Mahesh Puri

Women's Status and Violence against Young Married Women in Rural Nepal

BackgroundStudies conducted around the world consistently show the existence of violence against women. Despite the increasing number of studies being conducted on violence against young married women elsewhere, this subject has received little attention from researchers and policy makers in Nepal. This paper assesses the prevalence of violence among young married women in rural Nepal. Specifically, it examines [factors related to] womens status in order to better understand the risk of violence.MethodsA cross-sectional study was conducted in 2009 among 1,296 young married women aged 15-24 years in four major ethnic groups. Bivariate analysis and multivariate logistic regression were used to examine the association between selected risk factors and violence.ResultsMore than half the women (51.9%) reported having experienced some form of violence in their lifetime. One-fourth (25.3%) reported physical violence and nearly half (46.2%) reported sexual violence. Likewise, one-third (35.8%) of women reported experiencing some form of violence in the past 12 months. No or little inter-spousal communication and low autonomy of women significantly increases the odds of experiencing violence among married women.ConclusionsThe violence against women is quite common among young married women in rural Nepal. Although the Domestic Violence and Punishment Act 2066 has been enacted, equal attention needs to be given to increasing womens autonomy and activities that encourage inter-spousal communication. Furthermore, more research is required in Nepal that examines dynamics of violence perpetrated by husbands.

Effects of abortion legalization in Nepal, 2001-2010.

Background Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion. Methods We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001–2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001–2003), early implementation (2004–2006), and later implementation (2007–2010). Results 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75). Conclusion Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women’s health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Exploring the Nature and Reasons for Sexual Violence Within Marriage Among Young Women in Nepal

Sexual violence within marriage (SVWM) is a major public health and human right issue and yet remains a much neglected research area, especially in Nepal. An exploratory study using free listing, in-depth case histories and causal flow analysis was conducted among two major ethnic groups in Nepal. Descriptive data collected from free listing indicate that about half of the married women aged 15 to 24 years reported ever experiencing SVWM. Data revealed that the underlying reasons for SVWM are complex and complicated due to the multiple forms and contexts in which it occurs. For many couples, multiple factors alongside, and within, their socioeconomic and cultural contexts contribute to the risk of experiencing SVWM. Major factors escalating the risk to SVWM include gender norms, economic dependence of women, poverty, alcohol consumption of husband, lack of knowledge, social stigma, and lack of supportive familial and social environment. Raising awareness about sexual violence is required for its prevention and for managing the consequences. Further research is required to identify the determinants, the effects of SVWM on sexual and reproductive health outcomes and to help programs develop the best strategies for dealing with SVWM among young couples.

“Sometimes they used to whisper in our ears”: health care workers’ perceptions of the effects of abortion legalization in Nepal

BackgroundUnsafe 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.MethodsTo 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.ResultsOverall, participants had positive views of abortion legalization – many 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.ConclusionsProviders 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.

Falling sex ratios and emerging evidence of sex-selective abortion in Nepal: evidence from nationally representative survey data

Objectives To quantify trends in changing sex ratios of births before and after the legalisation of abortion in Nepal. While sex-selective abortion is common in some Asian countries, it is not clear whether the legal status of abortion is associated with the prevalence of sex-selection when sex-selection is illegal. In this context, Nepal provides an interesting case study. Abortion was legalised in 2002 and prior to that, there was no evidence of sex-selective abortion. Changes in the sex ratio at birth since legalisation would suggest an association with legalisation, even though sex-selection is expressly prohibited. Design Analysis of data from four Demographic and Health Surveys, conducted in 1996, 2001, 2006 and 2011. Setting Nepal. Participants 31 842 women aged 15–49. Main outcome measure Conditional sex ratios (CSRs) were calculated, specifically the CSR for second-born children where the first-born was female. This CSR is where the evidence of sex-selective abortion will be most visible. CSRs were looked at over time to assess the impact of legalisation as well as for population sub-groups in order to identify characteristics of women using sex-selection. Results From 2007 to 2010, the CSR for second-order births where the first-born was a girl was found to be 742 girls per 1000 boys (95% CI 599 to 913). Prior to legalisation of abortion (1998–2000), the same CSR was 1021 (906–1150). After legalisation, it dropped most among educated and richer women, especially in urban areas. Just 325 girls were born for every 1000 boys among the richest urban women. Conclusions The fall in CSRs witnessed post-legalisation indicates that sex-selective abortion is becoming more common. This change is very likely driven by both supply and demand factors. Falling fertility has intensified the need to bear a son sooner, while legal abortion services have reduced the costs and risks associated with obtaining an abortion.

Unsafe abortion after legalisation in Nepal: a cross‐sectional study of women presenting to hospitals

To investigate abortion practices of Nepali women requiring postabortion care.

