Wrapped waist-down in a lungi, the young woman takes small, cautious steps as she leaves the operating theatre with a nurse who has placed a supportive arm around her waist. As she settles into a child-sized bed, she curls her knees to her chest and turns to face the wall. Since her procedure went without complications, she will have just half an hour to rest, before she is sent to a counselor, and then discharged.
It´s been a busy morning at the Prasuti Griha Hospital’s abortion ward and all of its four temporary beds are occupied.[break]
Neelima Thapa (names of visitors and patients are changed in this story) lies in the one closest to the nurses’ station. Anticipating her imminent discharge, the 36-year-old housewife sits up, with her back to the wall, hugging her knees. She says the procedure has left her with a mild pain in the abdomen, but otherwise, she feels well– and somewhat relieved.
Neelima is a mother of three children, two sons and a daughter aged between three and 11 years old. Her husband of 11 years has a secure job in computing at the Coca Cola factory in Kathmandu. Nevertheless, they had decided, as a couple, that they couldn’t afford to raise another child.
Clutching her abdomen, Neelima says that under different circumstances, she might have kept her baby. “It’s better not to abort. But what else can you do when you can’t afford to educate another child?”
Since the legalization of abortion in Nepal in 2002, some 178 government-approved clinics have carried out more than 580,000 terminations, including more than 83,000 in the past year alone, according to statistics supplied by the family health division at the Ministry of Health and Population (MoHP). Although the data provides no information on the recipients, doctors and midwives at abortion clinics in Kathmandu report that most of their clients are married mothers done with childrearing.
“The most common reason women come for abortion is unwanted pregnancy, those who have completed their families and had contraceptive failures,” says Dr Yam Prasad Dwa, obstetrician and gynecologist at Vinayak Hospital.
In recent years, Nepalis have shown an ever increasing preference for smaller families. The 2011 Census revealed that the average number of children per couple had slipped over the decade from 5 to 3.2. And in Kathmandu, where the cost of living is higher than anywhere else in the country, the figure was as low as 1.6.
Explanations for the reduction in family size are, however, complex, covering everything from improvements in public healthcare to breakdowns in the joint family system. But whatever the reasons, there is no question that small families are regarded as optimal, especially in the capital.
Pratima Shrestha, 28, a visitor at the FPAN (Family Planning Association of Nepal) clinic in Pulchowk, says that she never planned to have more than one child. Shortly after the birth of her son three years ago, she had taken a single shot of Depo-Provera before resorting to the withdrawal method of contraception. When she got pregnant earlier this year, she never even considered keeping the baby since it is a struggle living on the sole income of her husband, a policeman, who earns just Rs 10,000.
Pratima, who is a housewife, is thankful she detected her pregnancy early enough to be able to avoid a surgical abortion and end it with a drug-inducing miscarriage. Now, two weeks after the termination, she is back at the clinic for a follow-up visit. She says she has had no regrets. “It really was the right decision,” she says, “and if anything, it’s taught me to be more careful.”
Back at the Prasuti Griha abortion ward, Neelima is preparing for her discharge. But before she can leave the hospital, she must see a counselor who will ask her about her contraceptive regime. Neelima will have little to report. Eight months before getting pregnant, she had stopped all forms of birth control alternatives after a series of adverse reactions.
Depo-Provera, a hormonal injection given at three-month intervals to stop ovulation, had induced heavy bleeding, she says. An IUSC plug, inserted at the base of her uterus, caused an infection. And an oral contraceptive pill made her drowsy. For months, she says, she had fretted about getting pregnant, and she wasn’t surprised when she missed her periods.
On the afternoon of her procedure at Prasuti Griha, her obstetrician and gynecologist, Dr. Shanti Shrestha, took a rough inventory of clients. That day she had treated three women who had become pregnant after misusing their Depo-Provera; for various reasons, they had not made it back to the clinics for three-month boosters and the effects of the drug had worn off. Dr Shrestha says she has not come across women who use abortion as a means of contraception, but other health professionals report abuses of the system they feel powerless to stop.
Shipra Joshi, a midwife at the government-run FPAN clinic in Pulchowk, says she treated a mother of two who had undergone 13 abortions. “Her husband is educated and she too knew what she was doing, she wasn’t mentally unsound. We couldn’t understand why she had aborted so many times.”
Although public debate over the morality of abortion has receded over the decade, many feel that the procedure has become too accessible, and should not, in good conscience, be used as a tool to limit family size.
Professor Meera Hada is an obstetrician and gynecologist at Patan Hospital which does not have an abortion ward. She has a professional policy of never performing terminations and says she will only refer clients under extreme circumstances, such as rape and incest and endangerment to life. She says it disturbs her that abortion is widely used as a form of contraception in Nepal, adding that the government needs to put more resources into educating women about contraception.
Confirming her views, she says, are numerous visits to rural areas where women misuse drugs such as Depo-Provera. In lieu of public information, they rely increasingly, she says, on advice from pharmacists who are not trained to dispense information on birth control.
“Abortion, I’m finding, is too common. Women are coming frequently with the effects, such as sterility, pelvic inflammatory disease and psychological problems, and advice on contraception is not enough,” says Professor Hada.
But 11 years after the legalization of abortion, the prospect of now limiting access to services appears dim. Such a measure would no doubt direct women to underground service providers, operating beyond the law. Reports abound of pharmacies selling abortion-inducing drugs smuggled across the border from India, unregistered practitioners offering cut-price abortions and sex-selection clinics specializing in female feticide. There is no accurate measure on the extent of toll of rogue operators, but it’s a widely known fact that unsafe abortions can cost lives.
By contrast, legal terminations have proved relatively safe in Nepal, accounting for only one recorded death, that of a woman three years ago in Banke in a clinic which was later stripped of its registration.
Shailendra Uprety, Director of the Family Health Division at the Department of Health says that all of the country’s 178 official clinics are closely regulated and subject to checks from district health departments. He says that to receive and maintain a license, such facilities must submit to assessments, be staffed by certified, specially trained doctors and midwives, and advertise the cost of procedures.
On a recent visit to the FPAN clinic in Pulchowk, 28-year-old Preeti Shah discovered just how strictly the rules are enforced. She had come to the clinic seeking an abortion – only to be told that she was ineligible as her pregnancy had just advanced into its second trimester. Preeti, who is a housewife, could have applied for a dispensation to the rule and sought an abortion elsewhere, but after briefly consulting her mother-in-law, who had accompanied her to the clinic, she decided to keep the baby.
Sitting in an office at the clinic moments after taking the decision, Preeti fights back tears of mixed emotion. Her son is only 14 months old and she worries at the prospect of caring for two babies under two years old on different sleep schedules. Her husband earns a good living as a laborer in Saudi Arabia, but much of his income goes to repaying a debt. Preeti, whose baby-bump is beginning to show under her long kurta, says another child will be an extra financial burden that the couple will have to struggle to shoulder.
But a part of her is pleased with the outcome. When she walked into the clinic, her pregnancy was a problem that needed to be fixed. But, now that termination is off the cards, she says she feels a stir of emotion towards the fetus she is carrying and her perspective has somewhat altered. "Now, I think it’ll be fine and I’m actually looking forward to it," she says.
alanarosenbaum@me.com
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