Integrating postpartum contraceptive counseling and IUD insertion services into maternity care in Nepal: results from stepped-wedge randomized controlled trial.

BACKGROUND: In Nepal, 54% of women have an unmet need for family planning within the 2 years following a birth. Provision of a long-acting and reversible contraceptive method at the time of birth in health facilities could improve access to postpartum family planning for women who want to space or limit their births. This paper examines the impact of an intervention that introduced postpartum contraceptive counseling in antenatal care and immediate postpartum intra-uterine device (PPIUD) insertion services following institutional delivery, with the intent to eventually integrate PPIUD counseling and insertion services as part of routine maternity care in Nepal. METHODS: This study took place in six large tertiary hospitals. All women who gave birth in these hospitals in the 18-month period between September 2015 and March 2017 were asked to participate. A total of 75,587 women (99.6% consent rate) gave consent to be interviewed while in postnatal ward after delivery and before discharge from hospital. We use a stepped-wedge cluster randomized design with randomization of the intervention timing at the hospital level. The baseline data collection began prior to the intervention in all hospitals and the intervention was introduced into the hospitals in two steps, with first group of three hospitals implementing the intervention 3 months after the baseline had begun, and second group of three hospitals implementing the intervention 9 months after the baseline had begun. We estimate the overall effect using a linear regression with a wild bootstrap to estimate valid standard errors given the cluster randomized design. We also estimate the effect of being counseled on PPIUD uptake. RESULTS: Our Intent-to-Treat analysis shows that being exposed to the intervention increased PPIUD counseling among women by 25 percentage points (pp) [95% CI: 14-40 pp], and PPIUD uptake by four percentage points [95% CI: 3-6 pp]. Our adherence-adjusted estimate shows that, on average, being counseled due to the intervention increased PPIUD uptake by about 17 percentage points [95% CI: 14-40 pp]. CONCLUSIONS: The intervention increased PPIUD counseling rates and PPIUD uptake among women in the six study hospitals. If counseling had covered all women in the sample, PPIUD uptake would have been higher. Our results suggest that providing high quality counseling and insertion services generates higher demand for PPIUD services and could reduce unmet need. TRIAL REGISTRATION: Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Providers' perspectives on denial of abortion care in Nepal: a cross sectional study.

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.

Intimate partner violence, food insecurity and COVID-19 among newly married women in Nawalparasi district of Nepal: a longitudinal study.

This paper examines factors associated with intimate partner violence (IPV) among newly married women in Nepal, and how IPV was affected by food insecurity and COVID-19. Given evidence that food insecurity is associated with IPV and COVID-19, we explored whether increased food insecurity during COVID-19 is associated with changes in IPV. We used data from a cohort study of 200 newly married women aged 18-25 years, interviewed five times over two years at 6-month intervals (02/2018-07/2020), including after COVID-19-associated lockdowns. Bivariate analysis and mixed-effects logistic regression models were used to examine the association between selected risk factors and recent IPV. IPV increased from 24.5% at baseline to 49.2% before COVID-19 and to 80.4% after COVID-19. After adjusting for covariates, we find that both COVID-19 (OR = 2.93, 95% CI 1.07-8.02) and food insecurity (OR = 7.12, 95% CI 4.04-12.56) are associated with increased odds of IPV, and IPV increased more for food-insecure women post COVID-19 (compared to non-food insecure), but this was not statistically significant (confidence interval 0.76-8.69, p-value = 0.131). Young, newly married women experience high rates of IPV that increase with time in marriage, and COVID-19 has exacerbated this, especially for food-insecure women in the present sample. Along with enforcement of laws against IPV, our results suggest that special attention needs to be paid to women during a crisis time like the current COVID-19 pandemic, especially those who experience other household stressors.

Denial of legal abortion in Nepal.

