Project summary The objective of this project is to examine the health consequences of unintended pregnancy and denial of legal pregnancy termination services in Nepal on women and their children. Births following unwanted pregnancies can be associated with negative physical, social and economic consequences for both the woman and child. Half of all unintended pregnancies are terminated before they are carried to term and, when performed in unsafe or illegal conditions, the consequences can include infection, infertility, and death. The incidence of mortality and morbidity from termination are notoriously difficult to measure. Widespread stigma associated with unwanted pregnancy – even in settings in which termination is legally available – contribute to misreporting, concealment, and misattribution of termination-related morbidity and mortality. In addition, many women seek illegal methods—both safe and unsafe—which further confounds efforts to measure the prevalence of mortality and morbidity from terminations. The effects of unwanted pregnancy on children, including children born prior to and subsequent to the unwanted pregnancy, are also not well established. A prospective longitudinal study of women with unwanted pregnancies is required to validly investigate the health consequences for women and their families of termination outside of the legal system and delivery of an unwanted pregnancy, as compared to legal termination. Such a study is only possible in places like Nepal, where termination is legal but barriers prevent some women from receiving the service. Aim 1: To investigate the predictors of denial of legal pregnancy termination services. Aim 2: To assess the health consequences of childbirth and illegal termination for women after denial of legal termination Aim 3: To measure the effects of legal and illegal termination compared to birth on the health and development of women’s existing and subsequent children Prospective longitudinal data from women in a less developed country would provide valuable evidence for the development of programs and policies globally to improve access to and utilization of safe termination services where they are legal, and harm reduction services for women who are unable to access services.

Project narrative This study will be the first to investigate how inability to receive a desired termination of pregnancy affects women’s and children’s health in Nepal, a country with legal termination services but large gaps in access to care. Prospective recruitment at the point of legal termination-seeking and interviews over the following three years will elucidate the health consequences of access to legal termination services and identify needed improvements in the prevention and treatment of unintended pregnancy.