of the 80,500 women who received postabortion care in Nepal in 2014, 68% were treated for complications of illegal abortion, 11% for complications of legal abortion and 21% for complications of miscarriage (not shown).

We estimate that 8.2 per 1,000 Nepali women of reproductive age obtained facility-based treatment for complications of illegal or legal abortion (Table 5). The rate varied substantially by region, from a low of 1.8 per 1,000 in the Far-Western region to a high of 11.3 per 1,000 in the Central region.

TABLE 5.
Selected demographic and abortion-related measures, by development region, Nepal, 2014
Development
region
No. of
women
aged
15–49
No. of
live
births
No. of
legal
abortions
No. of
women
treated
for
complications
Treatment
rate
for
complications
of
induced
abortion*
Total Miscarriages Legal
induced
abortions
Illegal
induced
abortions
All 7,754,148 577,718 136,951 80,469 17,263 8,747 54,459 8.2
Eastern 1,711,590 122,277 25,755 19,012 3,733 1,664 13,615 8.9
Central 2,772,219 183,241 54,272 36,867 5,524 2,718 28,625 11.3
Western 1,508,839 107,022 29,839 13,206 3,367 2,813 7,026 6.5
Mid-Western 1,028,475 93,167 13,768 8,062 2,669 789 4,604 5.2
Far-Western 733,025 72,011 13,316 3,322 1,969 763 589 1.8

Overall, about 323,100 induced abortions occurred in Nepal in 2014 (Table 6). The estimated annual abortion rate was 42 per 1,000 women aged 15–49; our low and high estimates were 24 and 59 per 1,000, respectively. The abortion rate varied by region. In the Central region, the rate was 59 per 1,000 (range, 26–92), substantially higher than the national value. The abortion rate was lower than the national rate in the other regions, ranging from 21 per 1,000 (half of the national rate) in the Far-Western region to 39 per 1,000 in the Eastern region.

TABLE 6.
Estimated numbers of legal and illegal abortions, percentage of abortions that were illegal, and abortion rates and abortion ratios—all by development region, Nepal, 2014
Development
region
No. of
illegal
abortions
resulting
in
treated
complications
Multiplier Total
no. of
illegal
abortions*
No. of
legal
abortions†
Total
no. of
abortions
% of
abortions
that
were
illegal
Abortion
rate
Abortion
ratio
Legal† Illegal* All
Low Medium High Low Medium High
All 54,459 3.30 186,144 136,951 323,094 58 17.7 24.0 24.2 41.7 59.2 33 56 80
Eastern 13,615 3.05 41,535 25,755 67,291 62 15.0 24.3 29.4 39.3 49.2 41 55 69
Central 28,625 3.83 109,638 54,272 163,910 67 19.6 39.5 26.0 59.1 92.2 39 89 140
Western 7,026 2.72 19,109 29,839 48,948 39 19.8 12.7 23.8 32.4 41.1 34 46 58
Mid-Western 4,604 3.05 14,062 13,768 27,830 51 13.4 13.7 16.2 27.1 37.9 18 30 42
Far-Western 589 3.05 1,799 13,316 15,115 12 18.2 2.5 17.2 20.6 25.1 18 21 26

The abortion ratio is an indicator of the likelihood that women who have a pregnancy will have an abortion rather than give birth. We estimate that the national abortion ratio was 56 abortions per 100 live births in 2014 (range of estimates, 33–80). Regionally, the ratio varied from 21 per 100 live births in the Far-Western region to 89 per 100 in the Central region.

Fifty-eight percent of abortions in 2014 were illegal. About three-fifths of these illegal terminations (representing 36% of all abortions) did not result in complications, while the remaining two-fifths (22% of all abortions) resulted in complications that required care at a health facility (not shown). The remaining 42% of abortions were legal; 6% of these abortions (accounting for 3% of all abortions) resulted in complications.

Unintended Pregnancies

Nepali women had an estimated 1,048,700 pregnancies in 2014 (Table 7). The pregnancy rate was 135 per 1,000 women of reproductive age, and it ranged from 121 per 1,000 in the Western region to 144 per 1,000 in the Central region. The national unintended pregnancy rate was 68 per 1,000 women of reproductive age; it was lowest (47 per 1,000) in the Far-Western region and highest (85 per 1,000) in the Central region. Nationally, 50% of all pregnancies in 2014 were unintended. The proportion of pregnancies that were unintended was lowest (34%) in the Far-Western region and highest (59%) in the Central region.

