More than a decade has passed since abortion was legalized in Nepal, with many advances for women’s access to abortion care. Notably, the national budget for 2015/16 allows for free abortion service in public health facilities. However, women in need of safe abortion services still are not guaranteed access, especially as the compounding issues of community norms, caste and geography affect so many Nepalese women. Fundamentally, stigma remains a significant barrier to Nepalese women accessing the safe abortion services and care that they have a right to.

With support from inroads, the Beyond Beijing Committee (BBC) and their partner, the Youth Welfare Society, conducted a baseline assessment in 2015 in order to inform a strategy for reducing abortion-related stigma in Nepal.

BBC is a feminist Nepalese network organization committed to achieving gender equality, sustainable development and women’s human rights. They support local communities, civil society organizations, international non- government organizations and government organizations to implement full suite of recognized human rights instruments in order to achieve gender equality and empowerment for women and girls.

BBC uses a four-pronged approach in their work: 1) Policy advocacy, 2) Grass-roots advocacy, 3) Program development, and 4) Networking and alliances. A cornerstone of their approach includes advocating for context-specific, rights-based quality comprehensive abortion care.

As BBC prepares to integrate stigma-reduction content to their Community Health Education Session (CHES) curricula, they wanted to fully understand the prevailing abortion stigma, its causes and consequences and to map the support services in the communities that exist to reduce the stigma and enable women to access abortion care. Trained interviewers with BBC and the Youth Welfare Society conducted 40 key informant interviews and focus group discussions with 107 participants across nine Village Development Committees and the sub-metropolitan city of Hatauda in the Makwanpur District.

When inroads Partnership Fund grantees convened in Peru last November, participants from BBC shared a bit with us about their participatory approach to focus groups. In this picture they are showing us how trained interviewers use wooden dolls to re-enact family structures and relationships to glean information on abortion stigma.

While abortion has been legal in Nepal since 2002 and is available through the public health system, BBC found that there are considerable barriers for women who need abortion care, many of which are rooted in stigma. Many participants didn’t know that abortion was legalized (37%)—and those who did know that abortion is legal had different understandings about the conditions under which abortion is legal. For example, one man whose wife has had an abortion shared that “I have no idea regarding abortion or its legal aspects. I was not involved at all while my wife had an abortion so I do not know about it.” Notably, women were more informed than men about the legal criteria for abortion.

Stigma figured prominently when participants were asked directly why women do not access abortion in the health system: 67% said that fear of being disparaged was the primary reason, followed by “abortion is a wrong concept” (62%), pressure from the family or spouse (60%), a family preference to have a son (37%), lack of access to abortion services (30%), lack of other choices (17%), and lack of knowledge (15%).

Understanding the driving factors of community-level stigma attached to abortion is necessary to support women’s access, agency and bodily autonomy. So, BBC dug deeper and found that:

• 93 percent of key informants said that their communities have negative attitudes about abortion
• Negative labels ascribed to women who have abortions are prevalent
• Abortion service providers are also labeled negatively, but not as intensely as women
• Women who have abortions have been bullied, mistreated, accused as a criminal, isolated or excluded from religious ceremonies
• The roots of these stigmatizing attitudes and behaviors include: religion, myths about abortion (safety and legality), and a male-dominated social system

BBC interviewers wanted to learn more about the consequences of abortion-related stigma and its manifestations. They found that there are health consequences when women’s families treat them poorly after abortion (whether the abortion was accessed through the health system or other methods). Women may be overloaded with work as a punishment, or may not seek post-abortion care due to fear of being identified in the community. This results in negative impacts on physical and emotional health, as well as diminished social status.

Respondents shared examples of when women are excluded and shunned in the community after an abortion: “The stigma affected their marital relationships as well. Most of the in-laws wanted their son to get married again when they recognized that their daughter-in-laws have had an abortion.” Male partners and spouses can also be negatively impacted and are called “Joitingre” (one who does everything as his wife says) or “Namarda” (one who does not act as a man). Other examples of social exclusion include

• Not being allowed to attend religious ceremonies
• Not being allowed to touch newborns
• Being thrown out of a family

BBC was also interested in learning if there were any factors mitigating the impact of abortion stigma. They found that efforts supported by International NGOs and Country-based Organizations in the community and health system to inform people about legalization and the right to safe abortion are having an indirect impact in some areas. Furthermore, they found that the structure of female community health volunteers (FCHVs) is facilitating an increase in knowledge about the right to abortion and where it’s available. The most common strategy shared by women is concealment in order to avoid community stigma and shaming. However, that concealment carries with it the additional weight of any physical or emotional distress, as well as contributing to the myth that abortion is rare and dangerous. Abortion service providers are another source of stigma mitigation and reduction. Providers are employing counseling and advocacy in order to reduce stigma, and taking care to protect confidentiality for women.

Given the prevalence and impact of stigma in the community, what does BBC want to do next? They see a need for a comprehensive strategy across sectors with multi-pronged goals:

• Increase women’s knowledge about abortion, its legality, its availability, its safety and their rights
• Organize women into groups to support one another, as well as to act against stigmatizing community norms
• Produce educational materials with a specific eye towards non-stigmatized language
• Work to sensitize CBOs, government, and non-governmental organizations to address abortion stigma, along with accessibility of safe abortion
• Sensitize community leaders and community groups to help them understand that abortion stigma is a social, educational and political issue
• Lobby and advocate for including abortion stigma as a measure in safe abortion implementation

BBC is getting to work! Their next step is to incorporate stigma-reduction content into their CHES materials and to train FCHVs about abortion stigma reduction. The whole inroads community benefits from BBC’s impressive work on this issue and their active membership in the network.