Perception of Climate Change Vulnerability and its Impact on Sexual and Reproductive Health and Rights in Khutiya and Banganga River Basins.

BACKGROUND: Nepal is one of the most vulnerable countries to climate change. The drivers of climate risk include its topography, ecological diversity, climatic variability, natural resource dependency, under-development, and socioeconomic vulnerabilities. Climate change affects women and girls in unique ways. Research conducted in Asia Pacific region highlight negative sexual and reproductive health outcomes from climate change-related stressors such as droughts, floods, and air pollution, factors also linked to decreased SRH services utilization, increased maternal mortality rates, and repercussions on women's mental health. METHODS: This is a mixed methods study conducted in two river basins including household surveys with 384 females ages 18-49, 12 focus group discussions, and 22 key informant interviews. We conducted descriptive and thematic analysis. RESULTS: More than half relied on agriculture for income (66%). Despite one-third being heads of households, land ownership was low (13%). Climate change perceptions included rising temperatures (88%), increased heat wave (70%), drying water source (99%), and delayed monsoons (83%), impacting agriculture and increasing women's workload (61%) due to displacement and male migration. 64% reported disturbances in antenatal and postnatal care visits . Inaccessible healthcare facilities during the rainy season increased maternal mortality risks. Heavy river flooding hindered female community health volunteers access leading to childbirth complications. 82% of women feared being unable to protect their children post-climate events. Moreover, 21% of women faced gender-based violence during or after climate disasters. CONCLUSIONS: Our findings suggest clear impacts of climate change on women and the communities. Thus, climate adaptation efforts must be designed to address the unique impacts of the crisis on women and girls, making space for their increased participation and leadership.

Trends and Inequities in Use of Abortion Services in Nepal: A Nepal Demographic and Health Survey Data Analysis 1996-2022 A.D.

BACKGROUND: Despite policy advances and public health initiatives in Nepal to improve access to reproductive healthcare, disparities persist in utilization of abortion services. Grounded in longitudinal data from the Nepal Demographic and Health Survey from 1996 to 2022, this study aims to shed light on evolving patterns in pregnancy outcomes and inequities in use of abortion services across ecological zones and wealth quintiles. METHODS: Utilizing six rounds of Nepal Demographic and Health Survey data, pregnancy outcomes were categorized as abortion, delivery, miscarriage, or stillbirth. Income-related inequality in the utilization of abortion services was assessed through the concentration index, ranging from -1 to 1. Trends over time were evaluated using the annual rate of change. RESULTS: The ARC indicated a substantial rise in induced abortion rates, surging from 0.4% in 1996 to 8.8% in 2022. In contrast, live births witnessed a decline from 92.8% to 81.2%. Significant variations were observed across ecological zones and wealth quintiles, with the Mountain zone and the Poorest group experiencing the most pronounced increases in induced abortion rates. By 2022, the concentration index reached a near-zero value, signifying a near-elimination of income-related disparities in the use of induced abortion services. DISCUSSION: The findings suggest that while there has been significant progress in access to and use of abortion services in Nepal, particularly post-2002 policy shifts, challenges remain. Women from lower socio-economic backgrounds continue to face barriers, indicating the need for a multi-pronged approach to address residual challenges. CONCLUSIONS: Nepal has made remarkable strides in enhancing equitable access to and use of induced abortion services, but more needs to be done to guarantee equitable access for all women. Future efforts should focus on policy reforms, infrastructural improvements, and societal change to eliminate existing barriers to reproductive healthcare.

Barriers to Abortion among Women and Girls in Selected Districts of Nepal.

BACKGROUND: Even after two decades of legalization of abortion in Nepal, most women and girls still do not have knowledge on abortion legality and face abortion barriers. This study will explore perceived barriers to safe abortion and the factors associated with it. METHODS: A Mixed method study design was conducted in 30 wards of 20 Municipals of seven districts of Lumbini and Sudurpaschim provinces. Quantitative data was analyzed for 673 women of reproductive age of 15-49 years. For qualitative data, key informant interviews were conducted. The analysis was done on five different barriers and a composite variable was created from them. RESULTS: Most women and girls perceived social (34.6%), followed by family (30.6%), physical (30.6%), personal (29.5%), and health facility (14.9%) barriers to access safe abortion services. The key finding was that women and girls with knowledge on abortion legality were more likely to perceive barriers to abortion (AOR:2.31, CI:1.574-3.394). Women and girls with higher educational and economic status as well as Dalit women were less likely to perceive barriers to abortion services whereas never married women and girls perceived more barriers in accessing abortion services. CONCLUSIONS: Women and girls perceived several barriers to access safe abortion services. Women who have better knowledge on abortion legality recognize more barriers regarding abortion. This highlights the importance of raising awareness of women and girls on abortion rights to empower them in recognizing and advocating for the removal of the obstacles that stop them from getting abortion services.

An Estimate of Abortion Incidence and Unintended Pregnancies.

