Practice and perception of illegal abortion in Nepal : a framework of choice

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Practice and Perception of Illegal Abortion in Nepal

A Framework of Choice

Carlijn Bettink 10275460 MSc Thesis Medical Anthropology & Sociology

University of Amsterdam Dr. Masae Kato Dr. Stuart Blume 28-06-2014

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Acronyms

ASAP – Asia Safe Abortion Partnership CRR – Center for Reproductive Rigths FHD – Family Health division

HDI – Human Development Index

IFAD – International Fund for Agricultural Development WHO – World Health Organization

MOHP – Ministry of Health and Population SFP – Society of Family Planning

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Introduction and background

Newly-married Sonia Nagarkoti (Lama), a resident of Rasuwa, had gone to the Miteri Pharmacy in Goldhunga, Kathmandu to terminate her pregnancy. Lama, who had been currently living in the Goldhunga area with her husband, fell unconscious within minutes after the pharmacy owner administered the anesthetic that had “expired” to conduct an abortion. Lama was then rushed to the Balaju-based Janamaitri Hospital where she was declared dead. Police record suggests that the girl died due to administration of date-expired injection. Mr. KC had provided abortion service clandestinely from his pharmacy shop to several women in the past (The Kathmandu Post 2011, may 2002 www.ekantipur.com). Over three fourths of the abortions in South Asia are illegal and the majority of these abortions are medically unsafe, with abortion-related deaths accounting for over one in ten maternal deaths (Ganatra 2006: 151). WHO defines that unsafe abortion is a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both, which can lead to serious complications or even death. This definition is given from a medical standpoint: unsafe abortions are performed under unsafe conditions which can cause serious and life-threatening complications. Unsafe abortion is the cause of 70.000 maternal deaths each year and approximately eight million more women per year suffer post-abortion complications that can lead to short- or long-term consequences (Guttmacher institute 2009). Of the women who experience serious complications each year, nearly three million women never receive treatment.

Since 1854 until 2002, women in Nepal were subject to strict abortion laws (Path 2005: 4). Under the law, induced abortion – intended pregnancy-losses - was classified as ‘infanticide’ or the murder of a child and it carried heavy criminal penalties (CRLP & FWLD report 2002: 23). As abortion was illegal, to terminate their unwanted pregnancies, women were prepared to take great risks and abortions were medically unsafe because they were carried out clandestinely in a most barbaric manner and usually performed by unskilled and unqualified providers. (CREHPA 2006). This often resulted in serious bodily injures and complications (Crehpa 2006). The contribution of illegal abortion to high maternal mortality was instrumental in the effort to legalize abortion (Rocca et al. 2013: 1075).

In 2002, the government of Nepal legalized abortion and services were made available in 2004 and by 2011, 500 authorized facilities were providing medically safe abortion services (Rocca et al. 2013: 1076). The level of medical safety of abortion increased, because both public and private sectors need to meet certain standards in order to be certified by the government, which ensures the physical health of women. Under the current law, a woman can legally obtain an abortion up to 12 weeks gestation, up to 18 weeks in the case of rape or incest, and at any time during pregnancy if her

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life is at risk or the fetus has congenital anomaly. Pregnancy termination on the basis of sex selection is prohibited (Puri et al. 2012). The maternal mortality ratio declined from 360 per 100.000 in 2000 to 170 per 100.000 in 2010 (WHO 2010). This declining severity of abortion complications is evidence that abortion legalization in Nepal has benefited maternal health (Henderson et al. 2013). Thus, with the legalization, abortion from an authorized service became a legal and medically safe choice. However, experience in many countries has shown that the availability of medically safe and legal abortion services is not sufficient to change the care seeking behavior of women with unwanted pregnancies1 (Bird 2005: 58). Despite the availability of legal and medically safe abortion care services in Nepal, many women still rely upon illegal and unskilled providers for abortion and unsafe abortion, which are a risk for women’s health. (CREHPA 2011: 1, Shah & Ahman 2008, Henderson et al. 2012). What are the reasons that women still subject themselves to high risk of bodily injury or even death? Why, even under legal condition, do women still resort to illegal abortion?

The circumstances and socio-economic backgrounds in which people make decisions is decisive in this process, referred to as frameworks of choice (Sleeboom-Faulkner 2010. These frameworks of choice influence the decisions people make, in this case the decision to conduct an illegal abortion. This stresses the need to investigate the framework of choice influencing these decisions more thoroughly. Elaborating on the important factors of these women’s frameworks of choice will help to find out why women still resort to unsafe abortions. This leads to the main question of this research: What are the most important factors creating the framework of choice influencing Nepalese women to resort to illegal abortion?

I explore the factors that create the framework of choice to understand why women still resort to illegal abortions. Research has to be done to improve the understanding of illegal abortion and its impact on women (Warriner & Shah 2006: v). Understanding the factors behind the persistence of illegal abortion can contribute to future attempts in eliminating illegal abortions (Warriner & Shah 2006: vii).

The nature of this study is qualitative and I conducted 24 in-depth interviews during my fieldwork in Kathmandu. The various respondents consist of experts who have been working in the field for many years, adolescents and public figures against abortion. Frameworks of choice shed light and emphasize the role of contexts and situations in which reproductive choices are made and for this reason qualitative research was specifically useful in understanding the context of Nepal.

This study provides insights and contributes to the research needed to address this problem. The aim of this study is to explore the framework of choice that can be used to look at reproductive choices made in Nepal, which helps to understand why women still resort to illegal abortions. In this research, I look at elements from frameworks of choice in similar contexts that were put forward as

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An example of the latter situation is India, where abortion is legal and provided free of charge in government authorized clinics, but significant numbers of abortions continue to take place in uncertified settings, a large proportion of which are unsafe (Warriner & Shah 2006: 3).

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important elements. I compare these elements so that I can find out the relevance of these elements for the specific context of Nepal. In addition, I complete this with new elements that need to be implemented in the framework of choice for the specific case in Nepal. In this way this thesis helps to paint a clear and comprehensive picture of the framework of choice that influences Nepalese women to resort to illegal abortion.

