This presentation is prepared as part of the Course assignment of “Analysis of Health Service Management in Nepal” for the Master's Degree of Public Health (MPH), Pokhara University, and can be used as reference materials. The content and facts included in the presentation are as of information available till August 2023 and no conflict of interest is associated with the presentation. The presentation is prepared by Sagar Parajuli.

1. Review & Critical
Appraisal of Abortion
related Laws and Act
of Nepal
Sagar Parajuli
MPH Third Semester 2023
School of Health & Allied Sciences
Pokhara University

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Presentation Outlines
• Introduction; Abortion
• Status Quo: Abortion in Nepal, including global status
• Review of Abortion related laws and act of Nepal
 Muluki Ain (The National Code)
 National Abortion Policy and Strategy 2003
 The Safe Motherhood and Reproductive Health Act 2018
• Critical Appraisal of Abortion related laws and act of Nepal

3. 3
Introduction to Abortion or Termination of Pregnancy (ToP)
• Expulsion or extraction of an embryo or
fetus from the uterus before stage of viability
• WHO define abortion as pregnancy termination
before 20 weeks gestation or with a fetus born
weighting <500g.
• "Abortion" means spontaneous or induced
termination of fetus from uterus before it
becomes capable of natural birth.-The Safe
Motherhood and Reproductive Health Act, 2018
• Miscarriage: abortion occurring spontaneously,
Induced abortion: abortion with the purpose
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4. 4
Abortion Types
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Spontaneous
Abortion
• Complete Abortion; complete discharge of product of conception
• Incomplete Abortion; incomplete discharge of product of conception
• Inevitable Abortion
• Septic Abortion; retained products of conception become infected
• Missed Abortion; asymptomatic or ‘missed’ death of the embryo or fetus
without sufficient uterine contractions to push out the products of
conception.
• Threatened Abortion; characterized by symptomatic, ‘threatened’ expulsion
of the products of conception, cervical remains closed, and embryo or
fetus remains viable
• Recurrent Abortion; three or more consecutive pregnancy losses
Induced Abortion
• Legal; Justifiable, legally considered
• Illegal; Criminal, beyond legal limits
Alves, C., & Rapp, A. (2023). Spontaneous Abortion. StatPearls. http://www.ncbi.nlm.nih.gov/books/NBK560521/

5. 5
Methods of Abortion
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In Nepal
Medical Abortion: Upto 9 weeks with women’s consent
MVA: Upto 12 weeks with
D & E: Beyond 12 weeks on recommendation of two subject experts
In case of rape and incest on recommendation of 1 subject experts

6. • Six out of 10 (61%) of all intended pregnancies and 3 out of 10 (29%) of all
pregnancies end in induced abortion
• Nearly 1 out of 2 abortions are unsafe
• About 45% of all global abortions are unsafe, of which 97% take place in
developing countries. (Global Estimates from 2010-2014)
• More than half of unsafe abortions occur in Asia, mostly in south and central Asia.
• Unsafe abortion is a leading cause of maternal deaths and morbidities
• Each year, 4.7–13.2% of maternal deaths attributed to unsafe abortion
• 25 percent of the world’s women live in countries where abortion is still restricted
to saving a woman’s life.
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Status Quo: Global and National Status

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Status Quo: Global Status
- In developed regions, it is
estimated that 30 women die for
every 100 000 unsafe abortions.
- In developing regions, that
number rises to 220 deaths per
100 000 unsafe abortions
• Comprehensive abortion care
listed in essential health care by
WHO in 2020.

8. Laws on Abortion
throughout the
globe
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Status Quo: Global Status

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Status Quo: National Status
• Miscarriages and induced abortions: 9% have had a miscarriage and 10% have had
an induced abortion (NDHS 2022)
• Total abortion rate in Nepal is 0.3 abortions per woman.
• Ethnicity: Lowest in the Muslim (3%) and Madhesi (4%), highest in
Brahmin/Chhetri (13%)
• Residence: Higher in urban
• Ecological region: Mountain-13.2%, Hill-12.3%, Terai-7.6%
• Province: Gandaki Province-16.9% (Highest), Madhesh-4.3% (Lowest)
• Abortion reported as the third leading cause of maternal death in 2011 study and
after abortion legalization contributed to decline in MMR in Nepal from 580 in
1995 to 190 per 100,000 in 2013.

