Does prior ultrasonography affect the safety of induced abortion at or after 13 weeks' gestation? A retrospective study.

INTRODUCTION: We aimed to assess whether ultrasonography prior to dilation and evacuation or medical abortion ≥13 weeks was correlated with safety. MATERIAL AND METHODS: We conducted a retrospective chart review of patients undergoing abortion ≥13 weeks at eight sites in Nepal from 2015 to 2019. RESULTS: We included 2294 women undergoing abortion ≥13 weeks (no upper gestational age limit); 593 underwent dilation and evacuation and 1701 had a medical abortion. Demographics differed by procedure for parity (19% vs 33% nulliparous, dilation and evacuation, and medical abortion) and gestational age (90% vs 52% were 13-15 weeks, dilation and evacuation, and medical abortion). Ultrasonography was performed in 81% of cases overall. Complications were rare (<1% of dilations and evacuations, 1.4% of medical abortions). The most common adverse events with dilation and evacuation were hemorrhage and cervical laceration; three women required re-aspiration. Following medical abortion, 13.5% had retained products, 12.9% with prior ultrasound and 16.3% who had not had an ultrasound. Hemorrhage and severe side-effects occurred at similarly low rates regardless of whether ultrasonography was performed. In a logistic regression model where patient characteristics and case clustering within facilities were controlled for, we found a correlation between ultrasonography and complications when retained placenta was included in the model, but there was no correlation between ultrasonography and complications when retained placenta was excluded. CONCLUSIONS: This study confirms low complication rates among women having an abortion ≥13 weeks' gestation in healthcare facilities. Settings without universal availability of ultrasound may still maintain low, comparable complication rates.

Retraction Note: Factors associated with induced abortion in Nepal: data from a nationally representative population-based cross-sectional survey.

The authors have retracted this article [1] because it contains significant conceptual and textual overlap with unpublished work from another group. Suresh Mehata, Jamie Menzel, Erin Pearson and Kathryn Andersen agree with this retraction. Navaraj Bhattarai, Sharad Kumar Sharma and Mukta Shah did not respond to correspondence regarding this retraction.

Factors associated with induced abortion in Nepal: data from a nationally representative population-based cross-sectional survey.

BACKGROUND: Despite the legalization of abortion services in 2002, unsafe abortion (abortion services conducted by persons lacking necessary skill or in substandard settings or both) continues to be a public health concern in Nepal. There is a lack of national research exploring the characteristics of women who choose to have an abortion. This study assessed abortion in Nepal and its correlates using data from a nationally representative population-based cross-sectional survey. METHODS: We employed data from the Nepal Demographic and Health Survey 2016. Sample selection was based on stratified two-stage cluster sampling in rural areas and three-stage sampling in urban areas. The primary outcome is report of induced abortion in the 5 years preceding the survey, as recorded in the pregnancy history. All values were weighted by sample weights to provide population-level estimates. Bivariate and multivariate logistic regressions were performed using STATA 14 considering cluster sampling design. RESULTS: A total of 12,862 women of reproductive age (15-49 years) were interviewed. Overall, 4% (95% CI: 3.41-4.29) reported an abortion within the last 5 years (and less than 1% had had more than one abortion during that time). A higher proportion of women aged 20-34 years (5.7%), women with primary education (5.1%), women aware of abortion legalization (5.5%), and women in the richest wealth quintile (5.4%) had an abortion in the past 5 years. Compared to women aged < 20 years, women aged 20-34 years had higher odds (AOR: 5.54; 95% CI: 2.87-10.72) of having had an abortion in the past 5 years. Women with three or more living children had greater odds (AOR: 2.24; 95% CI: 1.51-3.31) of having had an abortion than women with no living children. The odds of having an abortion in the past 5 years increased with each wealth quintile, with the richest wealth quintile having almost three-fold greater odds of having had an abortion. No significant association was observed between having an abortion and the ecological zone and place of residence. CONCLUSION: This nationally representative study shows that abortion is associated with women's age, knowledge of abortion legality, wealth status, number of living children, and caste/ethnicity. Targeted interventions to young women, those in the poorest wealth quintile, women from Terai caste groups, and those who reside in Province 2 would be instrumental to address disproportional access to abortion services. Overall, strengthening contraceptive provision and abortion education programs would be cornerstone to improving the health of women and girls in Nepal.

Prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among young women (24 and below) in Nepal: Strategy in the search for improvements.

INTRODUCTION: Postabortion contraceptive use differs across countries, suggesting the need for country-level research to identify barriers and suggest appropriate interventions. This study aimed to identify the prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among women aged 24 or younger in Nepal. METHODS: This is a cohort study using Health Management Information System (HMIS) data where individual case records of women seeking induced abortion or postabortion care were documented using structured HMIS 3.7 records. Analysis was performed on the individual case records of 20,307 women 24 years or younger who received induced abortion or postabortion care services in the three-year period from July 2014 to June 2017 at 433 public and private health facilities. FINDINGS: Overall, LARC uptake during the study period was 11% (IUD: 3% and implant: 8%). The odds of LARC acceptance was higher for young women (24 and below) who belonged to Brahmin/Chhetri (AOR = 1.23; 95% CI: 1.02-1.47) and Janajatis (AOR = 1.20; 95% CI: 1.01-1.43) as compared to Dalits; young women who had an induced abortion (AOR = 3.75; 95% CI: 1.75-8.06) compared with postabortion care; and those receiving service from public sector health facilities (AOR = 4.00; 95% CI: 2.06-7.75) compared with private sector health facilities. CONCLUSION: The findings from this study indicate the need to focus on barriers to acceptance of LARC among several groups of young women (24 and below) receiving abortion care in Nepal: Dalits, Madhesis and Muslims; nulliparous women; and those receiving services at private sector health facilities.

Examining the availability and readiness of health facilities to provide cervical cancer screening services in Nepal: a cross-sectional study using data from the Nepal Health Facility Survey.

OBJECTIVE: We assessed the availability and readiness of health facilities to provide cervical cancer screening services in Nepal. DESIGN: Cross-sectional study. SETTING: We used secondary data from a nationally representative 2021 Nepal Health Facility Survey, specifically focusing on the facilities offering cervical cancer screening services. OUTCOME MEASURES: We defined the readiness of health facilities to provide cervical cancer screening services using the standard WHO service availability and readiness assessment manual. RESULTS: The overall readiness score was 59.1% (95% CI 55.4% to 62.8%), with more equipment and diagnostic tests available than staff and guidelines. Public hospitals (67.4%, 95% CI 63.0% to 71.7%) had the highest readiness levels. Compared with urban areas, health facilities in rural areas had lower readiness. The Sudurpashchim, Bagmati and Gandaki provinces had higher readiness levels (69.1%, 95% CI 57.7% to 80.5%; 60.1%, 95% CI 53.4% to 66.8%; and 62.5%, 95% CI 56.5% to 68.5%, respectively). Around 17% of facilities had trained providers and specific guidelines to follow while providing cervical cancer screening services. The basic healthcare centres (BHCCs) had lower readiness than private hospitals. Facility types, province and staff management meetings had heterogeneous associations with three conditional quantile scores. CONCLUSION: The availability of cervical cancer screening services is limited in Nepal, necessitating urgent action to expand coverage. Our findings suggest that efforts should focus on improving the readiness of existing facilities by providing training to healthcare workers and increasing access to guidelines. BHCCs and healthcare facilities in rural areas and Karnali province should be given priority to enhance their readiness.

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.

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.

Development and validation of a perceived abortion self-efficacy scale: results from Bolivia, Nepal and Nigeria.