TABLE 7.
Measures of levels, intendedness and outcomes of pregnancy, by development region, Nepal, 2014
Development
region
No. of
pregnancies
Pregnancy
rate
Unintended
pregnancy
rate
% of
pregnancies
that
were
unintended
%
distribution
of
pregnancies
by
outcome
Planned
births
Miscarriages
of
intended
pregnancies
Unplanned
births
Abortion Miscarriages
of
unintended
pregnancies
Total
All 1,048,665 135 67.7 50 42 8 13 31 6 100
Eastern 220,752 129 64.3 50 42 8 14 30 6 100
Central 400,191 144 85.0 59 34 7 12 41 6 100
Western 182,269 121 57.2 47 44 9 15 27 6 100
Mid-Western 142,414 138 56.9 41 49 10 16 20 5 100
Far-Western 103,040 141 47.3 34 55 11 15 15 4 100

About 42% of pregnancies led to planned births in 2014; the proportion ranged from 34% in the Central region to 55% in the Far-Western region. Nationally, 31% of pregnancies ended in an abortion. This proportion was lowest in the Far-Western (15%) and Mid-Western (20%) regions, and highest in the Central region (41%). Sixty-two percent of unintended pregnancies in Nepal ended in abortion (not shown).

DISCUSSION

Since Nepal legalized abortion in 2002, women's ability to obtain safe abortions performed by trained providers in approved facilities has greatly improved.3,23 Nevertheless, women continue to face barriers to obtaining such services, and illegal abortions continue to be performed by unapproved providers in potentially unsafe conditions.6 In this study, our aim was to estimate total abortion incidence in Nepal as well as the number of illegal and potentially unsafe abortions that are performed.

We estimate that more than 300,000 abortions were performed in Nepal in 2014, and that nearly 60% of them were illegal. Out of every 1,000 women of reproductive age, eight were treated for complications of legal and illegal abortions. The overall abortion rate was 42 per 1,000 women aged 15–49, a rate comparable to the rates estimated using a similar methodology for two other South Asian countries—Pakistan, which had a rate of 50 per 1,000 women aged 15–49 in 2012, and Bangladesh, which had a rate of 37 per 1,000 women aged 15–44 in 2010.24,25

The abortion rate varied across regions; it was highest in the Central region and lowest in the Far-Western region. The higher-than-average rate in the Central region was likely the result of many factors. For example, compared with their counterparts in other regions, couples in the Central region are probably more motivated to have small families and are more likely to live in urban areas (where abortion tends to be more easily accessible), and women marry at an older age, which may increase the likelihood of premarital sex and, in turn, rates of unintended pregnancy and abortion.*20,26 In contrast, in the Far-Western region, educational attainment and women's mean age at marriage are lower than in the Central region, and residents are more likely to live in rural areas.

Another reason for the relatively high abortion rate in the Central region may be the greater availability of health care services, particularly from private facilities. Given its relative urbanity and greater density of providers (especially higher-quality and private providers), it is likely that the Central region is serving women from neighboring areas. If such an influx of women from other areas is occurring, the abortion rate for this region may be an overestimate, and the rates for the neighboring regions underestimates.

We calculated the incidence of unintended pregnancy in Nepal because such pregnancies are the root cause of women's seeking abortions. We estimated the rate of unintended pregnancy to be 68 per 1,000 women of reproductive age. This is much lower than the rates in such South Asian countries as Pakistan and Bangladesh (93 and 74, respectively).24,25 Nonetheless, about half of pregnancies in Nepal were unintended, and well over half of unintended pregnancies ended in an abortion.

The high proportion of pregnancies that were unintended is consistent with the substantial level of unmet need for contraception (about 27% among married women).9 Moreover, the proportion of married women using modern contraceptive methods changed only slightly between 2006 and 2011 (from 44% to 43%), while use of less-reliable traditional methods increased from 3.7% to 6.5%.9 The level of unintended pregnancy is also consistent with the country's high rate of contraceptive discontinuation—more than half of users stop use of pills, injectables and condoms within a year9—and, given the high proportion of women who want small families, with the moderately high abortion rate.

