LAMAHI, Nepal -- United States President Barack Obama set up the Global Health Initiative to take a more comprehensive approach to improving health care in developing nations. In particular, his administration has given great weight to saving the lives of women and to supporting countries' priorities in health care.
But there's one exception: abortion.
In Nepal, that exclusion is in plain view, and many say the lack of support disregards evidence that safe abortions can save women's lives. Nearly all experts here -- with the notable exception of those employed by the U.S. government -- publicly state that the best way to improve maternal health is by offering a wide range of services that includes more awareness about and access to safe abortion.
In a long-standing U.S. law, stretching back nearly 40 years, Congress has prevented any foreign aid for abortions.
The politics in Washington around the issue of funding abortion have become so heated in recent months that many global health supporters on Capitol Hill won't even talk about family planning services because so many conservatives falsely equate it with abortion.
Anti-abortion advocates have accused Obama and his administration of using the GHI as part of a larger strategy to link abortion rights to universal access to reproductive health. An article in the New American last year by senior editor William F. Jasper argues that Secretary of State Hillary Clinton has used "'reproductive health' and other similar code words... in attempts to camouflage policies that promoted abortion."
Clinton's State Department has dismissed such claims and stressed that U.S.-funded programs through the GHI are simply trying to offer comprehensive reproductive health within the accepted health practices of the host countries, including saving a woman's life if she suffered an unsafe abortion and working on family planning issues that adhere to the accepted health practices of the host country.
Some 7,000 miles from Washington and far from the charged debate around international aid and the question of abortion, there is a more pointed question in the villages of Nepal. That is, whether the unyielding U.S. policy against funding abortions is hurting its efforts to improve health care?
Some in Nepal say it does. U.S. officials say that's not so.
Anne Peniston, the GHI Field Deputy in Nepal, said the best way to improve maternal health in Nepal is by providing more access to family planning services.
She cited a 2010 study published in the British health journal The Lancet, in which the four main drivers of maternal mortality were total fertility, per capita income, maternal education, and skilled birth attendance. Abortion, she noted, was not in the top four.
"Abortion should not be used as a method of family planning in any case," she said. "It's too risky for a woman's health."
But inside a primary healthcare center in Terai, Nepal's plains region that runs along the border with India, a program that provides safe abortions is considered an integral part of maternal health.
Lamahi Primary Healthcare Center doctor Mahesh Gautan says that women in the area, like in much of rural Nepal, often have unsafe abortions because they do not know where to have a safe procedure or cannot afford to pay for a private clinic.
"They usually have unsafe abortion, and they're coming with a complication," he said. His center has about 40 cases a year of women showing up with life-threatening bleeding or infections from unsafe abortions.
The government-run center in Lamahi, which sits in Dang district, therefore decided it needed to improve its maternal health service beyond providing family planning, and antenatal, postnatal, and delivery services. The center sent nurse Dila Bhusal, 25, for training on safe deliveries and safe abortions.
Nepal legalized abortion in 2002 because so many women were dying due to unsafe abortions. Professor Sharad Onta in the department of community medicine and family health at Tribhuvan University's Institute of Medicine in Kathmandu said the death rate, while reduced, remains high in part because too many women are not aware of the abortion services.
Onta said that a donor cannot be forced to do something that its country does not allow. But he said that the U.S. Agency for International Development should not claim that they are offering comprehensive health services in Nepal.
"Donors should understand their own limitation and not claim they're complying with the national health plan [when they're not]," he said.
The Nepal Ministry of Health in 1998 estimated that 54 percent of gynecological and obstetric hospital admissions were due to women having complications after ending a pregnancy in an unsafe manner, according to a report by Ipas, an international organization that works on increasing women's access to safe abortion.
An information void
While abortion is now available in government hospitals and at private clinics, health advocates say there is still a serious need for awareness and education about the change in law, the dangers of medical imposters and where to go for a safe procedure. Too many women continue to end unwanted pregnancies by using unsafe methods like inserting pointed bamboo rods or ground up bangles into their uteri, or by following the misguided directions of untrained chemists.
