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Open Access Research article

“Sometimes they used to whisper in our ears”: health care workers’ perceptions of the effects of abortion legalization in Nepal

Mahesh Puri1*, Prabhat Lamichhane1, Tabetha Harken2, Maya Blum3, Cynthia C Harper3, Philip D Darney3 and Jillian T Henderson3

Author Affiliations

1 Center for Research on Environment Health and Population Activities, Kusunti, P.O. Box 9626 Kathmandu, Nepal

2 Department of Obstetrics and Gynaecology, University of California, Irvine, CA, USA

3 Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynaecology and Reproductive Sciences, University of California, San Francisco, 3333 California Street, Suite 335, San Francisco, CA 94118, USA

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BMC Public Health 2012, 12:297  doi:10.1186/1471-2458-12-297

Published: 20 April 2012

Abstract

Background

Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers’ views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care.

Methods

To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data.

Results

Overall, participants had positive views of abortion legalization – many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment.

Conclusions

Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.