Ever since abortion was legalised in March 2002, rights groups have wondered how long it will take for the legislation to actually have an impact on Nepal's maternal mortality rate.

Groups fought long and hard to get the law passed, and they don't want to believe that we may have to wait as long as 20 years to see its impact on the health of Nepali mothers. Four years after legalisation we still see headlines like 'Vet performs abortion, mother die&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'&#'216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;216;', 'Hetauda mother, seven months pregnant, dies after abortion'.

There are thousands of other sad stories that never make it to the media, of women who suffer and die quietly because of unsafe abortion every day. During a visit to a Valley maternity hospital recently, a senior gynaecologist related the case of a patient from Bhaktapur who had an unsafe abortion. Her uterus was perforated and a part of her kidney was damaged. "It was a real struggle to save her," the doctor told us. "Imagine what would happen to her if it was in a village."

The doctors in Hetauda who performed an abortion on a woman seven months pregnant had undergone training but ended up killing both the mother and child. In a situation where doctors don't even follow the simple guideline not to abort in advanced stages of pregnancy, legalisation of abortion may be a futile exercise.

There are also deficiencies in the legal system. In the four years since the law was passed, 19 women have been arrested for abortion and been sentenced to between three and 20 years in prison.

Advocate Sapana Pradhan Malla has been defending a 35-year-old mother of four from Dhankuta who gave birth to a stillborn baby after being raped by a neighbour while her husband was away in India. She was afraid to tell anyone, and after the baby was born dead wrapped it in plastic and disposed of it in the forest. Police arrested her, accusing her of killing the baby. No postmortem was conducted, which could have proved that the baby was born dead. The woman is now in prison, and her four children are living like orphans.

Advocate Malla has pleaded with the court that the woman was a victim of state neglect. The court verdict could go either way for the woman from Dhankuta, but if cases like these are still happening then Nepali women have a long way to go despite progressive legislation.

It is easy for us in Kathmandu to blame the victim, to ask why women visit quacks and why they don't go to the police if they are raped, or get legal advice when illegally arrested. But such arguments ignore the reality of medical services, law enforcement and the status of women in rural Nepal.

Anyone who has visited western Nepal knows how difficult it is to go the police or state machinery with a complaint of rape, how complicated it is to get abortion services and how difficult it can be for a mother to leave home even for a few days.

In fact, it may take over 20 years for the abortion legislation to have an impact on maternal mortality and morbidity in Nepal. It's not just a medical or legal issue, it is socio-economic and cultural, and these things take generations to change.