2.1 Research design

We utilized a systematic search strategy to identify relevant studies investigating the accessibility and safety of abortion services in Nepal.

2.2 Research question

The research question guiding the review was: “What are the barriers and facilitators for accessing safe abortion services in Nepal?”

2.3 Database searched

To systematically search for literature on abortion access and saftey in Nepal, a syntax was created combining the following keywords: abortion, access, safety, Nepal.

(("abortion" OR "terminat*" OR "miscarriage*") AND ("access*" OR "availability" OR "utilization") AND ("safety" OR "complication*" OR "risk*") AND ("Nepal" OR "Nepali"))

We then systematically searched four databases: PubMed, Embase, CINAHL, and Scopus. In addition to these databases, a search of the grey literature was also conducted, which included difficult-to-find sources such as conference proceedings, government reports, and dissertations. This search was carried out using the World Health Organization Global Health Library as well as other sources such as Nepalese medical journals and databases including the Nepal Journal of Obstetrics and Gynecology and Nepal Journals Online (NepJoL).

2.4 Data extraction

Identified studies underwent title/abstract and full-text screening for eligibility. Data were extracted from included studies through close reading. Barriers and facilitators were categorized into themes. Patterns and trends were analyzed across themes to synthesize insights on factors impacting abortion safety and accessibility in Nepal.

2.5 Ethical clearance

Ethical clearence is not applicaple as this study reviewed published studies.

4.1 Legal and policy factors

In various studies, a common barrier that was consistently found was a lack of understanding of abortion laws and service availability.^{7, 8, 23, 25, 32, 34, 37, 38} This leaves women unaware of their rights and options,⁸ which ultimately leads to uncertainty, fear of legal repercussions, and stigma. Additionally, the spread of misinformation exacerbates misconceptions.^{7, 8}

Strict legal restrictions pose significant challenges, making it very difficult for women to freely make choices about their own bodies and reproductive health.^{24, 34, 37} Particularly, in lower-income settings such as Nepal, restrictive legal status increases disparities in accessing safe abortion care.³⁵ Thankfully, the policy landscape has changed over the past two decades as abortion laws have become more liberal.^{25, 38} This has led to a significant shift toward recognizing women's reproductive health and that abortion is their fundamental right.

Despite these advances in the legal framework, barriers to access to abortion care remain. The policy requiring women who live far from healthcare facilities to obtain physician approval for medical abortion is an example of barriers that disproportionately affect rural populations.²⁸ This restriction may increase inequalities. However, its recent amendment allows community healthcare workers to provide medical abortion, a promising policy change to expand access.¹⁷

It is critical to comprehensively address the complex legal and policy barriers to protect and uphold women's reproductive health and rights. To achieve equitable and safe access to abortion, it is important that strategies not only address ongoing restrictions, but also tackle existing awareness gaps and inequities. This requires coordinated efforts across sectors to establish an enabling environment for all individuals to exercise their right to abortion.³³

Key facilitators such as legalizing abortion were transformative in decriminalizing the procedure and acknowledging women's autonomy.^{25, 38} Government–NGO partnerships have successfully increased awareness and availability of services.³³ Better education on abortion laws and services also empowers women by giving them accurate information about their rights and options.²⁶

4.2 Social and cultural factors

In Nepal, deeply rooted societal customs, values, and mindsets continue to uphold a harmful stigma surrounding abortion, impeding women's ability to access safe and necessary services.^{8, 23-25, 28, 30, 32-34, 38} This stigma originates from deeply ingrained patriarchal beliefs of women's morals and sexuality, which makes abortion taboo in our culture.³⁴ It manifests itself through social isolation, verbal abuse, denial of services, and community disapproval of women seeking abortion.^{23, 24} Beyond emotional distress, stigma deters timely care-seeking, compels unsafe procedures, and hinders women's ability to reach/afford services.^{32, 33, 38}

