We started the first clinical posting of this year in the Department of Obstetrics and Gynecology with utmost vigor and enthusiasm to learn. First ever ward duties, outpatient department postings, visit to operation theatre, group discussion, case studies and, all in all the thrill of being a final year medical students sufficed our eagerness and curiosity to learn new things every day. Three weeks of posting in this department went by in the blink of an eye, but one thing that has strung in our mind is the rampant number of patients who visited the hospital after the attempts of nescient self-induced abortion went wrong.
Simply put, abortion is the intentional termination of a pregnancy after conception. There are two methods of abortion: medical and surgical. Of the two, medical abortion is comparatively popular as it provides a safe, straightforward, non-invasive and reliable end to pregnancy. Medical abortion is effective within 9 weeks of pregnancy and involves taking two lots of medicine pills. One of the most common abortion pills come as a combination of Mifepristone and Misoprostol tablets. The combipack consists of 5 pills altogether, with 1 Mifepristone (200 mg) taken by mouth and 4 Misprostol (0.2 mg each) administered either vaginally or sublingually (by placing in between the tongue and gums). Ideally, Misprostol is taken 24-48 hours following Mifepristone.
Abortion has long been a topic of controversy around the world through history on religious, moral, ethical, practical, and political grounds. However, Nepal became generous with its policy and legalized abortion in March 2002, under the 11th Amendment to the Civil Code and legal services were successfully implemented on December 25, 2003.
As per the civil code, section 189, abortions can be performed by authorized health professional under following conditions:
a) Within 12 weeks of gestation as per will of the pregnant mother.
b) Within 18 weeks of gestation with consent from pregnant mother, if pregnancy is as the result of rape or incest.
c) In any weeks of gestation, If pregnancy is allowed to be continued, is likely to endanger the life of the pregnant woman or cause serious injury to her physical or mental health; and if there is an evidence to support that the child to be born would suffer from severe physical and mental anomaly certified by authentic medical Specialist. And
d) If pregnant woman is suffering from HIV/AIDS or similar nature of incurable disease.
The abortion law in Nepal before 2002 was highly restrictive, permitting abortion only to save a woman’s life. The 2002 amendment of the abortion law aimed to include abortion as a basic human right of women, designed to improve maternal health conditions and enhance women empowerment. It also played a pivotal role in the decreasing trend of the maternal mortality ratio from a baseline of 850 to 239 through a span of 26 years (1990-2016). However, 17 years after the legalization of abortion in Nepal, a number of maternal morbid conditions as well as a few maternal deaths can still be attributed to abortion related factors.
while, the 2002 amendment of the abortion law in Nepal is intended to reduce the incidence of illegal abortion and consequent maternal morbidity and mortality, almost two decades later we can still observe women visiting the hospitals, weeks to months after suffering some type of health problem related to abortion. Of these women, majority of them are found to have attempted abortion by themselves, without any consultation from the registered health personnel. Upon deeper enquiry, it is know that they are compelled to procure self-medicated abortion due to obstacles like fear of abortion stigma, lack of awareness, government restructuring, and the lack of proper implementation of government policies and effective monitoring.
Despite the Government of Nepal (GoN) prohibiting over the counter sales of medical abortion drugs, a lot of women complaining of abortion related problems admit to having procured abortion by use of drugs bought from pharmacies without a prescription. Also, the GoN has only approved 4 types of drugs viz. Medabone, MTP Kit, Mistol and Pregnon. A study conducted in eastern Nepal revealed that medical shops were selling at least 18 different brands of Mifepristone and Misoprostol tablets. Thus, it would be safe to say that clandestine abortions don’t happen in the back alley clinics, but rather through local pharmacies where women buy pills to self-induce abortion without proper medical guidance; contributing to the rising rate of abortion related complications faced by Nepali women.
Self-induced abortions shouldn’t be havoc, when the drugs are taken correctly and can safely terminate a pregnancy. But, the problem arises when women seeking medical abortion pills in pharmacies aren’t fully acquainted with knowledge on how and when to take the drug. Mrs. Bhandari, 22, was admitted in Kathmandu Medical College and Teaching Hospital (KMCTH) Gynecology Ward after she reached a state of shock following incomplete self-procured abortion. She had a history of taking abortion pills that she bought from the nearby medical store without doctor’s consultation. She took the pills a day apart but made a mistake of taking Misprostol orally, just like Mifepristone that led to incomplete abortion; causing heavy bleeding for two weeks, endangering her life.
Another point to be noted is how far along the women is, in her pregnancy. As stated above, medical abortion is best effective within 9 weeks of pregnancy. Many women unaware of this fact end up inducing abortion after the 9 week mark has passed. The good example is, Mrs. Yadav, who presented to KMCTH outpatient department with complaints of fever, foul smelling vaginal discharge and pain around the pelvis that followed self medicated abortion. On further examination and investigation, it was known that she had developed gross infection after the abortion attempt was unsuccessful as she had crossed 15 weeks of pregnancy while doing so. Other common mistakes women make are not maintaining an adequate time gap while administering the two drugs.
What surprised us the most was a case of an 18 year old unmarried high schooler who had a history of 3 consecutive abortions for 3 continuous cycles. It led us to question if the easy availability of abortion pills had become an alternative to contraceptives. There is a reason why contraceptives and medical abortion drugs have been classified accordingly: they are not the same. A very popular saying “prevention is better than cure” fits this situation like a glove. Abortion is not your go-to option for not having kids, contraceptives are. Abortion is reserved only for those select cases where pregnancy has to be terminated for reasons other than just wanting to avoid childbirth. Frequent abortions can have as serious complications including infertility.
Apparently, visiting pharmacies for abortion in Nepal has become as normal as doing so for a Handiplast. Women prefer pharmacies over hospitals as they offer more privacy, prompt service delivery and easier access. However, women need to understand that self-induced abortions, more often than not do more harm than good. Abortion has been legalized in Nepal and the services are even provided free of cost in public health centers. Why then, do women shy away from receiving safe abortion services?
Now, by 21st century, women have to overcome the fear of abortion related stigma. It is important for all women to rightfully embrace the abortion related facilities provided to them by the government of Nepal. If not now, this taboo will persist further, victimizing as many women as possible. It is very important to realize that risking their lives over “what the society thinks of them” is a plain blunder.
Furthermore, women should be encouraged to share abortion related experiences with their relatives, friends and neighbors. This won’t only abate the stigma stemming from abortion; it will also help enlighten other women in need about the entire process. In addition, it is important to inculcate positive mindset regarding abortion in every individual of the society; from child to old, male to female, educated to uneducated; and also in religious and political level if we are to ought minimal number of abortion related health hazards in Nepal.
As to whether medical abortion is a boon or a curse, it is the same as asking if the advent of internet and social media is a boon or a curse. Has it made our lives easier? Definitely, yes. But would we want its use to be optimized, such that its advantages are maximized and the shortcomings nullified? Why not!
(The writers are final year medical students at KMCTH)