Postabortion contraception a decade after legalization of abortion in Nepal

Exploring Reproductive Health Impact of COVID 19 pandemic: In Depth Interviews with key stakeholders in Pakistan

Objective:

To explore the effects of COVID 19 on reproductive and child health services and gender relations.

Methods:

This is a Qualitative Exploratory Research. Due to lockdown, setting was online interviews on Zoom. Sampling was purposive. Five in-depth interviews were conducted in June 2020 followed by compilation of results and manuscript writing in July and August 2020.

Results:

Maternal Neonatal morbidity and mortality will rise as part of collateral damage of C19. As all routine services of maternity care, family planning, post abortion care and vaccination were also in lockdown. Baby boom, unwanted pregnancies, unsafe abortions and violence against women will be the secondary consequences of C19.

Conclusion:

Some critical services should never stop which include maternal and neonatal essential services. MNCH service continuity has to be maintained to optimize maternal neonatal health, prevent unwanted pregnancy and abortion. With appropriate standard operating procedures, and protective equipments, health facilities need to open. LHWs and community mobilisers with PPEs should continue services.

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.

Medical abortion in Nepal: a qualitative study on women's experiences at safe abortion services and pharmacies

Background

Although Nepal legalised abortion in 2002, a significant number of women continue to access unsafe abortions. An estimated 60% of all abortions performed in 2014 were unsafe, with unsafe abortion continuing to be a leading contributor to maternal mortality. Despite medical abortion access being solely permitted through government accredited safe abortion services, medical abortion pills are readily available for illegal purchase at pharmacies throughout the country.

Methods

Utilising an Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology, underpinned by a health information pyramid conceptual framework, this qualitative exploratory study collected data from in-depth, open-ended interviews. The study explored the medical abortion and sexual and reproductive health experiences of ten women who accessed medical abortion through an accredited safe abortion service, and ten women who accessed unsafe medical abortion through pharmacies.

Results

Thematic content analysis revealed emerging themes relating to decision-making processes in accessing safe or unsafe medical abortion; knowledge of safe abortion services; and SRH information access and post-abortion contraceptive counselling. Findings emphasised the interconnectivity of sexual and reproductive health and rights; reproductive coercion; education; poverty; spousal separation; and women’s personal, social and economic empowerment.

Conclusions

While barriers to safe abortion services persist, so will the continued demand for medical abortion provision through pharmacies. Innovated and effective harm reduction implementations combined with access and information expansion strategies offer the potential to increase access to safe medical abortion while decreasing adverse health outcomes for women.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0755-0) contains supplementary material, which is available to authorized users.

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.

Abortion in Nepal: perspectives of a cross-section of sexual and reproductive health and rights professionals

Background

Globally, women face many barriers in the attainment of sexual and reproductive health and rights (SRHR). Since 2002, the legalisation of abortion in Nepal has seen significant progress in the expansion of safe abortion and family planning services.

Methods

This qualitative, exploratory study was conducted in 2014 and uses nine in-depth, open-ended interviews with a cross-section of SRHR professionals, to explore their perspectives on abortion in Nepal. The study was underpinned by the Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology and used the health information pyramid conceptual framework.

Results

Thematic content analysis revealed emerging themes relating to barriers to access and uptake of skilled safe abortion services and post-abortion family planning. Findings also emphasised current practical and legal components relating to the provision of medical abortion through pharmacies and highlighted issues of sex-selective abortion within the predominantly patriarchal society.

Conclusion

Effective and ongoing sector-wide monitoring and evaluation of safe abortion services and their staff is essential for women in Nepal to have adequate access to effective and efficient safe abortion services, access to contraception and sexual and reproductive health (SRH) information post-abortion and to ensure adherence to current Safe Abortion Policy. It is critical that the unsafe (less and least safe) provision of medical abortion through pharmacies and sex-selective abortion continues to be investigated and that innovative strategies are formulated to ensure the cultural, reproductive and sexual health and rights of Nepali women are realised.

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.

Access to contraception and sexual and reproductive health information post-abortion: a systematic review of literature from low- and middle-income countries

AIM

This systematic literature review documented, analysed and critiqued the accessibility of contraception and sexual and reproductive health (SRH) information for women living in low- and middle-income countries who have undergone medical or surgical abortion.

METHODOLOGY

This review systematically collated relevant and recent empirical evidence regarding women's access to contraception and SRH information post-abortion within low- and middle-income countries. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework Guidelines, Flow Diagram and Checklist were utilised to undertake the review. The Ovid (MEDLINE), ProQuest, Science Direct, Web of Science, PUBMED and CINAHL databases were searched and studies that met edibility criteria were assessed for validity and analysis. A narrative synthesis of characteristics and results of the included studies is presented.

FINDINGS

After detailed assessment of available and relevant literature, nine studies were selected for inclusion in the review. Studies highlighted barriers to contraception and SRH information including supply limitation, lack of comprehensive education and counselling, lack of skilled post-abortion care (PAC) providers and abortion stigma.