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1. Theoretical framework

This chapter elaborates on the conceptual and theoretical framework that is being used. First of all, a clarification is given of the concepts that are important for this study. Furthermore, I will discuss the theory that is used to understand why women still resort to unsafe abortion: ‘Frameworks of Choice’ (Sleeboom-Faulkner 2010). This research revolves around four central concepts: stigma, perception of sexuality, the therapeutic gap and gender discrimination. This conceptual framework therefore focuses on the operationalization of these concepts, as well as showing the relation between them. The following literature review will show how the following factors allow exploring the framework of choice that can be used to look at reproductive choices made within the context of Nepal.

1.1 Abortion

First of all, when the term ‘abortion’ is used in this thesis, it refers to an induced abortion. WHO defines this as ‘a provoked termination of pregnancy’ (WHO 2008). The concept of spontaneous abortion, defined as ‘unprovoked termination of pregnancy’ (WHO 2008), is not being referred to in this thesis.

In theory, legal abortions are likely to be safe, which means performed in a regulated medical setting where the providers are properly trained. However, there are significant exceptions to this generalization and the relationship between the legality of abortions and the safety of service provision is not always straightforward (Warriner 2006: 3). Legal abortions are not necessarily safe and illegal abortions are not necessarily unsafe. For example, illegal providers may be skilled in abortion provision, while government certified providers offer poor quality abortions and provide no care afterwards (Warriner 2006:3). It is therefore necessary to give a clear description of how the concepts safe, unsafe, legal and illegal abortions are used and understood in this thesis and how the different abortions are performed in Nepal. Furthermore, I mention the changes in abortion service after legalization.

1.1.1Safe and legal abortion

Furthermore, legal abortions are those who are not against the law, whereas illegal abortions are (United Nations Population Division 2011). Although the generalization that every legal abortion is safe or every safe abortion is legal cannot be made, in this thesis I refer to safe abortion as legal and vice versa. The reason I do so is because it has been scientifically proved than when abortion is performed by skilled providers using correct medical techniques and drugs, and under hygienic conditions which should be guaranteed during a legal procedure, induced abortion is a safe, medical procedure (WHO 2012: 21). Thus, when the term safe abortion is used in this thesis, it refers to the assumption that within a legal procedure of an abortion, a safe medical procedure is being guaranteed, defining the process as medically safe. Abortion in Nepal is legal on the following grounds, women’s health (Samandari et al. 2012):

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 Up to 18 weeks of gestation, if pregnancy results from rape or incest;

 At any time during pregnancy, with advice of a medical practitioner, or if the physical or mental health or life of a pregnant woman is at risk, or if the fetus is deformed and/or unable to live outside of the womb (of Law, Justice and Parliamentary Affairs, Nepal 2002).  Only providers certified in safe abortion care are eligible to provide induced abortion

services.

 The pregnant woman alone has the right to choose to continue or discontinue pregnancy.  In the case of minors (<16 years of age) or mental incompetence, a legal guardian must give

consent.

 Pregnancy termination on the basis of sex selection is prohibited.

After the legalization of abortion in 2002, the level of medical safety of abortion procedure changed, because the access to safe abortion from medical viewpoint was increased and both public and private sectors provided safe abortion services from then on. Public-sector abortion care facilities are authorized or ‘listed’, when at least one provider is trained in safe abortion and resource requirements are met. When they meet the requirements to perform safe abortion, they become certified by government, based on an official MOHP2_{listing of government-approved facilities (Rocca et al. 2013:}

1077). As for private clinics, they must meet the same standards but receive additional auditing from district public health office or the FHD (Samandari et al. 2012: 4). As of December 2011, over 1500 health-care providers have been trained in safe abortion care and 532 sites were authorized to provide safe abortion services (Samandari et al. 2012: 6).

Thus, because of the monitoring procedure regarding implementation, medical safeness has improved since the legalization. To be clear, when I refer to safe abortion in this thesis, I refer to abortions that are medically safe and legal by law. However, the medical and legal aspects are not the only aspects that measure whether an abortion is safe or not. The concept of a safe abortion extends both the legal and medical aspects and the following conditions need to be met (Ganatra 2006: 151):

(1) The decision to abort is a women’s informed choice, made without coercion and is free from the risk of family violence or societal stigma;

(2) The procedure is carried out in an enabling environment;

(3) The procedure is performed in early gestation with medically appropriate technology by an empathetic non-judgmental provider who is geographically and financially accessible;

(4) The procedure is backed up by medical services to detect and manage complications and provides information about and access to contraceptive options.

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These additional conditions are discussed on the basis of the analyzed data in chapter 5: ‘the therapeutic gap’, in which barriers to legal abortion are discussed.

1.1.2 Unsafe and illegal abortion

Illegal abortions are those who are against the law (United Nations Population Division 2011). Although the generalization that every illegal abortion is medically unsafe or every unsafe abortion is illegal cannot be made, in this thesis I refer to medically unsafe abortion as illegal and vice versa. The reason behind this is that the majority of illegal abortions in South Asia are medically unsafe, with abortion-related deaths accounting for over one in ten maternal deaths (Ganatra 2006: 151). Women undergoing abortions are at greater risk of serious and life-threatening complications (Warriner 2006: 9). This shows that illegal abortions are more likely to be dangerous for the health of women and can thus be seen as medically unsafe, because they tend not to follow the necessary medical procedures. This assumption is strengthened by the previous numbers shown by Ganatra (2006) showing a much higher mortality rate amongst women conducting illegal abortions compared to women who did this legally. The literature shows that in case of Nepal, illegal abortion is carried out in two ways:

(1) Medical abortion: medical termination of pregnancy can be achieved through the use of mifepristone in combination with a suitable prostaglandin, such as misoprostol, or a prostaglandin (Warriner 2006: 4). Women who take incorrect dosages may risk serious complications such as prolonged bleeding if they do not receive prompt medical attention or even death (Warriner 2006: 5). The study of Rocca (et al. 2013) shows that the large majority of women with abortion complications took medication, obtained illegally from a (local) pharmacy3, which refers to any substance or drug that was taken orally or inserted vaginally (Rocca et al. 2013: 1077). Pharmacies, providing ways for illegal abortions, offer benefits over certified hospitals and clinics, including accessibility, anonymity and less costly services (SFP 2013). Thus, medical abortion can in some situations be obtained more easily.