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Status Quo: National Status
Health Facility Readiness for Safe Abortion Services in
Nepal Study, 2023 Ipas Nepal & FWD, DoHS
57 % of NGOs abortion service, 20 % of public
facilities and 39 % private facilities
Availability of Abortion Service Abortion Service by type

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Status Quo: National Status
• 42 percent (four out of 10)
of WRAs were aware of the
legality of abortion in Nepal
• Highest in Sudurpaschim
Province followed by
Koshi.
• Madhesh Province with
lowest knowledge about the
legal status of abortion.
Exploring Determinants and Influential Factors of Unsafe
Abortion Practices and Service Access Study, 2023 Ipas
Nepal & FWD, DoHS
Percentage of WRA who think abortion is legal

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Abortion related Laws, Policies and Acts in Nepal

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The Muluki Ain (National Code-Penal and Criminal)
• Provision of punishing women for abortion before amendment
• Abortion considered priorly as ‘crime’ and provision of jail punishment of 1
year, 3 years or 5 years for committing abortion with pregnancy of 12 weeks,
25 weeks and beyond 25 weeks respectively.
• Approval of the 11th amendment bill to the Muluki Ain by the parliament on
14th march 2002 and on 27th September 2002 it achieved act status after
receiving the royal seal.
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The Muluki Ain (National Code)
The 11th amendment added two additional clauses to the Muluki Ain:
• Clause 28A: If the pregnant woman is negatively influenced or coerced for
abortion, there is provision for jail punishment of 3 to 6 months for the
individuals responsible and service providers. If sex selective abortion is
intended or performed, there is the provision for jail punishment of an
additional 1 year for both parties.
• Clause 28B: The clause provides for nullification of Clause 28A if the
qualified and authorized health workers accomplish pregnancy termination
with fulfillment of the abortion procedural process set by Government of
Nepal.

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The Muluki Ain (National Code)
Provisions related to Abortion
• Women's right to abortion up to 12 weeks of pregnancy on
voluntary consent
• Abortion right in case of rape and incest up to 18 weeks of pregnancy
• Abortion right at anytime in special situation with the advice of medical
practitioner at anytime for any pregnancy danger to the life of the
pregnant woman or to her physical or mental health or it leads to the birth
of a disabled child
• No abortion on the basis of sex identification

16. Comprehensive
Abortion Care
(CAC) services
Human Resource
Development
Rights of Women
Role of Non-
government and
Private Sectors
Advocacy, IEC
and Social
Mobilization
Planning,
monitoring,
supervision and
follow up
Research
Institutional
arrangements
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National Safe Abortion Policy and Strategy 2003
Developed based on The National’s Code (Muluki Ain) and Procedural Process for Safe
Pregnancy Termination Services, 2060 BS

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National Safe Abortion Policy and Strategy 2003
1. Comprehensive Abortion Care (CAC) services
 Ensuring safe, accessible and affordable abortion services with equity and
equality for all women
 Provision of CAC services through listed service providers as per Safe
Pregnancy Termination Order, meeting necessary medical standards and
professional conduct
 Establishment of referral mechanism
 Integration of CAC services into RH services and development of
protocols
 Pregnancy termination shall not be used as a method of family planning
and shall not be performed for the purpose of sex selection

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National Safe Abortion Policy and Strategy 2003
2. Human Resource Development: Identification of HR needs and
competencies for Safe abortion services, Orientation and competencies based
training, CAC curriculum for health service provider in pre-service and in-
service trainings, Prevention of unsafe abortion in school curriculum,
development of training sites in coordination with NGOs and private sectors
3. Rights of women: Right to continue or discontinue unwanted pregnancy
within legal framework, informed consent, right to information about risks,
benefits, methods and procedures, privacy and confidentiality of information

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National Safe Abortion Policy and Strategy 2003
4. Role of Non-government and private sectors: Provision of CAC services in
underserved areas and marginalized populations through private, semi and non-
governmental organizations including abortion information dissemination, IEC,
and advocacy.
5. Advocacy, IEC and social mobilization: Advocacy, IEC and social
mobilization on the prevention of unwanted pregnancy and danger of unsafe
abortion to address stigmatisation and misconceptions associated with safe
pregnancy termination advocacy to promote a woman's right to CAC

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National Safe Abortion Policy and Strategy 2003
6. Coordination, Planning, Monitoring, Supervision and Follow-Up:
 MoHP responsible for coordinating CAC trainings and services, for
planning, monitoring, supervising and follow-up of CAC services at all
levels in the public sector and support CAC services in the private sector,
 FWD as focal point for abortion related activities,
 District Health Office for management of CAC services
 Integration of CAC services in HMIS
 Monitoring, evaluation and Quality Assurance tool utilization
7. Research: Abortion related research for policy and program management

21. Chapter IV- Safe Abortion
1. To perform safe abortion: A pregnant woman shall have the right to seek
safe abortion under the following conditions:
 Up to 12 weeks of pregnancy with the consent of a pregnant woman;
 Up to 28 weeks of pregnancy with the consent of the concerned woman
under following condition
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The Safe Motherhood and Reproductive Health Act, 2018
Danger to the life of a
pregnant woman, her
physical or mental
health or child born
will be impaired,
In case of rape
or incest
Infection with virus
or incurable disease
that deteriorates
immune system
(HIV)
Fetal impairment and the chance
of ‘non-viable or unlikely to
survive’ after birth or deformity
due to any genetic disorder or
any other reason

