Reproductive Health Research Policy Brief Number 9, February 2004

Public Opinion Poll on Abortion Law and Service - III

CREHPA has been carrying out annual public opinion polls since abortion was legalized in the country in 2002. Annual public opinion polls reflect public perceptions and attitudes towards the abortion law that safeguards women’s reproductive rights. Opinion polls also echoes public awareness about and acceptance of the policies and programs related to legal and safe abortion services. The Poll results are relevant in designing appropriate IEC and advocacy strategies and behavior change communication (BCC) messages to enable women and couples to make informed decisions about their fertility without fear of social stigma and discrimination.

Methodology

The Public Opinion Poll III was conducted in 10 towns viz., Kathmandu, Bhaktapur, Bharatpur, Pokhara, Biratnanar, Dharan, Birgunj, Janakpur, Bhairahwa and Ilam bazar. 2,665 adult urban residents (1332 male & 1333 female) aged 18-60 years were interviewed between November 22 and December 12, 2004.

Population proportionate to size (PPS) technique was used for the allocations the sample in each urban municipalities. Depending upon the size of the urban population of a municipality, a minimum of 3 and a maximum of 11 urban wards were selected randomly. Cluster sampling technique was used to interview the desired number of adult male and female respondents in each sampled ward. The published voters' lists of each ward were used for the selection of the principal respondents.

Background:

It has been more than 2 years since abortion was legalized in Nepal. Abortion is legally permitted on request during first 12 weeks of pregnancy for any reason, and up to 18 weeks of pregnancy in case of rape or incest and up to any gestation period in case of fetal deformity or disability or risk of woman’s life.

Preventing unsafe abortion practices and increasing access to safe and affordable abortion care to women especially in rural area are some of the major post-legalization challenges. Currently, government approved comprehensive abortion care (CAC) services are limited to public (government) hospitals and selected non-government clinics located in the urban/peri-urban areas or at the district headquarters of approximately a third of the country’s 75 districts.

However, many of the government hospitals approved for CAC services are unable to provide full time CAC services due to the limited number of doctors serving in these hospitals. Few approved hospitals had not started CAC services despite receiving government approval.

Comprehensive Abortion Care (CAC) in Nepal

Since March 2004, selected government hospitals, non-governmental organizations and medical institutions began providing comprehensive abortion care (CAC) services. As of December 2004, there were 26 government hospitals and 13 non-governmental health clinics, which received government approval for providing CAC services. These government hospitals began charging fees for abortion (each hospital can independently decide the abortion fee) and the fee ranged from Rs. 900 (approx. US $ 13) to Rs. 1500 (approx. US $ 21). In non-governmental organizations and medical institutions, the abortion fee ranges from Rs. 950 to Rs. 3000 or more.

The objectives of the public opinion poll III

The objectives of the Annual Public Opinion Poll III (2004) are as follows:

• To assess the level of awareness among urban public about the legalization of abortion in the country;

• To understand whether or not the urban public perceived that legalization helps to decrease maternal mortality and unsafe abortion practices and increase the demand for abortion in the country;

• To assess the extent the urban public are aware of the 'approved' safe abortion service centers;

• To explore what the urban public think about the amount of fee currently being charged by government hospitals for abortion and also solicit their views regarding the reasons or advantages of charging high abortion fee.

RESULTS

Majority of the urban public are still ignorant about legalization

Even after 2 years, only 42% of the urban public mentioned that abortion is now legal in the country. The proportions of the respondents who said that abortion is not legalized (30%) or have no idea (28%) comprise a formidable percentage of the total urban respondents when combined (chart 1).

Chart 1: Is abortion legal in our country or not?

(N=2665)

Comparison of the three successive opinion poll results (2002, 2003 & 2004) reveal that there has been a remarkable increase in awareness level about the legal reform. For example, in 2002, only 22% were aware about legalization, this percentage increased only marginally in 2003 (26%) and increased by approximately one and a half times in 2004 (42%) (Chart 2).

A higher proportion of the adult males (47%) than the adult females (37%) are aware about the legalization. Likewise, urban public who are 'high literates' (59%), read newspaper regularly (55%) or are exposed to radio (47%), or TV (45%) regularly, are more aware of legalization than those who are low literates (25%), never read newspapers (21%) or never listen to the radio (24%) or TV (23%).These differences are significant.

Knowledge about the three legal conditions for abortion is still very low

Among the urban public who are aware of legalizations, only a third of them (37%) are aware that abortion is permitted on request during first 12 weeks of pregnancy. Very few repondents (7%) are aware that abortion is permitted up to 18 weeks in case of rape or incest and just one fifth (20%) are aware that it is permitted if pregnancy affects the health of mother or the fetus.

Most respondents viewed that maternal mortality ratio (MMR) and Unsafe abortion will decrease

The large majority of the respondents (81%) believed that MMR will decrease because of the legalization. Only 15% mentioned that it will increase and 3% said that it will remain same (Chart 3).

