Majority (40.2%) belonged to 20-24 years with Mean± SD of 25.68 ± 6.38 years. Almost 73% were Dalit, 38.3% had informal education and 88.6% were housemaker. Most (67.1%) of them belonged to nuclear family. Almost 95% had ever given birth: 39.3% had ≥ 3 children, 5.1% had stillbirth, 2.6% twin pregnancy and 62% were multiparous. During data collection, 9.2% were pregnant (Table 1).
We found that 76.9% were literate, 88.6% housemaker, 62.7% upper lower socioeconomic status and 82.6% had early marriage history (12-19 years). With regards to fertility preferences: 91.4% had history of intended pregnancy, 33.1% desire for future pregnancy, 12% had history of under 5 mortality, 30.1% wish to have 2 children irrespective of sex of children delivered. In reproductive healthcare decision making: 83.7% couples decide jointly on selecting contraception, 61.1% women were able to refuse sexual intercourse with their husbands, half (50.8%) women could ask their husband to use condoms during intercourse. Most couples (88.9%) had joint decisions on general healthcare seeking behaviours and 90.5% couples jointly decided on using income. More than half (51.6%) did not belong to any social group (Table 2) We found only 27.8% had knowledge on fertile period and 2.5% had knowledge on legal provision of abortion. Almost 14% had history of abortion; among them one participant did not receive post abortion care and family planning services. Seventy-seven percent had knowledge on modern contraceptive methods. Nearly two- third (63.84%) women were currently using contraception, in which majority (41.6%) were Depo-Provera users, 39.3% women had sterilisation and 47.4% were thinking to use it in the near future (Table 3). Current use of modern contraceptives were more among below average women empowerment groups (p 0.041, OR 0.593 C.I. 0.36-0.98). We could not find any statistical significant differences among women’s empowerment with abortion knowledge (p 0.549); family planning knowledge (p 0.495) and women’s decision for future use of modern contraceptives. (p 0.977) (Table 4).
Table 1: Baseline characteristics of participants (n=316)
Characteristics
|
n (%)
|
Age group (year)
|
Mean ± SD of 25.68 ± 6.38years.
|
15-19
|
35(11.1)
|
20-24
|
127(40.2)
|
25-29
|
69(21.8)
|
30-34
|
45(14.2)
|
35-39
|
20(6.3)
|
40-44
|
14(4.4)
|
45-49
|
6(1.9)
|
Ethnicity
|
|
Dalit
|
230(72.8)
|
Janajati
|
42(13.3)
|
Muslim
|
6(1.9)
|
Madhesi
|
38(12.0)
|
Education
|
|
Primary
|
51 (16.1)
|
Lower Secondary
|
29(9.2)
|
Secondary
|
37 (11.7)
|
Higher Secondary
|
5(1.6)
|
Informal
|
121 (38.3)
|
Illiterate
|
73 (23.1)
|
Education (Head of Household)
|
|
Primary
|
61(19.3)
|
Lower secondary
|
44(13.9)
|
Secondary
|
23 (7.3)
|
Higher secondary
|
4(1.3)
|
Informal
|
3 (0.9)
|
Illiterate
|
98 (31)
|
Occupation
|
|
House maker
|
280 (88.6)
|
Daily Wedge
|
23 (7.3)
|
Shop/Tailor
|
8 (2.5)
|
Factory Worker
|
5 (1.6)
|
Family type
|
|
Nuclear
|
212 (67.1)
|
Joint
|
104 (32.9)
|
Occupation (Head of Household)
|
|
Unskilled worker
|
138 (43.7)
|
Semi-skilled worker
|
116 (36.7)
|
Skilled worker
|
45(14.2)
|
Clerical, Shop-owner, Farmer
|
16 (5.1)
|
Semi-Profession
|
1 (0.3)
|
Family Income Per Month (in NPR)
|
≤2300
|
1(0.3)
|
2301 – 6850
|
22 (7.0)
|
6851 – 11450
|
56 (17.7)
|
11451 – 17150
|
114 (36.1)
|
17151 – 22850
|
79 (25.0)
|
22851 – 45750
|
44 (13.9)
|
Birth history (Yes)
1
2
≥ 3
|
300 (94.9)
87 (29.0)
95 (31.7)
118 (39.3)
|
Still born history (n=300)
|
4(1.3)
|
Twin pregnancy history (n=300)
|
8(2.6)
|
Current pregnancy status
|
29(9.2)
|
Parity
|
Nulliparous
|
18(5.7)
|
Primiparous
|
85(26.9)
|
Multiparous*
|
196(62.0)
|
Grandmultiparous**
|
17(5.4)
|
*Multiparous: >1 to 4 times pregnant **Grand multiparous: ≥5 times pregnant
Table 2: Women empowerment variables
Characteristics
|
n (%)
|
Education status (n=316)
|
|
Illiterate
|
73 (23.1)
|
Literate
|
243 (76.9)
|
Occupation (n=316)
|
|
Housemaker
|
280(88.6)
|
Other than housemaker
|
36(11.4)
|
Socio-economic status* (n=316)
|
|
Upper lower
|
198(62.7)
|
Lower middle
|
118(37.3)
|
Age at marriage (n=316)
|
12-19 years
|
261(82.6)
|
20- 30 years
|
55(17.4)
|
Fertility preferences
|
|
Intended pregnancy history(n=313)a
|
286(91.4)
|
Desire for future pregnancy(n=287)b
|
95(33.1)
|
Child mortality history (n=300)
|
36(12.0)
|
No sex preferences of child (n=316)
|
95(30.1)
|
Ideal number of children i.e. 2 (n=316)
|
95(30.1)
|
Reproductive healthcare decision making (n=312)**
|
|
Decision making on using contraception
Couple
Single/In laws
|
261(83.7)
51(16.3)
|
Able to refuse undesired sexual intercourse
|
190(61.1)
|
Able to ask husband to use condom during intercourse
|
158(50.8)
|
General healthcare decision making (n=316)
Couple
Other than couple
|
281(88.9)
35(11.1)
|
Decision for income use (n=316)
Couple
Other than couple
|
286(90.5)
30(9.5)
|
Involvement in social group (n=316)
Mothers/saving/women’s group
Doesn’t belong to any group
|
153 (48.4)
163 (51.6)
|
Women empowerment (n=316)
Above average
Below average
|
160(50.6)
156(49.4)
|
aIncluding at least one previous pregnancy history; bCurrent pregnant status excluded;* Modification of Kuppuswamy’s socioeconomic status scale in context to Nepal[16]**single women and widow excluded)
Table 3: Knowledge and practice on abortion and family planning
Characteristics
|
n(%)
|
Knowledge on fertile period (n=316)
|
88 (27.8)
|
Knowledge on conditions for legal abortion (n=316)
|
8 (2.5)
|
Overall abortion knowledge (n=316)
|
92 (29.1)
|
Post abortion care and family planning services received (n=43)
|
42 (97.67)
|
Knowledge on modern contraceptives (n=316)
|
244 (77.2)
|
Current use of modern contraceptives (n=271) a
Methods of family planning used (n= 173)
Depo-Provera
IUCD
Norplant
OCP
Male Condom
Female sterilization
|
173 (63.84)
72 (41.6)
4 (2.3)
18 (10.4)
9 (5.2)
2 (1.2)
68 (39.3)
|
Thinking of using in near future (n=116)b
|
55 (47.4)
|
a: Husband going abroad, widow, hysterectomy, and currently pregnant were excluded;
b Hysterectomy, husband going abroad, widow, current family planning users were excluded.
Table 4: Association of women empowerment with abortion and family planning
|
Abortion Knowledge
|
Post abortion care and family planning counseling received
|
Family Planning
knowledge
|
Current use of modern contraceptives
|
Thinking for future use of modern contraceptives
|
Women empowerment
|
|
Yes
|
No
|
Yes
|
No
|
Yes
|
No
|
Yes
|
No
|
Yes
|
No
|
Above average
|
49
(30.6%)
|
111
(69.4%)
|
26
(96.3%)
|
1
(3.7%)
|
121
(75.6%)
|
39
(24.4%)
|
80
(58%)
|
58
(42%)
|
29
(47.5%)
|
32
(52.5%)
|
Below average
|
43
(27.6%)
|
113
(72.4%)
|
16
(100%)
|
0
(0%)
|
123
(78.8%)
|
33
(21.2%)
|
93
(69.9%)
|
40
(30.1%)
|
26
(47.3%)
|
29
(52.7%)
|
OR (CI)
|
1.16 (0.713-1.886)
|
NAa
|
0.832 (0.49-1.41)
|
0.593
(0.36-0.98)
|
1.01
(0.49-2.097)
|
P value
|
0.549
|
NAa
|
0.495
|
0.041b
|
0.977
|
a Not applicable; bP value <0.05 considered statistical significant
Key informant interviews
Despite quantitative analysis of participants (service utilizers), we were not clear on women’s empowerment perspective from healthcare providers and community leaders. The community leaders have a major role in policy level decision-making and health care providers at service delivery. We conducted key informant interviews to explore further the women’s current issues, factors that may contribute to empowerment of women, their reproductive health status mainly in part of abortion and family planning, the available reproductive health facilities and its utilisation by marginalized women of that locality. The themes identified from key informant interviews further clarified status of women’s empowerment and explore abortion and family planning knowledge and practice.
