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In 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. We 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. Among 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. Denial 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.

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.

IntroductionMicronutrient deficiencies remain prominent drivers of adverse maternal and child health outcomes in Nepal. Gender-based inequalities and norms around women’s status and access to nutrition exacerbate poor nutritional status. Many newly married, preconception women lack adequate nutrition due to delayed engagement with the health system and limited autonomy to prioritise their own health. To address this gap, the Sumadhur trial provides multiple micronutrient supplements (MMS) alongside a household-level behavioural intervention targeting newly married women, their husbands and mothers-in-law.Methods and analysisThis will be a village-cluster randomised controlled trial across three districts in Nepal, enrolling 700 households, each comprising a triad of newly married woman, husband and mother-in-law. Villages will be randomised to receive either Sumadhur behavioural intervention+MMS (intervention) or standard of care (control). In intervention villages, participants will join weekly group sessions for 5 months, covering maternal and reproductive health, equitable household food allocation and nutrition information, and gender norms and household relationships. Women will receive three bottles of MMS (180 tablets each) over 18 months. Quantitative data collection at baseline, 6, 12 and 18 months will include surveys, venous blood draws (not at 12 months) and anthropometry. Primary outcomes will be anaemia prevalence and micronutrient status (iron, folate, vitamin B12). Secondary outcomes will include reproductive behaviours, birth outcomes and intrahousehold relationship dynamics. A nested qualitative component will employ longitudinal in-depth interviews with triads to understand the mechanisms of behavioural change. Impact will be measured through an intention-to-treat approach using mixed-effects logistic regression analyses.Ethics and disseminationThe study is approved by institutional review boards in the Ethics Board of the Nepal Health Research Council and the University of California, San Francisco IRB. Results will be disseminated to participating communities, local stakeholders and international audiences through workshops, peer-reviewed publications and policy briefs.All data will be made publicly available (deidentified) after the publication of the main impact paper.Trial registration numberNCT06810440.

This article develops the concept of \"menstrual justice\". The legal scholar Margaret E. Johnson has developed an expansive approach to menstrual justice incorporating rights, justice, and a framework for intersectional analysis, with a focus on the US. This framework provides a welcome alternative to the constrictive and medicalised approaches often taken towards menstruation. However, the framework is silent on several issues pertaining to menstruation in Global South contexts. This article therefore develops the concept of menstrual justice in order to extend its relevance beyond the Global North. It presents the findings of mixed-methods research conducted in April 2019 in the mid-western region of Nepal, particularly concerning the practice of chhaupadi, an extreme form of menstrual restriction. We conducted a quantitative survey of 400 adolescent girls and eight focus group discussions, four with adolescent girls and four with adult women. Our findings confirm that dignity in menstruation requires addressing pain management, security issues, and mental health, plus structural issues including economic disadvantage, environmental issues, criminal law, and education.

Introduction Although the Government of Nepal has developed strategies to integrate contraceptive services with abortion care to better meet the contraceptive needs of women, data indicate that significant gaps in services remain. This paper assessed post-abortion contraceptive use, trends over 36 -months, and factors influencing usage. Methods Data from this paper came from an ongoing cohort study of 1831 women who sought an abortion from one of the sampled 22 government-approved health facilities across Nepal. Women were interviewed eight times over 36 months between April 2019 to Dec 2023. Bivariate and multivariate analysis were used to analyze the data. Results Results show that after abortion, 59% of women used modern contraception, with injection being the most prevalent method, followed by condoms, pills, implants, and IUD. The hazard model showed that discontinuation of modern contraception was significantly higher among women desiring additional children (aHR 0.62) and lower among literate (aHR − 0.15) and those with existing children (aHR − 0.30). Women’s age, ethnicity, cohabitation with husband, household’s income and autonomy were not associated with continuation. Conclusion After having an abortion, we found that just slightly more than half of women used modern methods of contraception; this percentage did not increase significantly over the course of three years.

Background When maternal breastmilk is unavailable in sufficient quantity for infant needs, the World Health Organization (WHO) recommends the use of donor breastmilk if safe, affordable, and available. However, in Nepal and most other low- and middle-income countries (LMICs), there are significant barriers to accessing safe and affordable donor breastmilk, including a paucity of milk banks. An in-depth understanding of perceptions and experiences in Nepal related to use of donor breastmilk could inform the development of interventions to address identified barriers. Methods From December 2019 to January 2020, we conducted a qualitative study, including focus group discussions (FGDs) with parents and community health workers (CHW), and key informant interviews (KIIs) with public health stakeholders in Dhulikhel municipality, Kavrepalanchowk district in Nepal. In total, 44 individuals participated in five FGDs, including two with mothers, one with fathers, and two with CHW. Nine KIIs were conducted with stakeholders. Thematic analyses of translated transcripts were undertaken to explore perceptions and experiences of participants related to use of human donor breastmilk. Results Participants in this study reported that informal breastmilk sharing between relatives and neighbors is common when a mothers’ breastmilk is unavailable or insufficient and such sharing can occur via direct breastfeeding or milk expression. Numerous potential benefits with breastmilk sharing were described, including overcoming initial difficulties with milk supply in the postpartum period, convenience when mothers are unavailable, and reduced risk of infant infection and gastrointestinal distress. Hesitancies to breastmilk sharing included the risk of disease transmission from donor to infant and the possibility of decreased bonding between mother and infant. Some participants stated that animal milk is preferable to breastmilk sharing when mothers own milk is not available. Conclusion Participants were aware of the potential benefits of donor breastmilk but identified numerous barriers to widespread adoption, including concerns about infectious diseases and mother-infant bonding, and preference for animal milks over another mother’s milk. Addressing these concerns may help increase the acceptance and practice of donating and using donor breastmilk among mothers in Nepal.

Background Though modern contraceptive use among married women in Nepal has increased from 26% in 1996 to 43% in 2016, it remains low among postpartum women. Integration of counselling on family planning (FP) at the time of antenatal care (ANC) and delivery has the potential to increase post-partum contraceptive use. This study investigates the quality of FP counselling services provided during ANC visits and women’s perceptions of its effectiveness in assisting them to make a post-partum family planning (PPFP) decision. Methods In-depth interviews (IDIs) were conducted with 24 pregnant women who had attended at least two ANC visits in one of the six public hospitals that had received an intervention that sought to integrate FP counselling in maternity care services and introduce postpartum intrauterine device insertion in the immediate postpartum period. IDIs data were collected as part of a process evaluation of this intervention. Women were selected using maximum variation sampling to represent different socio-demographic characteristics. IDIs were audio recorded, transcribed verbatim in Nepali, and translated into English. Data were organized using Bruce-Jain quality of care framework and analyzed thematically. Results Overall, the quality of FP counselling during ANC was unsatisfactory based on patient expectations and experience of interactions with providers, as well as FP methods offered. Despite their interest, most women reported that they did not receive thorough information about FP, and about a third of them said that they did not receive any counselling services on PPFP. Reasons for dissatisfaction with counselling services included very crowded environment, short time with the provider, non-availability of provider, long waiting times, limited number of days for ANC services, and lack of comprehensive FP-related information, education and counselling (IEC) materials. Women visiting hospitals with a dedicated FP counselor reported higher quality of FP counselling. Conclusions There is an urgent need to re-visit the format of counselling on PPFP during ANC visits, corresponding IEC materials, counselling setting, and to strengthen availability and interaction with providers in order to improve quality, experience and satisfaction with FP counselling during ANC visits. Improvements in infrastructure and human resources are also needed to adequately meet women’s needs.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted health and well-being worldwide, but limited evidence exists on its effects on women seeking reproductive health services. This paper examined the reported prevalence of COVID-19 signs/symptoms among the women who sought abortion services and the impact pandemic had on women who either received or were denied abortion services over a 3.5-year period in Nepal. Methods This paper draws on data from a longitudinal study involving 1,832 women who sought abortions at 22 health facilities across Nepal between 2019 and 2020. Participants were interviewed at the time of enrollment, then again at 6 weeks, and every 6 months over a three- and a half-year period. For the analysis, data from 1,739 women were used to examine trends in the prevalence of COVID-19 symptoms and assess the broader impact of the pandemic. To evaluate the effects of COVID-19 pandemic over time, the study period was divided into 6-month intervals. Both bivariate analyses and multivariate regressions were employed to assess the pandemic’s impact on these women, considering overall trends as well as differences between those who received abortions and those who were denied. Results Approximately three-quarters of the respondents reported some impact of COVID-19 pandemic between March and August 2020. Following another peak in March-August 2021 (71% reporting impacts), experience of pandemic impacts decreased steadily to 26% by the end of the study period (Mar-Jun 2023). Economic disruptions related to work or business were the most common impact reported followed by impacts on children’s education and the inability to access or afford basic food or necessities After adjusting for baseline differences, women who gave birth after being denied an abortion were more affected by the pandemic when it came to affording daily necessities (OR = 1.78, p  < .01) and accessing reproductive (OR = 2.59, p  < .01) and non-reproductive health services (OR = 3.07, p  < .01). Conclusion The study highlights the increased vulnerability of pregnant women, particularly those seeking abortion care, during the COVID-19 pandemic. The findings emphasize the critical importance of maintaining access to essential reproductive health services, such as abortion, especially during disease outbreaks and humanitarian crises. Ensuring the continuity of these services should be a top priority, and health systems must be strengthened to deliver them without disruption in future emergencies.

