Understanding awareness of abortion legality and barriers to service access among adolescent girls in Karnali Province, Nepal: evidence from a mixed methods study

Abstract

Background

Although abortion has been legal in Nepal since 2002, the utilization of safe abortion services has not been universally adopted, especially among adolescents. Adolescent girls disproportionately experience barriers in accessing these services due to a lack of awareness and stigma. This study assessed awareness of abortion legality and barriers to accessing services among adolescents aged 12–19 years in Karnali Province, Nepal.

Methods

This study used a cross-sectional mixed-methods approach. A survey assessed the awareness about the legality of abortion, and focus group discussions, key informant interviews, and in-depth interviews were conducted to explore the barriers to accessing abortion services. We performed a binomial logistic regression analysis to identify the determinants of awareness of abortion legality. A thematic analysis was conducted for the qualitative data, and the findings were triangulated with the quantitative results.

Results

Nearly 9 out of 10 (89.2%) respondents had heard about abortion. However, only 49.8% knew that abortion is legal in Nepal. Adolescents aged 15–19 years (aOR = 1.976, 95% CI: 1.266, 3.084), who lived in Jajarkot (aOR = 2.784, 95% CI:1.529, 5.067) or Jumla (aOR = 2.419, 95% CI: 1.204, 4.860), and who had awareness on comprehensive sexuality education (aOR = 1.991, 95% CI: 1.175, 3.374) were more likely to be aware of the legality of abortion services. Key barriers to abortion services included social stigma, limited information, misinformation about consequences, distrust in available services, and a lack of confidentiality at health facilities. These challenges were further compounded by health workers’ behaviors and attitudes, poor service availability, and schoolteachers' limited knowledge of abortion legality.

Conclusion

Overall, adolescent girls had limited awareness of the legality of abortion and faced multiple demand- and supply-side barriers to accessing services. Addressing these challenges requires a multi-level approach, including social and behavior change initiatives to raise awareness of abortion legality among adolescents and teachers and reduce social stigma. In addition, abortion services should be strengthened by expanding service sites and ensuring that services are adolescent-friendly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-23964-x.

Introduction

Access to safe abortion care is a fundamental human rights and a critical component of sexual and reproductive health and the rights of women and girls [1]. Unsafe abortion is one of the leading but preventable causes of maternal morbidities and deaths [2, 3]. According to global estimates from 2015 to 2019, around 73 million abortions take place worldwide each year [3, 4]. Nearly half of them (45%) are unsafe (defined as a pregnancy termination performed either by a person lacking the necessary skills or in an environment lacking adequate medical standards), with most unsafe abortions (97%) occurring in developing countries. Of these, more than half take place in Asia [3, 5]. Globally, unsafe abortion accounts for up to 13% of deaths related to pregnancy and childbirth [6]. Adolescents are particularly at greater risk of undergoing unsafe abortion, accounting for 15% of all abortions globally, and nearly one-third of all unsafe abortion-related deaths each year [7–9].

Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality due to unsafe abortions. Since then, Nepal has seen significant progress in the implementation and expansion of safe abortion services. The 2002 abortion law grants women the rights to abortion up to a specific gestational age, depending on circumstances or medical conditions [10]. The abortion law permits women to seek abortion for any reason up to 12 weeks of gestation, and up to 28 weeks in cases of rape or incest. Abortion is also legal up to 28 weeks of pregnancy if a doctor concludes that the pregnancy poses a danger to women’s life or her physical or mental health, if the fetus has a serious deformity, or with the consent of a woman who is living with HIV or other incurable disease of a similar nature [10]. Following this legal reform, a comprehensive safe abortion care program was implemented in 2004. Since then, the country has made striking progress in rolling out abortion services, establishing comprehensive abortion care (CAC) at 100% of public sector sites at the regional, zonal, and district level, and in 46% of primary health-care centers [11]. Additionally, in August 2016, the Government of Nepal announced a plan to implement free safe abortion services in public health facilities, in combination with the provision of free family planning services, to help overcome the economic burden of accessing safe abortion services [12].

It has now been over 22 years since the legalization of abortion in Nepal, and we have seen more than a decade of programmatic responses. Yet, the utilization of safe abortion services has not been universally adopted. Access to safe abortion services remains inadequate, and many gaps and barriers persisting for women of all ages [13]. Of the estimated 333,343 abortions performed in Nepal during 2021, there are indications that more than half were not meeting the regulatory criteria and were carried out by traditional and unsafe methods [14, 15]. Unsafe abortion remains the fifth highest (5%) direct cause of maternal death in Nepal [16].

Despite abortion being legal, a significant number of Nepali women remain unaware of the legal status of abortion and have limited or no information on where to access safe abortion services [17]. This gap in awareness is particularly evident in Karnali Province, where only 33% of women are aware of the legal status of abortion, compared to the national average of 41% [18]. Nepalese adolescents often experience challenges in accessing safe abortion services [14]. Limited awareness of the legal status of abortion and the availability of abortion care remains a key factor in upholding unsafe abortion in Nepal [19]. Additional barriers include negative provider attitudes, fear of repercussion, lack of access to comprehensive sexuality education, cost of care, concerns over privacy and confidentiality, stigma surrounding adolescents’ sexuality, lack of transport to approved facilities, and restrictive gender norms that hinder women’s decision-making power [14, 20].

Adolescent girls who obtain abortion care tend to access it later in the pregnancy than older women [21] and are more likely to delay seeking help for abortion-related complications [21], primarily due to stigma and fear of social consequences [22]. Also, many girls lack negotiation and decision-making skills necessary for abstaining from unsafe sexual practices [23]. In Nepal, married adolescents experience a low contraceptive prevalence rate (14%) and a high unmet need for family planning services (30.9%), leading to high rates of unintended pregnancies that could potentially compel women and girls to use unsafe abortion services [24]. In 2017, nearly half of all pregnancies in Nepal (1.2 million) were unintended, with almost two-thirds (359,000) of them ending in abortion [20]. According to the latest Nepal Demographic and Health Survey (NDHS), 16% of pregnancies were mistimed, and 11% were unwanted. Of the pregnancies that ended in abortion, 62% were unwanted [19]. Further, Karnali province recorded the second highest rate of induced abortions, highlighting significant subnational disparities in reproductive health outcomes [18].

While some past studies have examined awareness and barriers to abortion services among women in general [13, 14, 24, 25], evidence specific to adolescent girls in Nepal remains limited. Understanding adolescents’ awareness about the legality of abortion and the access barriers they face is essential for crafting equitable policies and programs, ensuring that vulnerable and underserved populations are not left behind. Therefore, Save the Children Norway funded and initiated a study to assess the awareness of the legality of abortion and barriers in accessing and utilizing abortion services among adolescents in Karnali Province, Nepal. The findings from this study will aid policymakers and program managers in implementing existing abortion policies and programs through targeted strategies to eliminate unsafe abortion and reduce preventable maternal morbidities and mortalities. This may contribute to achieving the health-related Sustainable Development Goals (SDGs) by 2030 [26].

Methodology

Study design

The cross-sectional mixed-methods design was used to assess knowledge and barriers in accessing abortion services among adolescents in Karnali Province, Nepal. The study applied both qualitative and quantitative research approaches. A quantitative study examined adolescents’ awareness of abortion legality, while a qualitative study explored the barriers they face in accessing services. The findings were then triangulated to enhance understanding, validate results, and inform policy and program recommendations. Figure 1

Fig. 1.

Flow chart of quantitative and qualitative components of the study

Quantitative component of the study

Study setting, sampling, and sample size

A survey was conducted among adolescent girls aged 12 to 19 from August 15 to November 30, 2023. This study was conducted in the four municipalities of Karnali Province, where the Norwegian Agency for Development Cooperation (NORAD) has funded Save the Children’s SAHAYATRA-III project, which commenced on 1 January 2024. Karnali Province is the country’s largest Province, covering one-fifth of Nepal’s total area. However, it is sparsely populated, with a population of over 1.6 million, accounting for 6% of the national population. Adolescents comprise 24% of the population in the Province [27]. The majority, over 60% of the population, belongs to the Brahmin, Chhetri, and Thakuri ethnic groups [27].

The Province lags in both the development and prosperity index [28]. Nearly one-third of its population (28.9%) lives below the poverty line, and more than half of these poor people (51.2%) experience multidimensional poverty [29]. Similarly, the province ranks among the lowest on the Human Development Index (HDI), with a score of 0.427, below the national averages of 28% and an HDI of 0.49, respectively [30].

More than 4 in 10 women (44.3%) aged 15–49 years in Karnali were married before the age of 18, and 21% of adolescent girls reported having experienced a teenage pregnancy. Likewise, Karnali Province has a relatively high fertility rate of 2.6 children per woman [19].

For this study, we determined 384 as the minimal sample size using the formula N = Z²pq/d², which provided a precision of ± 5% points at a 95% confidence level, assuming 50% of the adolescents have correct knowledge of the legality of abortion. The total required sample size was 424, considering a 10% non-response rate. The study employed a three-stage random sampling method. Four out of six SAHAYATRA-III project implementing municipalities were randomly selected from four districts with comparable socio-economic, geographical, and cultural contexts. The number of municipalities was determined based on study feasibility, available resources, and the scope of data collection, while ensuring sufficient contextual diversity for the study objectives. These four municipalities have nearly 93,784 residents from 18,390 households, including 25,071 adolescent population (male and female) aged 10–19 years. Secondly, four wards were selected from each of the four municipalities using simple random sampling, ensuring adequate population coverage to achieve the required sample size. Then, the list of households consisting of at least one adolescent aged 10–19 in the selected wards was prepared as a sampling frame in collaboration with the ward office, which serves as the lowest administrative unit in Nepal. The adolescent’s data were not disaggregated by sex. The enumerators screened for the presence of female adolescents aged 12–19 during household visits. Only households with at least one eligible female adolescent were included in the study sample.

The adolescent population within each ward was evaluated to ascertain compliance with the predefined sampling threshold. The sample for each municipality was determined using probability proportionate to size (PPS) sampling, based on the adolescent population in each selected municipality. The sampling proportion in four municipalities and selected wards was calculated based on the data from the population and housing census of Nepal, 2021 [27]. Finally, the households for interviews in each ward were selected using a systematic random sampling method to reach the required sample size. If the selected households did not have adolescent girls aged 12–19 years at the time of the interview, we replaced them with the adjacent household consisting of an adolescent girl. In households with more than one eligible adolescent, one respondent was randomly selected using a lottery method to maintain response independence and avoid intra-household clustering bias.

Study variables

The outcome variable for this study was awareness about the legality of abortion. The respondents were asked whether they knew if abortion was legal. The outcome variable had the response of either ‘yes’ or ‘no’. Explanatory variables were selected based on a previous literature review [11, 25]. This study’s independent variables (explanatory variables) included sociodemographic factors and awareness related to comprehensive sexuality education. Sociodemographic related characteristics of adolescents covered ethnicity (relatively advantaged ethnic groups: Brahmin and Chhetri, and relatively disadvantaged ethnic groups: Dalits and Janajati), respondents’ education (no education, basic (1–8 grades), and secondary (9-12 grades) or above), respondent’s age (12–14 and 15–19 years), marital status of adolescent girls: (married and unmarried), respondent’s district (Dailekh, Jajarkot, Kalikot and Jumla), and disability status (yes, no). The disability status was self-reported and verified by checking multiple sources, including government-issued disability certificates, medical records, social protection documents, and field observations, when accessible and with consent, as reported by enumerators.

Furthermore, we included variables related to knowledge about comprehensive sexuality education (CSE) (yes, no). Comprehensive sexuality education is a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality. It aims to equip children and young people with the knowledge, skills, attitudes, and values to empower them to achieve their health, wellbeing, and dignity; and develop respectful social and sexual relationships [31]. Knowledge of comprehensive sexuality education was assessed using a set of validated questions related to CSE awareness, adopted from previous literature [32–34]. Each question’s response was dichotomized and coded as ‘1’ for yes and ‘0’ for no. If the participants responded “yes” to each question, that was counted as a score of 1. The mean score of the CSE knowledge was calculated. Using the mean score as a cut-off point, we have categorized them as having good knowledge, if their score was > = the mean, and as having poor or no knowledge, if their score was below the < mean [35].

