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Tamang J.,Center for Research on Environment Health and Population Activities | Hodgins S.,Nepal Family Health Program | Pathak L.R.,Ministry of Health and Population | Silwal R.C.,Nepal Family Health Program
BMC Pregnancy and Childbirth | Year: 2010

Background: The challenge of delivering multiple, complex messages to promote maternal and newborn health in the terai region of Nepal was addressed through training Female Community Health Volunteers (FCHVs) to counsel pregnant women and their families using a flipchart and a pictorial booklet that was distributed to clients. The booklet consists of illustrated messages presented on postcard-sized laminated cards that are joined by a ring. Pregnant women were encouraged to discuss booklet content with their families.Methods: We examined use of the booklet and factors affecting adoption of practices through semi-structured interviews with district and community-level government health personnel, staff from the Nepal Family Health Program, FCHVs, recently delivered women and their husbands and mothers-in-law.Results: The booklet is shared among household members, promotes discussion, and is referred to when questions arise or during emergencies. Booklet cards on danger signs and nutritious foods are particularly well-received. Cards on family planning and certain aspects of birth preparedness generate less interest. Husbands and mothers-in-law control decision-making for maternal and newborn care-seeking and related household-level behaviors.Conclusions: Interpersonal peer communication through trusted community-level volunteers is an acceptable primary strategy in Nepal for promotion of household-level behaviors. The content and number of messages should be simplified or streamlined before being scaled-up to minimize intervention complexity and redundant communication. © 2010 McPherson et al; licensee BioMed Central Ltd.


Tamang A.,Center for Research on Environment Health and Population Activities | Tuladhar S.,Asia Foundation | Tamang J.,Australian National University | Ganatra B.,World Health Organization | Dulal B.,Center for Research on Environment Health and Population Activities
International Journal of Gynecology and Obstetrics | Year: 2012

Objective: To investigate factors associated with women's choice of medical abortion (MA) or manual vacuum aspiration (MVA) in Nepal, where the government recently began offering MA services. Methods: Structured exit interviews were conducted between January 19 and May 21, 2010, with women with a pregnancy of 63 days or less who underwent abortions at 7 clinics in 3 districts of Nepal. All those who accepted MA, and 1 in each 4 or 5 of those who underwent MVA, were invited for an interview. Of those interviewed, 499 chose MA and 542 underwent MVA. Results: Many women were not aware of both abortion methods before they came to the clinic. The odds of choosing MA were more than 3 times as high among those who knew about both methods as among those who did not. Of those who had decided on MVA prior to receiving information at the clinic, 29% chose MA. In contrast, only 10% of those who intended to accept MA opted for MVA after receiving information and counseling. Women who had more education, were of the upper Hindu caste, or resided in urban areas were more likely to choose MA. Conclusion: Information and counseling have a large impact on the women's choice of an abortion method. To expand access to MA and to ensure that women can make an informed choice, it is essential that the government of Nepal create positions for trained counselors at all public abortion clinics. © 2012 International Federation of Gynecology and Obstetrics.


Puri M.,Center for Research on Environment Health and Population Activities | Lamichhane P.,Center for Research on Environment Health and Population Activities | Harken T.,University of California at Irvine | Blum M.,University of California at San Francisco | And 3 more authors.
BMC Public Health | Year: 2012

Background: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care. Methods: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data. Results: Overall, participants had positive views of abortion legalization many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment. Conclusions: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications. © 2012 Puri et al.; licensee BioMed Central Ltd.


Rocca C.H.,University of California at San Francisco | Puri M.,Center for Research on Environment Health and Population Activities | Dulal B.,Center for Research on Environment Health and Population Activities | Bajracharya L.,Capital Hospital Pvt. Ltd | And 4 more authors.
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2013

Objective To investigate abortion practices of Nepali women requiring postabortion care. Design Cross-sectional study. Setting Four tertiary-care hospitals in urban and rural Nepal. Sample A total of 527 women presenting with complications from induced abortion in 2010. Methods Women completed questionnaires on their awareness of the legal status of abortion and their abortion-seeking experiences. The method of induction and whether the abortion was obtained from an uncertified source was documented. Multivariable logistic regression was used to identify associated factors. Main outcome measures Induction method; uncertified abortion source. Results In all, 234 (44%) women were aware that abortion was legal in Nepal. Medically induced abortion was used by 359 (68%) women and, of these, 343 (89%) took unsafe, ineffective or unknown substances. Compared with women undergoing surgical abortion, women who had medical abortion were more likely to have obtained information from pharmacists (161/359, 45% versus 11/168, 7%, adjusted odds ratio [aOR] 8.1, 95% confidence interval 4.1-16.0) and to have informed no one about the abortion (28/359, 8% versus 3/168, 2%, aOR 5.5, 95% CI 1.1-26.9). Overall, 291 (81%) medical abortions and 50 (30%) surgical abortions were obtained from uncertified sources; these women were less likely to know that abortion was legal (122/341, 36% versus 112/186, 60%, aOR 0.4, 95% CI 0.2-0.7) and more likely to choose a method because it was available nearby (209/341, 61% versus 62/186, 33%, aOR 2.5, 95% CI 1.5-4.3), compared with women accessing certified sources. Conclusions Among women presenting to hospitals in Nepal with complications following induced abortion of pregnancy, the majority had undergone medically induced abortions using unknown substances acquired from uncertified sources. Women using medications and those accessing uncertified providers were less aware that abortion is now legal in Nepal. These findings highlight the need for continued improvements in the provision and awareness of abortion services in Nepal. © 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.