The methodological approach and data used in this study have some important limitations. In the absence of other evidence, we assumed that the likelihood of miscarriage was stable over time and across countries; however, more research is needed to confirm this assumption. A second limitation is that our estimation of the multiplier relied on the opinions and perceptions of health professionals, because alternative sources of data on the likelihood that women will have and receive treatment for abortion complications are unavailable; however, we acknowledge that direct, good-quality data from women themselves would be better. Given the number of assumptions that underlie the methodology, the resulting estimates should be viewed as approximations rather than as exact measures of abortion incidence. We provided high and low estimates to account for sampling, and recommend that readers keep these ranges in mind when interpreting the results. Finally, the measure of unintended pregnancy used retrospective survey data on the planning status of births; because women may revise their characterization of intendedness after giving birth (typically shifting from considering the pregnancy mistimed or unwanted to considering it wanted), we may be underestimating the incidence of unintended pregnancy.

Despite these limitations, our study helps fill an important evidence gap regarding sexual and reproductive behavior and needs, and provides information that should help inform programs and policies both in Nepal as a whole and in disadvantaged regions of the country. Though significant progress has been made in expanding abortion services, ensuring that all women seeking to terminate a pregnancy receive legal and safe abortion care remains an important challenge. The recently announced policy of providing legal abortions free of cost in public facilities is an important step in this direction. However, action needs to be taken to ensure that the policy is implemented, especially in rural areas.

Inadequate knowledge of the abortion law and of the availability of services continues to be an important barrier to accessing safe abortion care. A nationally representative survey found that 62% of Nepali women aged 15–49 did not know that abortion was legal, and a lower but still substantial proportion (41%) did not know of a place where they could get a safe abortion.9 Programs to educate women about the abortion law and where to obtain legal and safe abortion services are urgently needed. Furthermore, because the safety, efficacy and acceptability of medical abortion provided by trained auxiliary nurse-midwives (even at the sub–health post level) is now well established in Nepal, accrediting sub–health posts and staffing them with an auxiliary nurse-midwife trained in the provision of medical abortion could be an important step toward improving access to safe and legal abortion.23,27

Given the high level of unmet need for contraception and the large proportion of pregnancies that are unintended, improvements in access to and quality of contraceptive services are urgently needed in all regions. The terrain in Nepal makes the delivery of contraceptive services challenging. However, policymakers and other relevant parties need to devise programs to improve services in remote areas.

Finally, programs are needed to improve contraceptive access and care for the subgroups of men and women who may need it the most. This includes unmarried, sexually active adolescents, who may have an elevated risk of unintended pregnancy, as well as seasonal migrants and newly married couples.

NOTES

  1. *
    Unapproved providers include medical practitioners (e.g., doctors, staff nurses, auxiliary nurse midwives) who have not been approved by the government; paramedics; pharmacists; traditional providers (e.g., trained and untrained traditional birth attendants, quacks, homeopathic doctors, and Ayurvedic and traditional healers); and women themselves (i.e., those who self-induce abortions).
  2. *
    The mathematical equations used in each of these steps are outlined in Appendix A.
  3. To compute sample weights, we first divided the number of facilities of each type in the sample by the number of facilities of that type in the sampling frame. The inverse of this number is the sample weight.
  4. *
    See Appendix B for an example of how the multiplier is calculated.
  5. The HPS sample size was adequate (i.e., the number of respondents was greater than 15) to compute the multiplier for three regions; however, we calculated a combined multiplier for the Far-Western and Mid-Western regions, which together had 28 respondents.
  6. *
    In 2011, the mean age at marriage among Nepali women who married before age 50 was 20.9, up from 19.5 in 2001; it was 20.9 in the Central and Eastern regions, 20.4 in the Western region, 20.1 in the Far-Western region and 19.6 in the Mid-Western region. The proportion of the population that lived in urban areas was 24% in the Central region and 13% in the Far-Western region in 2011.