22. 2. Forced Abortion Prohibited: No one shall carry out abortion by enticing,
coercing or threatening or alluring a pregnant woman.
3. Sex-selective abortion prohibited: No one shall commit or cause to be
committed an act to identify the sex of the fetus in the womb.
4. Safe abortion services: Provision of SAS for a pregnant woman on her consent
by licensed health service provider (meeting standards and qualifications) but in
case of women less than 18 year and women not in condition to provide consent,
guardian or curator can give consent considering her best interest as per guideline.
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The Safe Motherhood and Reproductive Health Act, 2018

23. 5. Confidentiality to be maintained:
• A listed health institution and health service provider shall maintain the
confidentiality, of information and documents, relating to reproductive health
counseling and services provided
• Information can be made available to concerned authorities on demand by
investigation authority or court for hearing of any lawsuit, required to quote
without revealing identity of the related woman for the purpose of study,
research or monitoring relating to safe abortion
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The Safe Motherhood and Reproductive Health Act, 2018

24. The Constitution of 2015 and the 2018 SMRHR Act guarantee the right to an
abortion as a fundamental right for every woman.
The MOHP developed and updated regulations, strategies and directives for
implementing the abortion law and for expanding access to safe and legal
abortion services.
Training on SAS including CAC, as of 2021, about 4,500 clinician, 1,833
auxiliary nurse midwives, 743 nurses, 1,853 medical doctors, and 92
obstetrician gynecologists and general practitioners trained
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Critical Appraisal of Abortion related laws and act of Nepal

25. Unit costs reimbursements from provincial government for the provision of
free abortion care; NRs 800 for abortions up to 12 weeks’ gestation, NRs
2,000 for abortions at 13–28 weeks and NRs 3,000 for management of
complications of induced abortion.*
Development of Interim guidelines in 2020 during COVID19 pandemic to
ensure availability of essential RMNCH services (including safe abortion
services). Nepal’s safe abortion service directive 2022 has endorsed the
interim guideline for medical abortion through self-care and telemedicine.
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Critical Appraisal of Abortion related laws and act of Nepal
Reference *Ministry of Health and Population, Family Health Division, Safe Abortion Service Program Management Directives, 2022, Chapter 5, 18 kha (11)

26. Policies conflicts and inconsistencies in legal provisions between SMRHR
Act and Penal Code:
Abortion Under Purview of Criminal: Abortion related punishment
provisions in Penal code and SMRHR failed to address for the removal
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Critical Appraisal of Abortion related laws and act of Nepal
Penal Code SMRHR 2018
In case of rape and incest Abortion up to 18 weeks Up to 28 weeks
Risk Pregnancy, prescribed
by medical practitioner
At any time Up to 28 weeks

27. Lack of Provincial and local level acts, regulations and directives for SAS:
Four provinces with Public Health Services Act; Madhesh Pradesh, Bagmati,
Karnali and Sudurpaschim Province only, Policy guidance gap in effective
delivery of SAS at provincial and local level
Stigma, discrimination and lack of awareness: Unaware of legal provisions,
service and service center, cost preventing from accessing services
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Critical Appraisal of Abortion related laws and act of Nepal
NDHS 2016
Aware of legal provisions
- Know location to get service
41%
48%
Aware of abortion service up to 12 weeks 23%

28. Limited service providers and health facilities: About 58% were performed
by unapproved providers or at uncertified facilities.*
Lack of effective implementation of free abortion services policy: Issue in
purchase of registered and listed MA drugs and ignorant of reimbursement
policy from local government, lack of regulation on privates
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Critical Appraisal of Abortion related laws and act of Nepal
NFHS 2015
Surgical Abortion 45%
Medical Abortion
Postabortion care
26%
36%
Reference *Puri M et al., Abortion incidence and unwanted pregnancy in Nepal, International Perspectives on Sexual and Reproductive Health, 2016, 42(4):197–209.

29. Denial of access to abortion services: A study on the denial of abortion
services in Nepal showed that about 26% of women did not receive legal
abortion services on the day of their visit to an approved health facility.* One
study that collected data from providers in Nepal suggested that many women
who should legally qualify for free public services are denied care, even those
who are under the 12-week gestational limit.**
Sex-selective abortion: geographically concentrated, in the Kathmandu
Valley and in Lumbini Province, with 53% of cases of "missing girls" found in
only 11 of Nepal’s 77 districts
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Critical Appraisal of Abortion related laws and act of Nepal
*Puri M et al., Qualitative study of the effect of being denied legal abortion on women's lives in Nepal, Women’s Health, 2015, 15:85.
**Puri M et al., Providers’ perspectives on denial of abortion care in Nepal: a cross-sectional study, Reproductive Health, 2018, 15(1):170.