(2) Abortion via instrumentation: illegal abortion via instrumentations refers to the insertion of instruments into the vagina including aspiration, dilatation and curettage or objects (Rocca et al. 2013: 1077). Instrumentation is either or self-induced, or by a provider who is not certified and thus illegal. The above mentioned literature contributes to the assumption being made in this thesis that illegal abortions tend to be more dangerous to women’s health and therefore less safe than legal abortions. However, as mentioned, ‘safeness’ extends both legal and medical aspects and the other conditions of safeness are tested in this research in order to explore the full meaning of safe and unsafe abortion.

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1.2 Frameworks of Choice

A literature review is conducted on the concept of the book ‘Frameworks of Choice’ (Sleeboom-Faulkner 2010). The different studies in the book, originated from vastly different contexts and locations, show the interaction of frameworks of choice and the ever-changing range of factors defining situations in which major reproductive choices are made. Frameworks of choice refer to the circumstances and socio-economic backgrounds in which people make choices (Sleeboom-Faulkner 2010: 13). While frameworks of choice can provide understanding of all choices being made by people, within this thesis it specifically sheds light on and emphasizes the role of context and situations in which reproductive choices are made. The framework of choice puts approaches into perspective that regard ‘individual’ or ‘autonomous choice’ as the basis of reproductive decision-making and provides a complementary alternative to the classis approaches (Simpson; Kumar Patra & Sleeboom-Faulkner; Saxena et al. and Kato in Sleeboom-Faulkner 2010: 13). The latter approaches focus on narrow notions of choice in which the focus is on ‘individual choice’ without including the importance of context. (Sleeboom-Faulkner 2010). The framework of choice needs to be explored in order to understand the reproductive choices in specific contexts . The use of frameworks of choice as a theoretical framework is thus being used for understanding the socio-cultural context of reproductive health. Asian countries harbor a great variety regarding population policies, family organization, gender distinctions, views on the value of the embryo and life, medical health provision, and regulatory policies in the field of reproductive medicine. (Sleeboom-Faulkner 2010: 13). These factors influence reproductive decisions that are made in different contexts. Countless women are barred from access to legal abortion services due to a combination of social, economic, religious and policy factors (Warriner & Shah 2006: vii).

The literature on frameworks of choice shows many different factors that shape a framework of choice. However, this thesis revolves around four elements which are specifically significant in understanding reproductive choices. The following elements will help to understand why Nepalese women still resort to illegal abortion: stigma, the therapeutic gap and gender discrimination. Besides these three factors, I discuss the element, which I categorize as perception of sexuality.

The reason why I specifically chose to include these four elements, is because former research pointed out that these particular factors play a significant role as it comes to cases of abortion.

First of all, abortion-related stigma is under-researched and under-theorized and research has to be done to improve the understanding of abortion stigma (Norris et al. 2011). However, it is known that, as shown in the book ‘Frameworks of Choice’, stigmatization can have great impact on reproductive choices. Therefore, in order to understand the framework of choice in Nepal, stigma needs to be taken into account.

Secondly, the perception of sexuality is being discussed and analyzed as a part of stigmatization. Former research shows the close relationship between stigma and perception of sexuality and the importance to explore the role of sexuality in a country in order to understand how

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reproductive decisions are being made. Within this study, perception of sexuality is being discussed in relation to stigma.

Thirdly, I look at the therapeutic gap, a space between the availability of in this case illegal abortion and the actual access to the service. These therapeutic gaps can influence reproductive decisions and therefore also need to be taken into account.

Fourthly, gender discrimination plays a significant role in understanding reproductive choices. Nepal is largely a patriarchal and Hindu society, and women’s expected role of bearing many children is challenged by abortion (Puri et al. 2012: 8).

The above mentioned elements are given focus within this thesis and will be further elaborated on in the following chapters.

1.2.1 Stigma

Abortion can be characterized as a stigmatized medical service in Nepal and elsewhere in the world (Lekhak & Parajuli 2011, Norris et al. 2011 and Major & Gramzoow 1999). Due to stigma, women seeking or receiving abortion may seek abortion at higher gestation and visit illegal providers (Puri et al. 2012: 2).

Abortion stigma is widely acknowledged, though poorly theorized (Quinn & Chaudior 2009). Abortion stigma is defined as a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood (Kumar et al. 2009: 628). Stigmatization is a deeply contextual, dynamic social process, which is related to the disgrace of an individual through a particular attribute he or she holds in violation of social expectations (Norris et al. 2010: 3). Both Kumar et al. (2009) and Norris et al. (2010) dispute any universality of abortion stigma in their studies. They understand stigma as created across all levels of human interaction: between individuals to framing discourses.

Although stigma around abortion has to be seen within socio-cultural contexts, the following five reasons can explain why abortion is stigmatized (Norris et al. 2011).

(1) Abortion is stigmatized because it violates ‘feminine ideal’ of womanhood.

This first stigma is related to the idea of sexual purity and nurturing motherhood. Women should only have sex if they intend to procreate and this reinforces the idea that sex for pleasure is not allowed for women. Abortion therefore, is stigmatized because it is evidence that a woman has had ‘non-procreative’ sex and is seeking to exert control over her own reproduction and sexuality, both of which threaten existing gender norms (Kumar et al. 2009). Thus, the stigmatization in this case may not be rooted in the act of aborting a fetus, but instead more with having conceived an unwanted pregnancy and with the sexual practices.

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The attribution of personhood to the fetus is another factor influencing decision on reproductive health is mentioned by Norris et al. (2011). They state that the technological changes during the past three decades such as fetal photography, ultrasound, advances in care for preterm infants and fetal surgery, have facilitated personification of the fetus. This challenges previous constructed boundaries between fetus and infants. When and how children are first recognized as human has to be seen in the context. Boundaries between child, fetus and embryo are extremely blurred and the ideas concerning these boundaries – between life and non-life- are problematic, culturally specific and deeply contested (Montgomery 2009: 80). A child may be recognised as fully human from the moment of conception (the position of the modern Church) where others not recognise the fetus as a full human being until several days after its birth. This difference is important in the way people perceive and experience abortion. Beliefs about abortion also need to be taken in account. In Japan and Taiwan for example, both societies have seen a recent rise in the belief that aborted children will come back and haunt their mothers (Montgomery 2009: 82).

(3) Abortion is stigmatized because of legal restrictions.