REFERENCES

  1. 1.
    Nepal Ministry of Health, National Safe Abortion Policy, Kathmandu, Nepal: Ministry of Health, 2002, http://www.mohp.gov.np/images/pdf/policy/National%20abortion%20Policy.pdf.
  2. 2.
    Thapa PJ, Thapa S and Shrestha N, A hospital-based study of abortion in Nepal, Studies in Family Planning, 1992, 23(5):311–318.
  3. 3.
    Samandari G et al., Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care, Reproductive Health, 2012, 9:7, doi: 10.1186/1742-4755-9-7.
  4. 4.
    Ministry of Health and Population, Comprehensive Abortion Care Service Training Manual 2004, Kathmandu, Nepal: Family Health Division, Ministry of Health and Population, 2009.
  5. 5.
    Ministry of Health and Population, A Medical Abortion Scale-Up Strategy and Implementation Guidelines 2009, Kathmandu, Nepal: Family Health Division, Ministry of Health and Population, 2009.
  6. 6.
    Rocca CH et al., Unsafe abortion after legalization in Nepal: a cross-sectional study of women presenting to hospitals, BJOG, 2013, 120(9):1075–1083.
  7. 7.
    Henderson JT et al., Effects of abortion legalization in Nepal, 2001–2010, PLoS One, 2013, 8(5):e64775, doi: 10.1371/journal.pone.0064775.
  8. 8.
    World Health Organization (WHO) and World Bank, Trends in Maternal Mortality: 1990 to 2013, Geneva: WHO, 2014.
  9. 9.
    Ministry of Health and Population, New ERA and ICF International, Nepal Demographic and Health Survey 2011, Kathmandu, Nepal: Ministry of Health and Population and New ERA; and Calverton, MD, USA: ICF International, 2012.
  10. 10.
    Pradhan A et al., Nepal Maternal Mortality and Morbidity Study 2008/09, Kathmandu, Nepal: Department of Health Services, Ministry of Health and Population, 2010.
  11. 11.
    Thapa S, Sharma SK and Khatiwada N, Women's knowledge of abortion law and availability of services in Nepal, Journal of Biosocial Science, 2014, 46(2):266–277.
  12. 12.
    Puri M, Ingham R and Matthews Z, Factors affecting abortion decisions among young couples in Nepal, Journal of Adolescent Health, 2007, 40(6):535–542.
  13. 13.
    Puri M et al., “I need to terminate this pregnancy even if it will take my life”: a qualitative study of the effect of being denied legal abortion on women's lives in Nepal, BMC Women's Health, 2015, 15:85, doi: 10.1186/s12905-015-0241-y.
  14. 14.
    Sedgh G and Henshaw S, Measuring the incidence of abortion in countries with liberal laws, in: Singh S, Remez L and Tartaglione A, eds., Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review, New York: Guttmacher Institute, 2011, pp. 23–34.
  15. 15.
    Singh S, Prada E and Juarez F, The abortion incidence complications method: a quantitative technique, in: Singh S, Remez L and Tartaglione A, eds., Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review, New York: Guttmacher Institute, 2011, pp. 71–98.
  16. 16.
    Sedgh G et al., Estimating abortion incidence in Burkina Faso using two methodologies, Studies in Family Planning, 2011, 42(3):147–154.
  17. 17.
    Juarez F and Singh S, Incidence of induced abortion by age and state, Mexico, 2009: new estimates using a modified methodology, International Perspectives on Sexual and Reproductive Health, 2012, 38(2):58–67.
  18. 18.
    Sedgh G et al., Estimates of the incidence of induced abortion and consequences of unsafe abortion in Senegal, International Perspectives on Sexual and Reproductive Health, 2015, 41(1):11–19.
  19. 19.
    Samir KC et al., Projecting Nepal's Demographic Future: How to Deal with Spatial and Demographic Heterogeneity, Kathmandu, Nepal: Ministry of Health and Population, 2014.
  20. 20.
    Nepal Central Bureau of Statistics, Population Monograph of Nepal, Volume I: Population Dynamics, Kathmandu, Nepal: Central Bureau of Statistics, 2014.
  21. 21.
    Harlap S, Shiono PH and Ramcharan S, A life table of spontaneous abortions and the effects of age, parity, and other variables, in: Porter IH and Hook EB, eds., Human Embryonic and Fetal Death, New York: Academic Press, 1980, pp. 145–158.
  22. 22.
    Bongaarts J and Potter R, Fertility, Biology, and Behavior: An Analysis of the Proximate Determinants, New York: Academic Press, 1983.
  23. 23.
    Puri M et al., The role of auxiliary nurse-midwives and community health volunteers in expanding access to medical abortion in rural Nepal, Reproductive Health Matters, 2015, 22(44 Suppl. 1):94–103.
  24. 24.
    Sathar ZA et al., Induced abortions and unintended pregnancies in Pakistan, Studies in Family Planning, 2014, 45(4):471–491.
  25. 25.
    Singh S et al., The incidence of menstrual regulation procedures and abortion in Bangladesh, 2010, International Perspectives on Sexual and Reproductive Health, 2012, 38(3):122–132.
  26. 26.
    Nepal Ministry of Health and Population, Nepal Adolescents and Youth Survey, 2010/11, Kathmandu, Nepal: Ministry of Health and Population, 2011.
  27. 27.
    Warriner IK et al., Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomized controlled equivalence trial in Nepal, Lancet, 2011, 377(9772):1155–1161.
Acknowledgments

