When Ramila, a 27-year-old woman from Karmahi in Dhanusa, experienced continuous bleeding after taking a pill to terminate her pregnancy, she knew something had gone terribly wrong. What began as a desperate attempt to control her own body spiralled into a life-threatening situation.

Admitted to Janakpur Provincial Hospital, she was diagnosed with a uterine rupture—a direct result of the unauthorised abortion pill she had taken.

“I didn’t know the dangers of taking the pill or the pain I would endure,” said Ramila, speaking under a pseudonym for privacy reasons. “But maybe even if I had known, I would have still taken it because I had no options.”

Ramila, already a mother of two daughters, was pressured into conceiving again by her husband and in-laws, who hoped for a son. “I didn’t want another child, but they insisted,” she said. “I was dying inside.” Fearing societal backlash and opposition from her family, she sought the help of a friend to procure the abortion pill from a local pharmacy.

When the bleeding didn’t stop for days, her mother secretly took her to the hospital. The damage to her uterus was severe.

Ramila’s story highlights an alarming issue of the widespread and dangerous use of unregulated abortion pills in rural Madhesh.

Despite Nepal legalising abortion in 2002, unsafe procedures remain rampant.

A 2019 study revealed that 60 percent of abortions in 2014 were unsafe, making it a leading cause of maternal mortality.

Around 100,000 women seek abortions annually at legally authorised clinics, but the real number is suspected to be much higher, as many occur in unregistered facilities or through self-medication with pills purchased from pharmacies.

Chandra Rekha Issar, a gynaecologist at Janakpur Provincial Hospital and assistant professor at the Madhesh Institute of Health Sciences (MIHS), gets these kinds of cases frequently. “In Madhesh, many women fear abandonment if they don’t give birth to a son,” she said. “This fear pushes them to undergo gender tests and if the foetus is female, they seek unsafe abortions.”

This patriarchal pressure is compounded by a lack of access to safe abortion services, social stigma, and limited financial independence for women. “I’ve seen cases where women who gave birth to daughters faced such rejection from their husbands that they either remarried or the women took their own lives,” added Issar.

Unauthorised medical abortion pills are easily available in rural Madhesh despite being restricted to government-accredited facilities. These pills often lead to severe complications, including heavy bleeding, infections, and uterine rupture.

According to Issar, an average of 20–25 cases of complications related to abortion pills are treated at Janakpur Provincial Hospital every month. Some patients arrive in critical condition, with haemoglobin levels dangerously low—sometimes as little as 1 percent—due to excessive bleeding. “Even when we manage to save their lives, the damage is often irreversible,” she said.

One of the most troubling aspects, according to Issar, is the role of unregulated pharmacies. “More than half of the pharmacies in Madhesh provide medicines without a doctor’s prescription, including abortion pills, despite the law prohibiting it,” she says.

When these complications arise, hospitals are left to deal with the consequences, but they lack the authority to hold pharmacies accountable. “The Department of Drug Administration (DDA) is responsible for regulating pharmacies, but they’ve never consulted us on how to address this issue,” said Issar.

The desire for a male child fuels much of the unsafe abortion crisis in Madhesh. Ramila’s experience is an example of this preference. “It’s absurd that we women carry and nurture the child, yet men and society believe they have the right to decide for us,” she said.

The stigma around abortion further exacerbates the problem.

Women fear judgement from their families and communities, driving them to seek clandestine solutions that often endanger their health. The 2019 qualitative study found that decisions around abortion are influenced by confidentiality concerns, economic constraints, and accessibility.

The widespread availability of unauthorised pills is facilitated by the lack of stringent oversight. While government agencies occasionally carry out market inspections, local people allege that pharmacy owners often receive prior warnings about such monitoring and shut down temporarily to evade detection.

“There are many unregistered pharmacies here, but whenever the Drug Administration comes for checks, they close shop and disappear,” said Bholanath Yadav, a local vendor in Ramanand Chowk.

When the Post approached for comments, pharmacy owners in the area declined to speak on the matter.

Ram Gyanu Yadav, the Provincial Hospital’s information officer, emphasised the national scope of the problem. “This issue isn’t limited to Madhesh,” he said. “Even in Kathmandu, unauthorised sales of abortion pills happen. The government needs to take this seriously as it endangers the health of the population, especially in areas with low awareness.”

The crisis of unsafe abortions in rural Madhesh stems from a confluence of factors like patriarchal norms, lack of access to sexual and reproductive health resources, unregulated pharmacies, and insufficient enforcement of existing laws.

“The DDA must collaborate with provincial hospitals to curb the rampant misuse of abortion pills,” Issar said. “Awareness campaigns are also essential to educate women about their rights and the risks of unsafe practices.”

Ramila’s story is a reminder of the consequences of systemic neglect. Now divorced, she lives with her mother and children, working to rebuild her life. “Many women like me go through this—not just because we don’t have access to safe abortion but because our voices are silenced by society and circumstances,” she said.