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 (n = 1,835), at six weeks after abortion-seeking (n = 1523) and six-month intervals for three years. Using descriptive and multivariable logistic regression models, we examined factors associated with presenting for abortion before versus after 10 weeks gestation, with receiving versus being denied an abortion, and with continuing the pregnancy after being denied care. We also described reasons for the denial of care and how and where participants sought abortion care subsequent to being denied. Mixed-effects models was used to accounting clustering effect at the facility level. RESULTS: Among those recruited when eligibility included seeking abortion at any gestational age, four in ten women sought abortion care beyond 10 weeks or did not know their gestation and just over one in ten was denied care. Of the full sample, 73% were at or beyond 10 weeks gestation, 44% were denied care, and 60% of those denied continued to seek care after denial. Nearly three-quarters of those denied care were legally eligible for abortion, based on their gestation and pre-existing conditions. Women with lower socioeconomic status, including those who were younger, less educated, and less wealthy, were more likely to present later for abortion, more likely to be turned away, and more likely to continue the pregnancy after denial of care. CONCLUSION: Denial of legal abortion care in Nepal is common, particularly among those with fewer resources. The majority of those denied in the sample should have been able to obtain care according to Nepal's abortion law. Abortion denial could have significant potential implications for the health and well-being of women and their families in Nepal.

Provider and Women Characteristics as Risk Factors for Postpartum Copper IUD Expulsion and Discontinuation in Nepal.

CONTEXT: Providers' and women's characteristics are associated with postpartum copper IUD (PPIUD) outcomes, but the relationship between providers' level of experience and PPIUD expulsion and discontinuation has not been established. METHODS: Data on 1,232 women and 118 providers who took part in a randomized trial of a PPIUD counselling and provision intervention in Nepal between 2015 and 2017 were used to identify associations between providers' and women's characteristics and PPIUD outcomes. Multinomial logistic regression models were used to estimate PPIUD expulsion and discontinuation risks at two years after insertion. RESULTS: Thirteen percent of women had had partial or complete expulsions and 29% had discontinued PPIUD use by two years. Having a provider who had done at least 10 previous insertions was associated with lower risk of expulsion rather than continuation (relative risk ratio, 0.5) relative to having a less-experienced provider. Women had a higher risk of both expulsion and discontinuation relative to continuation if they were younger than 21 rather than aged 26-30 (2.4 and 1.7, respectively) or if they belonged to the Dalit rather than Brahmin caste (2.2 and 1.9, respectively). Women whose husbands did not live at home also had elevated discontinuation risks. CONCLUSION: The findings highlight the need for increased training and supervision of providers during their first 10 PPIUD insertions. Counselling on risk of expulsion may especially benefit younger and Dalit women, and should include partners and other family members to avoid any stigma surrounding PPIUD use by women whose partner is away from home for a prolonged period.

RESUMEN Contexto: Las características de proveedores de servicios de salud y mujeres están asociadas con los resultados del DIU de cobre posparto (DIUPP), pero no se ha establecido la relación entre la experiencia de los proveedores de servicios de salud y la expulsión y discontinuación del DIUPP. Metodos: Se utilizaron datos de 1,232 mujeres y 118 proveedores de servicios de salud que participaron en un ensayo aleatorio de una intervención de consejería y provisión de DIUPP en Nepal entre 2015 y 2017, para identificar asociaciones entre las características de proveedores de servicios de salud y mujeres y los resultados relacionados con el DIUPP. Se utilizaron modelos de regresión logística multinomial para estimar los riesgos de expulsión y discontinuación de DIUPP dos años después de la inserción. Resultados: El 13% de las mujeres había tenido expulsiones parciales o completas y el 29% había descontinuado el uso de DIUPP a los dos años. Haber tenido un proveedor con experiencia de al menos 10 inserciones previas en comparación con un proveedor con menos experiencia se asoció con un menor riesgo de expulsión en lugar de continuación (índice de riesgo relativo 0.5). Las mujeres tuvieron un mayor riesgo tanto de expulsión como de discontinuación si eran menores de 21 años, en lugar de tener entre 26 y 30 (2.4 y 1.7, respectivamente), o si pertenecían a la casta dalit en lugar de a la casta brahmán (2.2 y 1.9, respectivamente). Las mujeres cuyos maridos no vivían en casa también tenían un riesgo elevado de discontinuación del tratamiento. Conclusión: Los hallazgos destacan la necesidad de una mayor capacitación y supervisión de los proveedores de servicios de salud durante sus primeras 10 inserciones de DIUPP. La consejería sobre el riesgo de expulsión podría beneficiar especialmente a las mujeres más jóvenes y que pertenecen a la casta dalit; y debe incluir a las parejas y otros miembros de la familia para evitar cualquier estigma en torno al uso de DIUPP por parte de las mujeres cuya pareja está fuera de casa durante un período prolongado.