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Critical Appraisal of Abortion related laws and act of Nepal
A half of the 1.2 million
pregnancies in the country were
unintended and nearly 359,000
ended in abortion in 2017. (60%)
UNFPA’s “State of World
Population 2022” report titled,
“Seeing the Unseen”

31. Roe v Wade and Global Gag Rule (GGR) Impact: Funding and program
limitation resulting into disruption of reproductive health services
including safe abortion services in Nepal
- Family Planning Association Nepal (FPAN), a member of IPPF In 2019
received only $ 1.5 million in funding (operational cost of $9 million)
- Affected MS Ladies Program of Marie Stopes Nepal in 11 districts
- Radio talk shows Khuldulee.com (Partly funded by USAID) barred from
using the word ‘abortion’
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Global Influences on Safe Abortion Policies and Programs
References: The right to bodily autonomy—The Record. (n.d.). Retrieved July 26, 2023 fromhttps://www.recordnepal.com/the-right-to-bodily-autonomy

32. Resolve policy conflicts and inconsistencies
Development of provincial and local level directives for SAS
Awareness and community sensitization, targeted approach
Expediate accreditation process for public and private
Monitoring, Evaluation and supervision for effective delivery of free SAS
ensuring competencies of service provider and health facility
Integration of pharmacies into legal network and collaboration with private
sectors
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Way Forward

33. Address sex-selective abortion in line with National Strategy to Prevent
Gender-biased Sex Selection, 2021–2030
Assess feasibility and acceptability of medical abortion (MA) services through
telemedicine and self-care, as envisaged in the MOHP’s Safe Abortion
Services Program Management Directive 2022.
Value Clarification and Attitude transformation (VCAT) to reduce
stigmatization of abortion
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Recommendations

34. 1. Alves C, Rapp A. Spontaneous Abortion [Internet]. In: StatPearls. Treasure Island (FL): StatPearls Publishing;
2023 [cited 2023 Jul 24]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK560521/
2. Abortion Law: Global Comparisons [Internet]. Counc. Foreign Relat. [cited 2023 Jul 26];Available from:
https://www.cfr.org/article/abortion-law-global-comparisons
3. Nearly half of the pregnancies in Nepal are unintended, UN agency says [Internet]. [cited 2023 Jul 24];Available
from: http://kathmandupost.com/health/2022/03/31/nearly-half-of-the-pregnancies-in-nepal-are-unintended-un-
agency-says
4. Requirement of a separate law in Abortion in Nepal [Internet]. Forum Women Law Dev. - FWLD [cited 2023 Jul
24];Available from: https://fwld.org/publications/requirement-separate-law-abortion-nepal/
5. The right to bodily autonomy - The Record [Internet]. [cited 2023 Jul 26];Available from:
https://www.recordnepal.com/the-right-to-bodily-autonomy
6. Addressing Gaps in Safe Abortion Services in Nepal [Internet]. Guttmacher Inst.2022 [cited 2023 Jul
25];Available from: https://www.guttmacher.org/article/2022/06/addressing-gaps-safe-abortion-services-nepal
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References

35. 7. Countries - GAPD - The Global Abortion Policies Database [Internet]. [cited 2023 Jul 26];Available from:
https://abortion-policies.srhr.org/countries/
8. Civil-code.pdf [Internet]. [cited 2023 Jul 25];Available from: https://www.moljpa.gov.np/en/wp-
content/uploads/2018/12/Civil-code.pdf
9. Legal-categories-of-lawful-abortion.pdf [Internet]. [cited 2023 Jul 26];Available from: https://abortion-
policies.srhr.org/documents/reference/Legal-categories-of-lawful-abortion.pdf
10. Muluki-ain-general-code-2020.pdf [Internet]. [cited 2023 Jul 25];Available from:
https://www.lawcommission.gov.np/en/wp-content/uploads/2018/10/muluki-ain-general-code-2020.pdf
11. National-Safe-Abortion-Policy-2002.pdf [Internet]. [cited 2023 Jul 24];Available from: https://fwd.gov.np/wp-
content/uploads/2021/03/National-Safe-Abortion-Policy-2002.pdf
12. Regulatory-and-policy-environment-of-abortion.pdf [Internet]. [cited 2023 Jul 26];Available from: https://abortion-
policies.srhr.org/documents/reference/Regulatory-and-policy-environment-of-abortion.pdf
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References

36. 8/19/2023 36
Safe and legal
abortion is
not a women’
right but
human right.
Thank you !
“Abortion is often navigated through unending debate between ‘pro-life’
and ‘pro-choice’. Supporting safe abortion is supporting the choices of
women and respecting bodily autonomy.”