title: Effects of abortion legalization in Nepal, 2001-2010.
abstract: BACKGROUND
  Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion.
  
  
  METHODS
  We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010).
  
  
  RESULTS
  23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75).
  
  
  CONCLUSIONS
  Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, California, United States of America. Jillian.T.Henderson@gmail.com
authors.forename: Jillian T
authors.initials: JT
authors.lastname: Henderson
authors.forename: Mahesh
authors.initials: M
authors.lastname: Puri
authors.forename: Maya
authors.initials: M
authors.lastname: Blum
authors.forename: Cynthia C
authors.initials: CC
authors.lastname: Harper
authors.forename: Ashma
authors.initials: A
authors.lastname: Rana
authors.forename: Geeta
authors.initials: G
authors.lastname: Gurung
authors.forename: Neelam
authors.initials: N
authors.lastname: Pradhan
authors.forename: Kiran
authors.initials: K
authors.lastname: Regmi
authors.forename: Kasturi
authors.initials: K
authors.lastname: Malla
authors.forename: Sudha
authors.initials: S
authors.lastname: Sharma
authors.forename: Daniel
authors.initials: D
authors.lastname: Grossman
authors.forename: Lata
authors.initials: L
authors.lastname: Bajracharya
authors.forename: Indira
authors.initials: I
authors.lastname: Satyal
authors.forename: Shridhar
authors.initials: S
authors.lastname: Acharya
authors.forename: Prabhat
authors.initials: P
authors.lastname: Lamichhane
authors.forename: Philip D
authors.initials: PD
authors.lastname: Darney
mesh_terms: D000029:Abortion, Legal / Q000009:adverse effects / Q000266:history / Q000706:statistics & numerical data*; D000328:Adult; D005260:Female; D049674:History, 21st Century; D006801:Humans; D009017:Morbidity; D009026:Mortality; D009390:Nepal / Q000453:epidemiology; D016017:Odds Ratio; D011247:Pregnancy; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult