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Abortion was legalized in Nepal in 2002; however, despite evidence of safety and quality provision of medical abortion (MA) pills by pharmacies in Nepal and elsewhere, it is still not legal for pharmacists to provide medication abortion in Nepal. However, pharmacies often do provide MA, but little is known about who seeks abortions from pharmacies and their experiences and outcomes. The purpose of this study is to understand the experiences of women seeking MA from a pharmacy, abortion complications experienced, and predictors for denial of MA. Data was collected from women seeking MA from four pharmacies in two districts of Nepal in 2021-2022. Data was collected at baseline (N = 153) and 6 weeks later (N = 138). Using descriptive results and multi-variable regression models, we explore differences between women who received and did not receive MA and predictors of denial of services. Most women requesting such pills received MA (78%), with those who were denied most commonly reporting denial due to the provider saying they were too far along. There were few socio-demographic differences between groups, with the exception of education and gestational age. Women reported receiving information on how to take pills and what to do about side effects. Just under half (45%) of women who took pills reported no adverse symptoms after taking them and only 13% sought care. Most women seeking MA from pharmacists in Nepal are receiving services, information, and having few post-abortion symptoms. This study expands the previous limited research on pharmacy provision of MA in Nepal using a unique dataset that recruits women at the time of abortion seeking and follows them over time, overcoming potential biases present in other study designs. This suggests that expansion of the law to allow pharmacy distribution would increase accessibility and reflect current practice.

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.

Eating last is a gendered cultural norm in which the youngest daughters-in-law are expected to eat last after serving others in the household, including men and in-laws. Using women's eating last as an indicator of women's status, we studied the association between eating last and women's mental health. Using four rounds of prospective cohort data of 18-25-year-old newly married women (n = 200) cohabiting with mothers-in-law between 2018 and 2020 in the Nawalparasi district of Nepal, we examined the association between women eating last and depressive symptom severity (measured using 15-item Hopkins Symptom Checklist for Depression; HSCL-D). Twenty-five percent of women reported eating last always. The prevalence of probable depression using the established cutoff was 5.5%, consistent with the prevalence of depression in the general population. Using a hierarchical mixed-effects linear regression model, we found that women who always ate last had an expected depressive symptom severity (0-3 on HSCL-D) 0.24 points (95% confidence interval [CI]: 0.13-0.36) greater compared to women who did not eat last when adjusted for demographic variables, household food insecurity, and secular trends. Sensitivity analysis using logistic regression also suggested that women who eat last have greater odds of having probable depression (adjusted odds ratio [AOR] = 4.05; 95% CI: 1.32-12.44). We explored if the association between eating last and depressive symptom severity was moderated by household food insecurity and did not observe evidence of moderation, underscoring the significance of eating last as a woman's status indicator. Our study findings highlight that newly young married women in Nepal are a vulnerable group.

BackgroundMindful 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.MethodsIn 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.ResultsSumadhur significantly impacted (p

IntroductionIn 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.MethodsWe 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.ResultsAmong 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.ConclusionDenial 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.

BackgroundIn Nepal and across the globe, the COVID-19 pandemic has primed an environment for increased rates of violence against women (VAW). This paper explores pandemic-driven economic insecurity and increased alcohol use as instigators of VAW and Intimate Partner Violence (IPV) within newly married households in the rural, Nawalparasi region of Nepal.MethodsThis study is a secondary analysis of data obtained from the Sumadhur Intervention pilot study that has been previously described and demonstrates successful implementation of group-based, household-level intervention for women's empowerment and sexual and reproductive health education (1). Our three sets of data were collected before and during the COVID-19 pandemic. The first set is from a Longitudinal Cohort of 200 newly married women who were surveyed twice a year from February 2017 through July 2020. The second data set is a subset cohort of newly married women, their husbands, and their mothers-in-law (31 women, 31 husbands and 31 mothers-in-law) who participated in Sumadhur in January 2021. The third data set was obtained through in-depth interviews in July 2021 from 15 households following Sumadhur. The interviews were thematically coded, and subthemes were identified. A t-test of the January 2021 survey data set was run to look at correlations between income loss, alcohol consumption and experience of IPV among newly married women. All other survey data was analyzed for change over time.ResultsAt three months after the onset of the pandemic (July 2020), the Longitudinal Cohort survey data from newly married women reported increased rates of husbands' alcohol use as well as personal experiences of IPV as compared to pre-pandemic averages. There was a statistically significant difference (p