RÉSUMÉN Contexte: Les caractéristiques des prestataires et des femmes sont associées aux résultats du DIU au cuivre post-partum (DIUPP), mais le rapport entre l'expérience des prestataires, l'expulsion du DIUPP et l'arrêt de la méthode n'a pas été établi. Méthodes: Les données relatives à 1 232 femmes et 118 prestataires ayant participé à un essai randomisé d'intervention de conseil et de pose d'un DIUPP au Népal entre 2015 et 2017 ont permis d'identifier les associations entre les caractéristiques des prestataires et des femmes et les résultats relatifs au DIUPP. Les risques d'expulsion du DIUPP et d'arrêt de la méthode ont été estimés à deux ans après la pose par modélisation de régression logistique multinomiale. Résultats: Treize pour cent des femmes avaient connu une expulsion partielle ou complète et 29% avaient arrêté l'utilisation du DIUPP en l'espace de de deux ans. Le fait d'avoir un prestataire ayant pratiqué au moins 10 poses antérieures s'est avéré associé à un risque moindre d'expulsion que de continuation (rapport de risque relatif de 0,5), par rapport au fait d'avoir eu un prestataire moins expérimenté. Les femmes couraient un plus grand risque d'expulsion aussi bien que d'arrêt de la méthode si elles avaient moins de 21 ans par rapport à la tranche d'âge de 26 à 30 ans (2,4 et 1,7, respectivement) ou si elles appartenaient à la caste des Dalits plutôt que des Brahmanes (2,2 et 1,9, respectivement). Les femmes dont le mari ne vivait pas sous le même toit présentaient aussi de plus hauts risques d'arrêt. Conclusion: Les résultats révèlent clairement la nécessité d'une formation et d'un encadrement accrus des prestataires lors de leurs 10 premières poses de DIUPP. Le conseil relatif au risque d'expulsion pourrait bénéficier tout particulièrement aux femmes plus jeunes et de la caste des Dalits. Il doit aussi inclure les partenaires et d'autres membres de la famille pour éviter toute stigmatisation concernant l'utilisation du DIUPP par les femmes dont le partenaire est absent pendant une période prolongée.

The effect of antenatal counseling and intrauterine device insertion services on postpartum contraceptive use in Nepal: Results from a stepped-wedge randomized controlled trial.