Rocca C.H.,University of California at San Francisco | Puri M.,Center for Research on Environment Health and Population Activities | Harper C.C.,University of California at San Francisco | Blum M.,University of California at San Francisco | And 2 more authors.
International Journal of Gynecology and Obstetrics | Year: 2014

Objective To assess the contraceptive information received and methods chosen, received, and used among women having abortions one decade after legalization of abortion in Nepal. Methods We examined postabortion contraception with questionnaires at baseline and six months among women obtaining legal abortions (n = 838) at four facilities in 2011. Multivariate regression analysis was used to measure factors associated with method information, choice, receipt, and use. Results One-third of participants received no information on effective methods, and 56% left facilities without a method. The majority of women who chose to use injectables and pills were able to do so (88% and 75%, respectively). However, only 44% of women choosing long-acting reversible contraceptives and 5% choosing sterilization had initiated use of the method by six months. Levels of contraceptive use after medical abortion were on par with those after aspiration abortion. Nulliparous women were far less likely than parous women to receive information and use methods. Women living without husbands or partners were also less likely to receive information and supplies, or to use methods. Conclusion Improvements in postabortion counseling and provision are needed. Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential. © 2014 International Federation of Gynecology and Obstetrics.


Puri M.,Center for Research on Environment Health and Population Activities | Regmi S.,Center for Research on Environment Health and Population Activities | Tamang A.,Center for Research on Environment Health and Population Activities | Shrestha P.,Center for Research on Environment Health and Population Activities
Health Research Policy and Systems | Year: 2014

Background: Identifying unsafe abortion among the major causes of maternal deaths and respecting the rights to health of women, in 2002, the Nepali parliament liberalized abortion up to 12 weeks of pregnancy on request. However, enhancing women's awareness on and access to safe and legal abortion services, particularly in rural areas, remains a challenge in Nepal despite a decade of the initiation of safe abortion services.Methods: Between January 2011 and December 2012, an operations research study was carried out using quasi-experimental design to determine the effectiveness of engaging female community health volunteers, auxiliary nurse midwives, and nurses to provide medical abortion services from outreach health facilities to increase the accessibility and acceptability of women to medical abortion. This paper describes key components of the operations research study, key research findings, and follow-up actions that contributed to create a conducive environment and evidence in scaling up medical abortion services in rural areas of Nepal.Results: It was found that careful planning and implementation, continuous advocacy, and engagement of key stakeholders, including key government officials, from the planning stage of study is not only crucial for successful completion of the project but also instrumental for translating research results into action and policy change. While challenges remained at different levels, medical abortion services delivered by nurses and auxiliary nurse midwives working at rural outreach health facilities without oversight of physicians was perceived to be accessible, effective, and of good quality by the service providers and the women who received medical abortion services from these rural health facilities.Conclusions: This research provided further evidence and a road-map for expanding medical abortion services to rural areas by mid-level service providers in minimum clinical settings without the oversight of physicians, thus reducing complications and deaths due to unsafe abortion. © 2014 Puri et al.; licensee BioMed Central Ltd.


Puri M.,Center for Research on Environment Health and Population Activities | Misra G.,Crea - Tec | Hawkes S.,University College London
BMC Public Health | Year: 2015

Background: There is an increasing body of evidence on the extent and predictors of violence against women in Nepal. However, much of the published research does not yet take into account additional features of marginalization and vulnerability suffered by some women - for example, women socially excluded on account of their disability. Critical gaps exist in empirical data on the extent, risk factors, access to care, socio-economic and health consequences of violence among women with disabilities in Nepal. This paper addresses some these gaps and aims to promote evidence-informed policy and programme responses in Nepal. Methods: We conducted a cross-sectional survey of 475 women with disability aged 16 years and above in three districts in Nepal. In-depth interviews with 12 women who reported violence in the survey were also carried out. Using multivariate statistical methods we estimated the prevalence and risk factors for violence experienced both over the past 12 months and lifetime. Results: Over the lifetime, 57.7% of women reported they had ever experienced violence, including emotional violence (55.2%); physical violence (34%); and sexual violence (21.5%). Over the preceding 12 months, 42% of women reported that they had experienced violence. Multivariate analysis showed that women with disabilities who were young, working in paid employment, and those who required permission from husbands/family to go to health centres or participate in community organizations were at increased risk of violence. Women experienced a range of negative outcomes from violence - including physical and emotional trauma. However, a majority of women did not seek care or redress from the health, justice or other sectors. Conclusions: Women in Nepal are at high risk of violence, often from members of their immediate family or local community. Rates of violence are higher in women with disability than among women in the general population. Tackling violence requires a comprehensive approach that addresses the root causes of women's unequal position in society, and builds upon principles of equity and justice to ensure that all women are able to realize their rights to a life free from violence. © 2015 Puri et al.; licensee BioMed Central.