BackgroundIn a setting such as Nepal with malnutrition and persistent poor maternal and infant health outcomes, developing interventions to improve the nutrition of preconception and pregnant women is essential.ObjectiveThe objectives of this paper are to describe the full design process of an intervention for newly married women, their husbands, and mothers-in-law to improve maternal nutrition and gender norms, and findings from the feasibility and acceptability pilot.MethodsIn this paper we describe the three phases of the design of an intervention in rural Nepal. We first conducted a mixed methods formative phase which included in depth interviews with newly married women, their husbands and mothers-in-law (N=60) and a longitudinal study for 18 months with 200 newly married women. We then designed of a household level, group, intervention, in close partnership with community members. Finally, we conducted a pilot intervention with 90 participants and collected both pre/post survey data and in-depth qualitative interviews with a subset (N= 30). All participants from all phases of the study lived in Nawalparasi district of Nepal. Qualitative data was analyzed using a thematic analysis, with inductive and deductive themes and quantitative data was analyzed using descriptive statistics.ResultsOur formative work highlighted lack of awareness about nutrition, and how women eating last, limited mobility, household and community inequitable gender norms and poor household-level communication contributed to low quality diets. Thus we designed Sumadhur, an intervention that brought groups of households (newly married wife, husband, and mother-in-law) together weekly for four months to strengthen relationships and gain knowledge through interactive content. We found Sumadhur to be highly feasible and acceptable by all respondents, with most (83%) attending 80% of sessions or more and 99% reporting that they would like it to continue. Pre/post surveys showed a decrease in the proportion of women eating last and increase in knowledge about nutrition in preconception and pregnancy. Qualitative interviews suggested that respondents felt it made large impacts on their lives, in terms of strengthening relationships and trust, understanding each other, and changing behaviors.ConclusionsWe show how a designing an intervention in close partnership with the target recipients and local stakeholders can lead to an intervention that is able to target complicated and culturally held practices and beliefs, positively benefit health and wellbeing, and that is very well received.Trial registrationClinicalTrials.gov NCT04383847 , registered 05/12/2020.

ObjectiveAlthough 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.MethodsEligible 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.ResultsAlmost 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.ConclusionIntegrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.

Women's nutritional status remains poor in South Asia, impacting maternal and infant health outcomes. Women's household status is also low, as evidenced by eating behaviours. We started with triadic qualitative interviews with newly married women, husbands and mothers-in-law to explore the link between women's status and eating patterns, followed by longitudinal data from a cohort of 200 newly married women in rural Nepal to measure associations over time. Quantitative data were collected every 6 months for 18 months (four rounds of data) between 2018 and 2020. Interviews suggested that household relationships, women's status, and how much and what types of food she was given were intricately linked. Using mixed effects logistic regression models, we explore the association between markers of changing women's status (becoming pregnant, giving birth and working outside the home) on two outcomes (eating last always/usually and achieving minimum dietary diversity). We also explore for interaction between women's status and household food insecurity. Pregnancy increases women's dietary diversity, but this is not sustained post-partum. Women who work outside the home are less likely to eat last in the household. Food insecurity is associated with both the order of household eating and dietary diversity. Interactions between food insecurity and giving birth suggested that women who give birth in food insecure households are more likely to eat last in the household. Changes in women's household status are associated with some improvements in dietary diversity and order of household eating, but the associations are not long-lasting and depend on food security status.

BackgroundIntimate partner violence and nonpartner violence are common in Nepal, yet the relationship between violence and fertility is unclear. The risk of violence for young, newly married women in Nepal may be associated with becoming pregnant and giving birth due to either the family's desire to protect the fetus (reducing violence) or the added household stressors that accompany a pregnancy (increasing violence).ObjectiveThis study aimed to investigate changes in partner and nonpartner violence over time in early marriage and explore the hypothesis that conception and childbirth may be associated with risk of domestic violence.Study designWe surveyed newly married women aged 18 to 25 years and living in the Nawalparasi district of Nepal in 4 rounds of data collection at 6-month intervals over 2 years. At each survey, interviewers asked whether participants had experienced any violence within the previous 6 months, including details about the type and perpetrator of the violence, and whether they had ever been pregnant or given birth.ResultsA cohort of 200 participants completed the baseline survey and 183 (92%) completed all 4 survey rounds. The proportion of participants experiencing any recent violence increased substantially over time. By the end of the study, 58% of participants reported experiencing intimate partner violence, nonpartner violence, or both in the previous 6 months. Most participants had been pregnant (148 [79%]) and given birth (117 [64%]) during the study period. Multivariate models were used to estimate the odds of any intimate partner violence during the previous 6 months. The odds of experiencing any intimate partner violence were more than 2 times higher for participants who became pregnant (odds ratio, 2.2; 95% confidence interval, 1.0-4.7) and gave birth (odds ratio, 2.9; 95% confidence interval, 1.2-7.2) than for those who did not. After adjusting for covariates, pregnancy and birth were not statistically associated with a change in the odds of reporting any nonpartner violence.ConclusionOur study indicates that newly married young women in Nepal are vulnerable to violence in the home from both partners and nonpartners. Our findings support the hypothesis that risk of intimate partner violence may be greater during the perinatal period. The longitudinal nature of the study contributes to the existing literature by adding evidence that violence increases in early marriage and is positively associated with pregnancy and birth.

