1. Post-abortion Contraceptive Services in Nepal: Perspectives of Abortion Care Stakeholders
Lin-Fan Wang MD1, Mahesh Puri PhD2, Deepak Joshi MPH2, Maya Blum MPH3, Jillian T. Henderson PhD3
1. Albert Einstein College of Medicine Bronx, NY Center for Research on Environment Health and Population Activities Kathmandu, Nepal UCSF Bixby Center for Global Reproductive Health San Francisco, CA
Background
Maternal mortality rate is 229 deaths per 100,000 live births
One in four married women have an unmet need for contraception
Women obtaining abortions are at heightened risk of unintended pregnancy
Structural issues, counseling approaches, and provider knowledge and misperceptions can affect family planning acceptance by abortion patients
Results
Contraceptive supplies
Male condoms, combined oral contraceptive pills, Depo-Provera, Copper IUD, subdermal implant
No additional cost for supply or insertion
Providers perceive that:
Depo-Provera most commonly used, LARC underused
Unmarried women and young women less likely to accept
Contraceptive acceptance
Providers experience shortages in LARC supply and trained providers
Abortion units at governmental hospitals lack staff dedicated to family planning provision
“I have to work in my ward and CAC unit which is a big problem for me. …there should be a provision of separate doctor providing service…. At least full time staff, either ANM or nurse, should be place 10 to 4…. So that clients could get the service 10 to 4 and the problem of shifting the staff everyday would be solved.”
Counseling recognized as “backbone” of service provision, but need for more time, space, and dedicated counselors
“But we don't have the separate job, counselor…. We have the sisters, she's doing counselor and she's doing provider, and she's doing treatment part also, she's providing service part, also.”
Many believed that LARC should not be used by unmarried women or married women with no children
“There are some who are unmarried but ask for long term methods and which is not applicable as she is not married, she has no child, and in such case how can we provide such measure.”
Supply side barriers
Factors affecting family planning demand
Women believe that family planning is not needed or they fear stigma: unmarried women say that they do not have a regular partner and married women say that their husbands are abroad,
“…most of [married women] do not use [contraception] as their husbands are abroad for three years and our society has a concept that she doesn’t need to use it because she won’t be engaged with someone else. We cannot change the society regardless of how much effort we put, and when a woman gets a Depo then they think she is up to some mischief, and out of fear women do not want to use it when their husbands are not around….”
Rural women perceived to face more barriers, including lower literacy and education, higher level of misperceptions, and barriers to healthcare access
“Usually, when [rural women] haven't put in IUCD … somebody [in their village] will say, ‘It will go right up into your tummy somewhere’. They are naturally scared when they hear things like that. And if they have the problem, they have to travel all the way back to the hospital, or have an ultrasound scan or x-ray, if they can't see the thread there…. Follow-up is more difficult with the IUCD. “
Most women who choose home misoprostol administration do not return for follow-up, thus contraceptive uptake cannot be ensured by providers
Objective
Examine the perspectives and experiences of healthcare providers and administrators regarding family planning supply and provision for abortion patients
Methods
24 in-depth interviews conducted with providers and administrators
Setting: abortion units at governmental hospitals and private abortion clinics
Data analyzed using modified grounded theory
Implications
Providers need more structural support, including consistent stocking of supplies and dedicated, trained providers
Strategies needed to address contraceptive needs of women whose husbands are abroad and to reduce stigma associated with contraceptive use
Innovative strategies needed to improve contraceptive uptake and continuation among women in rural areas