Adapting and Validating the G-NORM (Gender Norms Scale) in Nepal: An Examination of How Gender Norms Are Associated with Agency and Reproductive Health Outcomes.

Research calls for the sexual and reproductive rights field to prioritize gender norms to ensure that women can act on their reproductive rights. However, there is a gap in accepted measures. We addressed this by including important theoretical components of gender norms: differentiating between descriptive and injunctive norms and adding a referent group. Our team originally developed and validated the G-NORM, a gender norms scale, in India. In this paper, we describe how we subsequently adapted and validated it in Nepal. We administered items to women of reproductive age, conducted exploratory and confirmatory factor analysis, and examined associations between the subscales and reproductive health outcomes. Like the original G-NORM, our factor analyses showed that descriptive norms and injunctive norms comprise two distinct scales which fit the data well and had Cronbach alphas of 0.92 and 0.89. More equitable descriptive gender norms were associated with higher decision-making scores, increased odds of intending to use family planning, disagreeing that it is wrong to use family planning, and older ideal age at marriage. Injunctive gender norms were only associated with disagreeing that it is wrong to use family planning. Findings offer an improved measure of gender norms in Nepal and provide evidence that gender norms are critical for agency and reproductive health outcomes.

Impact of Sumadhur intervention on fertility and family planning decision-making norms: a mixed methods study.

BACKGROUND: Mindful of social norms shaping health among women pressured to prove early fertility in Nepal, a bi-national research team developed and piloted a 4-month intervention engaging household triads (newly married women, their husbands, and mothers-in-law) toward advancing gender equity, personal agency, and reproductive health. This study evaluates the impact on family planning and fertility decision-making. METHODS: In 2021, Sumadhur was piloted in six villages with 30 household triads (90 participants). Pre/post surveys of all participants were analyzed using paired sample nonparametric tests and in-depth interviews with a subset of 45 participants were transcribed and analyzed thematically. RESULTS: Sumadhur significantly impacted (p < .05) norms related to pregnancy spacing and timing, and sex preference of children, as well as knowledge about family planning benefits, pregnancy prevention methods, and abortion legality. Family planning intent also increased among newly married women. Qualitative findings revealed improved family dynamics and gender equity, and shed light on remaining challenges. CONCLUSIONS: Entrenched social norms surrounding fertility and family planning contrasted with participants' personal beliefs, highlighting needed community-level shifts to improve reproductive health in Nepal. Engagement of influential community- and family-members is key to improving norms and reproductive health. Additionally, promising interventions such as Sumadhur should be scaled up and reassessed.

Societal norms are among the key influencers that shape the decisions that people make about their desired family size and the methods they will apply to achieve it. To support women in Nepal, where norms are often layered upon the expectation that women will prove their fertility soon after marriage, a bi-national research team developed and piloted a 4-month intervention, Sumadhur, engaging newly married women, their husbands, and mothers-in-law. This study evaluated the impact the Sumadhur had on norms, knowledge, and intent related to family planning. From pre- and post-questionnaires, we found norms significantly shifted and knowledge significantly improved among all participant groups as a result of participating in Sumadhur. From interviews following the intervention, we found that family dynamics and gender equity also improved despite lingering challenges including unchanged norms about the expected timing of a couple's first child. Our results confirmed that it is critical to engage influential community and family members in improving norms and supporting women to make decisions about their reproduction. Additionally, promising interventions like Sumadhur should be scaled up and re-evaluated.

Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up.

BACKGROUND: Health service providers play a key role in addressing women's need for postpartum pregnancy prevention. Yet, in Nepal, little is known about providers' knowledge, attitudes, and practice (KAP) on providing postpartum family planning (PPFP), particularly the immediate postpartum intrauterine device (PPIUD). This paper assesses providers KAP towards the provision of PPIUDs in Nepal prior to a PPIUD intervention to gain a baseline insight and analyzes whether their KAP changes both 6 and 24 months after the start of the intervention. METHODS: Data come from a randomized trial assessing the impact of a PPIUD intervention in Nepal between 2015 and 2017. We interviewed 96 providers working in six study hospitals who completed a baseline interview and follow-up interviews at 6 and 24 months. We used descriptive analysis, McNemar's test and the Wilcoxon signed-rank test to assess KAP of providers over 2 years. RESULTS: The PPIUD KAP scores improved significantly between the baseline and 6-month follow-up. Knowledge scores increased from 2.9 out of 4 to 3.5, attitude scores increased from 4 out of 7 to 5.3, and practice scores increased from 0.9 out of 3 to 2.8. There was a significant increase in positive attitude and practice between 6 and 24 months. Knowledge on a women's chance of getting pregnant while using an IUD was poor. Attitudes on recommending a PPIUD to different women significantly improved, however, attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Practice of PPIUD counseling and insertion improved significantly from baseline to 24 months, from 10.4 and 9.4% to 99% respectively. CONCLUSIONS: Although KAP improved significantly among providers during the PPIUD intervention, providers' knowledge on a women's chance of getting pregnant while using an IUD and attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Provider KAP could be improved further through ongoing and more in-depth training to maintain providers' knowledge, reduce provider bias and misconceptions about PPIUD eligibility, and to ensure providers understand the importance of birth spacing.

