Cohort Profile: The Nepal Turnaway Study

The Nepal Turnaway Study is a prospective, nationwide cohort of 1,832 abortion seekers followed for up to five years to investigate the longitudinal health and socioeconomic impacts of receiving versus being denied wanted abortions, while also capturing broader family-level outcomes.

The Gist

Imagine a massive, long-term experiment designed to answer a very difficult question: What happens to a woman's life, her family, and her health when she is denied the abortion she wants, compared to when she gets one?

This paper introduces the Nepal Turnaway Study, a massive research project that acts like a "time machine" for understanding these life-altering moments. Here is the story of the study, broken down into simple concepts.

1. The Big Picture: A "Natural Experiment"

Think of the researchers as detectives trying to solve a mystery. They wanted to know the difference between two paths:

• Path A: A woman gets the abortion she needs.
• Path B: A woman is told "no," and she has to carry the pregnancy to term.

In a perfect world, scientists would flip a coin to decide which path a woman takes (a randomized trial). But you can't ethically flip a coin on someone's life. So, instead, they watched what happened naturally in Nepal. They recruited women right at the moment they walked into a clinic asking for help. Some got help; some were turned away (denied) because they were too far along in the pregnancy or due to other barriers. The study followed these women for five years to see how their lives played out.

2. The Cast of Characters

• The Setting: The study took place across all seven provinces of Nepal, recruiting from 22 different clinics (both government and private).
• The Participants: They gathered 1,832 women. These weren't just random people; they were women actively seeking to end a pregnancy.
• The Timeline: The study ran from 2019 to 2024. The researchers didn't just ask them once; they checked in every six months for five years, like a very persistent but caring friend asking, "How are you doing? How is your job? How is your health?"

3. The Plot Twist: Who Got Denied?

You might think only a few women get denied abortions. In this study, nearly half (49%) of the women were initially told they couldn't get an abortion at that clinic.

• The "Turnaway" Group: These women were sent away. Some eventually found a way to get an abortion later (536 women), some had miscarriages (41 women), and some ended up giving birth (275 women).
• The "Abortion" Group: The other half (890 women) got the abortion they wanted right away.

The Big Discovery: The study found that the women who were denied were often already in a tougher spot. They were more likely to be younger, poorer, less educated, or from marginalized communities (like the Dalit caste). It's as if the system was already stacked against them, and being denied an abortion added another heavy weight to their backpack.

4. The "Five-Year Journey"

The researchers followed these women like hikers on a long trail. They measured:

• Mental Health: Are they anxious or depressed?
• Physical Health: Do they have chronic pain or new health issues?
• Money & Work: Did they lose their jobs? Can they afford food?
• Family Life: How is their relationship with their partner? How are their children doing?

They even tracked the health of babies born to these women (if the woman gave birth) for up to three years.

5. Why This Study is a "Superpower"

Most studies on this topic are like looking at a photo taken after the event. They ask women years later, "Did you have an abortion?" But women often lie or forget because of shame or stigma.

This study is different. It's like having a live video feed.

• No Guessing: They knew exactly who got an abortion and who didn't because they were there at the clinic.
• No Hiding: Because they asked before the outcome happened, the women didn't have to hide their feelings or experiences.
• The "Magic Weights": The researchers used a clever statistical trick (called "propensity score weighting"). Imagine you have two groups of people who are very different (one group is rich, one is poor). To compare them fairly, you give the "poor" group some "magic points" and the "rich" group some "magic penalties" so that, on paper, they look identical. This allows the researchers to say, "If these two women were exactly the same in every way, the only difference was the abortion, here is what happened."

6. The Takeaway

This paper isn't just a list of numbers; it's a blueprint for understanding the real-world consequences of abortion laws.

• The Good News: The study proved that women can be recruited and followed for years with high success (96% showed up to start, and 87% stayed for the long haul).
• The Hard Truth: Being denied an abortion often leads to worse outcomes for women and their families, especially for those who are already struggling.
• The Future: The data is now open for other scientists to use. It's like opening a massive library of life stories so that researchers everywhere can learn how to make policies that actually help women and families thrive.

In short: This study is a five-year documentary of real lives, proving that when women are denied the care they need, the ripple effects touch every part of their lives, from their wallets to their mental health.

Technical Summary

1. Problem Statement and Context

The study addresses a critical gap in understanding the longitudinal health and socioeconomic consequences of abortion denial in low-income settings. While global data indicates that 60% of unintended pregnancies in low-income countries do not end in abortion, and over 75% occur under unsafe conditions, the specific impacts of being denied a wanted abortion in Nepal remain understudied.

Nepal permits abortion up to 12 weeks (and up to 28 weeks for specific indications like rape or fetal anomaly), yet access is limited by provider shortages, geographic barriers, and stigma. Consequently, many women are denied legal services, leading to two potential outcomes: seeking unsafe alternatives or carrying unwanted pregnancies to term. Previous research in this area often relies on retrospective or cross-sectional data, which suffers from recall bias and selection bias (e.g., underreporting of abortions). The Nepal Turnaway Study was designed to emulate a natural experiment to rigorously estimate the causal effects of abortion denial versus receipt on maternal and child wellbeing.

2. Methodology

Study Design:
The Nepal Turnaway Study is a prospective, nationwide longitudinal cohort study modeled after the U.S. Turnaway Study. It utilizes a "target trial" emulation design to compare outcomes between women who received a wanted abortion and those who were denied one.

