Background: Unsafe abortion has been a significant cause of maternal morbidity and mortality in N... more Background: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers' views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care. Methods: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data. Results: Overall, participants had positive views of abortion legalizationmany believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment. Conclusions: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.
Objectives These were to: (1) produce national and subnational estimates of the sex ratio at birt... more Objectives These were to: (1) produce national and subnational estimates of the sex ratio at birth (SRB) and number of missing girl births in Nepal and (2) understand the socioeconomic correlates of these phenomena. Design Observational secondary data analysis of ( ) the 2011 population census of Nepal and (2) the Nepal Demographic and Health Survey (DHS) 2006, 2011 and 2016. Setting Nepal. Participants (1) 2 567 963 children age 0-4 in the 2011 population census and (2) 27 329 births recorded in DHSs. Primary and secondary outcomes We estimate the SRB, and number and proportion of missing girls in the year and 5 years before the census by district. We also calculate conditional sex ratios (the SRB dependant on parity and sex of previous children) by province, time, education and wealth. Results We find that 11 districts have significantly skewed sex ratios at birth in the 2011 population census, with the highest SRBs observed in Arghakhanchi (SRB=127) and Bhaktapur (SRB=123). 22 540 girl births were missing in the 5 years before the 2011 population census. Sex-selective abortion is geographically concentrated, especially in the Kathmandu Valley and Lumbini Province, with 53% of missing girls found in only 11 out of 75 districts. DHS data confirm this, with elevated conditional sex ratios observed in Bagmati and Lumbini Provinces; conditional sex ratios where previous births were all female also became more skewed over time. Skewed sex ratios are concentrated among wealthier more educated groups. Conclusions It is clear that sex selection will persist and develop in Nepal unless a coordinated effort is made to address both the demand for and supply of this service. Policies should be holistic and encompass economic and legal gender equity, and strengthen monitoring mechanisms to prevent technology misuse, without jeopardising the right to safe, free and legal abortion. ► This paper updates previous research that used older Demographic and Health Surveys to estimate sex ratios at birth and look at sociodemographic correlates of sex ratios at birth. ► Census data provide population-level information but lacks detail, while Demographic and Health Surveys include exceptional levels of detail with relatively small sample sizes. ► Sex-selective abortions are measured indirectly and rely on comparing the reported age and sex of births and young children, which may not always be accurate.
Background Despite the legalization of abortion in 2002 and the concerted efforts of the Ministry... more Background Despite the legalization of abortion in 2002 and the concerted efforts of the Ministry of Health and Population, abortion services remain inaccessible for many Nepali women. In 2017, the United States government enacted the Protecting Life in Global Health Assistance (PLGHA) policy, which prohibited international non-governmental organizations (INGOs) from receiving United States global health assistance from providing abortion services or referrals or engaging in advocacy on liberalizing abortion laws that may have had an impact on abortion services. Though this policy was revoked in January 2021, there is a need to assess its impacts in Nepal and mitigate its lingering effects, if any. We conducted in-depth interviews with 21 national-level stakeholders selected purposively on the basis of their experiences and expertise in sexual and reproductive health and rights (SRHR) in Nepal. Interviews were conducted two times: first between August and November 2020 when PLGHA was in place, and then between July and August 2021 after PLGHA was revoked. Interviews were digitally recorded, transcribed, translated and analysed thematically. Most participants reported that the implementation of PLGHA created gaps in SRHR services, affecting marginalized and underserved populations in Nepal. Participants reported that this policy has compromised the work of INGOs and civil society organizations (CSOs), posing additional risk to the sustainability of SRHR program achievements made so far. Beyond funding loss, participants also mentioned that PLGHA curtailed their freedom, with limited working areas and partnerships for CSOs leading to low or no utilization of services. Most participants welcomed the revocation of PLGHA and hoped it would have positive impacts on SRHR services by permanently repealing PLGHA. Most participants believed that the revocation of PLGHA opened opportunities for new funding and could re-establish partnerships and collaboration, though immediate results had not yet been seen. Conclusions PLGHA had negative impacts on access to and quality of SRHR services. The Nepal government and other donor agencies need to bridge the funding gap created by the policy. The revocation of the policy has created the hope of bringing positive impacts in SRHR sector; however, the implementation of revocation at the ground level and impacts made on SRHR programs in Nepal remains to be explored.