BACKGROUND: After the legalization of abortion in Nepal, there has been remarkable changes in policies and service delivery. However, even after two decades of legalization, access to and use of safe abortion services remains limited. The objective of this study is to estimate the incidence of abortion and unintended pregnancies in Nepal. METHODS: A cross sectional study was conducted in 767 health facilities using structured questionnaires to assess the availability of abortion services, and 231 key informant interviews were conducted. Information on medical abortion drugs was collected from distributors and pharmacies. Abortion estimations were segmented into categories: those performed within healthcare facilities, those conducted outside healthcare facilities, and those using other traditional methods. To estimate pregnancy outcomes, we utilized secondary data from national censuses and health surveys. RESULTS: The total incidence of induced abortion cases in Nepal was estimated to be 333,343 for the year 2021. Only 48 percent of abortion services were provided from the listed (legal) sites and providers. The estimates showed that total facility based induced abortion in Nepal was 176,216 in 2021, more than half were medical abortions. The highest and lowest abortion cases were in Bagmati and Karnali province respectively. The result showed that more than half of the pregnancies were unintended (53.3%). CONCLUSIONS: Despite a relatively liberal legal environment, more than half of all abortions are extra-legal in Nepal. Unintended pregnancies are also common, resulting in induced abortion. This demands for increasing access to information and services on contraception and safe abortion among women and girls.

Service Readiness for Safe Abortion Services.

BACKGROUND:  Health service readiness is a prerequisite to accessing quality services. This study analyzes the readiness of health facilities in Nepal to provide comprehensive abortion services by focusing on the availability and quality of care.   Methods:  This is a cross-sectional study, and a multi-stage sampling approach was used to select health facilities. A total of 767 health facilities were surveyed from 30 Municipalities across the country.   Results: In a study of 767 health facilities surveyed, only 223 (29%) offered abortion services. Among them, 92% offered medical abortion, 48% provided manual vacuum aspiration, 18% offered dilation and evacuation and 18% offered medical induction. Approximately 7% of health facilities lacked trained providers yet still provided services and 29% of health facilities providing abortion services were not compliant with legal requirements. Interestingly, 13% of these facilities lacked short-acting contraceptives.   Conclusions:  Most health facilities in Nepal lack readiness for Safe Abortion Services (SAS), failing to meet minimum criteria, including to provide abortion legally. Urgent collaborative efforts among policymakers, administrators, and healthcare providers are needed to align with Nepal's Sustainable Development Goals and address gaps in safe abortion service availability. This includes policy updates, strengthening Public-Private Partnerships (PPPs), and ensuring comprehensive SAS implementation and financing as part of essential health services.

A Critical Analysis of Safe Abortion Road Map in Nepal.

BACKGROUND: Abortion was legalized by the 2002 Muluki Ain to combat the surging rates of maternal mortality and morbidity. By 2021, the Maternal Mortality Rate plummeted to 151 from 539 in 1996. The decline in the abortion-related maternal mortality attributes to the implication of progressive abortion policies that includes expanded safe abortion services introduction of medical abortion, constitutional recognition of abortion, the mandates by Safe Motherhood and Reproductive Health Rights Act, and free-of-cost abortion services in government health facilities. This review study delves into exploring the contemporary abortion policies and its implications on women's access to safe abortion services as well as the factors that affect the access. METHODS: This study incorporates findings from extensive desk review of abortion services in Nepal. RESULTS: The 2021 safe abortion services Program Implementation Guideline aims to expand safe abortion sites; however, the Nepal's challenging geography ensues its inequitable distribution, especially in mountainous area. Policy provisions on information and financial accessibility to abortion are well navigated by the Safe Motherhood and Reproductive Health Rights Act and regulation but consistent to sporadic gaps in its implementation were comprehended in this study. This paper further discussed the Safe Motherhood and Reproductive Health Rights Act's regressive mandate of 28-week gestational limit at any condition and the role of gender in abortion decision-making under the pretext of factors influencing safe abortion services. CONCLUSIONS: The review study recommends strategies: improving capacity for abortion services under federalism, combating stigma, improving the private sector's readiness, and building a resilient health system.

Social determinants of tobacco consumption among Nepalese men: findings from Nepal Demographic and Health Survey 2011.