The role of auxiliary nurse-midwives and community health volunteers in expanding access to medical abortion in rural Nepal

Abstract Medical abortion was introduced in Nepal in 2009, but rural women’s access to medical abortion services remained limited. We conducted a district-level operations research study to assess the effectiveness of training 13 auxiliary nurse-midwives as medical abortion providers, and 120 female community health volunteers as communicators and referral agents for expanding access to medical abortion for rural women. Interviews with service providers and women who received medical abortion were undertaken and service statistics were analysed. Compared to a neighbouring district with no intervention, there was a significant increase in the intervention area in community health volunteers’ knowledge of the legal conditions for abortion, the advantages and disadvantages of medical abortion, safe places for an abortion, medical abortion drugs, correct gestational age for home use of medical abortion, and carrying out a urine pregnancy test. In a one-year period in 2011–12, the community health volunteers did pregnancy tests for 584 women and referred 114 women to the auxiliary nurse-midwives for abortion; 307 women in the intervention area received medical abortion services from auxiliary nurse-midwives. There were no complications that required referral to a higher-level facility except for one incomplete abortion. Almost all women who opted for medical abortion were happy with the services provided. The study demonstrated that auxiliary nurse-midwives can independently and confidently provide medical abortion safely and effectively at the sub-health post level, and community health volunteers are effective change agents in informing women about medical abortion. Resumé L’avortement médicamenteux a été introduit en 2009 au Népal, mais l’accès des femmes rurales aux services est demeuré limité. Nous avons étudié les opérations au niveau d’un district pour évaluer l’efficacité de la formation de 13 infirmières sages-femmes auxiliaires comme prestataires de l’avortement médicamenteux, et de 120 femmes comme bénévoles de santé communautaire et agents d’orientation pour élargir l’accès des femmes rurales à l’avortement médicamenteux. Des entretiens ont été organisés avec des prestataires de service et des femmes ayant mené un avortement médicamenteux, et des statistiques de service ont été analysées. Par comparaison avec un district voisin où aucune intervention n’avait été réalisée, dans la zone d’intervention, on a constaté une hausse sensible de la connaissance des bénévoles de santé communautaire sur les conditions juridiques de l’avortement, les avantages et les inconvénients de l’avortement médicamenteux, les lieux sûrs pour l’avortement, les médicaments abortifs, l’âge gestationnel correct pour pratiquer un avortement médicamenteux à domicile et la réalisation d’un test de grossesse urinaire. Sur une période d’un an en 2011-2012, les bénévoles de santé communautaire ont effectué un test de grossesse pour 584 femmes et adressé 114 femmes qui voulaient avorter aux infirmières sages-femmes auxiliaires ; les infirmières sages-femmes auxiliaires ont prêté des services d’avortement médicamenteux pour 307 femmes dans la zone d’intervention. Aucune complication n’a exigé l’aiguillage vers un centre plus spécialisé, à l’exception d’un avortement incomplet. Presque toutes les femmes qui avaient opté pour l’avortement médicamenteux étaient satisfaites des services obtenus. L’étude a montré que les infirmières sages-femmes auxiliaires peuvent pratiquer efficacement, indépendamment et en confiance des avortements médicamenteux en toute sécurité au niveau des sous-centres de santé, et que les bénévoles de santé communautaire sont de précieux agents de changement pour renseigner les femmes sur l’avortement médicamenteux. Resumen Los servicios de aborto con medicamentos fueron introducidos en Nepal en 2009, pero el acceso de las mujeres rurales a dichos servicios continu ó siendo limitado. Realizamos un estudio de investigación operativa a nivel de distrito para evaluar la eficacia de capacitar a 13 enfermeras-obstetras auxiliares como prestadoras de servicios de aborto con medicamentos, y 120 voluntarias comunitarias en salud como comunicadoras y agentes de referencia para ampliar el acceso de las mujeres rurales a dichos servicios. Se realizaron entrevistas con prestadores de servicios y mujeres que recibieron servicios de aborto con medicamentos y se analizaron las estadísticas de los servicios. Comparado con un distrito aledaño donde no hubo intervención, en la zona de la intervención se vio un considerable aumento en los conocimientos de las voluntarias comunitarias respecto a las condiciones para un aborto legal, las ventajas y desventajas del aborto con medicamentos, lugares seguros para tener un aborto, fármacos para inducir el aborto, edad gestacional correcta para el uso domiciliario de los medicamentos para inducir el aborto, y realizar una prueba de embarazo en la orina. En el plazo de un año, 2011-12, las voluntarias comunitarias en salud realizaron pruebas de embarazo en 584 mujeres y refirieron a 114 mujeres a enfermeras-obstetras auxiliares para aborto; 307 mujeres en la zona de la intervención recibieron servicios de aborto con medicamentos de enfermeras-obstetras auxiliares. No hubo complicaciones que necesitaron referencia a una unidad de salud de mayor nivel, excepto un aborto incompleto. Casi todas las mujeres que optaron por tener un aborto con medicamentos estuvieron contentas con los servicios que recibieron. El estudio demostró que las enfermeras-obstetras auxiliares pueden proporcionar servicios de aborto con medicamentos de manera independiente, confiada, segura y eficaz, en un nivel inferior al puesto de salud, y las voluntarias comunitarias en salud son agentes de cambio eficientes para informar a las mujeres acerca del aborto con medicamentos.

