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AbstractPurposeMethodsResultsConclusions\nSHORT CONDENSATIONTo evaluate the feasibility and acceptability of outpatient medical induction at 13-18 weeks’ gestation to limit overnight hospital stays.In this prospective cohort study, participants with 13-18-week pregnancies seeking abortions at two government hospitals swallowed mifepristone 200 mg and self-administered misoprostol 400 mcg buccally 24-48 h later, 1-2 h before returning to the outpatient clinic (OPD). Repeat misoprostol was dosed every 3 h until expulsion. Participants requiring care beyond OPD hours were admitted as inpatients. Acceptability was evaluated by exit interview before discharge. Participants were contacted two weeks later to assess any subsequent issues.Ninety-eight (82%) of 120 participants had successful outpatient abortions using a median two (IQR 2, 3) misoprostol doses. The median induction-to-abortion time was five hours (IQR 4, 7.5). Eleven (9%) participants expelled before clinic arrival. Twenty-two (18%) participants were transferred as inpatients at OPD closing. Transferred participants remained inpatient for a median 18 h (IQR 18, 21.25). There were no serious adverse events and satisfaction with the abortion process was high.Although the outpatient model did not meet statistical expectations, it is clinically feasible, acceptable, and improves efficiency, expands access, and reduces burdens for women and providers. Operational adjustments may facilitate higher outpatient success.Outpatient medical induction at 13-18 weeks’ gestation is feasible, improves efficiency, expands access, reduces staff and patient burdens, and aligns guidelines and practice with evidence. [ABSTRACT FROM AUTHOR]

Background: Early first-trimester medical abortion (MA) service (≤ 63 days) has been provided by doctors and nurses under doctors' supervision since 2009 in Nepal. This paper assesses whether MA services provided by specifically trained and certified nurses and auxiliary nurse-midwives independently from doctors' supervision, is considered as satisfactory by women as those provided by doctors. Methods: The data come from a multi-center, randomized, controlled equivalence trial conducted between April 2009 and March 2010 in five district hospitals in Nepal. Women seeking MA were randomly assigned to doctors or nurses and auxiliary nurse-midwives(ANMs). Eligible women were administered 200 mg mifepristone orally followed by 800 µg misoprostol vaginally two days later by their assigned providers and followed up 10-14 days later. At the follow-up visit women's reported satisfaction with MA service they received was measured. Results: Of 1295 women screened for eligibility, 535 were randomly assigned to a doctor and 542 to a nurse or ANM. Nineteen women were lost-to-follow up in the former group and 27 were lost-to-follow up or did not complete the acceptability interview in the latter group. This study is, therefore, based on516womenin the doctor's group and 515 women in the nurse or ANM group. All women in the nurse or ANM group reported being satisfied or highly satisfied by MA compared to 99% in the doctor's group. Satisfaction was similar regardless of the type of provider; 38% among nurse or ANM and 35% among the doctor group were "highly satisfied", and 62% and 64%, respectively, were "satisfied". Women's experiences such as 'less than expected amount or duration of bleeding following MA', 'shorter than expected duration of the abortion process', and 'able to manage symptoms', were found to be associated with women's higher satisfaction with MA. Counseling and information on the method, potential complications of MA and post-abortion contraception was nearly universal. No statistically significant differences were found in the level of satisfaction by age, parity, marital status, education or occupation of women. Conclusions: Women's satisfaction with MA service provided by trained nurses or auxiliary nurse-midwives was similar to that provided by doctors. The findings, therefore, provide support for extending safe and accessible medical abortion services by government-trained nurses and auxiliary nurse midwives to women seeking early first trimester pregnancy termination. Trial registration: The trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT01186302). Registered August 20, 2010. [ABSTRACT FROM AUTHOR]