The objective of this research was to develop and assess the validity of a scale to measure perceived abortion self-efficacy (PASE). Perceived abortion self-efficacy is defined as an individual's perceived confidence in their ability to carry out the tasks necessary to end a pregnancy safely and successfully. During the first phase of this study between February and April 2018, we conducted qualitative research using in-depth interviews and focus group discussions with women in Bolivia, Nepal, and Nigeria to explore domains of PASE. Using the qualitative data, we prepared a draft set of measures with 31 items. In October and November 2018, the second phase of the study included field testing 31 draft items with a convenience sample of approximately 1200 women across the three study countries. Exploratory factor analysis was conducted to identify an appropriate scale structure, resulting in a 15-item, 3-factor model. The three factors represent the concepts of enlisting social resources, accessing information and care, and resilience. In the third and final phase in September and October 2019, the validity of the 15 scale items was assessed. The scale was administered to a new sample of approximately 400 women in each country. Confirmatory factor analyses were conducted to test model fit for the scale structure identified during the second phase. The results from this study suggest that the final PASE scale has considerable potential to be a valid measure of PASE. The new 15-item PASE scale presented in this paper can be used to evaluate programmes or interventions designed to improve women's PASE and to assess the state of PASE in populations.

Socioeconomic Determinants of Inequalities in the Use of Modern Contraception among Currently Married Women.

BACKGROUND: Despite interventions for over four decades, the unmet need for family planning is high in Nepal. This study aims to examine the status and the socioeconomic determinants of inequalities in modern contraception among currently married women. METHODS:  We applied a mixed-method design. We interviewed key informants for qualitative information and analyzed secondary data from the Nepal Multiple Indicator Cluster Survey, 2019, and different rounds of Nepal Demographic and Health Surveys. We calculated ratios, differences in percentages, and concentration indices to analyse the inequality. We ran a binary logistic regression model to estimate the adjusted effect of each factor on the use of modern contraception. RESULTS:  The richest-to-poorest difference in using modern contraception has decreased over 13 years. The richest-to-poorest difference decreased from 23.6 percentage points in 2006 to 13.3 percentage points in 2011 and further to 1.2 percentage points in 2016. The richest-to-poorest difference was negative in 2019, indicating poor people are using more contraception than the richest. Multivariate analysis showed the wealth is a significant predictor for using contraception. Women of richer households (aOR=1.29, 95% CI=1.13-1.48), middle (aOR=1.21, 95% CI=1.05-1.40), poorer (aOR=1.36, 95% CI 1.17-1.58) and poorest (aOR=1.18, 95% CI=1.05-1.34) were more likely to use contraception than women from the richest households. CONCLUSIONS: Poor people are increasingly using the modern contraception, and the gap between the poor and rich people has decreased. However, the trend of contraception use in each wealth quintile indicates that Nepal struggles to meet the sustainable development goal target of reducing the unmet need for family planning to less than 10% by 2030.

Factors associated with HIV testing and counselling services among women and men in Nepal: a cross-sectional study using data from a nationally representative survey.

OBJECTIVES: This study is set up to explore the factors associated with Human Immunodeficiency Virus (HIV) testing among women and men in Nepal. STUDY DESIGN: Nepal Demographic and Health Survey, 2016 adopts a cross-sectional design. SETTING: Nepal. PARTICIPANTS: Women and men of age 15-49 years. PRIMARY OUTCOME MEASURES: Our primary outcome was ever tested for HIV. We used multivariable analysis at a 95% level of significance to measure the effect in outcome variables. RESULTS: About one in 10 women (10.8%) and one in five men (20.5%) ever tested for HIV. Women who had media exposure at least once a week ((adjusted odds ratio (aOR)=2.8; 95% CI: 1.4 to 5.3) were more likely to get tested for HIV compared with those who had no media exposure at all. Similarly, those who had their recent delivery in the health facility (aOR=3.9; 95% CI: 2.4 to 6.3) were more likely to get tests for HIV compared with those delivered elsewhere. Likewise, among men, compared with adolescents (15-19 years), those from older age groups were more likely to get tested for HIV. Compared with no education, secondary (aOR=2.3; 95% CI: 1.4 to 3.6) and higher education (aOR=1.7; 95% CI: 1.0 to 2.8) had higher odds of getting tested for HIV. Similarly, wealth quintiles in richer and richest groups were more likely to get tested for HIV compared with the poorest quintile. Other characteristics like media exposure, paid sex and 2+ sexual partners were positively associated with being tested for HIV. CONCLUSIONS: HIV testing is not widespread and more men than women are accessing HIV services. More than two-thirds of women who delivered at health facilities never tested for HIV. It is imperative to reach out to people engaging in risky sexual behaviour, people with lower educational attainment, and those in the lower wealth quintile for achieving 95-95-95 targets by 2030.

