Every morning, Pragati Soti Khanal packs her huge grey and blue rucksack, ready to trek through Nepal’s famous mountains.
But she is not packing crampons and climbing ropes. Instead, in go scales, vast bottles of hand sanitiser, assorted medical instruments and a plastic box filled with pill packets.
The pills are medical abortion drugs, which enable women to have safe terminations during the first trimester of pregnancy. And women’s rights advocates say they represent a potential global revolution in safe abortion care.
For Mrs Khanal – a midwife who provides family planning advice across the mountainous Tanahun district of Nepal – they are an essential. “It is a woman’s right,” she says simply.
It is a right she is prepared to fight for. During the Covid-19 lockdown in Nepal, when movements were restricted, she once spent four hours persuading the police to let her through a roadblock, arguing that she provides an essential health service.
Eventually convinced, the officers helped her hitch a lift on a fruit truck on the winding mountain roads, allowing her to reach the woman who needed an abortion. (They also took Mrs Khanal’s number, just in case they needed her services themselves in future).
Riding in a car or bus is not always an option in this remote region though, where houses perch on mountain tops that rise above the clouds, and roads dwindle to rocky mud tracks the higher you go.
No matter; Mrs Khanal just hitches her 15kg bag on her back, and walks. She looks nonplussed when it is suggested that this is above and beyond the call of duty. “I want to do the job. To do the job, I need to go, with the bag,” she says.
Mrs Khanal is an ‘MS Lady’, one of a team of intrepid women working for MSI Reproductive Choices (formerly Marie Stopes International).
Her job providing contraception and medical abortion in these beautiful but often difficult to reach parts of Nepal is at the sharp end of what women’s rights advocates say could change access to abortion forever.
The abortion pills she provides, mifepristone and misoprostol, are safe and effective, with decades of data behind them. And yet, until recently, they have been underutilised globally.
The pandemic could change that. Nepal’s government is one of a number worldwide that made at-home medical abortion legal during the pandemic, when clinics were closed during lockdowns.
KP Upadhyay, a senior advisor at MSI Reproductive Choices in Nepal, says the interim guidelines had such a huge impact that they are now lobbying for them to be made permanent.
“For women in Nepal, there were fears that the progress made on abortion would be set back [during Covid]. But the opposite has happened,” he says.
It is a similar picture globally. The UK also temporarily relaxed its abortion rules in March 2020, meaning women could get the pills over the phone or by post and take them at home without supervision in a clinic.
Last month, the United States – a country where access to abortion is looking increasingly shaky in the post-Trump era – ruled that the changes should be long-term, and UK legislators are considering this, too. For experts, this shift is a game-changer.
Dr Manisha Kumar, an abortion expert at Médecins Sans Frontières, told The Telegraph: “It’s a revolution, because it’s so safe, it’s relatively straightforward, and it puts power back into the hands of the person themselves.”
She says access to safe pills could help save thousands of women’s lives annually, and prevent many long-term injuries.
Globally, around 22,000 women die of unsafe abortions every year, and seven million are injured or disabled, according to figures from the World Health Organization.
The problem is far worse in low and middle-income countries, where around 97 per cent of unsafe abortions take place.
Dr Kumar has seen the horrific lengths women go to when they are denied access to contraception, including using pen cartridges or broken glass inserted into their vaginas. In Nepal, before abortion was legalised in 2002, women sometimes used sticks dipped in dung in a similar way, or rolled heavy stones over their abdomens to kill the foetus.
At the time, unsafe abortion was a leading cause of the country’s huge maternal mortality rates: 539 women died for every 100,000 births, the highest in the region. In the last two decades, this has been brought down to 186 per 100,000 thanks to determined efforts from successive administrations.
As well as tackling unsafe abortion, the work has included scaling up obstetric care, including particularly around caesarean sections, and training more midwives. Despite the progress, the mortality rate is still above the WHO’s target of less than 70 deaths per 100,000 births, and the situation varies around the country.
Still, Mrs Khanal, 34, knows how important abortion can be for women in the communities she serves. Abortion and pre-marital sex are still taboo in many places, and unmarried women who get pregnant face serious stigma.
“Unmarried girls who have used my services, they come to me and say I’ve saved their lives,” she says. “They say: ‘If I had not done this, the only way for me would have been to die.’”
Women whose husbands work abroad, like more than 10 per cent of Nepalis, also tell her she has saved them from ostracisation and abuse – particularly from their husband’s families who suspect, sometimes rightly, that they are pregnant after infidelity.
Others say they would have had no choice but to turn to unsafe methods if they could not access her help, including using unqualified providers who demand sky-high fees.
Mrs Khanal only charges those who can afford to pay; even then, only 1,000 Nepali rupees (£6.20) for the pills.
Unregulated providers can sometimes charge up to 100 times that, and Mrs Khanal says they have been known to use unsafe or unclean equipment, putting women at risk of tearing or perforation, or leaving them bleeding or with incomplete procedures – both dangerous complications.