Lamichhane P.,Center for Research on Environment Health and Population Activities | Puri M.,Center for Research on Environment Health and Population Activities | Tamang J.,Center for Research on Environment Health and Population Activities | Dulal B.,Center for Research on Environment Health and Population Activities
BMC Women's Health | Year: 2011

Background: Studies conducted around the world consistently show the existence of violence against women. Despite the increasing number of studies being conducted on violence against young married women elsewhere, this subject has received little attention from researchers and policy makers in Nepal. This paper assesses the prevalence of violence among young married women in rural Nepal. Specifically, it examines [factors related to] women's status in order to better understand the risk of violence.Methods: A cross-sectional study was conducted in 2009 among 1,296 young married women aged 15-24 years in four major ethnic groups. Bivariate analysis and multivariate logistic regression were used to examine the association between selected risk factors and violence.Results: More than half the women (51.9%) reported having experienced some form of violence in their lifetime. One-fourth (25.3%) reported physical violence and nearly half (46.2%) reported sexual violence. Likewise, one-third (35.8%) of women reported experiencing some form of violence in the past 12 months. No or little inter-spousal communication and low autonomy of women significantly increases the odds of experiencing violence among married women.Conclusions: The violence against women is quite common among young married women in rural Nepal. Although the Domestic Violence and Punishment Act 2066 has been enacted, equal attention needs to be given to increasing women's autonomy and activities that encourage inter-spousal communication. Furthermore, more research is required in Nepal that examines dynamics of violence perpetrated by husbands. © 2011 Lamichhane et al; licensee BioMed Central Ltd.


Puri M.,Center for Research on Environment Health and Population Activities | Frost M.,University of Oxford | Tamang J.,Center for Research on Environment Health and Population Activities | Lamichhane P.,Center for Research on Environment Health and Population Activities | Shah I.,World Health Organization
BMC Research Notes | Year: 2012

Background: Sexual violence within marriage is a public health and human rights issue; yet it remains a much neglected research area, especially in Nepal. This paper represents one of the first attempts to quantify the extent of sexual violence and its determinants among young married women in Nepal. Methods: A cross-sectional survey was conducted among 1,296 married women aged 15-24 years in four major ethnic groups in rural Nepal. The survey data were used to estimate the prevalence and identify determinants of sexual violence. The relative importance of different correlates of sexual violence in the past 12 months at the individual, household and community levels were examined by using a multi-level multivariate statistical approach. Results: Of the young women surveyed 46% had experienced sexual violence at some point and 31% had experienced sexual violence in the past 12 months. Womens autonomy was found to be particularly protective against sexual violence both at the individual and community level. Womens educational level was not found to be protective, while the educational level of the husband was found to be highly protective. Conclusions: The high prevalence of sexual violence against young women by husbands found in this study is a matter for serious concern and underscores the need for a comprehensive response by policymakers. © 2012 Puri et al.; licensee BioMed Central Ltd.


Lamichhane P.,Center for Research on Environment Health and Population Activities
Women's health issues : official publication of the Jacobs Institute of Women's Health | Year: 2011

Sex-selective abortion is expressly prohibited in Nepal, but limited evidence suggests that it occurs nevertheless. Providers' perspectives on sex-selective abortion were examined as part of a larger study on legal abortion in the public sector in Nepal. In-depth interviews were conducted with health care providers and administrators providing abortion services at four major hospitals (n = 35), two in the Kathmandu Valley and two in outlying rural areas. A grounded theory approach was used to code interview transcripts and to identify themes in the data. Most providers were aware of the ban on sex-selective abortion and, despite overall positive views of abortion legalization, saw sex selection as an increasing problem. Greater availability of abortion and ultrasonography, along with the high value placed on sons, were seen as contributing factors. Providers wanted to perform abortions for legal indications, but described challenges identifying sex-selection cases. Providers also believed that illegal sex-selective procedures contribute to serious abortion complications. Sex-selective abortion complicates the provision of legal abortion services. In addition to the difficulty of determining which patients are seeking abortion for sex selection, health workers are aware of the pressures women face to bear sons and know they may seek unsafe services elsewhere when unable to obtain abortions in public hospitals. Legislative, advocacy, and social efforts aimed at promoting gender equality and women's human rights are needed to reduce the cultural and economic pressures for sex-selective abortion, because providers alone cannot prevent the practice. Copyright © 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.

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