Background: Pain is often cited as one of the worst features of medical abortion. Further, inadequate pain management may motivate some women to seek unnecessary clinical care. There is a need to identify effective methods for pain control in this setting. Methods/Design: We propose a randomized, placebo-controlled trial. 576 participants (288 nulliparous; 288 parous) from study sites in Nepal, South Africa and Vietnam will be randomly allocated to one of three treatments: (1) ibuprofen 400 mg PO and metoclopramide 10 mg PO; (2) tramadol 50 mg PO and a placebo; or (3) two placebo pills, to be taken immediately before misoprostol and repeated once four hours later. All women will be provided with supplementary analgesia for use as needed during the medical abortion. We hypothesize that women receiving prophylactic analgesia will report lower maximal pain scores in the first 8 h following misoprostol administration compared to women receiving placebos for medical abortion through 63 days' gestation. Our primary objective is to determine whether prophylactic administration of ibuprofen and metoclopramide or tramadol provides superior pain relief compared to analgesia administration after pain begins, measured during the first eight hours after misoprostol administration. Secondary objectives include identifying covariates associated with higher reported pain scores; determining any impact of the study medicines on medical abortion success; and, qualitatively exploring women's physical experiences of medical abortion, especially related to pain, and how can they be improved. Data sources include medical records, participant symptom diaries and interview data obtained on the day of enrollment, during the medical abortion, and at follow-up. Participants will be contacted via telephone on day 3 and return for follow-up will occur approximately 14 days after mifepristone, concluding study participation. A subset of 42 women will also be invited to undergo in-depth qualitative interviews following study completion. Discussion: Although pain is one of the most common side effects encountered with medical abortion, little is known about optimal pain management for this process. This multi-arm trial design offers an efficient approach to evaluating two prophylactic pain management regimens compared to use of pain medication as needed. [ABSTRACT FROM AUTHOR]

In Nepal, despite policy restrictions, both registered and unregistered brands of mifepristone and misoprostol can easily be obtained at pharmacies. Since many women visit pharmacies for abortion information, ensuring that they receive effective care from pharmacy workers remains an important challenge. We conducted an operations research study to examine whether trained pharmacy workers can correctly provide information on safe use of mifepristone and misoprostol for early first trimester medical abortion. Pharmacy workers in one district were given orientation and training using a harm-reduction approach, and compared with a non-equivalent comparison group in the second district. Overall, trained pharmacy workers’ knowledge increased substantially, but no increase was found in the comparison group. Compared to the baseline (65%), 97% of trained pharmacy workers knew up to what stage of pregnancy and how women should use mifepristone and misoprostol. A higher percentage of pharmacy workers in the intervention group (77%) compared to the comparison group (49%) were knowledgeable at follow-up about determining whether an abortion was successful, implying a need for improving this aspect of training. As many mid-level health providers run their own pharmacies and offer medical abortion pills, it is important for the government to consider training these providers and registering their pharmacies as safe medical abortion service outlets. RésuméAu Népal, en dépit des restrictions politiques, les marques déposées ou non de mifépristone et misoprostol peuvent être obtenues aisément en pharmacie. Puisque beaucoup de femmes se rendent dans les pharmacies pour s’informer sur l’avortement, s’assurer que le personnel leur prodigue des soins efficaces demeure un enjeu important. Nous avons mené une étude de recherche opérationnelle afin de déterminer si le personnel de pharmacie formé pouvait informer correctement sur l’utilisation sûre de la mifépristone et du misoprostol pour un avortement du début du premier trimestre. Le personnel des pharmacies d’un district a reçu des conseils et une formation pour utiliser une approche de réduction des risques, et a été comparé avec un groupe de comparaison non équivalent dans le second district. Dans l’ensemble, les connaissances du personnel formé ont nettement augmenté, mais aucune augmentation n’a été observée dans le groupe