Investigating the quality of family planning counselling as part of routine antenatal care and its effect on intended postpartum contraceptive method choice among women in Nepal.

BACKGROUND: Though modern contraceptive use among married women in Nepal has increased from 26% in 1996 to 43% in 2016, it remains low among postpartum women. Integration of counselling on family planning (FP) at the time of antenatal care (ANC) and delivery has the potential to increase post-partum contraceptive use. This study investigates the quality of FP counselling services provided during ANC visits and women's perceptions of its effectiveness in assisting them to make a post-partum family planning (PPFP) decision. METHODS: In-depth interviews (IDIs) were conducted with 24 pregnant women who had attended at least two ANC visits in one of the six public hospitals that had received an intervention that sought to integrate FP counselling in maternity care services and introduce postpartum intrauterine device insertion in the immediate postpartum period. IDIs data were collected as part of a process evaluation of this intervention. Women were selected using maximum variation sampling to represent different socio-demographic characteristics. IDIs were audio recorded, transcribed verbatim in Nepali, and translated into English. Data were organized using Bruce-Jain quality of care framework and analyzed thematically. RESULTS: Overall, the quality of FP counselling during ANC was unsatisfactory based on patient expectations and experience of interactions with providers, as well as FP methods offered. Despite their interest, most women reported that they did not receive thorough information about FP, and about a third of them said that they did not receive any counselling services on PPFP. Reasons for dissatisfaction with counselling services included very crowded environment, short time with the provider, non-availability of provider, long waiting times, limited number of days for ANC services, and lack of comprehensive FP-related information, education and counselling (IEC) materials. Women visiting hospitals with a dedicated FP counselor reported higher quality of FP counselling. CONCLUSIONS: There is an urgent need to re-visit the format of counselling on PPFP during ANC visits, corresponding IEC materials, counselling setting, and to strengthen availability and interaction with providers in order to improve quality, experience and satisfaction with FP counselling during ANC visits. Improvements in infrastructure and human resources are also needed to adequately meet women's needs.

Exploring reasons for discontinuing use of immediate post-partum intrauterine device in Nepal: a qualitative study.

BACKGROUND: Postpartum intrauterine device (PPIUD) use remains very low in Nepal despite high levels of unmet need for postpartum family planning and the national government's efforts to promote its use. This study investigates reasons for continuing or discontinuing PPIUD use among Nepali women. METHODS: We conducted in-depth interviews (IDIs) with 13 women who had discontinued PPIUD use and 12 women who were continuing to use the method 9 months or longer following the insertion. All interviews were audio recorded, transcribed, translated into English, and analyzed using a thematic approach. RESULTS: Women discontinued PPIUD for several reasons: 1) side effects such as excessive bleeding during menstruation, nausea, back and abdominal pain; 2) poor quality of counselling and, relatedly, mismatched expectations in terms of device use; and 3) lack of family support from husbands and in-laws. In contrast, women who were continuing to use the method at the time of the study stated that they had not experienced side-effects, had received appropriate information during counselling sessions, and had the backing of their family members in terms of using PPIUD. CONCLUSION: Experiencing side-effects or complications following PPIUD insertion and poor quality of family planning counselling were the two main reasons for discontinuation. Family members appeared to play a major role in influencing a woman's decision to continue or discontinue PPIUD suggesting that counseling may need to be expanded to them as well. Improving quality of counselling by providing complete and balanced information of family planning methods as well as ensuring sufficient time for counselling and extending PPIUD service availability at lower level clinics/health posts will potentially increase the uptake and continued use of postpartum family planning, including PPIUD, in Nepal.

Delivering postpartum family planning services in Nepal: are providers supportive?

