Muliki Ain (Civil Code) 1956 prohibited abortion and abortion was taken as crime or sin as an offence against

life making no exception even when pregnancy threaten a womens life. The Mulili Ain had provision of punishing women for abortion that women who committed abortion there was provision of jail from 3 to 5 years. In 2002, Nepal changed its civil code to legally permit abortion largely in response to deaths and injuries from unsafe abortion care was provided in Kathmandu in 2004 and now it is available all 75 districts through the authorized safe abortion service centres through out the country. The abortion law which was implemented in 2002 the law has some following conditions: Up to 12 weeks of gestation for any women. Up to 18 weeks of gestation if the pregancy results from rape or incest. At any time during pregancy, with the recommendation of an authorized medical practitioner, if the life of the mother were at risk, if he physical or mental health were at risk or if the foetus was deformed. Abortion will be punishable in the following conditions: Sex selective abortion. Abortion without consent of pregnant woman. After the legalization of abortion in 2002 Nepal began to provide comprehesive abortion care (CAC) service centers in 2004 to make access to safe abortion and to protect the sexual and reproductive right of women. Now there is at least one CAC service center in each 75 district approved by government. During the period of 2004 to 2007 176 CAC service sites were established thoroughout the country and its nubered has increasing. Figure 1: Abortion related death reported in printed media since 1997 to 2006
10

4 2

Aug 1997-Sep 2002 Pre-legalization Era

Oct 2002-Feb 2004 Transition Period

Mar. 2004-July 2006 After the implementation of abortion law (CAC services)

Source: Unsafe Abortion Nepal Country Profile, 2006 Nepal is a Hindu religion dominated societies and abotion is still taken as sin due to social and religious reason it is not widely accepted as the right of women.Despite the legalization of abortion many women are not aware about it and unsafe abortion is being one of the major reason for maternal deaths.

Figure 3 : Awareness about legalization according to eduational level of CAC clients

Source: Comprehensive Abortion Care(CAC), National Facility-based Abortion Study, 2006, Government of Nepal & CREHPA Awareness about the abortion law is directly correlated with the lavel of education that higer the level of education higher the level of awreness about the abortion law. Among the never been to school clients of Comprehensive Abortion Care service center only one forth are aware about the legalization of abortion. It indicates that most of women had never been to school in Nepal still and these women are at high risk of unsafe abortion becaues the rate of contraceptive prevalance also lower among these group of women who are illetrate.Therefore implementation of law is not only improtant to increase the effectiveness of law there is equally importance of increasing access to awareness about the law as well as the legal or authorized servies providers. The rising number of abortion indicates that there is high demand for means of contractption though contraceptive prevalance rate (CPR) has been increaing among the women of age 15-49. According to MGDs Progress Report, 2010 still there is 26 percent of unmet need of family planning. At the same time unwanted pregnancy is higher which is major cause of induced abortion. The legalization of abortion is the cause of increasing the number of safe abortion. In developing countries countries where abortion is legally restricted the risk of death from an unsafe abortion may be several hundreds times higher than an abortion is legally provided under safe condition(WHO,2004). Figure 4 : Number of Safe abortions in CAC service centers, mid-2004 to mid-2007
97378 100000 80000 60000 40000 20000 0 2003 to 2004 2004 to 2005 2005 to 2006 2006 to 2007 2007-2008 11521 719 47210 73474

Source: Maternal Mortality and Morbidity Study, 2008/09, Ministry of Health and Population, Government of Nepal The above figure shows that there is rapid increase in number of safe abortion after the legalization of abortion which is directly responsible to reduce the number of maternal deaths during this period which can be cleared by observing the trends of maternal mortality ratio from the following figures. Figure 5 : Trends of Maternal Mortality Ratio( MMR) and Skilled Birth Attendence (SBA) since 1990-2010
900 800 700 600 500 400 300 200 100 0 Maternal Mortality ratio % if Skilled birth attendence 70 60 50 40 30 20 10 1990 850 7 2000 415 11 2005 281 18.7 2010 229 60 0

Source: MGDs Progress Report, 2010, Government of Nepal Despite these progress unsafe abortion is still a burning issue in Nepal that it is contributing as one of the major determing factor for maternal death. According to the Nepal Maternal and Morbidity Study, 2008/09 abortion is the third highest cause of maternal death. It is because most of the CAC service centers are located in the administrative zones. So most fo the rural women are deprived from these services due to transportion cost and distance. Furthermore the knowledge about abortion law is still low. But the following figure shows that awareness about legalization of abortion has been increasing which is nearly doubled during two years of period from 22 percent to 42 percent. Figure 2: Trend in awreness on legalization of abortion : 2002 to 2004 (% aware about legalization of abortion law in each opinion poll

Source: Unsafe Abortion Nepal Country Profile, 2006

Globtally it is estimated that there is 13 percent of contribution of unsafe abortion among the total maternal deaths. But in case of Nepal there is 7percent of maternal death due to unsafe abortion in 2009. Before the implementation of law there is no records that nuber of abortion and its contribution in maternal deaths because abotion was illigal and people did not disclose about it. But observing the following figure it is cleared that there was high parctice of unsafe abortion because in major government hospital during the pre era of legalizatiion of abortion in 1999 ufsafe abortion was major cause among toal obstetric and gynecologigal admissions. This figure also indicates that legal restirction on abotion did not stop the incedence of induced of abortion but it increased the practice of unsafe abortion resulting in complication in the womens reproductive health as well as maternal deaths.