Data collection and analysis

Data collection tools were developed based on a review of the literature [13, 14, 21, 24, 25]. The quantitative survey questionnaire included sociodemographic information and questions related to abortion awareness. Quantitative data were collected using a KoboCollect, a digital tool that can be administered via mobile phones. Adolescents’ awareness about abortion, including its legality and service uptake, was assessed through a semi-structured questionnaire. Trained enumerators conducted face-to-face interviews with adolescents using tablets to record responses. Data was uploaded to the system on the same day whenever an internet connection was available. A data analyst validated the data daily throughout the collection period. Both questionnaire guides are included as supporting files.

For the data analysis, data were exported from KoBoCollect to Excel and then imported into SPSS version 26.0 (SPSS Inc., Chicago, IL) for further analysis. Descriptive statistics were used to report frequencies and proportions related to awareness about the legality of abortion. The Chi-square test assessed the bivariate associations between explanatory variables and the outcome. Univariate logistic regression was conducted to examine the unadjusted associations. Variables with a p-value < 0.5 in bivariate analysis were considered for inclusion in the multivariable logistic regression model. We checked for multicollinearity using the variance inflation factor (VIF) values, and variables with high collinearity were excluded. The final multivariable logistic regression model was developed to identify factors independently associated with abortion awareness among adolescent girls. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and statistical significance was set at p ≤ 0.05.

Qualitative component of the study

The qualitative component of the study included Focus group discussions (FGD), Key Informant interviews (KII), and In-depth interviews (IDI) with adolescents and other stakeholders. We applied purposive sampling methods to select study participants for the qualitative component. The KIIs, IDIs, and FGDs were conducted by trained enumerators with substantial experience and expertise in qualitative research, using semi-structured interview guides.

A total of 16 FGDs were conducted with 122 adolescents, eight with each of the girls’ and boys’ groups. Additionally, 16 IDIs were held with health workers, school health nurses, and health teachers. Four KII were conducted with municipal health coordinators (Table 1). Appropriate data collection settings were used for IDIs, KIIs, and FGDs to ensure privacy, confidentiality, and comfort. Focus group discussions (FGDs) were conducted in private, neutral community spaces that ensured comfort, confidentiality, and accessibility for adolescents. Furthermore, to foster open and gender-sensitive dialogue, FGDs were divided by sex (male and female) with the same gender enumerator (aged 25–35), trained in qualitative methods, adolescent-friendly communication, and ethical handling of sensitive topics. All sessions were conducted in local languages by trained facilitators and note-takers, ensuring a safe, respectful environment and enhancing data credibility. We used the principle of data saturation to guide the number of interviews [36]. Data saturation was considered when no new information or themes emerged from the interviews, indicating that further data collection was unlikely to add value to the research objectives. Each KII, IDI, and FGD was audio recorded and transcribed verbatim in Nepali.

Table 1.

Sample distribution for the qualitative component of the study

Method	Participant type	Total FGDs, KIIs and IDIs
FGD	Adolescent Girls	8
	Adolescent Boys	8
IDI	Health Workers (male and female)	8
IDI	School Health Nurses/Health Teachers	8
KII	Municipal Health Coordinators	4

We conducted a thematic analysis of the qualitative data using a hybrid approach combining inductive and deductive elements. Initially, the transcripts were read multiple times for familiarization, then translated into English and imported into Taguette 1.3.0 [37] for data management, coding, and analysis. Two broad thematic categories, demand-side and supply-side barriers, were used as an organizing framework for initial coding. Within each category, sub-themes and codes were generated inductively based on repeated patterns and meaningful content emerging from the data.

After identifying key sub-themes and codes, we applied the Levesque, Harris, and Russell conceptual framework for healthcare access [38] to synthesize further and interpret the data. This framework conceptualizes access as the interaction between five dimensions of the health system (approachability, acceptability, availability/accommodation, affordability, and appropriateness) and five corresponding user abilities (ability to perceive, seek, reach, pay, and engage). Each identified sub-theme was reviewed and aligned with one or more relevant framework dimensions. This deductive mapping allowed us to present the barriers to safe abortion access within a comprehensive, system-level understanding of healthcare access. We followed the COREQ (consolidated criteria for reporting qualitative research) [39] checklist while developing the study protocol. The data analysis was supported through regular team discussions to enhance consistency and trustworthiness. Any disagreements in coding or theme alignment were resolved through discussion and consensus. This framework-guided synthesis enabled us to integrate individual, interpersonal, and system-level insights, highlighting multilevel barriers to accessing safe abortion services.

Data quality assurance

We pretested the interview tools to ensure data quality and provide clarity, relevance, and cultural appropriateness. Enumerators received a three-day training on qualitative and quantitative interviewing techniques, ethics, adolescent-friendly communication, probing, and handling sensitive topics before data collection. We used the standardized interview guide for qualitative data to maintain consistency across interviews and FGD. All interviews were captured as detailed notes on non-verbal cues, audio recorded (with consent), transcribed verbatim, and checked for accuracy and completeness to maintain data integrity. Further, transcripts or summaries were reviewed by a pair of field researchers or research supervisors for quality, consistency, and depth. A reflexive approach was adopted throughout the qualitative data collection process. Enumerators were trained to be mindful of their biases and the potential influence of adolescent and gender dynamics. Special attention was given to building trust and ensuring a nonjudgmental, respectful environment during discussions on sensitive topics such as abortion. The team leader and field supervisor closely monitored the data collection process, providing supportive supervision throughout the fieldwork. A data analyst reviewed and validated the collected information daily. We held regular debriefings, peer reviews, and team discussions to monitor data quality and address any challenges during data collection.

Research ethics

This study followed the Declaration of Helsinki Ethical Principles for Medical Research involving human subjects [40]. Ethical approval was obtained from the Nepal Health Research Council (NHRC) (Protocol registration number: 589/2023). Prior to data collection, participants were provided with a detailed explanation of the study’s purpose, benefits, potential risks, and estimated time of interview/discussion. The consent form was developed in Nepali and included a brief introduction of the research team, study objectives, voluntary participation, the right to withdraw, and data confidentiality. The respondents were requested to provide their consent on the paper, and consent forms were checked to ensure they were completed correctly and signed. Similarly, in addition to obtaining informed consent from the respondents, a signed assent form was sought from the parents/guardians of the adolescents under 18 years. Parental consent was sought sensitively and ethically, ensuring parents were informed about the study without pressuring the adolescents to participate. Separate verbal consent was obtained before the interviews were recorded. The interviews were conducted by trained enumerators in a professional and respectful manner, in full adherence to research ethics. If an adolescent showed discomfort or distress, the interview was paused or discontinued, prioritizing their well-being. Interviews were conducted in a private setting within the participant’s home to provide a familiar environment for adolescents to express themselves openly, while minimizing the risk of parental or external influence. No relatives were around or able to overhear the conversation. Furthermore, any personal identifiers in the collected data were replaced with codes to maintain participants’ confidentiality.