BACKGROUND: Health service providers play a key role in addressing women's need for pregnancy prevention, especially during the postpartum period. Yet, in Nepal, little is known about their views on providing postpartum family planning (PPFP) services and postpartum contraceptive methods such as immediate postpartum intra-uterine devices (PPIUD). This paper explores the perspectives of different types of providers on PPFP including PPIUD, their confidence in providing PPFP services, and their willingness to share their knowledge and skills with colleagues after receiving PPFP and PPIUD training. METHODS: In-depth interviews were conducted with 14 obstetricians/gynecologists and nurses from six tertiary level public hospitals in Nepal after they received PPFP and PPIUD training as part of an intervention aimed at integrating PPFP counseling and insertion into routine maternity care services. The interviews were audio recorded, transcribed, and analyzed using a thematic approach. RESULTS: Providers identified several advantages of PPFP, supported the provision of such services, and were willing to transfer their newly acquired skills to colleagues in other facilities who had not received PPFP and PPIUD training. However, many providers identified several supply-side and training-related barriers to providing high quality PPFP services, such as, (i) lack of adequate human resources, particularly a FP counselor; (ii) work overload; (iii) lack of private space for counseling; (iv) lack of IUDs and information, education and counseling materials; and (v) lack of support from hospital management. CONCLUSIONS: Providers appeared to be motivated to deliver quality PPFP services and transfer their knowledge to colleagues but identified several barriers which prevented them from doing so. Future efforts to improve provision of quality PPFP services should address the barriers identified by providers.

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.

Deaths among Women of Reproductive Age: an Explorative Case Study among Abortion Seekers.

In Nepal, abortion was legalized in 2002. Yet many women are denied abortion services. Women denied abortion services may either continue their pregnancies or find abortion care elsewhere. However, what is not known is the consequences on women, and their children after accessing abortion services or after being denied abortion services. This comment aims to understand the cause of death of women who sought abortion services between 2019 and 2020 and were enrolled in a longitudinal nationwide study of the consequences of legal abortion access in Nepal. Women were interviewed 6 weeks and every 6 months for 3 years after seeking abortion. During the follow-up interviews, the field research assistants were informed about the death of the clients. Once the death was reported, a trained senior research staff visited the deceased persons house and interviewed family members including husbands, maternal parents or in-laws to explore the cause of death. A total of nine deaths were reported between April 2019 and December 2022. Out of nine deceased women, four received abortions while five of them were initially denial abortion services. The majority of the deaths were due to suicide followed by tuberculosis. None of the deaths were caused by abortion or birth. Keywords: Death; Nepal; reproductive ages; womens health.

Developing the menstrual justice agenda: insights from a mixed method study in the mid-western region of Nepal.

This article develops the concept of "menstrual justice". The legal scholar Margaret E. Johnson has developed an expansive approach to menstrual justice incorporating rights, justice, and a framework for intersectional analysis, with a focus on the US. This framework provides a welcome alternative to the constrictive and medicalised approaches often taken towards menstruation. However, the framework is silent on several issues pertaining to menstruation in Global South contexts. This article therefore develops the concept of menstrual justice in order to extend its relevance beyond the Global North. It presents the findings of mixed-methods research conducted in April 2019 in the mid-western region of Nepal, particularly concerning the practice of chhaupadi, an extreme form of menstrual restriction. We conducted a quantitative survey of 400 adolescent girls and eight focus group discussions, four with adolescent girls and four with adult women. Our findings confirm that dignity in menstruation requires addressing pain management, security issues, and mental health, plus structural issues including economic disadvantage, environmental issues, criminal law, and education.

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.

Predictors of prior unsuccessful pharmacy abortion attempts among women presenting for abortion in government certified clinics in Nepal.

OBJECTIVE: Although abortion in Nepal is broadly legal and free of charge, many women seek abortion care outside the legal system, including from pharmacies. We evaluated the prevalence of, and factors associated with, prior unsuccessful abortion attempts among women presenting to 14 randomly-selected government approved abortion health facilities across Nepal. METHODS: Eligible participants were recruited in 2019 by trained research staff from certified abortion facilities. Participants (n = 1160) completed research staff-administered baseline surveys. We used multivariable mixed-effects logistic regression models to evaluate factors associated with having attempted pharmacy abortion prior to coming to the health facility. RESULTS: Almost one in seven (14%) women had tried to end their pregnancy before presenting to a participating clinic, often (9%) using medication obtained from a pharmacy. Women who lived farther from the clinic (aOR 1.28 per log hours travel time, 95% CI 1.10-1.49) and who reported financial difficulty in accessing the clinic (19% vs. 10%, aOR 2.10, 95% CI 1.20-3.70) had increased odds of having tried to access abortion through a pharmacy. CONCLUSION: Integrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.