ObjectiveWomen in South Asia, including Nepal, have some of the poorest nutritional indicators globally, leading to poor maternal and child health outcomes. Nepal also suffers from high levels of household food insecurity, and newly married women are at high risk. Intra-household relationships may mediate the relationship between food insecurity and women's nutrition in Nepal for newly married women. Our aim is to understand how newly married, preconception, women's food consumption changes when she enters her husband's home, compared with her natal home. We also explore whether relationship quality with husbands and mothers-in-law mediates the association between food insecurity and eating less high-quality food, using structural equation modelling.DesignCross-sectional survey data.SettingRural Nepal in 2018.ParticipantsData were collected from 200 newly married, preconception women.ResultsWomen had poor diet quality, and most ate fewer high-quality foods important for pregnancy in their marital, compared with natal, home. Higher quality relationships with mothers-in-laws mediated the association between food insecurity and a woman eating fewer high-quality foods in her marital, compared with natal, home. Relationship quality with husbands was not associated with changes in food consumption.ConclusionsPreconception, newly married women in Nepal are eating less high-quality foods important for women's health during the preconception period - a key period for avoiding adverse maternal and infant health outcomes. Relationships with mothers-in-law are key to women's access to high-quality food, suggesting that interventions aiming to improve maternal and child nutrition should target all household members.

Marriage is a point of change in young people's lives, especially in parts of the world that place high value on it, such as in South Asian countries including Nepal. However, marriage practices are changing, with a move towards more love marriage; this is likely to have important implications on women's status and agency, household and couple dynamics, and mental and physical health. The aim of this paper is to describe how changing marriage formation patterns and traditional practices such as co-residence and dowry are intersecting and impacting relationships post-marriage. In-depth qualitative interviews took place with 20 intact triads of newly married women, their husbands and their mothers-in-law, in one district of Nepal in 2017. Many marriages remain arranged; however, couples often talk or meet before marriage and feel that they are able to build a foundation of love before marrying. Access to technology facilitates this practice, although some couples are reluctant to admit their communication, suggesting stigma about this practice. Husbands have growing ambivalence about dowry, leading to confusion and negatively impacting on relationships post-marriage. A clash of traditional and modern ideas and practices is occurring in Nepal, influencing newly married women's household status and relationship quality, and potentially impacting women's health.

ContextIt is accepted as the norm that couples in South Asia begin childbearing immediately after marriage and that, even if they would like to delay, they are pressured to have children by household members. Little research, however, has explored the desire to delay childbearing among newly married couples and their household members in Nepal-a setting with changing marriage formation patterns, increasing women's education and falling fertility.MethodsTo explore the dynamics of current childbearing desires, in-depth interviews of 20 intact triads of newly married women, their husbands and their mothers-in-law were conducted in one district of Nepal in February-March 2017. Using thematic analysis, interviews were read and coded separately by type (wives, husbands, mothers-in-law), and then the triads were read together and coded to determine household-level patterns and themes.ResultsMost newly married women and men want to delay their first birth, but have not communicated with each other about this. Even though couples are often in agreement about delaying, they feel pressured by in-laws and society to bear children early. Contrary to expectations, some mothers-in-law support delaying childbearing to allow their daughter-in-law to mature, continue her education or earn wages; however, they too perceive societal pressure. Male migration for work also contributes to early childbearing pressure.ConclusionsHelping couples to sort through conflicting fertility norms and desires may be important to delay childbearing when desired. Programs should engage all household members, and work to increase couples' and household communication to address misperceptions about fertility desires.

BackgroundDespite 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.MethodsWe 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.ResultsAlmost 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.ConclusionsImprovements 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.