CONCLUSIONS

The review found that with access to a wide range of contraceptive methods combined with comprehensive SRH information and education, contraception uptake in women post-abortion does increase. The review also highlights the inconsistencies in clinic-reported 'counselling' and what this term actually involves within a PAC setting.

Postpartum and Post-Abortion Contraception: From Research to Programs

Contraception following delivery or an induced abortion reduces the risk of an early unintended pregnancy and its associated adverse health consequences. Unmet need for contraception during the postpartum period and contraceptive counseling and services following abortion have been the focus of efforts for the last several decades. This article provides an introduction to the more focused contributions that follow in this special issue. We discuss the validity and measurement of the concept of unmet need for family planning during the postpartum period. We then present key findings on postpartum contraceptive protection, use dynamics, and method mix, followed by an assessment of interventions to improve postpartum family planning. The evidence on postabortion contraceptive uptake and continuation of use remains thin, although encouraging results are noted for implementation of comprehensive abortion care and for the impact of post-abortion contraceptive counseling and services. Drawing on these studies, we outline policy and program implications for improving postpartum and post-abortion contraceptive use.

Using Behavioral Science to Design a Peer Comparison Intervention for Postabortion Family Planning in Nepal

Despite the provision of free and subsidized family planning services and clients' demonstrated intentions to delay pregnancies, family planning uptake among women who receive abortion and postabortion services at Sunaulo Parivar Nepal (SPN), one of Nepal's largest non-governmental sexual and reproductive health (SRH) providers, remains low. Through meetings, interviews, and observations with SPN's stakeholders, service providers, and clients at its 36 SRH centers, we developed hypotheses about client- and provider-side barriers that may inhibit postabortion family planning (PAFP) uptake. On the provider side, we found that the lack of benchmarks (such as the performance of other facilities) against which providers could compare their own performance and the lack of feedback on the performance were important barriers to PAFP uptake. We designed several variants of three interventions to address these barriers. Through conversations with team members at SPN's centralized support office and service providers at SPN centers, we prioritized a peer-comparison tool that allows providers at one center to compare their performance with that of other similar centers. We used feedback from the community of providers on the tools' usability and features to select a variant of the tool that also leverages and reinforces providers' strong intrinsic motivation to provide quality PAFP services. In this paper, we detail the process of identifying barriers and creating an intervention to overcome those barriers. The intervention's effectiveness will be tested with a center-level, stepped-wedge randomized control trial in which SPN's 36 centers will be randomly assigned to receive the intervention at 1-month intervals over a 6-month period. Existing medical record data will be used to monitor family planning uptake.

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.

Service provider perspectives on post-abortion contraception in Nepal

The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility's infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.

Contraceptive discontinuation and pregnancy postabortion in Nepal: a longitudinal cohort study

OBJECTIVE

To examine postabortion contraceptive discontinuation and pregnancy in Nepal, where abortion was decriminalized in 2002.

STUDY DESIGN

We conducted an observational cohort study of 654 women obtaining abortions from four public and nongovernmental facilities in 2011. Patients completed questionnaires at their abortion visit and 6 and 12 months later. We used Cox proportional hazards models to assess contraceptive discontinuation and pregnancy by method initiated postabortion and other sociodemographic and reproductive factors.

RESULTS

Among the 78% (508/654) of women who initiated a modern contraceptive method within 3 months postabortion, the 1-year contraceptive discontinuation rate was 62 per 100 person-years. Discontinuation was far lower among the 5% of women using long-acting reversible methods (21/100 person-years) than among those using condoms (74/100 person-years), pills (61/100 person-years) and the injectable [64/100 person-years; adjusted hazard ratio (aHR)=0.32 (0.15-0.68)]. Unmarried women and those not living with their husband experienced higher contraceptive discontinuation [aHR=2.16 (1.47-3.17)]. The 1-year pregnancy rate for all women was 9/100 person-years. Pregnancy was highest among those who initiated no modern method postabortion (13/100 person-years) and condoms (12/100 person-years), and pregnancy was lowest among users of long-acting reversible methods (3/100 person-years). The poorest women were at increased pregnancy risk [aHR=2.31 (1.32-4.10)].

CONCLUSION

Women using intrauterine devices and implants experienced greatly reduced contraceptive discontinuation and pregnancy within a year postabortion, although initiation of these long-acting methods was low. Increased availability of long-acting methods in Nepal and similar settings may help to prevent unwanted pregnancy and attendant maternal mortality and morbidities.

IMPLICATIONS

Initiation of modern contraception was high postabortion; however, 1-year discontinuation was high for the condom, pill and injectable, the methods most commonly used. Rates for intrauterine devices and implants were low. Results support efforts to facilitate patient knowledge and access to the full range of contraceptives, including long-acting reversible methods.