Results

Quantitative survey

Sociodemographic characteristics of respondents

Table 2 depicts the distribution of respondents according to their sociodemographic characteristics. Over 6 in 10 (63.2%) adolescent girls were between the ages of 15–19 years. Similarly, most respondents belonged to the Brahmin and Chhetri ethnicities (74.3%). More than 9 out of 10 (91%) adolescent girls were in schools, and most of the respondents were unmarried (89.9%) (Table 2).

Table 2.

Sociodemographic characteristics of respondents: adolescent girls aged 12–19 years in karnali, Nepal

Variable (N = 424)	Total (n)	%
Age
Below 15 years	156	36.8
15–19 years	268	63.2
Marital Status
Married	43	10.1
Unmarried	381	89.9
Caste/Ethnicity
Brahmin/Chhetri/Thakuri	315	74.3
Dalit	100	23.6
Janajati	9	2.1
School-going status
No	38	9.0
Yes	386	91.0
Education Status
No education	38	9.0
Basic education	164	38.7
Secondary and above education	222	52.4
District
Dailekh	114	26.9
Jajarkot	165	38.9
Jumla	70	16.5
Kalikot	75	17.7
Disability Status
No	417	98.3
Yes	7	1.7

Awareness about the legality of abortion and its types

Table 3 describes adolescent girls’ awareness of abortion laws and types of abortion. Nearly 9 out of 10 (89.2%) respondents had heard about abortion. However, only half of them (49.8%) knew about the legal status of abortion in Nepal. Of those who had heard about abortion, a significant proportion (73.3%) knew that abortions can be provided for up to 28 weeks of gestation if the mother is at risk during the pregnancy and a medical practitioner prescribes the procedure. However, only half of those who had heard about abortion (51.6%) knew that any woman can seek an abortion up to 12 weeks’ gestation. Out of those who had heard about abortion, more than two-thirds of the respondents (65%) mentioned safe abortion services provided by trained health workers, while only 22.3% knew about medical abortion. Likewise, 13.7% of the respondents were unaware of any abortion services (Table 3). The findings of the survey were consistent with the qualitative findings—most of the adolescent boys and girls mentioned during the FGDs that they had heard of abortion. However, many of them expressed their unfamiliarity with the legality of abortion in Nepal when asked about this.

Table 3.

Awareness about abortion among adolescent girls aged 12–19 years in karnali, Nepal

Variable (N = 424)	Total (n)	%
Heard of abortion
Yes	378	89.2
No	46	10.9
Awareness about the legality of abortion
Yes	211	49.8
No	213	50.2
Condition of abortion law (n = 378)
Any woman can seek an abortion up to 12 weeks of gestation
Yes	195	51.6
No	183	48.4
Women can seek abortion up to 28 weeks of gestation if mother’s health at risk of pregnancy and is prescribed by a medical practitioner or if the pregnancy resulted from rape or incest
Yes	277	73.3
No	101	26.7
Awareness of types of abortion
Medical Abortion	90	22.3
Safe abortion by trained Health Workers	276	65
Others (don’t know, and self-medication)	58	13.7

“I am not very much aware of abortion. I haven’t found couples aborting the first child, because it may cause infertility and depression in the future” (Adolescent, FGD).

Some adolescents said it is legal, while others said it is illegal. Some participants mentioned that due to the stigma associated with abortion, as well as the fear of confidentiality breaches, women resort to illegal abortions in private health facilities. Seeking abortion services for unmarried women is not socially acceptable, and these services are therefore often sought secretly due to fear of criticism from society, leading to unsafe abortions. Some people also choose to marry directly after discovering an unintended pregnancy due to fear of societal stigma. Most of the municipal health coordinators interviewed stated that illegal abortion practices are common in the municipality.

“Abortion is hidden and in private health facilities, though common, they (people) are hiding their abortion because of illegal practice”. (Municipal Health Coordinator, IDI)

Awareness of the legality of abortion by socio-demographic characteristics

Table 4 demonstrates that awareness of the legality of abortion varied with socio-demographic characteristics. The proportion of adolescent girls aged 15–19 years who knew that abortion is legal was higher (58.2%) than for younger adolescents aged below 15 years (35.3%). A significant proportion of married adolescents (65.1%) were aware of the legality of abortion compared to those who were unmarried. Similarly, a higher proportion of adolescents (58.6%) with secondary or higher education knew that abortion is legal compared to those having basic or no education. Likewise, adolescents with awareness of comprehensive sexuality education were more aware of abortion legality (64.4%) compared to those who did not have CSE awareness (46.0%) (Table 4). During an in-depth interview, schoolteachers stated that only a married woman can access abortion services with their husband’s consent, while an unmarried individual cannot receive this service. Similar opinions were expressed by several participants, implying a lack of accurate knowledge about the conditions for legal abortion in Nepal among some schools’ health teachers.

Table 4.

