Adolescent and youth responses to the Global Gag Rule in Nepal.

Introduction

In many developing countries, adolescents and youth face barriers accessing sexual and reproductive health (SRH) services including for family planning, contraceptives and safe abortion, due to country-specific restrictive laws and policies, based on age or marital status, regarding provision of these life-saving services. The United Nations defines adolescents as those persons aged between 10 and 19 years, and youth as those between the ages of 15 and 24 years, without prejudice to other definitions by Member States. Together, adolescents and youth are referred to as young people, encompassing the ages of 10–24 years.[1,2] This article aims to describe the situation of adolescent and youth sexual and reproductive health and rights (SRHR) in Nepal and share our organisation’s experiences of how the expanded GGR has affected SRH.

Asia is home to more than half the adolescents living globally. In absolute numbers, South Asia alone has more adolescents – nearly 350 million – than any other region. It is followed by East Asia and the Pacific with over 300 million. The adolescent population of each of these regions dwarfs that of any other region in the world.[3]

Adolescent pregnancies are a global problem occurring in high-, middle- and low-income countries. Every year, an estimated 21 million girls aged 15–19 years living in developing regions become pregnant and approximately 12 million of them give birth.[4] Around 10 million of these pregnancies are unintended.[6] At least 777,000 births occur in adolescent girls younger than 18 years.[5] Additionally, some 3.9 million unsafe abortions among girls aged 15–19 years occur each year, contributing to maternal mortality, morbidity and lasting health problems.

For decades, the United States (US) has been the world’s largest provider of bilateral assistance in global health. The US has a strong and collaborative partnership with the Government of Nepal, which spans over 70 years and includes the delivery of over $1.5 billion in US assistance to support development of the agriculture, education, health and other socio-economic sectors in Nepal. However, the Global Gag Rule (GGR) has resulted in a hardline stance against recipients of US government global health development funds with regard to abortion. After the reinstatement and expansion of the GGR in 2017, Nepali non-governmental organisations that receive US global health assistance now need to certify that they do not provide, counsel, refer, or advocate for abortion as a method of family planning – even with their own funds – as a condition for continuing to receive funding. Since the new policy applies to all global health funds, this may mean losing grants for programmes targeting HIV/AIDS, tuberculosis, malaria, infectious diseases, neglected tropical diseases, and water, sanitation, and hygiene. As a result, many national and international organisations working in SRH services, including abortion, are experiencing negative impacts of the Global Gag Rule on their programming and services. This disproportionately affects young people in Nepal.

Young people’s sexual and reproductive health in Nepal

In Nepal, adolescents account for nearly a quarter (approximately 6.4 million or 24%) of the country’s 26.5 million population.[7] The legal age of marriage in Nepal is 20 years, yet, in 2016, 40% of women aged 20–24 years were married before the age of 18 years, and 7% were married before the age of 15 years. One in every six married adolescent girls experiences emotional, physical or sexual violence by her spouse. The country’s adolescent birth rate is 88 per 1000 women, with 17% of girls aged 15–19 years already mothers of at least one child. Only 15% of married adolescent girls use modern contraceptive methods and 35% have an unmet need for modern family planning methods.[8] The 2010–11 Nepal Adolescent and Youth Survey reported that only a third of sexually active adolescent males, both married and unmarried, used a condom at last sex. Use of modern methods of contraception has stagnated in the last decade, and currently married adolescent girls have the highest unmet need for family planning of any age group. Pregnancy among adolescents is associated with poverty, social status, including socially disadvantaged castes, disadvantaged ethnic groups, and unemployment.[9]

The Ministry of Health and Population has led a national adolescent sexual and reproductive health (ASRH) initiative which aims to serve all adolescents. To support implementation, the Family Health Division developed the National Adolescent Health and Development Strategy in 2000, which included Adolescent Friendly Health Services as a key objective and detailed activities required to improve access to and utilisation of counselling and services.[8] Subsequently, the 2007 Implementation Guideline for ASRH was developed to assist district level managers to implement the national strategy, emphasising youth participation, equity, and linkages with other youth health and development initiatives.[8] In 2010 the National ASRH Program outlined the health sector response to ASRH needs. Despite the progressive health strategies for adolescents and young people, Nepal does not emphasise comprehensive sexuality education and has no mandatory course on sexuality education in its school curriculum. Sexuality education is limited to reproductive health and is not comprehensive.

