As a Public Health Officer working across Nepal from the remote corners of Karnali to the urban clinics of Kathmandu, I have seen what most people do not talk about: the silent, invisible reproductive crisis tearing through the lives of women and girls.
It does not look the same everywhere. In some places, it begins too early. In others, it comes too late. But it hurts just the same.
Adolescent pregnancy and motherhood
I have sat with 15-year-old girls who did not even know what pregnancy meant-girls who ran away from violence or poverty, only to find themselves pregnant, abandoned, and ashamed. As per the Nepal Demographic and Health Survey (NDHS) 2022, adolescent pregnancy has declined to 14 per cent, a step forward. Yet, 21 per cent of women aged 15–19 are currently married, and this persistent prevalence of child marriage remains a major driver of early motherhood. For many of them, motherhood is not even a choice, it’s a default.
Then, in urban fertility clinics, I have listened to 35-year-old women-smart, capable, hardworking-who are spending lakhs of rupees on IVF cycles, each one more emotionally and financially draining than the last. The heartbreak of infertility is rarely spoken about in Nepal, yet it’s estimated to affect around 17.5 per cent of adults globally-roughly 1 in 6-according to the WHO, and Nepal likely mirrors this burden, though we still lack reliable national data.
What’s common in both stories? Blame. And silence. And always, always-it is the woman who is blamed. Too young? Irresponsible. Too late? Selfish. Too many children? Careless. No children? Incomplete. We talk of women’s empowerment, but where is empowerment in a system that neither informs young girls nor supports hopeful mothers? The silence around these issues is not cultural-it’s systemic.
On paper, our policies seem promising. The Constitution of Nepal recognises reproductive health as a fundamental right, ensuring every individual’s right to make decisions about their own body and health.
Child marriage is explicitly prohibited, with the legal age of marriage set at 20. Abortion has been legal since 2002, and is now strengthened through the Right to Safe Motherhood and Reproductive Health Act (2018) which legally guarantees access to reproductive care.
Likewise, the National Health Policy 2019 emphasises equity and quality. And with over 1,200 Adolescent-Friendly Health Service (AFHS) sites, the structure exists. But the reality? Many of these centers operate in name only, without the dignity, empathy, or consistency that women and girls deserve.
Nepal’s government has indeed made notable strides as maternal mortality has declined, family planning programs have expanded, and adolescent-friendly services have been introduced nationwide. But the cracks in our reproductive health system are growing wider, especially at the margins.
Adolescent pregnancy rates remain stubbornly high, and infertility is almost invisible in the public health agenda. While a few public hospitals offer limited services, infertility care is mostly centralised in urban hubs, unaffordable for most, and excluded from Nepal’s Basic Health Service Package. There are no national clinical protocols, no service standards, and no mental health support for infertility embedded in reproductive health programs.
Even the well-intentioned youth-friendly services often fall short. Many are under-resourced, staffed by providers lacking the sensitivity or training to deal with complex realities. Girls walk in hoping for answers and walk out feeling judged, ashamed, or worse, unheard.
If we can talk about a triple burden of disease in public health, then this is our double burden of reproductive injustice where girls are pushed into motherhood too soon, and women are punished for reaching for it too late.
So who do we hold accountable?
The young girl who dropped out of school after Grade 5 and got married at 16? Or the woman who believed what society told her that education and independence matter only to hear later that she “waited too long”?
Neither. We hold systems accountable. It’s time we built a reproductive health system that reflects the lived realities of Nepali women not just the ones we find in policy documents. A system that integrates infertility screening and care into public health services, making support accessible, not exclusive. A system that normalises youth-friendly, respectful, and stigma-free care.
One that decentralises infertility services, brings low-cost IVF closer to people, and embeds fertility management into national guidelines. One that does not just treat the body, but also supports the mental and emotional toll of reproductive struggles.
Above all, a system that finally listens to women instead of blaming them-no matter their age, their choices, or the path their bodies take
Until we do, women and girls in Nepal will remain caught between too early and too late trapped by silence, weighed down by expectations, and failed by the very systems meant to protect them.
It’s time we stop calling this a “private problem.” It’s a national crisis. And it’s already here.
