Barriers to accessibility and availability of safe abortion services among young women in Nepal: a mixed-methods study

Abstract

Background: Despite Nepal’s progressive legal framework permitting abortion, young women continue to face barriers in accessing safe abortion services (SAS), leading to preventable maternal mortality and morbidity. This study aimed to identify the key obstacles to SAS access among young women in the Makwanpur district of Nepal. Methods: A convergent mixed-methods study was conducted in 2018. The quantitative component involved a cross-sectional survey of 447 female students aged 18–34, using a structured questionnaire to assess knowledge, stigma (via the Stigmatizing Attitudes, Beliefs, and Actions Scale - SABAS), and access to SAS. Multivariable logistic regression identified factors associated with low access. The qualitative component included six in-depth interviews with post-abortive women (PAWs), four with abortion service providers (ASPs), and three focus group discussions (FGDs) with 26 young community women. Data were analyzed thematically and integrated to provide a comprehensive understanding. Results: Quantitatively, only 54.14% of respondents had high access to SAS. Key factors associated with low access included high abortion stigma (AOR: 2.97, 95% CI: 1.06–8.35), no internet use (AOR: 1.99, 95% CI: 1.02–3.86), and no contact with Female Community Health Volunteers (FCHVs) (AOR: 2.20, 95% CI: 1.21–4.31). While 70.69% knew abortion was legal, knowledge of specific legal conditions and free services was limited (47%). Qualitatively, seven key barriers emerged: [1] critical knowledge gaps about legality and service availability; [2] financial constraints, particularly for transportation; [3] pervasive abortion stigma and discrimination, especially against unmarried women; [4] geographical inaccessibility in rural areas; [5] marital status discrimination; [6] concerns about service quality and confidentiality; and [7] a lack of trained providers and resources, particularly for manual vacuum aspiration (MVA). Conclusion: A complex interplay of informational, social, financial, and structural barriers impedes young women’s access to safe abortion in Nepal. Interventions must be multi-faceted, including targeted awareness campaigns (leveraging media and FCHVs), stigma reduction programs, expansion of services in rural areas, and strengthening of healthcare provider training and resources to ensure equitable access to safe abortion for all young women.