Chart 3: In your opinion, would the maternal mortality ratio of our country increase or decrease because of legalization?

(N=2665)

Likewise, most of the respondents (81%) viewed that illegal and unsafe abortion practices will decrease because of legalization. Only a tenth of the respondents felt that it will increase (Chart4).

Chart 4: Would illegal and unsafe abortion practices increase or decrease because of the legalization?

(N=2665)

Majority believed that demand of abortion will increase

Three fifths (61%) of the urban public believed that the number of women seeking abortion service will increase because of legalization. Less than a fifth of the respondents opined that the demand for abortion will decrease (19%) or remain the same (18%) (chart 5).

Chart 5: Would the number of women seeking abortion service increase or decrease because of legalization?

(N=2665)

Over a half of the respondents are unaware about CAC services

In districts having government approved CAC centers, more than half of the urban public (except Kathmandu; 72%) are still unaware about their district hospitals having approved safe abortion service centers. Even in districts not having CAC centers, a considerable proportion (25%-49%) of the urban public have the misconceptions that their district hospitals provide safe abortion services.

Nearly a half of the urban public approves hospitals charging Abortion Fee

Nearly half of the respondents (49%) mentioned that it is right for the government hospitals to charge some fees for abortion. On the other hand, less than a half (45%) of the respondents felt that abortion services should be provided free of cost in government hospitals.

The large majority of the urban public desired modest abortion fee

Two fifths of the urban public (44%) suggested that the government hospitals in their districts should charge abortion fees ranging between Rs. 250 (approx. $4) and Rs. 500 ($8). Another about one third (34%) suggested Rs. 250 or less. About a sixth (18%) suggested the fee between Rs 501-Rs. 1000 and only 4% suggested that the fee should be more than Rs. 1100 (Average= Rs.517) (Chart 6).

Chart 6: How much should the government hospital in your district charge clients for abortion care?

(N=2665)
Average= Rs. 517

Government hospitals highly preferred for safe abortion care

Around three quarter (74%) of the urban public would prefer visiting a government hospital than other facilties for safe abortion services. Only 18% mentioned that they prefer private nursing homes and clinics (Chart 7).

Chart 7: Where would you like to obtain safe abortion care if you wish to have one in the future?

(N=2665)

Inexpensive service (82%) was the main reason for prefering a government hospital. Other reasons for preference are trustworthy (40%), good care (32%), proximity (28%) and presence of skilled doctor (14%). Only 8% cited 'service available all the time' and 2% mentioned 'privacy' for prefering a government hospital (Chart 8).

Chart 8: Why do you prefer government hospital?

(N=2665)

Large majority of the urban residents rated current abortion fee in certain government hospitals as 'Low'

Two in three urban respondents (67%) considered Rs 900 as fee currently being charged by some government for CAC service as 'moderate' or 'low'. Only 3% rated this amount as 'high'.

Majority disagrees with the view that high abortion fee would ensure quality services and that women are ready to pay any amount

More than two third of the urban public (68%) have rejected the views that high abortion fee (more than Rs.1000) would ensure quality service in hospitals. Likewise, roughly two thirds (63%) disagreed with the views that women are ready to pay any amount of fee for abortion.

On the other hand, almost all (92%) accepted the view that high abortion fee would encourage clients to be careful next time and adopt FP method. While over two thirds (68%) agreed that a high abortion fee would minimise client flow in the hospital (Chart 9).

Chart 9. Do you agree or disagree that a high abortion fee (above Rs. 1000) will help in the following ?

(N=2665)

Recommendations and Policy Implications

· Though there is a remarkable increase on awareness about the legalization, more IEC/public awareness efforts are essential to impart correct knowledge about abortion rights, legal provision and safe abortion (CAC) services.

· The higher public preference for government hospitals for safe abortion care is highly noteworthy. However, presently, CAC services are confined to some districts only and hence it is imperative to expand CAC centers in the remaining districts and at PHC levels to increase safe abortion access to rural women.

· In view of the urban public stressing for a lower abortion fee and endorsing Rs. 900 charged by few hospitals, government and concerned NGOs should ensure that govt. hospitals do not charge abortion fee above this limit and also make honest provision to provide free CAC service to poor women.

· Opinion polls and KAP surveys on abortion in the rural areas are necessary to document and compare the attitudes and perceptions of rural communities on the above key issues.

References

CREHPA, 2002. Public Opinion Poll on Abortion and Abortion Law -I 2002

CREHPA, 2003. Public Opinion Poll on Abortion Law and Rights- II 2003

HMG/MoH, 2003. Safe Abortion Service Procedure 2060 (B.S.)

HMG/MoH/FHD, 2003. National Safe Abortion Policy 2060 (B.S.)

Press conference by CREHPA disseminating Opinion Poll 2004 Results;
Hotel Himalaya, Jan. 5, 2005