Though there is rapid decline in maternal death at the nation level there is wide variation according to different caste group as well as according to the regional differences. According to the table the maternal mortality ratio varies from 181 to 301 per 100,000 live births. It idicates that the highest MMR is 301 in Rasuwa district which is one of the districts of mountain region whereas the lowest is 181 in Sunsari district which is one the district of Tarai(plain belt) region where is higher access to transportion and health facilities compared to the mountainous region. So from this variation it idicates that in the mountain region there is low access to reproductive health services compared to the Terai region.

Disticts

MMR (Per 100,000 live births) Sunsari 181 Rupandehi 274 Kailali 263 Okhaldhunga 153 Baglung 181 Surkhet 192 Rasuwa 301 Jumla 275 Nepal 229 Source: Nepal Mortality and Morbidity study 2008/09 Caste/Ethicity Muslim Dalit Tarai/Madheshi/other caste Janajati Brahman/Chetri Newar Nepal MMR per 100,000 Literacy rate among live births (2008/09) the 15yrs+ (2001) 318 273 307 207 182 105 229 14.5 21.6 46.4 55.4 62.6 42.5 CPR 2001 14 29.9 36.2 41.2 45.3 54.3 29 2006 18.5 42.4 45.2 51.1 49.4 61 48

Source: Maternal Mortality and Morbidity Study, 2008/09, CBS, 2001, NDHS, 2001 & NDHS,2006.

The above table indicates that maternal mortality varies according to caste/ethnic groups. Among the Muslim women it is highest and lowest among the Newar ethnicity. Similarly contraceptive rate and literacy rate is highest among the Newar women and lowest among the Muslim women. According to the table awareness of abortion law is positively correlated with the educational status of women. Therefore among the Muslim women illiteracy is more than 80 percent and the awareness about the abortion law is comparatively among these women which can be one of the major cause of unsafe abortion resulting in risk maternal deaths.

Figure: Reasons for abortion among the currently married women

Others Studying Husband/partner suggestion Health problem Family problem Economic problem Youngest child small/breastfeeding Contraceptive failure Too early/Mistimed No desire of additional childred 0 10 20 30 40 50 60 70 80

Percentage total exceed due to multiple response. Source: Unsafe abortion Nepal Country profile, 2006 The major cause of induced abortion is unwanted pregnancies followed by economic problem and birth spacing. It indicates that there is high demand for family planning. References: WHO,2004 Unsafe Abortion: Global and regional Estimates of the incidence of unsafe abortion and associated mortality. Geneva; World Health Organization.

Source: Comprehensive Abortion Care(CAC), National Facility-based Abortion Study, 2006, Government of Nepal & CREHPA Source: MGDs progress report, 2010, Governmet of Nepal

Legal restrictions on abortion do not affect its incidence. For example, the abortion rate is 29 in Africa, where abortion is illegal in many circumstances in most countries, and it is 28 in Europe, where abortion is generally permitted on broad grounds. The lowest rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions. [1] Where abortion is legal and permitted on broad grounds, it is generally safe, and where it is illegal in many circumstances, it is often unsafe. For example, in South Africa, the incidence of infection resulting from abortion decreased by 52% after the abortion law was liberalized in 1996. [3] Since 1997, the grounds on which abortion may be legally performed were broadened in 17 countries: Benin, Bhutan, Cambodia, Chad, Colombia, Ethiopia, Guinea, Iran, Mali, Nepal, Niger, Portugal, Saint Lucia, Swaziland, Switzerland, Thailand and Togo. One territory and three states in Australia (Capital Territory, Victoria, Tasmania and Western Australia) and one state in Mexico (Mexico Federal District) also liberalized their laws. In contrast, El Salvador and Nicaragua changed their already restrictive laws to prohibit abortion entirely while Poland withdrew socioeconomic reasons as a legal ground.[15] References 1. Sedgh G, Henshaw S, Singh S, hman E, Shah IH. Induced abortion: rates and trends worldwide. Lancet 2007; 370: 133845. 2. Henshaw SK, Singh S and Haas T, The incidence of abortion worldwide, International Family Planning Perspectives , 1999, 25(1):4448. 3. Jewkes et al, "The impact of age on the epidemiology of incomplete abortion in South Africa after legislative change," BJOG 2005, 112, 355-9. 4. World Health Organization (WHO), The prevention and management of unsafe abortion: report of a technical working group, Geneva: WHO, 1992. 5. Singh S, Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries, Lancet, 2006, 368(955):18871892. 6. World Health Organization (WHO). Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2003, Geneva: WHO, 2007. In Press. 7. Grimes DA et al., Unsafe abortion: the preventable pandemic, Lancet, 2006, 368(9550):1908 1919.

8. The Alan Guttmacher Institute (AGI), Sharing Responsibility: Women, Society and Abortion Worldwide, New York: AGI, 1999. 9. Population Division, United Nations Department of Economic and Social Affairs, World population prospects: the 2004 revision, New York: United Nations, 2005. 10. Leridon H, Human Fertility: The Basic Components, Chicago: University of Chicago Press, 1977. 11. Singh S et al., Adding It Up: The Costs and benefits of Investing in Family Planning and Maternal and newborn Health, New York: Guttmacher Institute and United Nations Population Fund, 2009. 12. Sedgh G et al., Women with an unmet need for contraception in developing countries and their reasons for not using a method, Occasional Report, New York: Guttmacher Institute, 2007, No. 37. 13. Boland R and Katzive L, Developments in laws on induced abortion: 1998-2007, International Family Planning Perspectives, 2008, 34(3): 110-120 14. Gynuity Health Projects, Mifepristone approval, gynuity.org/documents/mife_approval_2007_list.pdf>, accessed June 15, 2008 <http://www.

15. Singh S et al., Abortion Worldwide: A Decade of Uneven Process, New York: Guttmacher Institute, 2009

Literature Review