Background Health service providers play a key role in addressing women’s need for pregnancy prevention, especially during the postpartum period. Yet, in Nepal, little is known about their views on providing postpartum family planning (PPFP) services and postpartum contraceptive methods such as immediate postpartum intra-uterine devices (PPIUD). This paper explores the perspectives of different types of providers on PPFP including PPIUD, their confidence in providing PPFP services, and their willingness to share their knowledge and skills with colleagues after receiving PPFP and PPIUD training. Methods In-depth interviews were conducted with 14 obstetricians/gynecologists and nurses from six tertiary level public hospitals in Nepal after they received PPFP and PPIUD training as part of an intervention aimed at integrating PPFP counseling and insertion into routine maternity care services. The interviews were audio recorded, transcribed, and analyzed using a thematic approach. Results Providers identified several advantages of PPFP, supported the provision of such services, and were willing to transfer their newly acquired skills to colleagues in other facilities who had not received PPFP and PPIUD training. However, many providers identified several supply-side and training-related barriers to providing high quality PPFP services, such as, (i) lack of adequate human resources, particularly a FP counselor; (ii) work overload; (iii) lack of private space for counseling; (iv) lack of IUDs and information, education and counseling materials; and (v) lack of support from hospital management. Conclusions Providers appeared to be motivated to deliver quality PPFP services and transfer their knowledge to colleagues but identified several barriers which prevented them from doing so. Future efforts to improve provision of quality PPFP services should address the barriers identified by providers.

Background Mindful 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. Methods In 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. Results Sumadhur significantly impacted (p < .05) norms related to pregnancy spacing and timing, and sex preference of children, as well as knowledge about family planning benefits, pregnancy prevention methods, and abortion legality. Family planning intent also increased among newly married women. Qualitative findings revealed improved family dynamics and gender equity, and shed light on remaining challenges. Conclusions Entrenched social norms surrounding fertility and family planning contrasted with participants’ personal beliefs, highlighting needed community-level shifts to improve reproductive health in Nepal. Engagement of influential community- and family-members is key to improving norms and reproductive health. Additionally, promising interventions such as Sumadhur should be scaled up and reassessed. Plain language summary Societal norms are among the key influencers that shape the decisions that people make about their desired family size and the methods they will apply to achieve it. To support women in Nepal, where norms are often layered upon the expectation that women will prove their fertility soon after marriage, a bi-national research team developed and piloted a 4-month intervention, Sumadhur , engaging newly married women, their husbands, and mothers-in-law. This study evaluated the impact the Sumadhur had on norms, knowledge, and intent related to family planning. From pre- and post-questionnaires, we found norms significantly shifted and knowledge significantly improved among all participant groups as a result of participating in Sumadhur . From interviews following the intervention, we found that family dynamics and gender equity also improved despite lingering challenges including unchanged norms about the expected timing of a couple’s first child. Our results confirmed that it is critical to engage influential community and family members in improving norms and supporting women to make decisions about their reproduction. Additionally, promising interventions like Sumadhur should be scaled up and re-evaluated.