"This is a big challenge for our communities. Most of the young women don't know about abortion facilities or that it is legal," said Khem Karki, the executive director of SOLID Nepal, an organization that works on sexual and reproductive health.
Furthermore, advocates say it would be more cost effective, efficient and logical for a woman to be able to receive all services related to maternal health, including abortion, in one place.
"Especially developing countries, poor countries, we can't afford to offer one service by itself," said Indira Basnett, the Nepal country director of Ipas. She said all reproductive health services should be delivered like a "package" through the health system.
The Obama administration chose Nepal to be one of its eight GHI focus countries as it redefines how American aid is delivered in developing nations. In Nepal, GHI seeks to strengthen the country's health care system by boosting the local capacity of health care providers like nurse Bhusal and service locations like the Lamahi Primary Healthcare Center, say U.S. health officials here. GHI, they said, strives to support the government of Nepal's health plan and promote country-ownership of health care services.
With a focus on gender equality and the inclusion of remote and disadvantaged groups, one of GHI's main goals is to help Nepal improve its maternal health and thereby reduce the number of women dying during pregnancy or childbirth.
With the exception of abortion services, GHI in Nepal supports a broad range of maternal health services: It provides more access to contraception methods; trains community volunteers to counsel women on family planning and the need for antenatal check ups; collaborates with a private social marketing company to provide counseling and contraceptive services in local pharmacies; lends resources to beef up the number of skilled birth attendants in health centers; and encourages girls to stay in school and delay marriage and pregnancy.
Under GHI, USAID has also shifted its focus to target more remote and disadvantaged communities. For example, it now recruits and trains more community health volunteers who are living deep in Nepal's mountainous region to provide better counseling on modern contraception as well as the need for antenatal checkups and giving birth at a hospital, primary healthcare center or health post that has a skilled birth attendant.
Abortion, however, has not been part of any overseas assistance since a 1973 amendment was made to the U.S. Foreign Assistance Act, known as the Helms Amendment. It prohibits U.S. funds from being used for abortion services overseas for the purpose of family planning.
Still, USAID officials in Nepal argue that it can help the country boost its maternal health without offering safe abortion services.
The USAID team in Kathmandu gave different reasons for why they do not need to provide awareness about safe abortion or access to such services. They stressed that abortion is not a safe method of family planning and that they can help with other interventions to prevent unwanted pregnancies. The team also said that USAID cannot do everything, and they coordinate with other donors who provide different services.
The government of Nepal and civil society actors say that it would help Nepal's maternal health strategy if USAID supported the government plan in providing access to safe abortion, but they disagree over its impact.
"It would have been better if they were on board," said Praveen Mishra, the population secretary at Nepal's Ministry of Health and Population. But given that USAID legally cannot support safe abortions, he said, at least it can contribute to Nepal's family planning programs and help manage complications resulting from unsafe practices. Furthermore, he said if USAID gave the government infrastructure for other health services, the government could also use those rooms or buildings to provide abortion services.
The case for family planning
A landlocked nation that has had a tumultuous political history, Nepal is one of the world's poorest countries with severe social, economic and geographic disparities. Maoist rebels took on the cause of Nepal's marginalized people and waged an armed conflict against the monarchy in 1996. By the time the civil war ended a decade later, about 13,000 people had died and much of the nation's rural development had been disrupted. Nepal has spent the past five years trying to transition to a firmly established democratic republic, but an unstable government has struggled to complete the peace process and draft a new constitution.
Despite challenges related to its mountainous terrain, inequalities, corruption, lack of human resources in rural areas and political instability, Nepal has made great strides in improving its maternal health. It had a high maternal mortality ratio of 539 deaths per every 100,000 live births in 1995, but it has successfully brought the ratio down to 281 deaths per every 100,000 live births as of 2006.
USAID argues that the main reason for this drop has been their work convincing more women to use modern contraception and making various options available.
"To our minds it was very clear it was family planning," Peniston said.
Only 29 percent of married women in Nepal used a modern method of contraception in 1995, but that number jumped to 48 percent in 2006, according to government statistics.