Legal restrictions such as parental consent requirements, gestational limits and waiting periods can also make it more difficult for women to obtain abortions. Such legal restrictions can also reinforce the notion that abortion is morally wrong. Legal restrictions are correlated with unsafe abortion, which contributes to morbidity and mortality (Singh et al. 2009). Stigma does not necessarily diminish after changes in the legal situation. For example in the case of the United States, the stigma did not decrease after legalization, but the legalization in fact revealed an enduring cultural stigma (Joffe 1995).

(4) Abortion is stigmatized because it is viewed as dirty or unhealthy.

The perception of abortions as being dirty or unhealthy is another way abortion is being stigmatized. Stigma in this sense denies the normalcy of abortion as technique and as medical care and instead focuses on the idea that abortion is unhealthy. In contrast to the other examples, in which abortion symbolizes the flaws in the character of a woman, here women become flawed because of the experience of having an abortion. Also related with this kind of stigma is the clinic itself as a stigmatized place. Abortion providers themselves are not always free of stigmatizing attitudes. As a result, the women can feel judged even by those who work at a clinic. Research is needed to understand whether women are less likely to challenge poor treatment if treated disrespectfully (Norris et al. 2011: 7).

(5) Abortion is stigmatized because anti-abortion forces have found stigma a powerful tool.

Anti-abortion movements can use barriers to abortion as a tool to influence cultural values, beliefs and norms so that people adopt a negative attitude towards abortion. Sending out emotional messages is a

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common strategy to do so. From photographing women entering clinics to distributing flyers to the neighbors of providers, anti-abortion movements use abortion stigma as a deliberate tactic.

This thesis tests the relevance of these five reasons given by Norris (et al. 2011) by comparing them to the data found during fieldwork in Nepal.

1.2.1.1 Perception of sexuality

Several studies show that there is a direct link between the role of sexuality in a society and the stigma associated with abortion. The moral worlds, in which abortions take place, and the perception of sexuality in society affects stigmatization of abortion. The examples set out hereafter demonstrate that abortion stigma is a social phenomenon that is constructed and reproduced locally through various pathways (Kumar et al. 2009: 627). The idea that there are ‘good abortions’ and ‘bad abortions’ is prevalent, influenced by certain perceptions of sexuality. However this differs per context. This distinction between good and bad abortions tells us about how sexuality is perceived in a context, about stigmatization and about the different levels of acceptance of abortion.

In Thailand, abortion is only permitted under limited circumstances and religious authorities are opposed to easing restrictions. Both women and providers are prosecuted under the law. Whittaker’s (2002) research indicates that ideology-surrounding abortion in general remains unsupportive and remains a stigmatized act. However, the villagers in his research acknowledge that there are circumstances in where abortion may be understood as a socially responsible and ethical act. In case of Thailand, ‘good abortions’ are related to motherhood and poverty. Some argued that raising a child in poverty was a greater sin than having an early abortion (Whittaker 2002: 12).

In Vietnam, despite the relatively easy accessibility of abortion services, young men and women felt heavily stigmatized after an abortion. They expressed feelings of regret that they had committed a sinful and immoral act based on their ideas of family and religion. Abortion has become an increasingly prevalent solution to the social problems that unwanted pregnancies pose to individuals and couples as well as to the government. It is seen as an outcome of a vigorously implemented policy for population control, in combinations with shortcomings in sex education and contraceptive services (Gammeltoft 2003).

In Zambia, abortion is associated with secrecy, shame, fear of ridicule and taboos (Koster-Oyekan 1998). Her research shows that socio-cultural factors forbid the open discussion of sexuality, including abortion and therefore, abortion-related issues remain undiscussed. Although a girl should be virgin at marriage according to the social norms of the tribes in the Western province, the study shows that pregnancy is a serious problem for schoolgirls who are then forced to leave the school. With their pregnancy, they bring shame to their family. Girls often decide to terminate pregnancy before being discovered or expelled or because of the anticipated harsh attitude of the parents.

Norris et al. (2012) conducted their study in the United States and found that there is a clear distinction being made between ‘bad’ and ‘good’ abortions. Stigma experienced by women who have

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had abortions may be exacerbated by whether their abortions fall into one category or the other. ‘Good abortions’ are those judged to be more socially acceptable and characterized by one or more of the following: a fetus with major malformations, a pregnancy that occurred despite a reliable method of contraception, a first-time abortion, an abortion in the case of rape or incest, a very young woman, or a contrite woman who is in a monogamous relationship. Abortions considered as bad, occur at later gestational ages and are had by selfish women who have had multiple abortions without using contraception (Norris et al. 2012: 5).

What these different cases show is the close relation between stigma and the perception of sexuality. The role of sexuality in a context and what is considered as ‘good’ and ‘bad’ abortion influence the stigmatization of abortion. This in turn can affect the practice of abortion and help to answer the main question of the research why women still resort to unsafe abortion in Nepal. Because of the relation between stigma and the perception of sexuality, I want to explore how and why these two influence each other in the context of Nepal. Furthermore, during my fieldwork, I want to explore which aspects could help to analyze the perception of sexuality.

1.2.2 Therapeutic gap

Another factor helping to understand the framework of choice regarding reproductive decisions, is ‘the therapeutic gap’. The therapeutic gap is central to many of the accounts in different contexts in Asia and refers to the space that opens up as a result of the lacunae between the availability of predictive tests and knowledge and the possible means of dealing with the predicted condition (Holtzman & Shapiro 1998). These gaps can appear in different forms, varying from religious and cultural to economic and regulatory spaces. For instance, when diagnosed with thalassemia, the high cost of chelation therapy and blood transfusion for the poor in India and China opens up one kind of therapeutic gap (Sleeboom-Faulkner 2010:226). In this study, by looking at the therapeutic gap, the barriers to legal abortion are being explored. In the case of Nepal, the centre for research on environment health and population activities (CREHPA 2011) categorized three barriers which may make women turn to unsafe abortion: the knowledge barrier, service access & delivery barriers and cost barrier. These three barriers can be seen as therapeutic gaps.

First, the knowledge barrier is visible in Nepal shown by the fact that the majority of the Nepalese women are still unaware about the legalization of abortion (CREHPA 2011). There is also little known about the precise circumstances under which abortion is legal in Nepal. Lack of knowledge can also produce incorrect use of dangerous medicine, such as medical abortion pills from pharmacy shops, which are sold despite the government efforts to regulate these pills.