While abortion has been legal in Nepal for almost two decades, only around 44 per cent of women know this, and 42 per cent of the around 320,000 abortions performed annually are done through informal channels. Around 30 per cent of women know about medical abortion, and fewer in rural areas, according to MSI.
These often risky “informal channels” were a route Maya Tamang, 37, considered, before managing to reach Mrs Khanal during lockdown earlier this year.
She is one of several women who are willing to speak to us about their abortions despite the stigma. Their willingness is testament to Mrs Khanal’s force of personality, and how grateful they are: most have told almost no-one about their procedures, and they took the pills in part to keep their terminations secret.
Mrs Tamang wants to talk in the small quarry behind her house where she occasionally works, rather than in her home where the neighbours listen in. She lives in the slum area of Shuklagandaki Municipality, Tanahun, by a river, with the peaks of Annapurna glistening in the distance.
As she speaks, the 37-year old picks up stones from the floor, fiddling with them to hide her discomfort. She has four children already, aged from 12-20, and could not afford another, particularly as lockdown effectively ended her husband’s work as a driver.
“And what would our children think about us? We were very worried about that,” she says. She has not told them about her abortion. “I had a lot of fear I would not be able to get this service,” she adds, her gratitude to Mrs Khanal obvious as they link arms and she calls her “doctor”, rather than “sister”, as she traditionally would.
After the abortion, she accepted the contraceptive implant, taking away the worry for the future – a common choice in post-abortion counselling, Mrs Khanal says.
Another “client”, as Mrs Khanal describes them, Sita Sunar, 34, speaks passionately about what the abortion has meant for her family’s future.
Until she was referred to Mrs Khanal she felt her only option was to continue the pregnancy. It would have been her third child, and she was panicked about the impact this would have had.
“I feel I have a better life because of this service,” she says. “I’ve got back to normal life; with the child, it’s nine months of pregnancy, but you are impacted for years and years. It is very costly for women not just to bear a child, to bring them up until they are grown-up.”
She stresses how important it was for her to be able to take back control of her life. “It was very important to me that I could manage this on my own,” she says.
That power is fundamental to what the abortion pills mean for women, says Dr Kumar from MSF, pointing out that this has always been central. Misoprostol, the main drug which causes the uterus to contract and empty, was originally developed to treat stomach ulcers, and it cautioned on the bottle that it should not be used by pregnant women.
“Women in South America put two and two together, and realised it could be used to induce abortion,” she says. “It was always owned by the women themselves, and with that discovery we started to see a reduction in maternal mortality in those places.”
Mifepristone was developed later, and works to block progesterone, a hormone necessary for continued pregnancy. When it became widely available in France, the prime minister at the time called it the “moral property of women”.
“From the beginning, with both of these pills, there was a recognition that it allowed and facilitated a type of ownership over one’s body, and a type of autonomy that people didn’t have before,” says Dr Kumar. “So some people saw the potential to increase access as a positive development, and revolutionary; for others, it is very threatening.”
The pills do have their critics, with some suggesting they make abortion too easy, and others raising concerns over guaranteeing quality or raising concerns over sex-selective abortion (although the pills are used too early in pregnancy for this to be an issue – the World Health Organization allows the use of the pills at home at up to ten weeks of pregnancy, and later at clinics. The same guidelines are followed in Nepal).
Abortion remains a hotly debated topic globally, with passionate voices on both sides of the debate. But Dr Kumar says getting people all the information is a crucial first step, including with medical abortion.
She says women must be able to access the pills with some form of counselling or guidance on how to take them as well as the potential side effects and things to watch out for. “The more informed people are, the safer they are,” she says. “If we try to be gatekeepers, all we are doing is getting in people’s way.”
Mrs Khanal sees the abortion pills as an emergency form of contraception, like the morning-after pill; but admits she is ashamed when people have to use them, as for her it as a failure to provide family planning advice at an earlier point.
She gives around 15 medical abortions a month; closer to 30 women get the contraceptive implant from her. Even that can be controversial, though. She remembers one woman attempting to tear it out of her daughter-in-law’s arm.
“Family planning gives a woman control of her own body. Women feel pain – that’s why they should have the right to do what they want with their own body,” says Mrs Khanal. “[Medical abortion] is related to the dignity of women, it allows them to do this without all of the eyes on them. That’s why it is important to me.”
She believes the topic should be far more openly discussed in Nepal, and provides counselling to women in her front room to prove the point: her 10 and 13 year old children are welcome to listen in.
Her best moment came close to home, too. Her neighbour used to disparage her job, talking negatively about the role she played in the community.
Then, one day, she needed Mrs Khanal’s help. She needed an abortion, and her only other option was unaffordable, totalling thousands of rupees and requiring a trip to Pokhara, a city around two hours’ drive away.
Mrs Khanal provided the pills for the usual 1,000 rupee fee. “Now the respect has grown up,” she says with a grin.
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