BACKGROUND: In the 20th century, 100 million people across the globe lost their lives due to consumption of tobacco. Every year 15,000 deaths in Nepal are attributable to tobacco smoking and using other products of tobacco. This study aimed to establish the proportion and the social determinants of tobacco use among Nepalese men based on the Nepal Demographic and Health Survey (NDHS), 2011. METHODS: This study used the NDHS 2011 data. The prevalence of cigarette smoking, other forms of tobacco 16 smoking and use of tobacco in any form is reported as a percentage (%). The significance of association of the statistically significant variables established using Chi-square test was further tested by using multiple logistic regression. RESULTS: Of the 4121 participants, the prevalence of consuming any form of tobacco was 51.9% [95% confidence interval (CI) (49.6%- 54.3%)]; chewing/sniffing tobacco was 34.8% (95% CI: 32.4%- 37.3%) and tobacco smoking was 33.6% (95% CI 31.3%-36.0%).Men with no education [Odds Ratio (OR) 3.477; 95% CI (2.380-5.080)], from an older age group (36-49) [OR 2.399; 95% CI (1.858-3.096)] who were from a manual occupation [OR 1.538; 95% CI (1.188-1.985)], who were married[OR 1.938; 95% CI ( 1.552-2.420)], and who were from the Terai region [OR 1.351; 95% CI (1.083-1.684)] were more likely to consume tobacco. Men who watched television at least once a week [OR 0.642; 95% CI (0.504-0.819)] were less likely to consume tobacco. CONCLUSIONS: The current study showed that over half of Nepalese men consume tobacco. There is an urgent need to fully implement Nepal's Tobacco Control and Regulation Act which will ban smoking in public places; enforced plain packaging and display of health warnings over 75% of the packaging, and has banned selling of tobacco products to those under 18 years of age. There is a need to increase the social unacceptability of tobacco in Nepal by raising awareness through different electronic and cultural media. Anti-tobacco campaigns should focus on those who are less educated, have manual occupations, are in poorer economic groups, and are from the Terai region of Nepal.

Factors that determine women's autonomy to make decisions about sexual and reproductive health and rights in Nepal: A cross-sectional study.

Women's autonomy on sexual and reproductive health issues is critical to women's health and well-being. Women have the right to decide on their fertility and sexuality, be free from coercion and violence, and achieve well-being. This study has identified women's autonomy regarding decision and exercise of their sexual reproductive health and rights and its association with determining factors in Nepal. Descriptive and analytical statistics such as bivariate and multivariate regression analysis were performed using data from Nepal Demographic and Health Survey 2016. The survey collected data from 12,862 women of reproductive age groups i.e. 15-49 years. However, for this study, we analyzed the data of only ever-married women and they were 9,875 in total. The analysis showed that women's autonomy in exercising their sexual reproductive health rights is highly associated with media exposure after controlling demographic variables. The frequency of exposure to media (i. less than a week: adjusted odds ratio (AOR):1.383; confidence interval (CI):1.145-1.670, p<0.001, ii. at least once a week: AOR:1.657; CI:1.359-2.021, p<0.001) is positively associated with women's autonomy. Furthermore, factors like women from Janajati (AOR:1.298; CI:1.071-1.576, p<0.01) and other Terai ethnic groups (AOR:1.471; CI:1.160-1.866, p<0.01), higher education attainment (AOR:1.482; CI:1.164-1.888, p<0.01), richest wealth quintile (AOR:1.527; CI:1.151-2.026, p<0.01), paid work (AOR:1.277; CI:1.045-1.561, p<0.05) and living in Lumbini Province (AOR:0.622; CI:0.486-0.797, p<0.001) and Sudur Paschim Province (AOR:0.723; CI:0.554-0.944, p<0.05) were found to be significantly associated with women's autonomy in sexual and reproductive health decision making. Similarly, women's autonomy is also increased with their increased age. In conclusion, women's exposure to media, improved socio-economic status and increased age influence their autonomy to make decisions about sexual and reproductive health rights in Nepal. Therefore, this study underscores the need to address socio-economic barriers and improve women's exposure to the media to enhance their autonomy further.

The Know-Do Gap: Understanding and Improving Service Quality Among Pharmacies Providing Injectable Contraceptives Through a Mystery Client Study in Nepal.

Nepal is one of the first countries to license pharmacists to administer injectable contraceptives, through Nepal CRS Company's (CRS) Sangini private pharmacy network. There are more than 3,400 Sangini pharmacies in Nepal, including in hard-to-reach mountain areas, where these outlets are a key access point to injectables and other short-acting methods for those who lack access through the public sector or prefer the private sector.We compared the performance of Sangini pharmacists in (1) CRS-led technical support visits, when providers were aware of being observed, and (2) mystery client visits, when providers were not aware of being observed, to assess any gaps between pharmacists' knowledge and practices. We also assessed how well Sangini providers counseled on injectables and compared counseling on injectables with counseling for oral contraceptives.We found high levels of adherence to training guidelines on counseling on injectables. However, we identified significant differences between pharmacists' understanding of what they should do and what they actually do in practice, referred to as the know-do gap, in providing privacy, assessing client needs, and determining medical eligibility for hormonal methods. CRS took several steps to narrow the know-do gap through its programming, which may be a useful example for other countries as they expand the role of pharmacies in family planning service provision. Despite highlighting several areas for improvement, the findings show that Sangini providers both know how to and practice appropriate counseling on both injectable and oral contraceptives, suggesting that pharmacists can successfully expand their family planning offerings and equip clients with the information needed to select an appropriate method of their choice.