Access to abortion and subsequent fertility preferences and reproductive outcomes in Nepal (2019–2024): a prospective cohort study

Background Access to abortion is central to people's ability to act on their fertility preferences, yet little research has examined whether the ability to avoid having an unwanted birth shapes subsequent fertility outcomes or enables people to align future childbearing with their preferences. This study examines whether and how access to a desired abortion is associated with fertility preferences and reproductive outcomes over the subsequent years. Methods We analyzed data from the Nepal Turnaway Study , a five-year prospective cohort study of women seeking abortion, comparing those who obtained an abortion with those who were denied and subsequently gave birth. We examined fertility preferences over time using mixed-effects multinomial logistic regression, time to subsequent pregnancy and birth using flexible parametric survival models, and cumulative births using mixed-effects Poisson regression. Finally, we assessed whether subsequent births were undesired prior to conception using mixed-effects logistic regression. Findings Among 1742 participants seeking abortion, 1467 had an abortion or miscarried (the no-birth-to-index-pregnancy group) and 275 were denied and gave birth (the gave-birth-to-index-pregnancy group). Initially (at year one through year four), the no-birth-to-index-pregnancy group was more open to pregnancy than the gave-birth-to-index-pregnancy group; by year five, their fertility preferences converged. Four years after return to fecundability, the cumulative incidence of a subsequent pregnancy was 41.8% in the no-birth-to-index-pregnancy group and 18.3% in the gave-birth-to-index-pregnancy group (difference: 23.5 percentage points; 95% CI: 17.3–29.7), and of a subsequent birth was 30.8% and 10.0%, respectively (difference: 20.8 percentage points; 95% CI: 15.1–26.6). The predicted mean total number of births, including the index birth, per woman by year five was 1.04 for the gave-birth-to-index-pregnancy group and 0.37 for the no-birth-to-index-pregnancy group (difference: 0.67; 95% CI: 0.56–0.79). A smaller proportion of post-index births were undesired (before conception) in the no-birth-to-index-pregnancy group compared with the gave-birth-to-index-pregnancy group (35.1% vs. 84.5%; difference: 49.4 percentage points; 95% CI: 33.8–65.0; p=0.0001). Interpretation Access to abortion shapes subsequent fertility preferences and outcomes and can lead to greater alignment between future reproductive preferences and outcomes. Funding This study was supported by the National Institutes of Health and the David and Lucile Packard Foundation.