Secondly, access to safe abortion services also remains a challenge for many women in Nepal, and especially women living in rural areas. Of the total 403 health facilities approved by the government for providing safe abortion services, there are only 127 facilities located in the rural areas of the country, where over 80 percent of the country’s population lives (CREHPA 2011:3)

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Thirdly, another significant barrier in accessing legal abortion is the fact that there are women who cannot afford it. In the research of Puri et al. (2012) the cost barrier was a common reason for couples not to terminate an unwanted pregnancy. The therapeutic gap is related to the concept stigma. For instance, incorrect knowledge about abortion such as the belief that abortion is not allowed, disapproved of for unmarried women or not possible without a husband’s permission, further underscores the role of stigma in the context of abortion care (Puri et al. 2012: 8).

1.2.3 Gender discrimination

Gender discrimination refers to the socially constructed roles, behaviors, activities and attributes that a society considers appropriate for women and men (Amnesty international 2014: 23).

There are various cases in the book ‘Frameworks of Choice’, where gender discrimination is included in the framework of choice to understand reproductive decision-making. For example the paper about bioethics in China, which looks at the socially meaningful pattern of the practice of gender- or sex-related selection (Döring in Framework of Choice 2010). Instead of focusing on particular technique, preferences of individual cases, it looks at the context and phenomena such as systematic discrimination against females, male favoritism and paternalism, targeted abortion of females, infanticide and neglect. Döring explores the links between gender preference and Chinese cultural and philosophical traditions to understand reproductive decisions. The practices are observed in perspective, according to their relative position in a process of cultivation (Döring 199 in Sleeboom-Faulkner 2010).

Another case can be seen in neighboring country India. There is the significant issue of determining the gender of the fetus for social reasons, followed by abortion of healthy female fetuses (Saxena et al. in Framework of Choice 2010). Women are considered as men’s property and their body is not seen as autonomous or independent (Mathur 2008). Gender discrimination therefore influences the framework of choice. The author analyzes various cases of discrimination and violence against women from the vantage point of patriarchy. She argues that the discrimination towards women starts the moment they are born (Mathur 2008).

Nepal is largely a patriarchal and Hindu society, and women’s expected role of bearing many children is challenged by abortion (Puri et al. 2012: 8).In early society, patriarchy was created by Hindu religious leaders to protect girls and women, but in reality, the patriarchal society they are being discriminated and oppressed (Dhungana 2014). For this reason, gender discrimination is an important factor to analyze and needs to be taken into account. It is impossible to give a complete overview of the gender context in Nepal, however this chapter provides some background information that can be used as part of the framework of choice.

The large majority of Nepal’s population follows Hindu religion (80,6%). Buddhist faith is believed by 10,7% of the population and those following Islam is 4,3% (CREPHA 2006: 4). The dominant family system among Hindu Nepalis is known for its patriclocal extended marriage system

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and patrilineal inheritance and kinship (Brunson 2010: 92). Within this context, a joint-family is the overarching system and ideal and the wife will live with her in-laws and husband. This ideal contains that when a son gets married, he and his wives will live with his family. Brunson (2010) states that having a joint-family household influences son preference because the family will want a daughter-in-law to replace the daughters lost to other households through marriage. The daughters-in-daughter-in-law will help their mother-in-law in the household, which reduces her household jobs.

Research done by the office of the high commissioner for human rights (2011) points out the joint statement (OHCHR, UNFPA, UNICEF, UN Women & WHO) that there is indeed a huge pressure on women to produce sons. Religious and cultural values encourage the preference of son. Not only are there many Hindu rituals that can only be performed by male members of the family, but sons are also the support of parents during their old age and looked down upon as a liability (FWLD 2011: 72). The practice of ‘dowry’4

worsens the situation (FWLD 2011: 72). The son preference does not only affects women’s sexual and reproductive lives, but it also maintains the lower status of girls through son preference. Women in Nepal face gender inequality and are discriminated from an early age: they have less access to education, health care and means of production than men (Donker 2001: 361).Bennett (1983) looks at the position of women in Nepal and argues that the position between men and women needs to be understood from the Hindu Patrilineal ideology. For Bennett, their position is directly linked to the Hindu culture. Her study shows that due to patrilineal Hindu values, women are dominated by men and treated as impure or polluted. The ideas of pollution and purity are found in the Hindu culture (Sekine 2007). Bodily substances such as saliva, phlegm, seamen, and blood are considered as impure and women are treated as bodily polluted during the period of menstruation. Both women and lower caste people are considered as bodily impure (Amgain 2011: 18). The Chhaupadi system, a traditional practice prevalent in far-West and some parts of mid-West region in Nepal, forbids girls and women to live inside the home during their pregnancy. Especially during menstruation, they are considered impure and polluted (Amgain 2008: 3). The Nepalese social system is based on patriarchal Hindu philosophy that empowers men and subordinates women and most women derive their social status (including inheritance right, ritual status and access to property) from their fathers, husbands and sons (Luintel 2001: 109).

However, what is missing in the studies of Mathur and Bennett is the dynamics of political and economic power. According to Luintel (2001), the social situation of Nepalese women is complex and cannot be explained with a single paradigm (Luintel 2001: 84). The social situation is demarcated by the economic situation, the cultural and caste variations and by the different geographical regions. The study of Amnesty International (2014) proves that the social situation of Nepalese women can indeed not be understood within one single paradigm. Aspects of women’s identity such as caste,

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ethnicity, religion of residence, age, disability, sexual orientation and gender identity can combine with gender discrimination.

2. Research questions

The aim of this study is to explore the framework of choice that can be used to look at reproductive choices made in Nepal, which helps to understand why women still resort to illegal abortions. The main question of this research is: What are the most important factors creating the framework of choice influencing Nepalese women to resort to illegal abortion?

The theoretical framework leads to the following sub-questions which supplement the research and help to answer the main question:

 In what way plays stigma a role in influencing women in resorting to illegal abortion in Nepal?

 In what way plays therapeutic gap a role in influencing women in resorting to illegal abortion in Nepal

 In what way plays gender a role in influencing women in resorting to illegal abortion in Nepal?