Participants and Recruitment:

• Sample: 1,832 women seeking abortion care were recruited between April 2019 and December 2020.
• Sites: 22 facilities (public and private/non-profit) across all seven provinces of Nepal. Sites were selected via probability proportional to size from a national list of certified facilities.
• Eligibility: Women aged 15+ residing in Nepal. Recruitment criteria shifted mid-study: initially, all gestational ages were eligible; later, eligibility was restricted to women $\ge$10 weeks gestation or with uncertain gestation to ensure adequate representation of those likely to be denied.
• Retention: 96% of eligible women participated in the baseline interview. Follow-up occurred at 6 weeks, then every 6 months for up to 5 years.

Data Collection:

• Frequency: Baseline survey followed by interviews at 6-week, 6-month, 12-month, and subsequent 6-month intervals up to 60 months.
• Measures: Comprehensive data on socioeconomic status, physical and mental health, reproductive history, child health (for children under 3), and household dynamics.
• Exposure Definition: Participants were categorized based on pregnancy outcomes:
  1. Abortion Group: Initially received an abortion.
  2. Turnaway – No Birth: Initially denied but did not carry to term (later obtained abortion or miscarried).
  3. Turnaway – Birth: Initially denied and carried the pregnancy to term.

Statistical Approach:
To address confounding (as participants were not randomized), the study employs propensity score weighting (specifically overlap weighting). This method balances covariates across exposure groups to estimate Average Treatment Effects (ATE). The study accounts for administrative censoring (due to funding ending in Dec 2024) by treating it as "Missing at Random" (MAR), explained by baseline gestational age, allowing for unbiased estimation via maximum-likelihood methods.

3. Key Contributions

• First Prospective Cohort in South Asia: This is the first study in a high-maternal-mortality, low-income setting to prospectively track abortion seekers from the point of care-seeking through long-term outcomes.
• Causal Inference Framework: By using exposure-balancing weights derived from over 15 baseline characteristics, the study moves beyond simple association to provide rigorous estimates of the causal effects of abortion denial.
• Granular Outcome Classification: Unlike binary studies, this cohort distinguishes between those denied who eventually obtained an abortion and those who gave birth, allowing for nuanced analysis of the "denial" experience.
• Comprehensive Data Infrastructure: The study collected detailed data on child health, maternal mental health, and socioeconomic trajectories, creating a rich resource for future research on family dynamics in Nepal.
• Public Data Availability: The dataset is publicly available (via Harvard Dataverse) with a data access agreement, facilitating secondary analysis by the global research community.

4. Results (Findings to Date)

Demographics and Baseline Characteristics:

• Sample Size: Of the 1,832 baseline participants, 1,742 had known pregnancy outcomes.
• Denial Rates: 49% (n=856) were initially denied their abortion. Of those denied, 536 eventually obtained an abortion, 41 experienced a pregnancy loss, and 275 gave birth.
• Socioeconomic Disparities: Women who gave birth (Turnaway–Birth group) were significantly more likely to be socioeconomically disadvantaged compared to those who received abortions. They were younger, more likely to be from the Dalit caste, had lower educational attainment, lower income adequacy, and faced higher rates of intimate partner violence and restricted mobility.
• Gestational Age: A significant portion of the "Turnaway–Birth" group presented at >10 weeks gestation, often exceeding legal limits or provider capacity, though many were denied despite being within legal limits due to provider bias or lack of availability.

Retention and Follow-up:

• Retention Rate: 87% retention was achieved over the follow-up period.
• Censoring: 27% of respondents were administratively censored after 48–54 months due to the study end date, while 11% were lost to follow-up. The study notes that attrition was non-differential regarding abortion denial status.
• Balance: After applying propensity score weights, baseline differences between the "Gave Birth" and "No Birth" groups were eliminated (standardized mean differences <0.1), validating the use of these weights for causal analysis.

Preliminary Observations:

• Abortion Access Barriers: Nearly half of the women were denied services, often citing gestational age limits that were stricter than national law or lack of provider availability.
• Pharmacy Role: Preliminary analysis (cited in the paper) indicates that 14% of participants attempted abortion before enrollment, with 83% using medication obtained from pharmacists, highlighting the critical role of pharmacists in the abortion care continuum.
• Pandemic Impact: A subset analysis showed that 93% of participants faced pandemic-related economic and health challenges, with those denied abortions facing greater difficulties.

5. Significance

The Nepal Turnaway Study provides a robust evidence base for policymakers and health advocates in Nepal and similar low-resource contexts.

• Policy Implications: The data challenges the assumption that legal abortion access is sufficient; it highlights that structural barriers (provider availability, stigma, distance) effectively deny care to nearly half of seekers, disproportionately affecting marginalized women.
• Health Outcomes: By isolating the effects of carrying an unwanted pregnancy to term versus receiving an abortion, the study will inform interventions to reduce maternal morbidity and improve child health outcomes.
• Methodological Advancement: The successful application of overlap weighting in a non-randomized, observational setting with complex censoring offers a methodological blueprint for future reproductive health research in developing nations.
• Future Research: The cohort serves as a platform to investigate long-term intergenerational effects, the impact of abortion stigma, and the efficacy of different service delivery models.

In summary, the Nepal Turnaway Study is a landmark epidemiological effort that transforms the understanding of abortion access in Nepal from a cross-sectional snapshot to a dynamic, longitudinal narrative of women's lives, offering high-quality evidence to guide reproductive health policy.