OBJECTIVE: There is high unmet need for family planning in the postpartum period in Nepal. The current study assessed the effects of a contraceptive counseling and postpartum intrauterine device (PPIUD) insertion intervention on use of contraception in the postpartum period. STUDY DESIGN: We utilized a cluster, stepped-wedge design to randomly assign two hospital clusters (compromised of six hospitals) to begin the intervention at time one or time two. From 2015 to 2017, women completed surveys after delivery but before discharge (n = 75,893), and then at one year and two years postpartum. We estimated the intent-to-treat effect of the intervention using weighted, linear probability models and the adherence-adjusted effect (antenatal counseling) using an instrumental variable approach. Outcomes included modern contraceptive use and method mix measured at one and two years postpartum in a sample of 19,298 women (year I follow-up sample) and a sample of 19,248 women (year II follow-up sample). We used inverse probability weights to adjust for incomplete follow-up and bootstrap methods to give correct causal inference with the small number of six clusters. RESULTS: The intervention increased use of modern contraceptives by 3.8 percentage points [95% CI: -0.1, 9.5] at one-year postpartum, but only 0.3 percentage points [95% CI: -3.7, 4.1] at two years. The intervention significantly increased the use of PPIUDs at one year and two years postpartum, but there was less use of sterilization. Only 42% of women were counseled during the intervention period. The adherence-adjusted effects (antenatal counseling) were four times larger than the intent-to-treat effects. CONCLUSIONS: Providing counseling during the antenatal period and PPIUD services in hospitals increased use of PPIUDs in the one- and two-year postpartum period and shifted the contraceptive method mix. IMPLICATIONS: In order for antenatal counseling to increase postpartum contraceptive use, counseling may need to be provided in a wider range of prenatal care settings and at multiple time points. Healthcare providers should be trained on contraceptive counseling and PPIUD insertion, with the goal of expanding the available method mix and meeting postpartum women's contraceptive needs.

Determinants of imbalanced sex ratio at birth in Nepal: evidence from secondary analysis of a large hospital-based study and nationally-representative survey data.

OBJECTIVES: To quantify sex ratios at births (SRBs) in hospital deliveries in Nepal, and understand the socio-demographic correlates of skewed SRB. Skewed SRBs in hospitals could be explained by sex selective abortion, and/or by decision to have a son delivered in a hospital-increased in -utero investments for male fetus. We use data on ultrasound use to quantify links between prenatal knowledge of sex, parity and skewed SRBs. DESIGN: Secondary analysis of: (1) de-identified data from a randomizedrandomised controlled trial, and (2) 2011 Nepal Demographic and Health Survey (NDHS). SETTING: Nepal. PARTICIPANTS: (1) 75 428 women who gave birth in study hospitals, (2) NDHS: 12 674 women aged 15-49 years. OUTCOME MEASURES: SRB, and conditional SRB of a second child given first born male or female were calculated. RESULTS: Using data from 75 428 women who gave birth in six tertiary hospitals in Nepal between September 2015 and March 2017, we report skewed SRBs in these hospitals, with some hospitals registering deliveries of 121 male births per 100 female births. We find that a nationally representative survey (2011 NDHS) reveals no difference in the number of hospital delivery of male and female babies. Additionally, we find that: (1) estimated SRB of second-order births conditional on the first being a girl is significantly higher than the biological SRB in our study and (2) multiparous women are more likely to have prenatal knowledge of the sex of their fetus and to have male births than primiparous women with the differences increasing with increasing levels of education. CONCLUSIONS: Our analysis supports sex-selective abortion as the dominant cause of skewed SRBs in study hospitals. Comprehensive national policies that not only plan and enforce regulations against gender-biased abortions and, but also ameliorate the marginalizedmarginalised status of women in Nepal are urgently required to change this alarming manifestation of son preference. TRIAL REGISTRATION NUMBER: NCT02718222.

Pharmacy access to medical abortion from trained providers and post-abortion contraception in Nepal.

OBJECTIVE: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies was 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. RESULTS: Of 605 participants, 600 completed follow-up at 14-21 days; 474 (79.0%) were using a contraceptive method, most commonly pills (180 [30.0%]) and injectables (175 [29.2%]), followed by condoms (82 [13.7%]), long-acting reversible methods (33 [5.5%]), and sterilization (4 [0.7%]). Receipt of care from a private pharmacy was not associated with a difference in the use of hormonal or long-acting methods (adjusted odd ratio 0.89, 95% confidence interval 0.60-1.33). CONCLUSION: Medical abortion provision from pharmacies by qualified providers can provide women with necessary induced-abortion care while not compromising longer-term pregnancy prevention.

Effectiveness and safety of early medication abortion provided in pharmacies by auxiliary nurse-midwives: A non-inferiority study in Nepal.

BACKGROUND: Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal. METHODS: Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 µg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression. RESULTS: Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%]). CONCLUSIONS: Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.