de comparaison. Par rapport à la valeur de référence (65%), 97% du personnel de pharmacie formé savait jusqu’à quel stade de la grossesse et de quelle manière les femmes devaient utiliser la mifépristone et le misoprostol. Un pourcentage plus élevé de personnel dans le groupe d’intervention (77%) que dans le groupe de comparaison (49%) connaissait le suivi pour déterminer si un avortement avait réussi, ce qui dénote le besoin d’améliorer cet aspect de la formation. Comme beaucoup de prestataires de soins de santé de niveau intermédiaire gèrent leur propre pharmacie et proposent des comprimés abortifs, il est important que les pouvoirs publics envisagent de les former et habilitent leurs pharmacies comme centres fiables d’avortement médicamenteux. ResumenEn Nepal, pese a restricciones de políticas, tanto las marcas registradas como las no registradas de mifepristona y misoprostol son fáciles de obtener en farmacias. Dado que muchas mujeres visitan la farmacia para obtener información sobre el aborto, continúa siendo un reto importante asegurar que reciban atención eficaz del personal de farmacia. Realizamos un estudio de investigación operativa para examinar si el personal de farmacia capacitado puede proporcionar información correcta sobre el uso seguro de mifepristona y misoprostol para el aborto con medicamentos en el primer trimestre del embarazo. El personal de farmacia en un distrito recibió orientación y capacitación basadas en el enfoque de reducción de daños, y fue comparado con un grupo de comparación no equivalente en el segundo distrito. En general, los conocimientos del personal de farmacia capacitado incrementaron considerablemente, pero no se encontró ningún aumento en el grupo de comparación. Comparado con la línea base (65%), el 97% del personal de farmacia capacitado sabía hasta qué etapa del embarazo y cómo las mujeres deben usar mifepristona y misoprostol. Durante el seguimiento, se encontró que un mayor porcentaje de personal de farmacia en el grupo de intervención (77%) comparado con el grupo de comparación (49%) estaba bien informado sobre cómo determinar si el aborto había sido completo, lo cual implica la necesidad de mejorar este aspecto de la capacitación. Dado que muchos prestadores de servicios de nivel intermedio operan su propia farmacia y ofrecen medicamentos para inducir el aborto, es importante para el gobierno considerar capacitarlos y registrar su farmacia como un lugar seguro donde obtener servicios de aborto con medicamentos. [ABSTRACT FROM PUBLISHER]

Medical abortion was introduced in Nepal in 2009, but rural women’s access to medical abortion services remained limited. We conducted a district-level operations research study to assess the effectiveness of training 13 auxiliary nurse-midwives as medical abortion providers, and 120 female community health volunteers as communicators and referral agents for expanding access to medical abortion for rural women. Interviews with service providers and women who received medical abortion were undertaken and service statistics were analysed. Compared to a neighbouring district with no intervention, there was a significant increase in the intervention area in community health volunteers’ knowledge of the legal conditions for abortion, the advantages and disadvantages of medical abortion, safe places for an abortion, medical abortion drugs, correct gestational age for home use of medical abortion, and carrying out a urine pregnancy test. In a one-year period in 2011–12, the community health volunteers did pregnancy tests for 584 women and referred 114 women to the auxiliary nurse-midwives for abortion; 307 women in the intervention area received medical abortion services from auxiliary nurse-midwives. There were no complications that required referral to a higher-level facility except for one incomplete abortion. Almost all women who opted for medical abortion were happy with the services provided. The study demonstrated that auxiliary nurse-midwives can independently and confidently provide medical abortion safely and effectively at the sub-health post level, and community health volunteers are effective change agents in informing women about medical abortion. ResuméL’avortement médicamenteux a été introduit en 2009 au Népal, mais l’accès des femmes rurales aux services est demeuré limité. Nous avons étudié les opérations au niveau d’un district pour évaluer l’efficacité de la formation de 13 infirmières sages-femmes auxiliaires comme prestataires de l’avortement médicamenteux, et de 120 femmes comme bénévoles de santé communautaire et