Awareness of abortion legality by socio-demographic characteristics of adolescent girls in karnali, Nepal

Variable (N = 424)	Total (%) *	Awareness of abortion legality		P-value
		No (%) #	Yes (%) #
Age
15–19 years	268 (63.2)	112 (41.8)	156 (58.2)
Below 15 years	156 (36.8)	101 (64.7)	55 (35.3)
Marital Status
Unmarried	381 (89.9)	198 (52.0)	183 (48.0)	0.034
Married	43 (10.1)	15 (34.9)	28 (65.1)
Caste/Ethnicity
Brahmin/Chettri	315 (74.3)	157(49.8)	158(50.2)	0.782
Dalit and Janajati	109 (25.7)	56(51.4)	53(48.6)
Education status
No education	38 (9.0)	18 (47.4)	20 (52.6)
Basic education	164 (38.7)	103 (62.8)	61 (37.2)
Secondary and above education	222 (52.4)	92 (41.4)	130 (58.6)
District
Dailekh	114 (26.9)	65 (57.0)	49 (43)	0.001
Jajarkot	165 (38.9)	67(40.6)	98(59.4)
Jumla	70 (16.5)	32 (45.7)	38 (54.3)
Kalikot	75 (17.7)	49 (65.3)	26(34.7)
Awareness of Comprehensive Sexuality Education
No	337 (79.5)	182 (54.0)	155 (46.0)	0.002
Yes	87 (20.5)	31 (35.6)	56 (64.4)

P-value obtained from the chi-squared test of association

Bold significant at P < 0.05, * Column percentage and # Row percentage

“A married woman can get abortion service with the consent of her husband, but an unmarried person cannot. They have to travel far for a safe abortion service to maintain secrecy”. (Health Teacher, IDI)

Factors associated with awareness of the legality of abortion

Table 5 shows the association between various background characteristics and awareness of the legality of abortion derived from multivariate logistic regression analyses. The likelihood of being aware of the legality of abortion was found to be higher among adolescents aged 15–19 years, those who were from certain districts, and who had awareness about comprehensive sexuality education. Adolescents aged 15–19 years were more than twice as likely to have awareness (aOR = 1.976, 95% CI: 1.266, 3.084) compared to younger adolescents aged below 15 years. Similarly, adolescent girls from Jajarkot (aOR = 2.784, 95% CI: 1.529, 5.067) and Jumla (aOR = 2.419, 95% CI: 1.204, 4.860) were over twice as likely to be aware of the legality of abortion compared to those from Kalikot. Adolescent girls having CSE awareness were nearly two times more likely to be aware of the legality of abortion (aOR = 1.991, 95% CI: 1.175, 3.374) compared to those who did not have this knowledge. Marital status showed a marginal association with abortion awareness (aOR = 2.087, 95% CI: 0.998–4.366; p = 0.05), indicating that married girls may have approximately twice as likely to be aware of abortion compared to their unmarried counterparts. However, this finding should be interpreted cautiously due to the borderline confidence interval (Table 5).

Table 5.

Factors associated with awareness of the legality of abortion

Variable (N = 424)	Crude odds ratio-COR (95% CI)	p-value	Adjusted odds ratio- (AOR) (95% CI)	p-value
Age
Below 15 years	1.0		1.0
15–19 years	2.558 (1.700, 3.848)		1.976 (1.266, 3.084)	0.003 †
Marital Status
Unmarried	1.0		1.0
Married	2.202 (1.045, 3.902)	0.034	2.087 (0.998, 4.366)	0.050 †
Education status
No education	1.0
Basic education	0.533 (0.262, 0.185)	0.083
Secondary and above education	1.272 (0.638, 2.537)	0.495
District
Kalikot	1.0		1.0
Dailekh	1.421 (0.777, 2.597)	0.254	1.261 (0.656, 2.424)	0.486
Jajarkot	2.757 (1.562, 4.865)		2.784(1.529, 5.067)	0.001 †
Jumla	2.238 (1.147, 4.368)	0.018	2.419 (1.204, 4.860)	0.013 †
Awareness of Comprehensive Sexuality Education
No	1.0		1.0
Yes	2.121 (1.302, 3.456)	0.003	1.991 (1.175, 3.374)	0.010 †
p-value obtained from the chi-squared test. † Significant at p < 0.05. # Adjusted for the following covariates: respondent’s age, marital status, district, and adolescents’ awareness of CSE

Qualitative findings

Under the broad themes of demand- and supply-side barriers, we synthesized our findings using the Healthcare Access Framework by Levesque, Harris, and Russell [38], which conceptualizes access as a dynamic interaction between individuals’ abilities to perceive barriers, seek services, reach or pay, and engage with care, and the characteristics of health systems. This framework guided our analysis by helping us map adolescents’ experiences onto key dimensions of access, including approachability, acceptability, availability, and appropriateness of abortion services.

Demand side barriers

Ability to perceive barriers

Adolescents’ perspectives on approachability or their ability to perceive barriers included limited knowledge about the legal status of abortion and a lack of awareness about available safe abortion services in government facilities.

Limited knowledge about the legality of abortion

Lack of information about the legality of abortion among adolescents and health teachers was found to be one of the major demand-side barriers for accessing abortion services. All the health teachers participating in in-depth interviews believed that abortion is illegal in Nepal and that the government has not given authority to the health facilities to provide abortion services. These findings are consistent with the information many adolescents provided during FGDs. Around half of the adolescent girls and boys reported being unaware that abortion is legal in Nepal, and many did not know that abortion services are available at their nearest health facilities. In contrast, all the health workers interviewed were aware of the legal status of abortion in Nepal.

“If we talk about abortion, there is no difference in terms of married or unmarried, abortion is not legal in Nepal, the government does not give validity to the abortion, which means it is illegal now”. (Health Teacher, IDI)

Lack of information about the availability of safe abortion services in government health facilities

Most of the health workers interviewed reported that abortion is more commonly sought by married women in their community. They stated that most of the women, including adolescents, primarily accessed abortion services from private medical clinics or pharmacies. They noted that many community members, including adolescents, are still unaware that abortion services like counseling and medical abortion are available in nearby government health facilities.

“It is common for married people, but not for unmarried girls. On the other hand, they don’t speak openly, we don’t even know about adolescents obtaining abortion services; they go to the medical center and use medicine to get an abortion. We don’t even know much”. (Health Worker, IDI)

Most adolescents participating in FGDs also expressed limited awareness about abortion services available locally. They mentioned that those seeking abortion services often visit private clinics or public hospitals in cities, but that they do not know about the available abortion services in the health facilities near their home.

“Abortion services are also found in public hospitals in cities, but not in our nearest health post. It is available in private clinics or hospitals if someone mistakenly gets pregnant”. (Adolescent Girls, FGD)

Ability to seek services

Challenges in the acceptability of or ability to seek services were shaped by social stigma, son preference, rumours about the consequences of abortion, and lack of family support.

Experience of social stigma

Social stigma was found to be one of the major barriers to accessing abortion services among adolescent girls. FGDs with adolescent boys highlighted a discrepancy between the knowledge and persistence of unsafe practices, primarily driven by societal stigma around pre-marital sex and abortion. Participants noted that an abortion could cause fear of community judgment, often leading to secrecy, mental stress, and avoidance of formal health services. Some shared that such incidents could result in strong criticism or hate in the local community, leading to mental stress and even suicide. This highlights how social stigma not only limits access to safe abortion services but also affects adolescents’ mental health and potentially harmful coping mechanisms.

“When unmarried girls become pregnant or seek abortion services,it causes mental stress due to the spread of negative rumors in society. Sometimes,a girl may have been in a relationship but did not get married, which creates an atmosphere in the society that can lead to suicide”. (Adolescent Boys,FGD)

Additionally, it was revealed that unsafe abortions are more common in unmarried adolescents, and girls expressed difficulties accessing abortion services due to societal stigma. Adolescents mentioned that abortion services were often sought secretly due to fear of criticism from society. Furthermore, it was reported that the adolescents talked about both safe and unsafe abortion practices, with some boys helping girls obtain abortion pills from private clinics and others choosing to marry directly after discovering an unplanned pregnancy.

“If teenagers are not married but get pregnant, they will be criticized a lot in society. Society hates them by saying that they have had an abortion before getting married,so they go for abortion services secretly”. (Adolescent Girls,FGD)

Sex preferences

Strong son preferences are also found to be one of the barriers and enablers for abortion. Many participants in Jumla mentioned that the women in the community receive abortion services in the case that the sex of the fetus is revealed to be female.

“It’s a shame. Abortion isn’t done if the baby is a boy. In the hope of having a son,10 daughters are born. Baby girls are aborted, and there is not much importance placed on the girl child. Here in Jumla,a culture of aborting girl child and keeping a boy child exists”. (Adolescent Girls, FGD)

Rumors about the consequences of abortion

Adolescents believe that abortion is linked to infertility and adverse mental health outcomes. Many of the adolescent girls in Jajarkot district mentioned that medical abortion or having an abortion at all before marriage can cause infertility in the future. Adolescents in Dailekh added that it is not common for couples to consider abortion for their first pregnancy because of the perceived risk of becoming infertile and the possibility of developing mental health problems.

“Health facility staff give medicine, and we have it. But we don’t think it is safe…[pause] …and…, we heard that if you take medicine or do an abortion during early age, it can stop you from having a baby later when we get married”. (Adolescent Girl, FGD)

Lack of support at the family level

It was found that unmarried adolescents fear disclosing their pregnancy status due to the lack of support from their household and community. The participants said that the community does not accept abortion for unmarried women, and that it is perceived as an illegal act to have an abortion before marriage. As a result of these attitudes, many unmarried girls and young women hide their pregnancy status from their families and end up resorting to unsafe abortions.

“The community environment is somewhat supportive, but the family is not supportive because they are open about menstruation but not about abortion”. (Health Worker,IDI)

“The society does not think it is good that an unmarried person gets pregnant, the society looks down on the matter, and that is why it is not normal”. (Adolescents Girls, FGD)

For married adolescents, the issue of accessing abortion services was further complicated by the need for the husband’s consent. Teachers interviewed during IDIs shared that married adolescents often sought abortion services from a hospital, but this process was contingent on obtaining approval from their husbands. This requirement posed a challenge, particularly in cases where husbands were unsupportive or where social norms dictated that husbands should make all decisions.

A married girl wanted to have an abortion, but she couldn’t decide on her own. She needs to ask her husband, and her husband must agree. Without his permission, she won’t do it. (Health Teacher, IDI)

In contrast, unmarried adolescents did not face this specific barrier. Still, they struggled with geographical distance, as they were often forced to travel far from their communities to access safe abortion services in private clinics or hospitals.

We don’t know where to go to get an abortion. The health post in our place doesn’t have such a facility. We heard some private clinics do it, but we heard they are far and expensive. (Adolescents Girls, FGD)

Ability to reach services and pay for them

Barriers affecting the ability to reach the services mainly included preferences for private clinics over public services, influenced by perceived privacy, quality, and accessibility, although cost was a major concern. Some adolescents during the FGDs pointed out that many women in their community preferred to visit hospitals or private clinics for abortion services. One key reason for this preference was the social stigma and concerns regarding privacy and confidentiality at nearby public health facilities. However, the high cost was the major barrier to seeking services at private clinics. The fees charged by private clinics were often unaffordable, especially for many adolescents, making it a significant financial barrier. Although these clinics offered perceived benefits such as discretion and better privacy, the cost remained an obstacle for those without financial resources.

“They do not have an abortion because of financial problems, it requires 20 thousand for having an abortion, but they don’t have the money”. (Adolescents Boys, FGD)

Ability to engage

Adolescents’ ability to engage with abortion services in Karnali was primarily undermined by mistrust, fear, and negative past experiences related to the quality and safety of available abortion services. During focus group discussions with adolescent girls, participants expressed doubts about the safety of abortion procedures offered in both private clinics and government hospitals, raising concerns about the methods used, the competence of providers, and fears that services might not be confidential or safe. These perceptions contributed to a general lack of confidence in the formal health system for engaging and accessing abortion services.

I heard that sometimes the doctors don’t do it properly, which may cause problems later. And… [pause]…If we do it in the nearest hospital or private clinics, they might talk with other people, so we are scared to go to the nearest hospital. (Adolescent Girls, FGD)

Many adolescents perceived that the quality of care at local health facilities might be substandard, which contributed to their lack of confidence in seeking legal abortion services. Some adolescents also expressed that they thought health workers at these facilities may not be adequately trained or equipped to perform the procedure safely, leading to fears about potential complications.

“Yes, medicine can be safe…umm, but I don’t think the doctors and nurses at our health post are trained to provide abortion services, whether it’s with medicine or surgery”. (Adolescent Boys, FGD).

Supply-side barriers

On the supply side, barriers were identified across several dimensions of the health system: limited approachability and acceptability due to the mismatch between service availability and community awareness, and judgmental attitudes of health workers; restricted availability and accommodation, particularly the unequal access and lacking privacy at community-level health facilities; and challenges related to appropriateness, as medical abortion services were only available in select hospitals.