Objective: To evaluate whether conducting a bimanual examination prior to medication abortion (MA... more Objective: To evaluate whether conducting a bimanual examination prior to medication abortion (MAB) provision results in meaningful changes in gestational age (GA) assessment after patientreported last menstrual period (LMP) in Nepal. Study Design: Women ages 16-45 (n=660) seeking MAB at twelve participating pharmacies and government health facilities, between October 2014 and September 2015, self-reported LMP. Trained auxiliary nurse midwives assessed GA using a bimanual exam after recording LMP. We compared GA assessments as measured via patient-reported LMP alone versus via LMP plus bimanual exam. Results: Overall, 660 women (326 at pharmacies, 334 at health facilities) presented for MAB, and 95% were able to provide an LMP. Overall agreement between LMP alone and LMP with bimanual exam was 99.3%. If LMP alone had been used without bimanual exam, fewer than one in 200 women would have been given MAB beyond the legal gestational limit. Among the three women who were ≤63 days by LMP but >63 days by bimanual exam, only one would have *
Gender-Biased sex selection and unBalanced sex ratios at Birth in south asia: case studies of the... more Gender-Biased sex selection and unBalanced sex ratios at Birth in south asia: case studies of the situation and promisinG approaches to restore Balance shireen Jejeebhoy rajib acharya sharmistha Basu aJ francis Zavier Population Council, India ubaidur rob md. noorunnabi talukder md. irfan hossain forhana rahman noor Population Council, Bangladesh Zeba a. sathar Gul rashida sabahat hussain anushe hassan Population Council, Pakistan mahesh puri anand tamang
Background In Nepal and across the globe, the COVID-19 pandemic has primed an environment for inc... more Background In Nepal and across the globe, the COVID-19 pandemic has primed an environment for increased rates of violence against women (VAW). This paper explores pandemic-driven economic insecurity and increased alcohol use as instigators of VAW and Intimate Partner Violence (IPV) within newly married households in the rural, Nawalparasi region of Nepal. Methods This study is a secondary analysis of data obtained from the Sumadhur Intervention pilot study that has been previously described and demonstrates successful implementation of group-based, household-level intervention for women’s empowerment and sexual and reproductive health education (1). Our three sets of data were collected before and during the COVID-19 pandemic. The first set is from a Longitudinal Cohort of 200 newly married women who were surveyed twice a year from February 2017 through July 2020. The second data set is a subset cohort of newly married women, their husbands, and their mothers-in-law (31 women, 31 hu...
Adapting and Validating the G‐NORM (Gender Norms Scale) in Nepal: An Examination of How Gender Norms Are Associated with Agency and Reproductive Health Outcomes
Introduction In Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 we... more Introduction In Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 weeks for health and other reasons. Abortion is available at public facilities at no cost and by trained private providers. Yet, over half of abortions are provided outside this legal system. We sought to investigate the extent to which patients are denied an abortion at clinics legally able to provide services and factors associated with presenting late for care, being denied, and receiving an abortion after being denied. Methods We used data from a prospective longitudinal study with 1835 women aged 15–45. Between April 2019 and December 2020, we recruited 1,835 women seeking abortions at 22 sites across Nepal, including those seeking care at any gestational age (n = 537) and then only those seeking care at or after 10 weeks of gestation or do not know their gestational age (n = 1,298). We conducted interviewer-led surveys with these women at the time they were seeking abortion service (...
International Journal of Gynecology & Obstetrics, 2022
Objective-Although abortion in Nepal is broadly legal and free of charge, many women seek abortio... more Objective-Although abortion in Nepal is broadly legal and free of charge, many women seek abortion care outside the legal system, including from pharmacies. We evaluated the prevalence of, and factors associated with, prior unsuccessful abortion attempts among women presenting to 14 randomly-selected government approved abortion health facilities across Nepal. Methods-Eligible participants were recruited in 2019 by trained research staff from certified abortion facilities. Participants (n=1,160) completed research staff-administered baseline surveys. We used multivariable mixed-effects logistic regression models to evaluate factors associated with having attempted pharmacy abortion prior to coming to the health facility. Results-Almost one in seven (14%) of women had tried to end their pregnancy before presenting to a participating clinic, often (9%) using medication obtained from a pharmacy. Women who lived farther from the clinic (aOR 1.28 per log hours travel time, 95% CI 1.10-1.49) and who reported financial difficulty in accessing the clinic (19% vs. 10%, aOR 2.10, 95% CI 1.20-3.70) had increased odds of having tried to access abortion through a pharmacy. Conclusions-Integrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.
Over 400,000 children die annually from neonatal sepsis, despite several RCTs finding that this c... more Over 400,000 children die annually from neonatal sepsis, despite several RCTs finding that this can be prevented by chlorhexidine cord care (CHX) for only US$0.23 per dose. Unresolved heterogeneity in findings and other RCT scalability concerns contribute to slow CHX adoption. Studying the first national CHX roll-out — in Nepal — we find that CHX reduces neonatal mortality by 56 percent for births predicted to take place at home. We find no effect for predicted health facility births, which is consistent with heterogeneity in prior experimental estimates. Conditional on predicted place of delivery, there is little significant treatment effect heterogeneity.