Characteristics of participants
Key informant interviews were conducted with 15 key persons of the same community where eight were healthcare providers and seven were local leaders. The mean age of participants was 44.67 years with standard deviation of 13.38 years ranging from 26 years to 62 years. Majority of them were male (60%) and all were literate.
Present status of marginalized women
Majority of the informants said illiteracy, poverty and domestic violence are the major issues of marginalized women. They are completely dependent on their husband and had to tolerate any types of physical or emotional violence. The quotations highlight the reasons behind lack of women empowerment. The status of women specially marginalized women in our society is very poor. The main reason is lack of education and poverty. Our ward is under municipality but the status of the society is worse than the village development committee (VDC) because the population and the area coverage of our ward is bigger and we have access to only one health post here. (Local leader, Male)
The present status of marginalized women is poor day by day, Ammm.... Loan support from nongovernmental organisations (NGOs), international nongovernmental organisations (INGOs), co-operative limited did somehow help in earlier days but recently all the families are being affected by the poor socioeconomic status and inability to pay loans offered by the banks. (Local leader, Male)
Abortion knowledge and practice
One informant reported, abortion is common among 20-35 years female in their locality. Sometimes abortion is practiced illegally after sex determination even at 3-4 months of pregnancy. One health worker often stated that unmarried teenagers, factory workers even seek to health posts with complication of induced illegal abortion. Causes of abortion was unwanted pregnancy, unmet family planning and default of depo provera. As stated by healthcare providers, DPHO, IPAS has been constantly supporting abortion services in some primary health centers (PHC) and they often do have medical abortion and urinary pregnancy test services available. The quotations highlight the reason and sequelae of abortion.
“Abortion is practiced with some native techniques or with use of herbals at home by some females and come to health centers with complication like bleeding, infection or incomplete expulsion.” (Healthcare Provider, Female)
“Nowadays extra marital sexual practices have landed up with many abortion cases.”(Healthcare Provider, Male)
Many attempt to take medicines at home from nearby clinics to avoid disclosure. While many did not visit local health centers due to stigma and fear of unacceptance in society. (Healthcare Provider, Female)
“Some practiced abortion after sex determination illegally.” (Healthcare Provider, Female)
One of the Muslim local leader stated that their society do not consider abortion as a good practice even though the people have some knowledge in it.
We do not consider abortion as good things in our society. If anyone had induced abortion in 2 or 3 months of pregnancy, our society views them as a social stigma. However, people are a little aware and are positive regarding abortion nowadays, but abortion practice is uncommon in our society. (Local leader, Male)
Family planning knowledge and practice
Many informants said that people’s awareness on family planning methods is improving. The common methods available were copper T, male condom, injection (depo provera), one is electric operation (Tubectomy) and one is hand operation (Vasectomy). These services has been provided by PHCs, FCHVs, mobile camps, NGOs, INGOs, Marie Stopes and Zonal hospitals. However, people demand for all types of free of cost family planning services in their nearby primary healthcare centers. The quotations highlight the commonly used family planning devices, its availability and preferences.
We have copper-T, male condom, injection, one is electric operation and one is hand operation. Some are using these methods and some not. We still have a lack of public awareness on these methods. Most (80%) seek services from primary healthcare centers and 20% goes to Koshi Zonal Hospital. (Local leader, Female)
“People demand for free of cost availability of modern family planning services in health centers” (Healthcare Provider, Male)
“Mobile camp on permanent sterilization is organised sometimes in community health centers but very often they have to take service from Marie Stopes.” (Healthcare Provider, Female)
Cafeteria choice for family planning was not into practice. Female users were more than male users. Many couples practiced natural methods like lactational amenorrhea, withdrawal and emergency contraception. They preferred to take temporary methods, especially depo-provera.
Females use more family planning methods than male. (Local leader, Male)
“Many people use family planning only after 2-3 children.” (Healthcare Provider, Female Community Health Volunteer)
“The client's mind set is already fixed on using Depo-Provera, they don’t want to hear about any other methods.” (Healthcare Provider, Male)
“Even elderly females prefer using depo knowingly and unknowingly.” (Healthcare Provider, Female Community Health Volunteer)
“Yes, many newly married male come to me and ask for advice on natural methods. They were not satisfied with family planning devices thinking of its side effects and decrease in sexual pleasure.” (Healthcare Provider, Female)
Most clients asked us - Why don’t you have provision of distributing emergency contraception pills in your health center? We demand for these services.” (Healthcare Provider, Male)