Availability and readiness to provide sexually transmitted infections and HIV testing and counselling services in Nepal: evidence from comprehensive health facility survey.

OBJECTIVE: We assessed the availability and readiness of health facilities to provide sexually transmitted infections (STI) and HIV testing and counselling (HTC) services in Nepal. DESIGN: This was a cross-sectional study. SETTING: We used data from the most recent nationally representative Nepal Health Facility Survey (NHFS) 2015. A total of 963 health facilities were surveyed with 97% response rate. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of this study was to assess the availability and readiness of health facilities to provide STI and HTC services using the WHO Service Availability and Readiness Assessment (SARA) manual. RESULTS: Nearly three-fourths (73.8%) and less than one-tenth (5.9%) of health facilities reported providing STI and HTC services, respectively. The mean readiness score of STI and HTC services was 26.2% and 68.9%, respectively. The readiness scores varied significantly according to the managing authority (private vs public) for both STI and HTC services. Interestingly, health facilities with external supervision had better service readiness scores for STI services that were almost four points higher than compared with those facilities with no external supervision. Regarding HTC services, service readiness was lower at private hospitals (32.9 points lower) compared to government hospitals. Unlike STI services, the readiness of facilities to provide HTC services was higher (4.8 point higher) at facilities which performed quality assurance. CONCLUSION: The facility readiness for HTC service is higher than that for STI services. There are persistent gaps in staff, guidelines and medicine and commodities across both services. Government of Nepal should focus on ensuring constant supervision and quality assurance, as these were among the determining factors for facility readiness.

Prevalence, awareness, treatment and control of hypertension in Nepal: data from nationally representative population-based cross-sectional study.

BACKGROUND: Previous studies in Nepal noted an alarming increase in prevalence of hypertension. However, these studies were geographically sparse and coverage of population, mostly limited to single site. The current study fills this gap by examining the current status of prevalence, awareness, treatment and control of hypertension, using recently collected population-based data. METHODS: We used the Nepal Demographic Health Survey 2016 data. Sample selection was based on stratified two-stage cluster sampling in rural areas and three stages in urban areas. Blood pressure was measured in all women and men aged 15 and above. RESULTS: A total of 13 598 participants: 5593 men and 8005 women aged 15-69 had their blood pressures measured. Overall, 18% (95% CI 16.7-19.2) of the participants aged 15-69 years were hypertensive. Prevalence of hypertension was more among men (22%; 95% CI 21.1-23.5), aged 45-69 years (34%), with no formal education (22%), richest quintile (25%), formerly/ever married (32%), urban dwellers (19%), residents of Province 4 (24%), residents of hills (21%), and obese (41.6%). Among the total hypertensive individuals, only 38% were aware of their hypertensive status and 18% were taking antihypertensive medication. Only half of the hypertensive participants on treatment (52%) had their blood pressure under control. CONCLUSION: This nationally representative survey data showed that the prevalence of hypertension is high in Nepal, whereas its awareness, treatment and control rates are low at entire population level.