agents d’orientation pour élargir l’accès des femmes rurales à l’avortement médicamenteux. Des entretiens ont été organisés avec des prestataires de service et des femmes ayant mené un avortement médicamenteux, et des statistiques de service ont été analysées. Par comparaison avec un district voisin où aucune intervention n’avait été réalisée, dans la zone d’intervention, on a constaté une hausse sensible de la connaissance des bénévoles de santé communautaire sur les conditions juridiques de l’avortement, les avantages et les inconvénients de l’avortement médicamenteux, les lieux sûrs pour l’avortement, les médicaments abortifs, l’âge gestationnel correct pour pratiquer un avortement médicamenteux à domicile et la réalisation d’un test de grossesse urinaire. Sur une période d’un an en 2011-2012, les bénévoles de santé communautaire ont effectué un test de grossesse pour 584 femmes et adressé 114 femmes qui voulaient avorter aux infirmières sages-femmes auxiliaires ; les infirmières sages-femmes auxiliaires ont prêté des services d’avortement médicamenteux pour 307 femmes dans la zone d’intervention. Aucune complication n’a exigé l’aiguillage vers un centre plus spécialisé, à l’exception d’un avortement incomplet. Presque toutes les femmes qui avaient opté pour l’avortement médicamenteux étaient satisfaites des services obtenus. L’étude a montré que les infirmières sages-femmes auxiliaires peuvent pratiquer efficacement, indépendamment et en confiance des avortements médicamenteux en toute sécurité au niveau des sous-centres de santé, et que les bénévoles de santé communautaire sont de précieux agents de changement pour renseigner les femmes sur l’avortement médicamenteux. ResumenLos servicios de aborto con medicamentos fueron introducidos en Nepal en 2009, pero el acceso de las mujeres rurales a dichos servicios continu ó siendo limitado. Realizamos un estudio de investigación operativa a nivel de distrito para evaluar la eficacia de capacitar a 13 enfermeras-obstetras auxiliares como prestadoras de servicios de aborto con medicamentos, y 120 voluntarias comunitarias en salud como comunicadoras y agentes de referencia para ampliar el acceso de las mujeres rurales a dichos servicios. Se realizaron entrevistas con prestadores de servicios y mujeres que recibieron servicios de aborto con medicamentos y se analizaron las estadísticas de los servicios. Comparado con un distrito aledaño donde no hubo intervención, en la zona de la intervención se vio un considerable aumento en los conocimientos de las voluntarias comunitarias respecto a las condiciones para un aborto legal, las ventajas y desventajas del aborto con medicamentos, lugares seguros para tener un aborto, fármacos para inducir el aborto, edad gestacional correcta para el uso domiciliario de los medicamentos para inducir el aborto, y realizar una prueba de embarazo en la orina. En el plazo de un año, 2011-12, las voluntarias comunitarias en salud realizaron pruebas de embarazo en 584 mujeres y refirieron a 114 mujeres a enfermeras-obstetras auxiliares para aborto; 307 mujeres en la zona de la intervención recibieron servicios de aborto con medicamentos de enfermeras-obstetras auxiliares. No hubo complicaciones que necesitaron referencia a una unidad de salud de mayor nivel, excepto un aborto incompleto. Casi todas las mujeres que optaron por tener un aborto con medicamentos estuvieron contentas con los servicios que recibieron. El estudio demostró que las enfermeras-obstetras auxiliares pueden proporcionar servicios de aborto con medicamentos de manera independiente, confiada, segura y eficaz, en un nivel inferior al puesto de salud, y las voluntarias comunitarias en salud son agentes de cambio eficientes para informar a las mujeres acerca del aborto con medicamentos. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND Medication abortion, with a combination of mifepristone and misoprostol, is highly effective and safe. However, there is insufficient evidence on efficacy and safety at very early gestations before a pregnancy can be visualized with ultrasonography. METHODS We conducted a multicenter, noninferiority, randomized, controlled trial involving women requesting medication abortion at up to 42 days of gestation with an unconfirmed intrauterine pregnancy on ultrasound examination (visualized as an empty cavity or a sac-like structure without a yolk sac or embryonic pole). Participants were randomly assigned to either immediate start of abortion (early-start group) or standard-care treatment delayed until intrauterine pregnancy was confirmed (standard group). The