An increase in contraception usage decreases a nation's maternal mortality because fewer pregnancies mean fewer chances a woman could die while pregnant or giving birth. Plus, spacing out births enables a woman's body to fully recover from a past pregnancy and be in the best position to have a healthy delivery.
USAID says now they are trying to use GHI funds to target groups of women and girls who have been the hardest to reach with family planning messages, such as those married to migrant workers. With insufficient job opportunities at home, Nepal has seen a dramatic increase in the number of people working abroad. The wives back home benefit from the remittances, but their health can suffer. While the women might not need protection for most of the year, when their husbands come home to visit, they find themselves unprepared.
Sunita Thakur is one of those women. Thakur, who wears a line of red vermillion powder through her parted hair, says her husband works in Delhi and returns to their village in Terai region once every two to four months. Thakur, who estimates her age at about 18, dropped out of school when she was about 11 because she did not live near a secondary school and was already married. She had her first child around age 15 and her second, a little boy with disheveled hair sitting on her lap, nine months ago.
"Two is enough," she said through a translator as she sat in a family planning clinic in Nepalgunj. USAID pamphlets explaining the various contraception methods available, including implants, intrauterine devices, Depo-Provera, birth control pills and condoms, sit on a nearby table. The young mother said she does not want more children because she wants to ensure she can afford to send her two to school. "I will educate them even if I have to sell my jewelry," she said as she sat on a bench in the clinic, waiting to meet with a counselor. She hopes that if her daughter can become educated and wait until she is at least 18 to marry, she will have more opportunities than she has had.
"If I had completed my education, I would have a small job. I would be able to manage my home," she said.
Thakur learned about using modern contraception from a friend, discussed it with her husband and mother-in-law and then accompanied her friend to this clinic, which received staff training as well as maintenance, repair and essential equipment from USAID.
Nepal, though, has a long way to go before all its adolescent girls and women know about and have access to modern contraception. One of the biggest challenges, say reproductive health specialists, is overcoming the myths and misconceptions surrounding modern contraception.
During a recent visit to an abortion clinic in Kathmandu, Mamata Adhikari, a petite, married college student, said she had not been using any form of contraception because she had heard it would make her infertile. Another college student, a 20-year-old with neatly manicured eyebrows and big, powerful black eyes, said she had accidentally gotten pregnant because her husband had insisted on using the so-called withdrawal method.
All the women at the Marie Stopes International clinic easily agreed to talk to GlobalPost about their decision to end their pregnancy. Most also agreed to have their names printed and even photographs taken. They said they didn't feel any shame concerning their decision. Unlike in the United States, abortion is not a political issue here. To these young women, they said it's simply a decision they're making regarding their bodies and families. When GlobalPost asked the doctor present if the clinic ever faced protests, pickets or people handing out anti-abortion pamphlets, she laughed at the questions.
Another woman at the clinic, 23-year-old Rita Tamang, said she and her husband did not use contraception because they had wanted to have another child. But then she changed her mind.
Tamang, sipping a mango juice box and holding a heat pack against her uterus as she recovered from the procedure, said she finished her education when she was 12 or 13 because her mother died and her father couldn't afford to keep her in school. She married soon thereafter and now has a six-year-old son. Tamang said her husband makes good money working as an agent for those who want to migrate abroad. He earns a hefty commission and makes about 150,000 rupees ($2,100) a month. The problem: He likes to party. Tamang and her son therefore see little of the money.
"Whatever he earns, he spends," Tamang said. "I want to save before having another baby."
She has decided she wants to open a small shop so that she can earn some money for her family and keep her son in school.
In a room nearby, a counselor talked to Tamang about the various contraception options. The young woman with straight black hair and purple toenails said birth control pills make her feel dizzy and nauseated. Instead, she will bring home condoms and try to convince her husband to use them.
Nepal still has far to go in educating women about family planning and maternal health, said Onta. "But the level of awareness has gone up dramatically," he said. "At least we have hope for the future."
Funding for this project is provided by the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.