Nepal’s government has its own targets to meet the Sustainable Development Goals by 2030. Expansion of safe abortion services is one of the major ways to achieve SRHR-related goals, including reduction of maternal mortality from 239 per 100,000 live births in 2015 to below 70 per 100,000 live births by 2030. Nepal amended its Country Code (Muluki Ain) in 2002 to allow abortion under certain conditions, contingent to the woman’s decision to abort, as follows: (i) Up to 12 weeks gestation on any grounds; (ii) up to 18 weeks gestation in cases of rape or incest, and (iii) at any time during pregnancy, if the pregnancy poses a danger to the woman’s life, affects physical or mental health, or if there is a fetal abnormality. The Right to Safe Motherhood and Reproductive Health Act 2018 replaced the Muluki Ain and further guarantees women’s rights to legal and safe abortion care on wider grounds. Under this Act, abortion is permitted up to 12 weeks of gestation for any reason, and up to 28 weeks with the woman’s consent in case of (a) pregnancy resulting from rape or incest; (b) if the woman is suffering from HIV or other incurable disease; and (c) if the pregnancy poses a danger to the woman’s life, affects physical or mental health, or if there is a fetal abnormality. Despite the progressive law on abortion, fewer than half (42%) of all abortions were provided legally in government-approved facilities. The remaining (58%) were clandestine procedures provided by untrained or unapproved providers or induced by the pregnant woman herself.[10]

Within the context described above, the expanded GGR is creating gaps in SRH service availability and utilisation, predominantly affecting already marginalised and underserved populations. The US government funding cuts have affected programme activities like the supply of equipment and community awareness-raising, ultimately leading to low or no utilisation of services. In many situations, organisations receiving US government funding for family planning projects were forced to end the projects before the scheduled completion date, due to cutbacks related to the GGR. This has deep-rooted implications for young people’s SRH. It has worsened the scenario, leading young people to access abortion services from unauthorised sites where unregistered drugs and medical herbs are sold.

The Government of Nepal and its development partners have been working to increase access to family planning services and information. Unfortunately, the country’s healthcare system has been negatively impacted by the GGR, reducing availability of healthcare services, creating major funding gaps, halting the work of US-funded programmes, dissolving collaborative partnerships, and silencing the voices of civil society organisations, according to the research.[10] By reducing access to modern contraception among young people, the GGR might ultimately serve to increase the number of abortions. This is not just a shocking irony, but an attempt to control and coerce young people’s SRHR. There can be no right to health without the right to access safe abortion.

In our work, we have also found that stigma associated with abortion is a challenge for young people in accessing abortion services. We have found that the extended GGR increases hate toward and discrimination against both people accessing abortion and the service providers. At YoSHAN (Young feminist-led Sexual and Reproductive Health Advocacy Network), we strongly believe that safe abortion is a human right, as well as an essential service in any situation, and that safe abortion should be available to all women, girls and gender non-conforming people. We need to ensure bodily autonomy and empowered body politics to allow women and girls to live and function in a dignified way. We have seen that one of the best ways to reach people seeking abortion is by providing stigma-free information. Storytelling has helped dispel stigma and increase support for abortion access. Youth movements in Nepal have also utilised social media campaigns to call out the inaccurate and highly inflammatory statements about abortions that have been made by US President Trump. We have found that the level of heightened rhetoric from the highest office in the US has only served to embolden anti-abortion extremists and to propagate stigma.

At YoSHAN, we are engaged in social media campaigns where we encourage youth to share their stories through which many other young people can get evidence-based information and counter abortion stigma. We have noted increases in conscientious objection from service providers and rejection of abortions beyond 12 weeks of gestation, resulting in continuation of unintended pregnancies. In response, YoSHAN has set up a referral mechanism with government hospitals, referring safe abortion clients to government-listed health facilities. Although YoSHAN is a grass-roots network, we are building forces by working with national, regional and international networks like the Asia Safe Abortion Partnership (ASAP), Inroads and Women’s Global Network for Reproductive Rights (WGNRR) to amplify our voices locally and to represent internationally how the GGR has an adverse effect on adolescents and youth in Nepal.

A call for action

As young people we have the right to protect our health and plan for our future including making decisions about pregnancy and parenting. Yet we face many barriers to reproductive health care, including the lack of sex education and access to contraception.

Talking about sex and sexuality is taboo in our country, making it challenging for young people to talk, explore and learn. In Nepal, sexuality education is limited, with contents driven from a “health”, rather than an information or rights perspective. The government of Nepal should make sexuality education compulsory, with age-appropriate and rights-based concepts. The curriculum should be designed in consultation with young people, civil society organisations, NGOs working in SRHR with a special focus on comprehensive sexuality education, child psychologists, parents, and teachers. Furthermore, sexuality education should not be limited to young people in school. Information can also be disseminated through local health facilities, adolescent-friendly health service sites, radio, television, internet, mobile phones, text messaging and setting up hotlines.

When it comes to abortion care, we live in an increasingly hostile climate, and have seen that access to safe abortion services is shrinking. Despite the progress the Government of Nepal has made to address adolescent and youth SRH programmes, the GGR has undermined or reversed the progress Nepal has made. It has cut off the funding for safe abortion services, affecting the availability of essential equipment and medicines. The extended GGR has impacted adolescent and youth movements for advocacy and awareness raising on rights to safe and free abortion services, as granted by the country’s law.

We demand that the Government of Nepal become economically self-reliant and not depend upon the US Government funds any more, particularly if such funds have strings tied, as in the GGR. It is high time the government allocates adequate internal funding and resources for the implementation of national SRHR programmes and discusses foreign policies that are affecting national programmes with high-level government officials and in the parliament. Now is the time to identify ways to mitigate the long term impacts of the extended Global Gag Rule.