Two decades of safe abortion policy evolution and reform in Nepal (2002-2025): progress, implementation, challenges, and opportunities.

Abstract

Nepal has made significant strides in reproductive rights, legalizing safe abortion services (SAS) in 2002, and recognizing them as fundamental rights in its 2015 constitution. Despite this, over half of abortions remain unsafe, with persistent disparities in access to and utilization of safe abortion services. This study examines the trajectory of Nepal's abortion policy evolution and reform process, and implementation status, and ongoing challenges and opportunities using the heuristic policy cycle framework to inform evidence-based strategies for equitable reproductive rights. A policy process and content analysis was conducted using a mixed-methods approach. To identify relevant policy documents and literature, we used search terms related to three concepts: abortion, law, and location (Nepal). We identified 25 peer-reviewed studies and 32 grey literature policy documents published in English or Nepali up to 30 June 2025, identified via PubMed, Embase, Medline Ovid, Google Scholar, and government sources. Quantitative data were extracted from government annual reports and national census data. Data analysis involved thematic coding of qualitative data across five policy stages (agenda setting, formulation, adoption, implementation, and evaluation) and descriptive analysis of quantitative service utilization and the sex ratio at birth (SRB) data. Agenda setting of the legalization of abortion in Nepal was driven by high maternal mortality ratio and advocacy aligning with global commitments. The 2002 legal reform legalized abortion up to 12 weeks on demand, with provision requiring spousal consent, and banned on sex-selective abortion. Implementation efforts focused on capacity building, service expansion-expanding SAS to 1,685 sites-and equitable distribution of services, delivering 1.6 million SAS over two decades. The proportion of medical abortion has increased from 50% to 73% of cases. However, 53% of pregnancies are unintended, with abortion often used as contraception. More than 50% of service providers are outside the formal system. There is inequitable access to SAS, and the SRB is skewed towards male, indicating ongoing sex-selective abortion. Nepal's abortion policy journey represents remarkable progress in legal reforms and service expansion; however several contextual and systemic barriers such as low awareness, rural inequity, unregulated providers, sex selective abortion, and the repeated use of abortion as family planning undermine equitable access and reproductive rights. Key reforms include expanding second-trimester services, strengthening regulations, combating sex-selective abortion practices, enhancing access to family planning services, and implementing abortion related awareness campaigns to address gender discrimination, service information gaps, and unintended consequences of unsafe practices.