Effects of abortion legalization in Nepal, 2001-2010

Abstract

Background: Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion.

Methods: We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010).

Results: 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75).

Conclusion: Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Figure 1. Trend in the percentage of abortion cases with serious complications presenting at four tertiary care hospitals in Nepal, 2001–2010, N = 23,493.

Early implementation, monthly IRR from segmented Poisson regression = 1.002, p<.001; later implementation, monthly IRR = 0.993, p<.001; marginal spline test for slope change, p<.001) Serious complications are those with infection (sepsis or septic shock, peritonitis, endometritis, severe pelvic or peritoneal infection, or body temperature> = 102 F), evidence of foreign body or mechanical injury, systemic complications, such as organ failure, or death. 2002 - Passage of legal abortion legislation 2004 - First trimester services and trainings begin 2007 - Second trimester services and trainings begin 2008 - Midlevel providers trained and legally provide first trimester abortion 2009 - Medication abortion added to safe abortion program.