Understanding awareness of abortion legality and barriers to service access among adolescent girls in Karnali Province, Nepal: evidence from a mixed methods study

Abstract

Background: Although abortion has been legal in Nepal since 2002, the utilization of safe abortion services has not been universally adopted, especially among adolescents. Adolescent girls disproportionately experience barriers in accessing these services due to a lack of awareness and stigma. This study assessed awareness of abortion legality and barriers to accessing services among adolescents aged 12–19 years in Karnali Province, Nepal. Methods: This study used a cross-sectional mixed-methods approach. A survey assessed the awareness about the legality of abortion, and focus group discussions, key informant interviews, and in-depth interviews were conducted to explore the barriers to accessing abortion services. We performed a binomial logistic regression analysis to identify the determinants of awareness of abortion legality. A thematic analysis was conducted for the qualitative data, and the findings were triangulated with the quantitative results. Results: Nearly 9 out of 10 (89.2%) respondents had heard about abortion. However, only 49.8% knew that abortion is legal in Nepal. Adolescents aged 15–19 years (aOR = 1.976, 95% CI: 1.266, 3.084), who lived in Jajarkot (aOR = 2.784, 95% CI:1.529, 5.067) or Jumla (aOR = 2.419, 95% CI: 1.204, 4.860), and who had awareness on comprehensive sexuality education (aOR = 1.991, 95% CI: 1.175, 3.374) were more likely to be aware of the legality of abortion services. Key barriers to abortion services included social stigma, limited information, misinformation about consequences, distrust in available services, and a lack of confidentiality at health facilities. These challenges were further compounded by health workers’ behaviors and attitudes, poor service availability, and schoolteachers' limited knowledge of abortion legality. Conclusion: Overall, adolescent girls had limited awareness of the legality of abortion and faced multiple demand- and supply-side barriers to accessing services. Addressing these challenges requires a multi-level approach, including social and behavior change initiatives to raise awareness of abortion legality among adolescents and teachers and reduce social stigma. In addition, abortion services should be strengthened by expanding service sites and ensuring that services are adolescent-friendly.