Road map to scaling-up: translating operations research study’s results into actions for expanding medical abortion services in rural health facilities in Nepal

BackgroundIdentifying unsafe abortion among the major causes of maternal deaths and respecting the rights to health of women, in 2002, the Nepali parliament liberalized abortion up to 12 weeks of pregnancy on request. However, enhancing women’s awareness on and access to safe and legal abortion services, particularly in rural areas, remains a challenge in Nepal despite a decade of the initiation of safe abortion services.MethodsBetween January 2011 and December 2012, an operations research study was carried out using quasi-experimental design to determine the effectiveness of engaging female community health volunteers, auxiliary nurse midwives, and nurses to provide medical abortion services from outreach health facilities to increase the accessibility and acceptability of women to medical abortion. This paper describes key components of the operations research study, key research findings, and follow-up actions that contributed to create a conducive environment and evidence in scaling up medical abortion services in rural areas of Nepal.ResultsIt was found that careful planning and implementation, continuous advocacy, and engagement of key stakeholders, including key government officials, from the planning stage of study is not only crucial for successful completion of the project but also instrumental for translating research results into action and policy change. While challenges remained at different levels, medical abortion services delivered by nurses and auxiliary nurse midwives working at rural outreach health facilities without oversight of physicians was perceived to be accessible, effective, and of good quality by the service providers and the women who received medical abortion services from these rural health facilities.ConclusionsThis research provided further evidence and a road-map for expanding medical abortion services to rural areas by mid-level service providers in minimum clinical settings without the oversight of physicians, thus reducing complications and deaths due to unsafe abortion.

Assessing the Factors Associated With Sexual Harassment Among Young Female Migrant Workers in Nepal

This article explores the extent of, and factors associated with, sexual harassment of young female migrant workers in the carpet and garment factories in Kathmandu Valley. Information is drawn from a survey of 550 female workers aged 14 to 19 and 12 in-depth case histories. Bivariate and multivariate techniques were applied to identify the factors associated with harassment. The survey found that 1 in 10 young women had experienced sexual harassment or coercion. Those who were exposed to pornographic movies were more likely than those with no exposure to any kind of movies to report sexual harassment. Perpetrators included coworkers, boyfriends, employers, and relatives. Case histories revealed that the inability of young women to communicate effectively with their peers and sex partners, lack of self-esteem, job insecurity, and other socioeconomic problems made them vulnerable to these abuses. The results suggest the need for advocacy and a range of factory-based interventions.

Contraceptive discontinuation and pregnancy postabortion in Nepal: a longitudinal cohort study

OBJECTIVE To examine postabortion contraceptive discontinuation and pregnancy in Nepal, where abortion was decriminalized in 2002. STUDY DESIGN We conducted an observational cohort study of 654 women obtaining abortions from four public and nongovernmental facilities in 2011. Patients completed questionnaires at their abortion visit and 6 and 12 months later. We used Cox proportional hazards models to assess contraceptive discontinuation and pregnancy by method initiated postabortion and other sociodemographic and reproductive factors. RESULTS Among the 78% (508/654) of women who initiated a modern contraceptive method within 3 months postabortion, the 1-year contraceptive discontinuation rate was 62 per 100 person-years. Discontinuation was far lower among the 5% of women using long-acting reversible methods (21/100 person-years) than among those using condoms (74/100 person-years), pills (61/100 person-years) and the injectable [64/100 person-years; adjusted hazard ratio (aHR)=0.32 (0.15-0.68)]. Unmarried women and those not living with their husband experienced higher contraceptive discontinuation [aHR=2.16 (1.47-3.17)]. The 1-year pregnancy rate for all women was 9/100 person-years. Pregnancy was highest among those who initiated no modern method postabortion (13/100 person-years) and condoms (12/100 person-years), and pregnancy was lowest among users of long-acting reversible methods (3/100 person-years). The poorest women were at increased pregnancy risk [aHR=2.31 (1.32-4.10)]. CONCLUSION Women using intrauterine devices and implants experienced greatly reduced contraceptive discontinuation and pregnancy within a year postabortion, although initiation of these long-acting methods was low. Increased availability of long-acting methods in Nepal and similar settings may help to prevent unwanted pregnancy and attendant maternal mortality and morbidities. IMPLICATIONS Initiation of modern contraception was high postabortion; however, 1-year discontinuation was high for the condom, pill and injectable, the methods most commonly used. Rates for intrauterine devices and implants were low. Results support efforts to facilitate patient knowledge and access to the full range of contraceptives, including long-acting reversible methods.