Persistent gender inequities and limited control over reproductive decisions act as catalysts for perpetuation of stigma.³⁴ As a result, women are left with few options and often resort to unsafe and secretive methods of abortion.³⁴ Adding to this cycle, healthcare providers perpetuate stigma through their discriminatory actions and refusal to offer essential services.^{8, 30} Women encounter multilayered stigma originating from communities and the healthcare system.^{23, 24} Addressing stigma requires comprehensive strategies that span sociocultural, legal, health systems, and geographic spheres. Increased awareness, community engagement, improved provider training, and more robust legal frameworks can slowly transform social attitudes and norms.^{7, 24, 25, 33} Including parents in communicating about SRH with adolescents fosters supportive family environments.²³ Adolescent-friendly healthcare services meet the needs of young women by providing a welcoming space for information and care.²³ Confidential, nonjudgmental care from trained staff mitigates stigma and makes women more likely to seek timely, appropriate care.³² Positive attitudes among healthcare staff toward abortion laws create an atmosphere of empathy and understanding that encourages care-seeking.²⁶

4.3 Geographic and accessibility factors

Nepal's diverse terrain creates geographic barriers that, along with economic and social factors, challenge access to SAS and underscore disparities.^{8, 9, 25, 32} Rural areas suffer from scarce facilities and trained providers, obstructing services.^{8, 9, 25, 32} Rugged topography poses transportation obstacles, with remote regions especially affected.^{30, 33} Many women struggle to afford travel and clinic fees, creating financial barriers.^{8, 34} Rural populations have limited access to SAS availability in general.^{7, 24} High private clinic costs further constrain the affordability.^{7, 23-25, 30, 33} These intertwined geographic, economic, and social barriers hinder timely and appropriate care.

However, some facilitators show promise in improving access. Reducing service costs alleviates financial limitations.²⁴ Expanding availability beyond cities helps address geographic disparities in rural areas.^{7, 24} Leveraging local auxiliary nurses, midwives, and volunteers facilitates community-level care.³³

4.4 Healthcare system factors

Numerous barriers within Nepal's healthcare system obstruct the provision of SAS, requiring careful attention to pave the way for improved accessibility and quality.^{7, 8, 22, 25, 30, 33-35, 38} A major challenge is the lack of knowledge about abortion and available services among women.^{8, 33} Being uninformed hinders their ability to make appropriate decisions, potentially delaying care or leading to unsafe practices. The shortage of trained healthcare providers equipped to offer SAS results in inadequate counseling and care.³⁴ The absence of a safe and confidential environment can deter women from seeking SAS, perpetuating unsafe abortions.^{7, 23, 37} The scarcity of trained providers and facilities, especially in certain regions, forces women to endure logistical hurdles to access care far from home.^{8, 30, 38} This underscores the urgency of expanding the reach of services to remote areas. Failure to provide effective postabortion contraception contributes to repeat unintended pregnancies and unsafe practices.³⁴ The provision of inaccurate information and unsafe medications provided by untrained pharmacy staff further endangers women's health and lacks a proper referral system.^{26, 35}

Despite these challenges, numerous facilitators show promise in improving SAS in Nepal. Providing women with comprehensive counseling and information promotes informed choices and timely, safe care.²⁴ Training female CHV to offer referrals bridges the access gap, particularly in rural areas.²⁸ Widening availability of medical abortion pills enables convenient, safe termination of early pregnancies.^{25, 33, 38} Pharmacies can serve as accessible points to obtain these medications privately.^{9, 33, 35} Training non-clinicians in abortion care enhance access in underserved regions.^{29, 33, 35} Expanding the number of trained providers and facilities ensures that the services are within reach for more women.^{7, 25} Referral networks prevent denial of care and resorting to unsafe means.²⁹ Fostering confidential, nonjudgmental settings encourages care-seeking.^{7, 24} Reducing stigma creates a supportive environment.⁷ Collaborations with organizations provide resources to strengthen SAS delivery.²⁵ Training mid-level health providers such as ANM brings care closer to the communities.³¹ Ongoing monitoring and evaluation maintain quality and equity.⁹

4.5 Strengths and limitations

This review has both strengths and limitations. A major strength is the comprehensive search across multiple databases and gray literature, providing a solid foundation of evidence. The included studies utilized sound methodologies, including surveys, interviews, and record reviews. However, the quality and depth of evidence varied. Some barriers/facilitators were only supported by a few studies, indicating a need for more research in those areas. Many studies relied on self-reported data, which could introduce bias. Most of the evidence came from cross-sectional studies, limiting the ability to infer causality between barriers/facilitators and access outcomes. There was minimal data directly linking identified factors to abortion morbidity/mortality. Few studies evaluated interventions or policies to improve access. While valuable insights emerged, higher-quality longitudinal and interventional studies are required to strengthen the knowledge base on improving the safe provision of abortion in Nepal.