Mismatch between service availability and community awareness

A clear disconnect was observed between the availability of abortion services and adolescents’ awareness or perceptions of access. While health workers reported that abortion services had recently been introduced at local health facilities, adolescent girls participating in focus group discussions continued to believe that such services were only available in distant hospitals and were difficult to access.

Abortion service is not available near our areas; it is only available in hospitals, and it’s not easy to access services there”. (Adolescent Girls, FGD)

Health workers acknowledged the availability of abortion services starting from the current fiscal year but noted that no clients had come forward to use them. This suggests that technically available services remain underutilized due to a lack of community-level awareness, limited outreach, or lingering mistrust in local facilities.

“Regarding abortion, we have no idea about previous years, but currently, we have services starting from this fiscal year. Unfortunately, we have no users”. (Health Worker, IDI)

This mismatch points to a critical gap in communication between health providers and the adolescent population, potentially contributing to the underuse of safe and legal abortion services.

Health workers’ judgmental attitudes and behaviors

It was found that access to abortion services varied by health workers’ attitude and behavior, particularly around adolescent sexuality and premarital pregnancy. Unmarried adolescent girls were found to be vulnerable to the health workers’ judgmental attitudes and their negative perceptions when seeking abortion at local health facilities. Adolescents reported that although medical abortion services are available at local health posts, access is significantly easier for married women, whereas unmarried girls face additional social and provider-related barriers.

Many adolescent girls shared that their friends had faced scolding or moral judgment from providers, which created a sense of fear and shame around accessing services. Adolescent boys echoed with similar concerns during the focus group discussions. These experiences, whether direct or observed, contributed to a growing mistrust of health providers among adolescents. As a result, many chose to avoid formal services altogether, reinforcing barriers to safe and legal abortion care.

“This is impossible here because the medicine for abortion is not given easily to unmarried women; they must be married. If unmarried women seek medicine from a health post, health workers may badly judge them. It is not that easy if an unmarried girl gets pregnant”. (Adolescent Girls, FGD)

“The health post near our house provides only medicine for abortion. A married woman gets it easily, but an unmarried one has some problems because an unmarried girl getting pregnant is not acceptable in our society”. (Adolescent Boys, FGD)

Unequal access and privacy at community-level health facilities

Findings revealed that access to abortion services is influenced not only by service availability but also by privacy and societal norms. Many adolescents mentioned challenges related to accessing abortion-related information and services due to the lack of privacy at the nearest health facility. Many girls also said they preferred female health workers, but they are few and far between, as most health workers are men. The adolescent girls often feel shy and uncomfortable when having to access services from male service providers.

“There is only one nurse….(referring to the health post of their village). We feel more comfortable talking to nurses, but there aren’t many of them. Most of the time, we have to see male doctors, and it makes us feel shy and uncomfortable”. (Adolescent Girls, FGD)

“Even for married women, it could be difficult to get abortion service or suggestions from sisters (nurses) or doctors, because there is no separate room to talk…everyone can hear what the sister (nurse) to the patient is saying”. (Adolescent Boys, FGD)

Discussion

This study provides important insights into adolescents’ awareness of abortion legality and the barriers girls face in accessing abortion services in Nepal. Only about half of the adolescent girls knew that abortion is legal up to 12 weeks of gestation, underscoring an inadequate dissemination of reproductive health information needed to support informed decision making. While the awareness in our study is higher than that reported in the past Nepalese study (41%) [11]. It remains lower than in comparable contexts such as Ethiopia, where more than 60% of adolescent girls were informed [41]. Qualitative findings substantiated these results, revealing that misinformation was widespread not only among adolescents but also among teachers, many of whom believed that abortion is illegal and that health facilities are not authorized to provide such services. These findings align with previous studies in Nepal [14, 42], which shows that limited awareness about abortion legality and inadequate service information, combined with the cost barriers, continue to hinder access to safe and legal abortion services.

The awareness of abortion legality was influenced by socio-demographic factors such as age, marital status, geographical location, and exposure to comprehensive sexuality education. Older adolescents (15–19 years) were more likely to be aware of the legality of abortion than younger adolescents (below 15 years). This is possibly due to greater exposure to reproductive health information from different sources, making the older adolescents more knowledgeable and more comfortable discussing these issues. These findings are consistent with similar studies conducted in Nepal [11], Brazil [43], Nigeria [44], and elsewhere [45].

Similarly, married adolescents demonstrated higher awareness, likely due to the relatively more social acceptability of accessing abortion related information and services compared to unmarried adolescents, who face significant stigma and barriers in accessing such information. This echoed in qualitative findings; participants noted that married women can obtain abortion information and services relatively easily with fewer barriers, whereas unmarried girls faced stigma and negative community perceptions [46]. These findings are consistent with similar studies conducted in other parts of the country [21, 25] and elsewhere [45].

Our study also showed that exposure to comprehensive sexuality education was significantly associated with legal awareness. Adolescents who have received comprehensive sexuality education were more likely to be aware of the legality of abortion compared to those who did not have CSE awareness. This finding indicates that comprehensive sexuality education can be a critical factor, having positive effects, empowering adolescents, and increasing their awareness about sexual and reproductive health and rights, including abortion laws. This reinforces global evidence that sexuality education enhances adolescents’ understanding of their sexual and reproductive health rights [47].

The qualitative findings of the study highlighted additional multifaceted barriers to accessing safe abortion services, categorized into demand and supply-side barriers. On the demand side, misinformation about the legality of abortion, lack of awareness about available services, family support deficits, and pervasive social stigma are significant obstacles. These barriers are compounded by rumors and myths about the consequences of abortion, leading many adolescents to seek services secretly, often in unsafe conditions.

The study identified social stigma and rumors about the consequences of abortion as significant informational barriers. It reveals a widespread belief that abortion may lead to infertility, depression, and other adverse health outcomes. Combined with a lack of acceptance and negative attitudes in the communities, this contributes to many adolescent girls and women seeking abortion services secretly due to the fear of societal criticism. Unmarried adolescents face even greater difficulties in accessing safe abortion services and end up obtaining these services secretly in an unsafe manner, as Nepalese society does not accept them opting for abortion services. This leads to feelings of embarrassment and fear of judgment [21] and contributes to a preference for private facilities over government health services, which can provide privacy and confidentiality. However, it does so with a very high financial cost that many young girls cannot afford. Some adolescent girls travel to distant hospitals or private clinics to keep their abortions confidential, and in some cases, the stigma is so strong that adolescents would rather choose marriage in the case of an unwanted pregnancy to avoid the associated shame and suicide. Similar observations have been reported in other studies from Sub-Saharan Africa [48]. Past evidence has also highlighted misconceptions, stigma, and myths related to safe abortion, influencing adolescents’ and women’s decisions to seek safe abortion services [49].