This research was supported by grants from the UK Department for International Development, the Dutch Ministry of Foreign Affairs and the Norwegian Agency for Development Cooperation. An earlier version of this article was presented at the 2015 Annual Meeting of the Population Association of America. The authors thank the Family Health Division of the Nepal Ministry of Health, the chair and members of the Technical Advisory Committee, and Akinrinola Bankole, whose comments and suggestions helped improve this article.

NOTES

  1. *
    Unapproved providers include medical practitioners (e.g., doctors, staff nurses, auxiliary nurse midwives) who have not been approved by the government; paramedics; pharmacists; traditional providers (e.g., trained and untrained traditional birth attendants, quacks, homeopathic doctors, and Ayurvedic and traditional healers); and women themselves (i.e., those who self-induce abortions).
  2. *
    The mathematical equations used in each of these steps are outlined in Appendix A.
  3. To compute sample weights, we first divided the number of facilities of each type in the sample by the number of facilities of that type in the sampling frame. The inverse of this number is the sample weight.
  4. *
    See Appendix B for an example of how the multiplier is calculated.
  5. The HPS sample size was adequate (i.e., the number of respondents was greater than 15) to compute the multiplier for three regions; however, we calculated a combined multiplier for the Far-Western and Mid-Western regions, which together had 28 respondents.
  6. *
    In 2011, the mean age at marriage among Nepali women who married before age 50 was 20.9, up from 19.5 in 2001; it was 20.9 in the Central and Eastern regions, 20.4 in the Western region, 20.1 in the Far-Western region and 19.6 in the Mid-Western region. The proportion of the population that lived in urban areas was 24% in the Central region and 13% in the Far-Western region in 2011.

