KATHMANDU, Nepal – On a bright afternoon in April, Jiya Shreshta* met her sister in an empty field near her apartment. Her sister slipped a pack of medical abortion pills into her hands. Shreshta swallowed one pill immediately as her sister relayed the pharmacist’s sole instruction: “Take the next pill after 24 hours.” Shreshta felt relieved as she scurried home, hoping no one had seen.

After taking the pills, Shreshta, 30, maintained her routine: cooking, cleaning, helping her son with his homework. A week passed but the heavy bleeding, a normal side effect of medical abortions, didn’t abate. The pain sharpened. She spent her time coiled up in bed, swapping out four sanitary napkins a day.

Shreshta had taken the pills because she feared a doctor would berate her for getting pregnant. But now she wondered if they had even worked.

She eventually sought treatment for her bleeding at a health clinic, one of thousands of women in Nepal who face complications from clandestine abortions each year. She had had an incomplete abortion – a situation in which the fetus has stopped developing but some products of conception remain within the woman’s body. At the clinic, a doctor completed her abortion surgically.

Nepal legalized abortion in 2002, but clandestine procedures are still common, according to a recent study by the Guttmacher Institute. Experts believe most clandestine abortions don’t happen in back-alley clinics, but rather through local pharmacies where women buy pills to self-induce without receiving medical guidance.

When taken correctly, self-inducing abortions using misoprostol and mifepristone can safely terminate a pregnancy. However, in Nepal, pharmacy workers often sell pills to women who are past their first trimester or without giving them instructions, which increases the risk of hemorrhage, serious infection or incomplete abortion. Under Nepal’s laws, women seeking medical abortions must visit a doctor for a prescription before buying pills at pharmacies.

“We see two or three women per day for bleeding,” said Dr. Saroja Pande of Paropakar Maternity and Women’s Hospital in Kathmandu. Although nearly all these cases involve incomplete abortions and aren’t serious, the hospital treated two women who contracted life-threatening infections after visiting pharmacists this past year. Their uteruses had to be removed.

Some of the hospital’s patients are teenagers whose friends linger in the lobby; others are adult women accompanied by their husbands. Some have just left the office; others have never worked out of the home or learned to read or write.

Reproductive health workers in Nepal told News Deeply that women and girls prefer pharmacies over doctors for a variety of reasons: They offer more privacy, extended working hours, a closer distance or speedier service. Deep in the Himalayas or across Nepal’s southern plains – where the nearest health clinic may be a long hike away – pharmacies might be a woman’s only option for terminating a pregnancy.

“It’s in the culture,” said Shreejana Bajracharya, a reproductive health activist who works for Marie Stopes Nepal. “When you have a headache or something you don’t rush to the hospital. You go directly to the pharmacist.”

Abortion access is among several factors that have helped lower Nepal’s maternal mortality rate, said Khemraj Shrestha, the director of programs at the NGO Population Services International (PSI). However, many women don’t realize abortion is legal and free at public health clinics. Poor women or those in rural areas often don’t know that abortion is an option if they cannot read or if they lack access to media that advertise safe abortion services.

“They’re collecting fodder, taking care of their cattle and families, farming. They’re too busy to listen to the radio,” Shrestha said. “Then when they go to health facilities, they have to walk two to three hours, so their nearest point of health service is small pharmacies.”

Engaging Pharmacists

The belief that women will visit pharmacies for abortion pills regardless of whether they have a prescription has led the government to feel that the solution lies in educating pharmacy workers.

Nepal’s pharmaceutical industry is difficult to regulate. Only four brands of misoprostol and mifepristone abortion kits are legal in the country, but at least 20 different brands are smuggled across its porous border with India. According to PSI, it is difficult to assess the quality of these brands, but pharmacists have a high incentive to sell them since they can pocket hundreds of rupees each time they sell medical abortion kits.

“Government officials can’t find these drugs [when they raid pharmacies],” said Dr. Naresh Pratap K.C., the director of Nepal’s Family Planning Division. “Pharmacists hide it when they come to check.”

Now, the government and PSI are holding orientations for pharmacy workers. These will cover which brands they can legally sell to women who have a prescription, the right dosage and counseling for those brands and which safe abortion sites they can refer women to without prescriptions. A thousand pharmacists in southern Nepal volunteered for the orientations, which are running from August to the end of October this year.

Dr. Heera Tuladhar, the president-elect of Nepal’s Society of Obstetricians and Gynecologists, believes these orientations could help, but that additional efforts are needed.

She was involved in a different orientation program for pharmacists through PSI several years ago and said it didn’t seem to reduce the number of complications she treated. She suspects some pharmacists who attended the orientations still sell pills to women without a prescription.

“They’re running a business,” she said.

She recommends that this time there should be follow-ups to see whether the pharmacists, after completing the new orientation, then correctly refer women without prescriptions to safe abortion sites.

Dr. Pande also worries that pharmacists won’t properly prepare women for emergencies. Trained healthcare workers tell women to contact relatives or friends who can take them to a hospital if they face complications, she said.

“It’s not like so many developed countries where you can just push a button and the ambulance will come,” she said. “It’s not that easy.”

To address such concerns, PSI has recruited ob-gyns to lead harm-reduction sessions for pharmacists. They are also teaming up with Nepal’s Department of Drug Administration to conduct follow-up visits that will assess whether these pharmacists still sell unregistered abortion pills, how they handle prescriptions and whether they refer women to safe abortion sites.

Still, Dr. Tuladhar said prevention has to go beyond educating pharmacists: Media campaigns need to advise women seeking medical abortions to first visit a doctor for a prescription. Buying drugs over the counter is both illegal and potentially unsafe, she said.

“There’s a demand for medical abortion, but women don’t know they need a prescription,” she said. “Orientations for pharmacists can help, but women need awareness, too.”

*Name has been changed.