primary outcome was complete abortion. The noninferiority margin was set at 3.0 percentage points for the absolute between-group difference. RESULTS In total, 1504 women were included at 26 sites in nine countries and were randomly assigned to the early-start group (754 participants) or the standard group (750 participants). In an intention-to-treat analysis, a complete abortion occurred in 676 of 710 participants (95.2%) in the early-start group and in 656 of 688 (95.3%) in the standard group; the absolute between-group difference was -0.1 percentage points (95% confidence interval, -2.4 to 2.1). Ectopic pregnancies occurred in 10 of 741 participants (1.3%) in the early-start group and in 6 of 724 (0.8%) in the standard group, with one rupture before diagnosis (early-start group). Serious adverse events occurred in 12 of 737 participants (1.6%) in the early-start group and in 5 of 718 (0.7%) in the standard group (P = 0.10); the majority were uncomplicated hospitalizations for treatment of ectopic pregnancy or incomplete abortion. CONCLUSIONS Medication abortion before confirmed intrauterine pregnancy was noninferior to standard, delayed treatment with respect to complete abortion. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the safety, acceptability and feasibility of a one-day outpatient medication abortion service at gestations 13-18 weeks.Study Design: Open-label prospective study in which participants received mifepristone 200 mg orally to swallow at home or at the clinic followed 24 h later by misoprostol 400 mcg buccally. They presented to the outpatient clinic 24-48 h after mifepristone for misoprostol 400 mcg buccally every three hours (no maximum dose). The primary outcome was successful abortion without transfer to overnight inpatient care. Secondary outcomes included time to abortion from initial misoprostol dose, safety, additional interventions and side effects.Results: We enrolled 230 women from December 2017 to November 2018. Approximately nine of ten (n = 206, 89.6%) achieved a successful abortion without transfer to overnight care. Twenty-four were transferred to overnight inpatient care; of these 18 were to manage a complication, five for incomplete abortion and two by choice. Among these 24, three women experienced an SAE. The median time to successful abortion from time of the first misoprostol dose was 7.2 h (range: 0.75-92.3), with an average of three misoprostol doses. Most participants expelled the fetus and the placenta at or around the same time; median time between fetal and placental expulsion was 15 minutes (range: 0-4.5 h). Fifteen participants (6.6%) received more than five misoprostol doses and were transferred to inpatient care. Administration of more than five doses of misoprostol was associated with nulliparity. Provision of antibiotics (27.9%, n = 64), manual removal of placenta (15.3%, n = 35), uterotonics (4.4%, n = 10) and surgical interventions (4.4%, n = 10) were also reported. About one in four participants experienced nausea, vomiting and chills; fever was infrequent (2.5%, n = 5).Conclusions: For gestations 13-18 weeks, an outpatient day process for medication abortion is safe, effective and feasible.Implications: Medication abortion in 13 - 18 weeks need not be limited to inpatient care; nine of ten cases can be managed as an outpatient day service. [ABSTRACT FROM AUTHOR]

Objective: To examine incidence of child marriage among displaced and host populations in humanitarian settings., Design: Cross-sectional surveys., Setting: Data were collected in Djibouti, Yemen, Lebanon and Iraq in the Middle East and in Bangladesh and Nepal in South Asia., Participants: Adolescent girls aged 10-19 in the six settings and age cohort comparators., Outcome Measures: Cumulative incidence of marriage by age 18., Results: In Bangladesh and Iraq, the hazard of child marriage did not differ between internally displaced populations (IDPs) and hosts (p value=0.25 and 0.081, respectively). In Yemen, IDPs had a higher hazard of child marriage compared with hosts (p value<0.001). In Djibouti, refugees had a lower hazard of child marriage compared with hosts (p value<0.001). In pooled data, the average hazard of child marriage was significantly higher among displaced compared with host populations (adjusted HR (aHR) 1.3; 95% CI 1.04 to 1.61).In age cohort comparisons, there was no significant difference between child marriage hazard across age cohorts in Bangladesh (p value=0.446), while in Lebanon and Nepal, younger cohorts were less likely to transition to child marriage compared with