ObjectiveTo evaluate whether conducting a bimanual examination prior to medication abortion (MAB) provision results in meaningful changes in gestational age (GA) assessment after patient-reported last menstrual period (LMP) in Nepal.Study designWomen ages 16-45 (n=660) seeking MAB at twelve participating pharmacies and government health facilities, between October 2014 and September 2015, self-reported LMP. Trained auxiliary nurse midwives assessed GA using a bimanual exam after recording LMP. We compared GA assessments as measured via patient-reported LMP alone versus via LMP plus bimanual exam.ResultsOverall, 660 women (326 at pharmacies, 334 at health facilities) presented for MAB, and 95% were able to provide an LMP. Overall agreement between LMP alone and LMP with bimanual exam was 99.3%. If LMP alone had been used without bimanual exam, fewer than one in 200 women would have been given MAB beyond the legal gestational limit. Among the three women who were ≤63 days by LMP but >63 days by bimanual exam, only one would have received MAB beyond 70 days gestation. Fewer than one in 600 women would not have received MAB care when eligible by adding a bimanual exam.ConclusionThere was high agreement between LMP alone and LMP plus bimanual exam. Routine bimanual exam may not be essential for safe and effective MAB care for women who are able to report an LMP. Removing the bimanual exam requirement could decrease barriers to provision outside of currently approved clinical settings and allow for expanded abortion access through provision by providers without bimanual exam training or facilities.ImplicationsRoutine bimanual exams may not be essential for safe medication abortion provision by trained clinicians in pharmacies and health facilities in low resource settings like Nepal.

BackgroundAlthough abortion was legalized in Nepal in 2002, many women are not able to obtain legal services. Using qualitative data from women who were denied legal abortion services, we examined reasons for seeking an abortion, options considered and pursued after being denied an abortion, reasons for delaying seeking care, as well as complications experienced among women who were denied legal abortion.MethodsAfter obtaining authorization from two health facilities in Nepal, we requested informed consent from all women who were seeking abortion services to complete a case report form to determine their eligibility for the study. We then recruited all eligible and interested women in to the study. Two months after recruitment, we conducted in-depth interviews with 25 women who were denied abortion services from the two recruitment facilities due to advanced gestational age (>12 weeks). Interviews were translated and transcribed, and the transcripts were analyzed through an iterative process grounded in thematic analysis, involving both a priori and emergent codes.ResultsEleven women were recruited from the government hospital and 14 from an NGO facility. The majority of women (15 women or 60 %) were living rural settings, ranged in age from 18 to 40 years and had an average of 2 children. None had completed any post-secondary education. Women most commonly cited financial concerns and health concerns as reasons for seeking termination. Not recognizing pregnancy, uncertainty about how to proceed, needing time to coordinate the trip to the facility or raise money, and waiting to know the sex of fetus were the commonly cited delays. Among the women interviewed, 12 decided to continue their pregnancies following denial, 12 terminated their pregnancies elsewhere, and one self-induced using medication. At least two women experienced significant complications after obtaining an abortion. Most women who continued their pregnancies anticipated negative consequences for their health, family relationships, and wellbeing.ConclusionsBarriers to seeking early abortion need to be addressed in order to reduce utilization of abortion services that may be unsafe and to improve women's health and wellbeing in Nepal.

BackgroundFactors such as poverty, stigma, lack of knowledge about the legal status of abortion, and geographical distance from a provider may prevent women from accessing safe abortion services, even where abortion is legal. Data on the consequences of abortion denial outside of the US, however, are scarce.MethodsIn this article we present data from studies among women seeking legal abortion services in four countries (Colombia, Nepal, South Africa and Tunisia) to assess sociodemographic characteristics of legal abortion seekers, as well as the frequency and reasons that women are denied abortion care.ResultsThe proportion of women denied abortion services and the reasons for which they were denied varied widely by country. In Colombia, 2% of women surveyed did not receive the abortions they were seeking; in South Africa, 45% of women did not receive abortions on the day they were seeking abortion services. In both Tunisia and Nepal, 26% of women were denied their wanted abortions.ConclusionsThe denial of legal abortion services may have serious consequences for women's health and wellbeing. Additional evidence on the risk factors for presenting later in pregnancy, predictors of seeking unsafe illegal abortion, and the health consequences of illegal abortion and childbirth after an unwanted pregnancy is needed. Such data would assist the development of programmes and policies aimed at increasing access to and utilisation of safe abortion services where abortion is legal, and harm reduction models for women who are unable to access legal abortion services.

AbstractBackgroundUnsafe 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.MethodsTo 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.ResultsOverall, 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.ConclusionsProviders 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.