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3. Research methods

Prior to the actual fieldwork I have conducted a literature study in order to construct the theoretical framework of my research. The focus of this research was on frameworks of choice in order to: (1) Provide a theoretical underpinning of abortion in the context of Nepal

(2) Find out which factors were used in previous studies to explore the framework of choice in Nepal (3) Choose three factors, which will help to understand the framework of choice in Nepal

The epistemological paradigm in this study is constructivism, the position that our understanding of reality is a social construction, not an objective truth, and that there exist ‘multiple realties’ associated with different groups and perspectives (Guba and Lincoln 1985, 1989, 1994 & Guba 1990). This constructionist position implies that social properties are outcomes of the interactions between individuals, rather than phenomena separated from those involved (Bryman 2008: 366). The nature of this study is exploratory and the research will be a qualitative study. Qualitative research seeks to understand a given topic from perspectives of the local population it involves and is especially effective in obtaining culturally specific information about the values, opinions, behaviors and social contexts of particular populations (Northeastern University 2014: 1-2). As explained before, frameworks of choice shed light and emphasize the role of contexts and situations in which reproductive choices are made. For this reason, qualitative research will be specifically useful in understanding the context of Nepal in which reproductive choices are made.

While quantitative research is more focused on quantities, qualitative research emphasizes words in the collection and analysis of data (Bryman 2008). Qualitative research consists of in-depth research on human behavior and understanding the reasons for this behavior. This is the case within my research, where the focus is on how people make reproductive choices and why. Although, due to time limit, this study will be small-scale, the in-depth perception of qualitative research will give a new impulse to this study field.

One of the qualitative research methods is the in-depth interview. In-depth interviews can be used to deeply explore the respondent’s point of view, feelings and perspectives (Pereira et al. 2013: 1). In-depth interviews are useful to find out detailed information about a person’s thoughts (Boyce & Neal 2006). In order to explore the factors that influence the framework of choice, in-depth interviews will therefore be a good instrument to find out.

During my fieldwork I noticed that it some respondents answered with short answers like yes and no, without sharing thoughts behind those answers. In order to encourage them to talk more openly, I made use of both follow-up and probing questions. This means asking questions such as ‘What do you mean with that’ or by repeating the words of the respondent in an answer, in order to get the respondent elaborate his or her answer (Bryman 2008: 446).

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The in-depth interviews used were individual, semi-structured interviews. Within a semi-structured interview, the researcher has a list of questions or topics to be covered, but the respondent has much room left in how to reply (Bryman 2008). In contrast to a fully structured interview, the semi-structured interview allows the respondent to pursue topics of particular interest to them, and the emphasis is on what the respondent experiences as important. The list of topics that was used during the interviews can be found in the attachment.

Another qualitative method I considered using was the focus group discussion. However, because of the sensitivity of the topic ‘abortion’, I have decided not to organize any focus groups. I noticed in the in-depth interviews that people sometimes felt shy talking about the topic of abortion and with other people this would make it worse.

The in-depth interviews will be transcribed. I also noted my own observations immediately after each interview. By doing so, my own insights at the beginning of the field research and in a later phase are preserved instead of forgotten. The transcribed conversations and interviews contain pseudonyms. As written in the Code of Ethics, a researcher is obliged to avoid harm or wrong (AAA Code of Ethics 1998). Informed consent5 is therefore needed. I will come back to this in the section ethical considerations.

3.1 Sample population and respondents

In order to explore the perception of the local community, ideal would be to talk to all kinds of people, both living in the cities and to people living in the rural areas. Due to the time limit of this study, the language barrier and barriers brought by the sensitivity of this topic, I have chosen to interview key informants who have been active in both urban and rural areas. These interviews are also referred to as expert interviews. Expert interviews can reveal tacit knowledge on a certain subject, in other words experiential knowledge of an expert who has been working on the specific subject for years (Bryman 2008).

From the beginning of the movement for abortion law reform, many different organizations and individuals have been involved in the various processes and activities (Bird 2005: 9). Despite their diverse priorities and perspectives, they were united in their commitment to a common cause: to bring change to improve women’s lives. (Bird 2005: 9). This collaboration led to the amendment of Nepal’s abortion laws by parliament in March 2002. Since the legalization, many of the formed alliances have grown into longer-term partnerships, with the government taking the lead. The collaboration with international and national NGOs and the private sector has enabled the government to mobilize resources and move programs rapidly forward. In this way, the government benefits from

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‘Informed consent is the principle that individuals should not be coerced, or persuaded, or induced, into research ‘against their will’, but that their participation should be based on voluntarism, and on a full understanding of the implications of participation’ (Green & Thorogood 2004: 68-69).

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the expertise and resources that partners are able to provide (Bird 2005: 9). Thus, to get a good sense of how abortion is perceived by the Nepali community, I interviewed different key partners that are active in the national safe abortion program. Because these different organizations have been involved in the different activities and project around safe abortion services for many years, they have a good knowledge of how abortion is perceived. The key informants can be divided into four groups: government bodies; national advocacy NGOs; private sector and NGO service providers and lastly, international NGOs.

During my two months of fieldwork, I have conducted 12 expert in-depth interviews working in these different sectors. The majority has been working in the field of abortion from before the legalization and had knowledge about both rural and urban areas in Nepal. I talked with service providers, policy makers, human rights organizations, teachers and women organizations. These people from different backgrounds could provide a good view on three factors: stigma, the therapeutic gap and gender but also shed light on other important aspects.

Besides these expert interviews, I also conducted an interview with the executive director of the biggest anti-abortion organization: Voice of Fetus. The key partners can describe to a certain extent what opponents of abortion think of the legalization, but talking to them myself, benefited the data collection. He showed me the perception of himself and groups in Nepal who are against the legalization of abortion.

Furthermore, I also talked with a political figure in Nepal, known for her strong opinion against abortion. She tried to stop the court in adopting the new law on abortion in 2002. This woman follows the Hindu religion, so it was interesting for the data to explore her viewing points on abortion. In order to get an as good as possible understanding of the perception and practice of abortion, I also wanted to, besides the generation of the key partners (25-60) talk to the younger generation (18-25). They were young when abortion was legalized in 2002, so there might be some generational differences. With the influences from outside via Social Media and films, the world they are being brought up in is different than their parents.

Because of previous stays in Nepal, I had various connections to youngsters living in Kathmandu area. Therefore, I had several entrances to get into contact with respondents who complied to this sample size. I also used the snowball sampling as a technique for gathering other respondents. Snowball sampling is ‘when the researcher accesses informants through contact information that is provided by other informants’ (Noy 2008: 330). I was aware of the risks this might bring when only talking to people with the same kind of view on abortion. In order to prevent this, I used the snowball sampling technique, but via different canals.