The European Journal of Development Research, 2021
This article describes the mixed-methods approach used by the Gender and Adolescence: Global Evid... more This article describes the mixed-methods approach used by the Gender and Adolescence: Global Evidence (GAGE) research programme. It discusses how qualitative and quantitative methods can be used both in isolation and combined to learn about the lives of adolescents in low- and middle-income countries (LMICs), focusing on the methodological and ethical approaches used to reach socially marginalised adolescents (including adolescents with disabilities, adolescents not in school, adolescent refugees, adolescents living in urban slums, adolescents who married as children, and adolescent mothers). We reflect on the implementation of the GAGE conceptual framework, discussing its strengths and weaknesses, and the challenges to promoting inclusive and genuinely mixed-methods research practices. While these methods have been adapted in the countries where research was undertaken, the conceptual framework provides a common methodological approach, utilising an intersectional lens. We show how...
Background: Despite legalization of abortion in Nepal in 2002, many women are still unable to acc... more Background: Despite legalization of abortion in Nepal in 2002, many women are still unable to access legal services. This paper examines providers' views, experiences with abortion denial, and knowledge related to abortion provision, and identifies areas for improvement in quality of care. Methods: We conducted a structured survey with 106 abortion care providers at 55 government-approved safe abortion facilities across five districts of Nepal in 2017. We assessed reasons for denial of abortion care, knowledge about laws, barriers to provision and attitudes towards abortion. Results: Almost all providers (96%) reported that they have ever refused clients for abortion services. Common reasons included beyond 12 weeks gestation (93%), sex selective abortion (86%), and medical contraindications (85%). One in four providers denied abortion for lack of drugs or trained personnel, and one third denied services when they perceived that the woman's reasons for abortion were insufficient. Only a third of providers knew all three legal indications for abortion-less than or equal to 12 weeks of pregnancy on request, up to 18 weeks for rape or incest, and any time for maternal or fetal health risk. Overall, providers were in favor of legal abortion but a substantial proportion had mixed or negative attitudes about the service. Conclusions: Improvements in training to address providers' inadequate knowledge about the abortion law may reduce inappropriate denial of abortion. Establishing referral networks in the case of abortion denial and ensuring regular supply of medical abortion drugs would help more women access abortion care in Nepal.
International Journal of Gynecology & Obstetrics, 2018
Objective: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies... more Objective: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies is associated with reduced post-abortion contraceptive use in Nepal. Methods: The present prospective observational study compared contraceptive use among women aged 16-45 years and up to 63 days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21 days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression.
Best Practice & Research Clinical Obstetrics & Gynaecology, 2019
Despite the legalization of abortion in 2002, has made extensive efforts to expand services throu... more Despite the legalization of abortion in 2002, has made extensive efforts to expand services throughout the country, access to safe abortion care remains constrained in Nepal, particularly in remote areas where trained providers and equipment are scarce. Expanding access to medical abortion (MA) through pharmacy workers could be a promising avenue to reach such women with safe and convenient care but neither Nepali law nor World Health Organizations (WHO) recommended pharmacy provision of MA citing the reason of insufficient evidence. This paper examines the pharmacy provision of MA in expanding women's access to safe MA service in Nepal. Available literature between 2005 and 2018 was searched and relevant information was extracted using a template and findings were summarized and interpreted according to the objective this study. We identified 83 studies that were related to MA in Nepal but only five of them reported about pharmacy workers involvement in the provision of MA in Nepal. Findings suggest that trained pharmacy workers can safely and effectively provide MA. MA services provided by pharmacy workers are acceptable to women who were satisfied with the service they had received. Therefore, it is essential that the Government of Nepal acknowledges the role pharmacy workers currently play in the provision of MA and formulate polices to permit pharmacy workers to give information about and dispense MA tablets to women in the first trimester of pregnancy.
Background Mindful of social norms shaping health among women pressured to prove early fertility ... more Background Mindful of social norms shaping health among women pressured to prove early fertility in Nepal, a bi-national research team developed and piloted a 4-month intervention engaging household triads (newly married women, their husbands, and mothers-in-law) toward advancing gender equity, personal agency, and reproductive health. This study evaluates the impact on family planning and fertility decision-making. Methods In 2021, Sumadhur was piloted in six villages with 30 household triads (90 participants). Pre/post surveys of all participants were analyzed using paired t-tests and in-depth interviews with a subset of 45 participants were transcribed and analyzed thematically. Results Sumadhur significantly impacted (p < .05) norms related to pregnancy spacing and timing, and sex preference of children, as well as knowledge about family planning benefits, pregnancy prevention methods, and abortion legality. Family planning intent also increased among newly married women. Qua...
Additional file 1 of Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up
Additional file 1. Knowledge, attitude, and practice index of health care providers not PPIUD tra... more Additional file 1. Knowledge, attitude, and practice index of health care providers not PPIUD trained (N = 17).
Additional file 2 of Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up
Additional file 2. Health care providers' knowledge, attitudes, and practice towards family p... more Additional file 2. Health care providers' knowledge, attitudes, and practice towards family planning and PPIUD among those not PPIUD trained (N = 17).
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