Supply-side barriers include a mismatch between service availability and community awareness, judgmental attitudes and behaviour of health workers, and unequal access and privacy at community-level health facilities. Although the Government of Nepal has concentrated on improving access to safe abortion services by strengthening the health system and expanding service sites [48], we found a clear disconnect between the availability of abortion services and adolescents’ awareness or perceptions of access. While health workers reported that abortion services had recently been introduced at local health facilities, adolescent girls participating in focus group discussions continued to believe such services were only available in distant hospitals and remained difficult to access. This disconnect reflects a breakdown in communication and community engagement, where services may be technically available, but perceived as unavailable or unacceptable by those who need them most. It also suggests a need for proactive outreach, awareness-raising, and confidence-building measures to bridge the gap between service provision and utilization.

Additionally, unequal access to abortion services and lack of privacy at community-level health facilities emerged as significant barriers for adolescents, particularly unmarried girls. Social stigma around premarital pregnancy contributed to discriminatory treatment, with married women reportedly finding it easier to access abortion services. Gender dynamics further influenced access, as female adolescents expressed discomfort interacting with male providers, especially in the absence of female health staff. Limited infrastructure, such as inadequate private consultation spaces, further compromised confidentiality and discouraged adolescents from seeking abortion-related care. In addition to these barriers, concerns about the safety and quality of abortion procedures were prominent among adolescents. Many perceived local services as unsafe due to the poor quality of care and lack of trained providers. These factors collectively undermine adolescents’ trust in local health facilities and reinforce inequities in access to safe and legal abortion services.

The National Safe Abortion Policy of Nepal states that safe, accessible, and affordable abortion services should be provided equitably to all women. However, as we have found, many Nepali women and girls still lack adequate access to such abortion services [14, 50]. This corresponds with studies conducted in other countries [45], and with findings from other studies in Nepal [14]. Despite the expansion of safe abortion services in Nepal, there remains a vital need to increase information, access, and availability to high-quality, adolescent-friendly safe abortion services to all Nepali women and girls, regardless of their identity and geographical location.

Strengths and limitations of the study

This study had a mixed-methods design and assessed the awareness and underlying drivers of poor awareness, as well as explored barriers to accessing abortion services among the most unreached groups, specifically adolescents. In addition, we have used pretested and well-designed questions. However, there are several limitations. The cross-sectional design did not allow for inferences about causality. Additionally, our quantitative study population was restricted to adolescent girls, so the findings regarding the awareness about the legality of abortion should not be generalized to all women in Nepal. This also prevents direct comparisons of awareness of the legality of abortion between genders. As a result, the findings may not fully capture potential gender differences in awareness. Moreover, this study did not address gender-based inequalities or women’s status, which are relevant to ensuring equitable access to healthcare for women. While medical abortion is commonly practiced in Nepal, our study did not examine the practice in depth. Our qualitative study did not systematically collect the information for comparative analysis of perception among health workers by certification status, which may have provided different perspectives. These areas may demand further research to provide deeper insights. Given the topic’s sensitive nature, this study may have been influenced by social desirability bias, as participants might have given socially acceptable rather than accurate reflections. Finally, some important covariates, such as household wealth status, distance to health facilities, and past intention to use abortion services, as identified by previous studies [11], were not included in this study.

Conclusion

This study highlights significant gaps in the awareness and accessibility of legal abortion services among adolescents in rural Nepal, particularly in the Karnali region. These gaps are most prevalent among younger adolescents (aged 12–14), unmarried girls, and those lacking comprehensive sexual education. Adolescents face both demand and supply-side barriers to accessing abortion services, including social stigma, limited trust in available abortion services, and poor service availability. Addressing these barriers requires multi-level interventions targeting adolescents and influencers in their families, communities, and health systems. Past evidence from Nepal indicates that such integrated approaches can be effective [51], suggesting their potential effectiveness in this context.

On the supply side, improving service delivery by equipping health workers with knowledge on abortion rights and counseling skills can help reduce misconceptions, support informed decision-making, and facilitate referrals and follow-up care [52, 53]. On the demand side, Social Behavior Change interventions are needed to increase awareness about the legality of abortion and reduce social stigma. Targeted education programs for adolescents, families, and communities can correct misinformation, reduce myths, and strengthen support systems. Promoting comprehensive sexuality and life skills education, especially for younger and unmarried adolescents, could equip them with decision-making and negotiation skills for informed reproductive choices.

Abbreviations

NDHS

Nepal Demographic and Health Survey

SDGs

Sustainable Development Goals

SBC

Social and Behavior Change

HDI

Human Development Index

SRH

Sexual and Reproductive Health

CSE

Comprehensive Sexuality Education

FGDs

Focus Group Discussions

KII

Key Informant Interview

IDI

In-depth Interview

WHO

World Health Organization

Authors’ contributions

DST conceptualized the manuscript; DST and RB performed the data analysis and interpretation; DST prepared the first draft of the manuscript; RB reviewed and revised the qualitative results and discussions; and DST, RB, and HLM reviewed and edited the manuscript. All authors read and approved the final manuscript.

Funding

Funding for this study was received from the Save the Children, Norway.

Data availability

The data supporting our findings can be made publicly available.

Declarations

Ethics approval and consent to participate

This study followed the Declaration of Helsinki Ethical Principles for Medical Research involving human subjects. Ethical approval was obtained from the Nepal Health Research Council (NHRC) (Protocol registration number: 589/2023). Prior to data collection, participants were provided with a detailed explanation of the study’s purpose, benefits, potential risks, and estimated time of interview/discussion. The respondents were requested to provide their consent on the paper. Similarly, in addition to obtaining informed consent from the respondents, a signed assent form was sought from the parents/guardians of adolescents under 18. All the personal identifiers were replaced with codes to ensure confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.