older comparators (p value<0.001). Only in Yemen were younger cohorts more likely to transition to child marriage, indicating an increase in child marriage rates after conflict (p value=0.034). Pooled data showed a downward trend, where younger age cohorts had, on average, a lower hazard of child marriage compared with older cohorts (aHR 0.36; 95% CI 0.29 to 0.4)., Conclusions: We did not find conclusive evidence that humanitarian crises are associated with universal increases in child marriage rates. Our findings indicate that decision-making about investments in child marriage prevention and response must be attuned to the local context and grounded in data on past and current trends in child marriage among communities impacted by crisis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy's reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy's harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR's impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to identify the multilevel factors that influence contraceptive use and childbearing decisions in Nepal and examine relationships among these factors., Design: The study drew on qualitative data collected through in-depth interviews (IDIs) and key informant interviews (KIIs) and triangulated results., Setting: An urban municipality and a rural municipality in Bara district, Nepal., Participants: We recruited a total of 60 participants (e.g., 20 married adolescent girls aged 15-19, 20 husbands, 20 mothers-in-law) for IDIs and 10 (e.g., four healthcare providers, three health coordinators, three female community health volunteers) for KIIs., Results: Married adolescent girls faced a range of barriers that are inter-related across different levels. Patriarchal norms and power imbalances between spouses limited their decision-making power regarding contraception. Social pressures to give birth soon after marriage drove the fear of infertility, abandonment and the stigmatisation of childless married couples, which leads to lack of women's autonomy in making decisions about family planning. Mothers-in-law and religion exerted considerable influence over couples' decisions regarding contraception. Limited access to information about the benefits and methods of family planning contributed to fear of the side effects of contraceptives and low awareness about the risks involved in adolescent pregnancy., Conclusions: The convergent results from triangulation confirm that the decision to postpone childbearing is not merely the personal choice of an individual or a couple, highlighting the importance of targeting families and communities. The study underscores the need to challenge restrictive sociocultural norms so that adolescent girls become empowered to exercise greater control over contraceptive use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to investigate whether child marriage had causal effects on unmet needs for modern contraception, and unintended pregnancy, by estimating the marginal (population-averaged) treatment effect of child marriage., Design: This study used secondary data from the Nepal Demographic and Health Survey 2016. Applying one-to-one nearest-neighbour matching with replacement within a calliper range of ±0.01, 15-49 years old women married before the age of 18 were matched with similar women who were married at 18 or above to reduce selection bias., Setting: Nationally representative population survey data., Participants: The sample consisted of 7833 women aged 15-49 years who were married for more than 5 years., Outcome Measures: Unmet needs for modern contraception and unintended pregnancy., Results: The matching method achieved adequate overlap in the propensity score distributions and balance in measured covariates between treatment and control groups with the same propensity score. Propensity score matching analysis showed that the risk of unmet needs for modern contraception, and unintended pregnancy among women married as children were a 14.3 percentage point (95 % CI 10.3 to 18.2) and a 10.1 percentage point (95 % CI 3.7 to 16.4) higher, respectively, than among women married as adults. Sensitivity analysis indicated that the estimated effects were robust to unmeasured covariates., Conclusions: Child marriage appears to increase the risk of unmet needs for modern contraception and unintended pregnancy. These findings call for social development and public health programmes that promote delayed entry into marriage and childbearing to improve reproductive health and rights., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)