Policy change to improve access to safe abortion care in federal Nepal.

In Nepal's constitution, safe abortion care is recognized as an essential component of a comprehensive approach to fulfill individuals' sexual and reproductive health and rights. In the current context of transition to a three-level governance (federal, provincial, and local), there are opportunities to accelerate decentralization and devolution of decision-making power, increase access to and coverage of safe abortion services, and improve health outcomes. This article documents the processes and results of the policy change undertaken by the Ministry of Health and Population in collaboration with development partners to decentralize the approval process of safe abortion sites and providers with the objective to increase access to and coverage of safe abortion services. With the decentralization of certification, the approval process for safe abortion service sites and providers has become simpler, less time consuming, and less expensive by reducing cost of traveling to Kathmandu or approaching authorities at the federal level. This has resulted in expanding safe abortion services across the country including remote areas with marginalized populations. Evidence-based advocacy enabled policy change for decentralization of the approval process. Collaboration among stakeholders has been vital for implementing the policy change, including issuing directives from the federal to provincial levels and capacity strengthening of provincial level officials in understanding the requirements for approval of sites and providers.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal.

INTRODUCTION: Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. METHODS: A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. RESULTS: Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. CONCLUSIONS: The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study.

BACKGROUND: Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV's knowledge through orientation on PPFP. METHODS: We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data. RESULTS: In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling. CONCLUSION: The orientation improved the FCHV's knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV's role in improving community-based PPFP services.

Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study.

BACKGROUND: The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. METHODS: This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. RESULTS: The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women's intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband's preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. CONCLUSION: As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

Institutionalizing postpartum family planning and postpartum intrauterine device services in Nepal: Role of training and mentorship.

OBJECTIVE: To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD). METHODS: In this qualitative study, data were collected from 40 participants in December 2017 via focus group discussions (FGD) and in-depth interviews (IDI) in three hospitals implementing PPFP/PPIUD services and government line agencies in Nepal. Data were analyzed through content analysis and grouped into themes and categories. RESULTS: The majority of participants reported that PPFP/PPIUD training and mentoring was useful and contributed to their professional development. Most found that on-the-job training (OJT) was more effective than group-based training (GBT). CONCLUSION: Training and mentoring activities were perceived to be useful by health providers and OJT was the approach preferred by the majority. Further studies are necessary to explore the existing challenges and long-term effects of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers.