Abuse of abortion pills among reasons for high number of maternal deaths in Nepal

In July, a 28-year-old woman from Kavrepalanchok was rushed to Paropakar Maternity and Women’s Hospital in Thapathali after suffering septic shock, a life-threatening condition that occurs when blood pressure drops to an extremely low level after an infection.

Doctors who treated the patient said the woman was bleeding profusely due to the misuse of a “medical abortion kit” – a series of pills that terminate a pregnancy in nine weeks.

The woman was five months pregnant and had taken a medical abortion kit without seeing a doctor, according to Dr Shanti Shrestha, a consultant gynecologist who treated the patient. “When she started to feel the movement of the fetus in her womb, her husband bought over-the-counter abortion pills,” Shrestha said.

Such incidents are common among many Nepalese women who use over-the-counter medical abortion pills and reach the stage of shock due to excessive bleeding and other health complications.

Abortions were legalized in Nepal in 2002, a milestone for women’s reproductive rights, empowerment and right to bodily autonomy. With legalization, the persecution and prison sentences for women who terminated unwanted pregnancies have ceased and unsafe abortions have dramatically decreased.

Between 1996 and 2016, the maternal mortality rate fell from 539 to 239 per 100,000 live births as the country reached the Millennium Development Goal, a feat in which the legalization of abortions played an important role, according to the doctors.

Since then, however, the decline in the rate has become stagnant, with conditions such as septic shock posing serious challenges to ensuring maternal health.

According to doctors, one of the main reasons for this ongoing stasis is the misuse of abortion pills.

According to Shrestha, the woman’s husband also did not consult the pharmacist on the proper way to use the abortion pills nor did the pharmacist deem it necessary to inform him.

The woman continued to take one pill a day for five days, which doctors say is the wrong way to take it.

A 2021 study of “Medical Abortion Kit Dispensing Practices in Community Pharmacies in Pokhara” shows that pharmacy workers provide their customers with limited knowledge about medications.

Doctors say that for a medical abortion, a pregnant woman must first take a pill called mifepristone. Pregnancy needs a hormone called progesterone to develop normally. Mifepristone blocks the body’s progesterone, thus preventing the growth of the fetus.

Then the woman should use four pills of the second medicine called misoprostol at a time, either immediately or up to 48 hours later. This medication causes cramping and bleeding to empty the uterus. It’s a bit like having a very heavy cramping period, and the process is very similar to an early miscarriage.

Due to the use of abortion pills in late pregnancy, Kavrepalanchok’s wife suffered a ruptured uterus, which caused excessive bleeding. The woman was admitted to the hospital’s intensive care unit for seven days, transfused with several pints of blood and treated on the general ward for another week.

“You should know that abortion pills can only be used up to nine weeks of pregnancy,” said Dr. Jageshwor Gautam, obstetrician and gynecologist. “The said drug should be used under the supervision of qualified health workers. Its misuse can be fatal.

Maternity doctors said Kavrepalanchok’s wife already had three children and had used contraceptive injections in the past.

But when she suffered some side effects from the injections, she stopped using it and her husband also did not find it necessary to use any other means of contraception.

According to a recent UNFPA report on the “neglected crisis of unwanted pregnancies”, half of the 1.2 million pregnancies in Nepal in 2017 were unintended and nearly 359,000 were aborted.

“Unintended pregnancies are a reality for millions of people every year, accounting for nearly half of all pregnancies,” the report said. “Sixty percent of these unwanted pregnancies will end in abortion.”

The report further stated that “the toll of these pregnancies is – and has long been – invisible.”

Nepal must reduce the number of maternal deaths to 116 per 100,000 births by 2022 to achieve one of the United Nations Sustainable Development Goals. The country has already missed its own 2020 target of reducing maternal mortality to 125 per 100,000 births.

The SDG health target is to reduce the maternal mortality rate to 75 per 100,000 births by 2030.

Even as safe medical abortions are challenged around the world as emblematic of women’s rights to reproductive health and bodily autonomy, doctors say some men are increasingly refusing to use other forms of contraception and force their partners to abort.

“Despite the fact that over-the-counter medical abortion kits are illegal, relevant authorities have failed to regulate the trade and prevent their misuse,” Gautam said. “Due to the authorities’ indifference, the said drug was used as contraception, which is alarming.”

The UN agency’s report says many unwanted pregnancies occur because a woman has lost, or never had, autonomy over her own body. “Together, these figures unequivocally point to persistent levels of gender discrimination and human rights and development deficits,” the report said. “These must be resolved to achieve the Sustainable Development Goals.”

Meanwhile, Paropakar Maternity and Women’s Hospital said they were training auxiliary midwives and auxiliary nurses in the proper use of medical abortion kits.

Dr Amir Babu Shrestha, director of the hospital, said: “Towards the Ministry of Health and Population, we have provided training to auxiliary nurse midwives and nurses on the proper use of the kits. ‘medical abortion’.

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