REFERENCES

  1. 1.
    Nepal Ministry of Health, National Safe Abortion Policy, Kathmandu, Nepal: Ministry of Health, 2002, http://www.mohp.gov.np/images/pdf/policy/National%20abortion%20Policy.pdf.
  2. 2.
    Thapa PJ, Thapa S and Shrestha N, A hospital-based study of abortion in Nepal, Studies in Family Planning, 1992, 23(5):311–318.
  3. 3.
    Samandari G et al., Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care, Reproductive Health, 2012, 9:7, doi: 10.1186/1742-4755-9-7.
  4. 4.
    Ministry of Health and Population, Comprehensive Abortion Care Service Training Manual 2004, Kathmandu, Nepal: Family Health Division, Ministry of Health and Population, 2009.
  5. 5.
    Ministry of Health and Population, A Medical Abortion Scale-Up Strategy and Implementation Guidelines 2009, Kathmandu, Nepal: Family Health Division, Ministry of Health and Population, 2009.
  6. 6.
    Rocca CH et al., Unsafe abortion after legalization in Nepal: a cross-sectional study of women presenting to hospitals, BJOG, 2013, 120(9):1075–1083.
  7. 7.
    Henderson JT et al., Effects of abortion legalization in Nepal, 2001–2010, PLoS One, 2013, 8(5):e64775, doi: 10.1371/journal.pone.0064775.
  8. 8.
    World Health Organization (WHO) and World Bank, Trends in Maternal Mortality: 1990 to 2013, Geneva: WHO, 2014.
  9. 9.
    Ministry of Health and Population, New ERA and ICF International, Nepal Demographic and Health Survey 2011, Kathmandu, Nepal: Ministry of Health and Population and New ERA; and Calverton, MD, USA: ICF International, 2012.
  10. 10.
    Pradhan A et al., Nepal Maternal Mortality and Morbidity Study 2008/09, Kathmandu, Nepal: Department of Health Services, Ministry of Health and Population, 2010.
  11. 11.
    Thapa S, Sharma SK and Khatiwada N, Women's knowledge of abortion law and availability of services in Nepal, Journal of Biosocial Science, 2014, 46(2):266–277.
  12. 12.
    Puri M, Ingham R and Matthews Z, Factors affecting abortion decisions among young couples in Nepal, Journal of Adolescent Health, 2007, 40(6):535–542.
  13. 13.
    Puri M et al., “I need to terminate this pregnancy even if it will take my life”: a qualitative study of the effect of being denied legal abortion on women's lives in Nepal, BMC Women's Health, 2015, 15:85, doi: 10.1186/s12905-015-0241-y.
  14. 14.
    Sedgh G and Henshaw S, Measuring the incidence of abortion in countries with liberal laws, in: Singh S, Remez L and Tartaglione A, eds., Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review, New York: Guttmacher Institute, 2011, pp. 23–34.
  15. 15.
    Singh S, Prada E and Juarez F, The abortion incidence complications method: a quantitative technique, in: Singh S, Remez L and Tartaglione A, eds., Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review, New York: Guttmacher Institute, 2011, pp. 71–98.
  16. 16.
    Sedgh G et al., Estimating abortion incidence in Burkina Faso using two methodologies, Studies in Family Planning, 2011, 42(3):147–154.
  17. 17.
    Juarez F and Singh S, Incidence of induced abortion by age and state, Mexico, 2009: new estimates using a modified methodology, International Perspectives on Sexual and Reproductive Health, 2012, 38(2):58–67.
  18. 18.
    Sedgh G et al., Estimates of the incidence of induced abortion and consequences of unsafe abortion in Senegal, International Perspectives on Sexual and Reproductive Health, 2015, 41(1):11–19.
  19. 19.
    Samir KC et al., Projecting Nepal's Demographic Future: How to Deal with Spatial and Demographic Heterogeneity, Kathmandu, Nepal: Ministry of Health and Population, 2014.
  20. 20.
    Nepal Central Bureau of Statistics, Population Monograph of Nepal, Volume I: Population Dynamics, Kathmandu, Nepal: Central Bureau of Statistics, 2014.
  21. 21.
    Harlap S, Shiono PH and Ramcharan S, A life table of spontaneous abortions and the effects of age, parity, and other variables, in: Porter IH and Hook EB, eds., Human Embryonic and Fetal Death, New York: Academic Press, 1980, pp. 145–158.
  22. 22.
    Bongaarts J and Potter R, Fertility, Biology, and Behavior: An Analysis of the Proximate Determinants, New York: Academic Press, 1983.
  23. 23.
    Puri M et al., The role of auxiliary nurse-midwives and community health volunteers in expanding access to medical abortion in rural Nepal, Reproductive Health Matters, 2015, 22(44 Suppl. 1):94–103.
  24. 24.
    Sathar ZA et al., Induced abortions and unintended pregnancies in Pakistan, Studies in Family Planning, 2014, 45(4):471–491.
  25. 25.
    Singh S et al., The incidence of menstrual regulation procedures and abortion in Bangladesh, 2010, International Perspectives on Sexual and Reproductive Health, 2012, 38(3):122–132.
  26. 26.
    Nepal Ministry of Health and Population, Nepal Adolescents and Youth Survey, 2010/11, Kathmandu, Nepal: Ministry of Health and Population, 2011.
  27. 27.
    Warriner IK et al., Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomized controlled equivalence trial in Nepal, Lancet, 2011, 377(9772):1155–1161.
Acknowledgments

This research was supported by grants from the UK Department for International Development, the Dutch Ministry of Foreign Affairs and the Norwegian Agency for Development Cooperation. An earlier version of this article was presented at the 2015 Annual Meeting of the Population Association of America. The authors thank the Family Health Division of the Nepal Ministry of Health, the chair and members of the Technical Advisory Committee, and Akinrinola Bankole, whose comments and suggestions helped improve this article.

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