Providing medical abortion services through pharmacies: Evidence from Nepal.

Despite the legalization of abortion in 2002 has made extensive efforts to expand services throughout the country, access to safe abortion care remains a constraint in Nepal, particularly in remote areas where trained providers and equipment are scarce. Expanding access to medical abortion (MA) through pharmacy workers could be a promising avenue to reach such women with safe and convenient care, but neither Nepali law nor the World Health Organization (WHO) recommends pharmacy provision of MA citing the reason of insufficient evidence. This paper examines the pharmacy provision of MA in expanding women's access to safe MA service in Nepal. Available literature between 2005 and 2018 was searched, and relevant information was extracted using a template, and findings were summarized and interpreted according to the objective of this study. We identified 83 studies that were related to MA in Nepal, but only five of them reported about pharmacy workers' involvement in the provision of MA in Nepal. Findings suggest that trained pharmacy workers can safely and effectively provide MA. MA services provided by pharmacy workers are acceptable to women who were satisfied with the service they had received. Therefore, it is essential that the Government of Nepal acknowledges the role pharmacy workers currently play in the provision of MA and formulate polices to permit pharmacy workers to give information about and dispense MA tablets to women in the first trimester of pregnancy.

Abortion service provision in South Asia: A comparative study of four countries.

OBJECTIVES: Nationally representative evidence on abortion service provision is scarce in South Asia. To inform improvements in service provision, this paper assesses the availability of facility-based postabortion services in Nepal, India (six states), Bangladesh and Pakistan, and legal abortion services in India and Nepal and Bangladesh (where the official term used is menstrual regulation or MR). STUDY DESIGN: The paper presents comparable indicators on three aspects of abortion service provision from representative surveys of public and private sector facilities, conducted over 2012-2015. Indicators cover three areas: (a) need for abortion-related care (total number of abortions and percent of abortions that are legal and the postabortion treatment rate); (b) availability and accessibility of facility-based abortion-related services (percent of facilities offering only one of the two services, percent which are public and percent located in rural areas); (c) quality of facility-based abortion care (percent of legal abortions using procedures not recommended by WHO and percent of women turned away when seeking abortion or MR services). RESULTS: The proportion of all abortions that are illegal ranges from 58% to almost 78% in the three countries where abortion is permitted under broad criteria. The annual treatment rate for abortion complications ranges from about 4 to 26 per 1000 women ages 15-49 across the countries and states covered. In India and Nepal, less than 40% of public sector facilities that are permitted to provide abortion services do so; in Bangladesh, the situation is somewhat better, at 53% providing MR. Across the six Indian states, 4-43% of facilities that offer abortion care are located in rural areas, disproportionately lower than the proportion of women living in rural areas (49-87%). About 30-60% of facilities offered only postabortion care and did not offer legal services in the three countries where legal services are permitted (with the sole exception of Tamil Nadu where this proportion was only 11%); of the remaining facilities, the large majority offered both services. Medication abortion is offered by the large majority of facilities that provide induced abortion and accounts for 40-45%, of facility-based abortions in Nepal and four of the states of India; in Assam and Bihar, this proportion was much lower (13% and 27% respectively). Invasive procedures that are not recommended by WHO are more widely used in India (up to 25-37% of facility-based abortions are D&C procedures; the large majority of this group are D&C, and a small proportion may be D&E, a WHO-recommended abortion procedure, that could not be separated out in this study because providers use the two labels interchangeably); by comparison, the proportion is much smaller in Nepal (5%). Between 22% to a little over half of facilities turned away some women who would otherwise be eligible for an abortion or MR procedure in Nepal, the six Indian states, and Bangladesh. CONCLUSIONS: There is an urgent need to increase access to abortion, MR and postabortion services, especially for rural women. Greater access to legal abortion/MR services in the three countries that permit these procedures would increase the proportion of abortions that are legal and safe, reduce morbidity and the need for facility-based treatment for complications. Broadening the legal criteria under which abortion is permitted in Pakistan, and implementing access under such broader criteria, is needed to achieve the same improvements in Pakistan. Ensuring that these services are of high quality and comprehensive-meeting WHO-recommended standards-is essential to protect women's reproductive health and rights. IMPLICATIONS: To improve access to abortion, MR and postabortion care in South Asia, all facilities (public and private) permitted to provide these services should do so, and should include medication abortion. Improvements in quality of care are critical: invasive procedures (D&C) should be eliminated through adherence to WHO's standards of safe abortion care and women seeking abortions should not be turned away because of providers' biases.

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.