I conducted five interviews with male respondents aged 18-25 and five female respondents aged 18-25 living in Kathmandu.

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language of business and education remains to be English. My respondents were, for the most part, highly educated who had good command of English, so I did not encounter many language barriers.

3.2 Analysis

The analytic technique that I used to analyze the factor gender discrimination is thematic analysis, a strategy for eliciting the key emerging factors from text based data (Puri et al. 2007: 4). Thematic analysis as an independent qualitative descriptive approach is mainly described as a method for identifying, analyzing and reporting patterns (factors) within data (Braun & Clarke, 2006: 79). I categorized the data in factors that recur throughout my research and which reflect the most important elements of social and cultural norms of abortion and look for certain patterns (Green & Thorogood 2004: 199). I focused mostly on repetition to find out which factors reflected important elements and I labelled the factors that many respondents talked about as important.

Furthermore, for the factors stigm and therapeutic gap, I used the approach of directed content analysis, in which initial coding starts with a theory or relevant research findings. Then, during data analysis, the researcher immerses the findings in the data and allows factors to emerge from the data (Zang & Wildemuth 2014: 2). The topics stigma, perception of sexuality and the therapeutic gap that derived from my theoretical framework were in this way be of help in the interview and the framework of choice provided a useful way to explore the perception of abortion in the Nepali context. At the same time, the data analysis remained open for other factors to emerge. I will now further clarify how I analyzed the factors stigma, perception of sexuality and therapeutic gap.

3.2.1 Stigma

As discussed in the literature review, there are five reasons given why abortion is stigmatized, although stigma around abortion has to be seen in socio-cultural context (Norris et al. 2011).

(1) Abortion is stigmatized because it violates ‘feminine ideal’ of womanhood. (2) Personhood to the fetus.

(3) Abortion is stigmatized because of legal restrictions.

(4) Abortion is stigmatized because it is viewed as dirty or unhealthy.

(5) Abortion is stigmatized because anti-abortion forces have found stigma a powerful tool.

The derived data about stigma is analyzed on the basis of the above reasons. This not only explores the relevance of the research of Norris et al. (2011) for the data I collected, but will also analyze if these reasons are applicable to the socio-cultural context in Nepal.

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23 3.2.2 Perception of sexuality

On the basis of the data derived from the interviews, I will demonstrate four aspects that can help to explore the perception of sexuality of a country: (1) ‘good and bad abortions’ (2) sexuality and

marriage (3) openness and (4) contraceptive use. 3.2.3 Therapeutic gap

In order to analyze the data collected about the therapeutic gap, I categorized three factors that derived from previous literature (Crehpa 2011) as discussed in the literature review.

(1) Knowledge barrier

(2) Service access & delivery barrier (3) Cost barrier

The issue of confidentiality and judgment was found during the research and appeared to be perceived by the respondents as a barrier to legal abortion.

3.3 Reflection on methodology

Within this paragraph I reflect on the value of data gathered by looking at the reliability and the validity of the data and the methodological steps I took during this research.

3.3.1 Reliability

Different from quantitative research, reliability is not about the generalizability of the research. Maxwell (1992) observes that the degree to which an account is believed to be generalizable is a factor that clearly distinguishes quantitative and qualitative research approaches.

However, although some qualitative researchers have argued that the term validity and reliability are not applicable to qualitative research, they have realized the need for some kind of quality check or measure for their research (Golafshani 2003: 602). Golafshani (2003) argues that reliability and validity can be conceptualized as quality and trustworthiness in qualitative paradigm. A good qualitative study can help us “understand a situation that would otherwise be enigmatic or confusing” (Eisner, 1991: 58). By means of the 22 in-depth interviews, I tried to create a framework of choice, which can help to understand and explain why there are women in Nepal who resort to unsafe abortion. I recorded all the interviews and permission for this was given by the respondents before the start of the interview. Because I recorded everything, I did not have to make any notes during the interview and I could focus on the conversation with the respondents. After every interview, I wrote out the entire interview so that I would not miss any detail. I regularly found valuable information while writing out the interviews that I did not noticed during the interview. Furthermore, because I recorded and typed out the interviews, I could make use of citations to present my data analysis. Although some respondents felt shy in the beginning knowing their interview was recorded, this feeling disappeared after a few minutes and I have never felt that recording them influenced the answers given.

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Apart from gathering data, the interpretation of the data is also important for the reliability. Whereas quantitative researchers attempt to disassociate themselves as much as possible from the research process, qualitative researchers have come to embrace their involvement and role within the research (Winter 2000).

It is possible that I, as a researcher, influenced the respondents and that they gave answers that would have been different if I had been someone else. For example in the expert interviews, there were two respondents who talked about ‘the West’ in the interview.

It’s not like Europe, parents don’t talk with their children about sex.

In all religion, one should not sleep together before marriage. In Nepal, this thought is still Nepal, we are not taking this easy, but in Western culture, it is common.

During the research, I tried to be aware of my perceived identity and the way in which this could affect my data. Respondents could, for example, give socially desirable answers. However, I tried to keep this tendency small by making the goals of my research clear and in communicating with the respondents in an open way.

As for the adolescents I knew that my personal history differs a lot from most of the younger people I spoke with. This quote of Leigh Pigg describes the importance of realizing the differences in some cases.

That April in 1997, watching the Nepali students struggle with their worksheets during sex education lessons, it struck me that outside of this training session there were few (if any) other ways that they would encounter this particular configuration of information of the body. I realized then just how deeply my own body sense was informed by the sexual sciences. The facts of life that seemed obvious and basic to me and that shaped the way I handled my sexual relationships and my reproductive possibilities were not the same as those shared by the rest of the people in the room that day (Leigh Pigg 2005: 40).

I realized that there were some respondents who did not really know the meaning of abortion, because no one ever told them. In my interviews, I constantly ensured if we understood each other before discussing a certain topic.

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Although some qualitative researchers have argued that the term validity and reliability are not applicable to qualitative research, they have realized the need for some kind of quality check or measure for their research (Golafshani 2003: 602).To solve the dilemma of the measurement of validity, qualitative researchers have developed measurement concepts in line with the qualitative paradigm. I will reflect upon the validity of this research on the basis of the five categories developed by Maxwell (1992) to judge the validity of qualitative research: descriptive validity, interpretive validity, theoretical validity, generalizability and evaluative validity.

First the descriptive validity has to be guaranteed. Descriptive validity refers to the accuracy of the data and must accurately reflect what the participant has said or done (Thomson 2011: 78). I ensured this by recording the interviews and transcribing the entire interview afterwards. In my analysis, I used citations of the respondents derived from these transcribed interviews. In this way, I made sure the data reflects what was said in the interviews.

Secondly the interpretive validity needs to be ensured. This form of validity captures how well the researcher reports the participants’ meaning of events, objects and/or behaviors (Maxwell 1992). This validity points out the importance for the interview to be about the participants’ perspective and not about the perspective of the researcher. I have tried to ensure this validity by making sure that we understood each other when discussing a certain topic. I also tried to stay as objective as possible, not only during the interview but also during the analysis. Objectivity and subjectivity are concepts that have played a central role in the sciences and there are many different definitions (Helegund 2005: 647). I refer to the definition of Soanes and Stevenson (2003) which says that being objective can be defined as ‘not influenced by personal feelings or opinions in considering and representing facts or not dependent on the mind of existence (Soanes & Stevenson 2003). Although in practice, complete objectivity might never be fully obtained (Mathews 1987). I tried to focus on the respondent perspectives instead of my own.

The third category describes the theoretical validity. This validity explicitly addresses the theoretical constructions that the researcher brings to, or develops during the study (Maxwell 1992). Simply said, the theory must fit to the existing data and the study has to be coherent. The theoretical framework and the analyzed data have to complement each other. The theoretical framework I used in my study formed the basis of the research. Because of the factors derived from other frameworks of choice - stigma, the therapeutic gap and gender discrimination -, I was able to explore the meaning of these factors in the Nepali context. After analyzing the data, new theoretical insights were found that contribute to the existing literature. This combination of theory and conducting new data ensured the theoretical validity.

Fourthly, some form of generalizability needs to be guaranteed, this term refers to the ability to apply the theory resulting from the study universally (Thomson 2011: 79) However, generalizability can be problematic for qualitative research, because qualitative research is concerned

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with the concepts of a select group and therefore the findings may only be applicable to a similar group (Thomson 2011: 79). The results of my study are context-specific and therefore no generalizability is ensured. However the findings of this research can be used for future research. The framework of choice this study creates for Nepal, and the factors used in this framework of choice, can be used for other contexts as a framework to explore and look at reproductive decisions. A form of generalizability is in this way ensured.

The final category is the evaluative validity, which assesses the evaluations drawn by the researchers and how one evaluates the data they receive (Maxwell 1992). As mentioned before, I recorded the interviews and typed out the entire conversations. I this way, I tried to guarantee the ‘evaluative validity’ and tried to minimalize my own understanding of the situation, but instead focus on the information given by the respondents.

3.4 Limitations

The limitations of this study are important. This research aimed to find out why there are still women who resort to unsafe abortion. The ideal situation would be to talk to women who experienced unsafe abortion themselves. However, due to ethical considerations, this was not realistic. Furthermore, I also wanted to explore how abortion is perceived in the Nepali society and if and why abortion is stigmatized. Ideal would be to talk to all kinds of people, both living in the cities and people living in the rural areas (mountain and terai). Due to the time limit of this study, the geographical difficulties and the language barrier brought by the sensitivity of this topic, it was not possible to interview respondents from all three areas. I tried to solve this limitation by interviewing key informants who have been working in the field of safe abortion and who have been active in both urban and rural areas.

Another limitation has to do with the language barrier. I explicitly choose to have the interviews in English because the informants I interviewed had a good knowledge of the English language and because I did not want the data to be transformed or biased due to a translator.

However two limitations developed because I held the interviews in English. The first limitation is that respondents might feel difficult expressing themselves in a language other than their mother language. A second limitation was that I only spoke to people who were able to talk in English, which means they had to be educated. As for the expert interviews, this was not an issue, because all the experts I wanted to interview were educated. However the adolescents I talked to also were educated and living in the urban area. The people investigated in qualitative research are not meant to be representative of a population (Bryman 2008: 391). The information derived from the interviews with adolescents does not represent the perception of adolescents in Nepal. They only represent the thoughts of the respondents I talked with during my fieldwork. Thus, my findings cannot be applied more generally to other cases, but it can provide a framework to explore reproductive decisions, which can be used for future research in other contexts.

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3.5 Ethical considerations

During my fieldwork, I aimed to preserve the privacy and autonomy of each respondent in my research. Ethical considerations are that I avoid any harm to the people involved in the study ( AAA Code of Ethics 1998:2). To ensure their privacy, the respondents remain anonymous and requested that each participant signs an informed consent form, which provided them with the goal and information about the research. The respondents were able to withdraw from the conversation or interview at any given time.

In both proposing and carrying out research, anthropological researchers must be open about the purpose of the research (AAA Code of Ethics 1998: 2). During my fieldwork I made sure my respondents knew in advance what the aim of the research was. The respondents were asked for permission to record the interview. A strict commitment to secrecy was kept for any personal information shared with in an in-depth interview of informal conversation.

Abortion is a highly emotional and stigmatized topic and can therefore be difficult to talk about it. Great care must be taken in running discussions on sensitive topics, especially with natural groups who have to live, work or socialize together after the researcher have gone home (Green & Thorogood 2004: 127). I respected the wellbeing of the respondents by closely observing the reactions.

I have chosen not to talk with women who have gone through illegal or legal abortion, because of ethical clearances. It would be too sensitive to bring these women into my research. Having said that, the topic remains highly emotional, also for others who haven’t had an (il)legal abortion themselves. I understand that the development of knowledge can lead to change, which may be positive or negative (AAA Code of Ethics 1998:2). Therefore I paid close attention to the cultural environment as to ensure that no respondent’s mage became stigmatized for being interviewed by me.

Since abortion was legalized in the Netherlands in 1984, I have been raised with the idea of the possibility to terminate a legal and safe abortion in case of unwanted pregnancy. In this research, it was of importance that I put aside my own perceptions of abortion and I listened to stories and perceptions of others from an objective and anthropological view.

Practice and perception of illegal abortion in Nepal : a framework of choice