Evaluation of Women’s Knowledge and Practice on Safe Motherhood, Abortion and the Abortion Law

EXECUTIVE SUMMARY

BACKGROUND

This evaluation study was aimed at determining the effectiveness of the PPFA-I/FPAN/CREHPA collaborative project entitled ‘Creating an enabling environment for reproductive health and safe abortion services among women and couples in rural Nepal’ in terms of enhancing women’s knowledge regarding the abortion law, availability of safe abortion services, and safe motherhood including abortion practices.

CREHPA conducted the baseline and the endline surveys in all six project districts (three core and three peripheral). The baseline and endline surveys were conducted in June 2003 and February 2004 respectively. A total of 1,100 married women aged 15-44 years were sampled in both the surveys using multi staged Probability Proportionate to Size (PPS) sampling technique.

RESULTS

A. Background Characteristics of the Study Population

The socio-demographic characteristics of the respondents, such as age and number of living children are more or less similar between the baseline and endline samples. However, the endline survey sample represented a higher proportion of literate respondents (69%) compared to the baseline survey (55%).

B. Knowledge regarding Safe Motherhood and Abortion

Women’s knowledge about various components of safe motherhood practices such as antinatal care (ANC), nutrition intake and danger signs during pregnancy and delivery were already high at the time of the baseline survey (69% to 99%).

Knowledge that abortion is now legal in the country increased from 15% in the baseline to 26% in the endline survey. The increase is more pronounced in the core districts (16% to 31%) compared to peripheral districts (14% to 22%). Among the women who were aware of the legal reform, the proportion of those reporting correctly that abortion is legal up to 12 weeks of gestation has increased by more than two folds (21% in baseline to 48% in endline).

The proportion of women citing radio as the first source of information about legalization of abortion increased from one third (33%) to two fifths in the endline survey (40%). Likewise, those mentioning community based volunteers of FPAN [e.g. female community health volunteers (FCHVs), reproductive health volunteers (RHVs)] increased from a low 6.7% in the baseline to high 16.4% in the endline survey. On the other hand, the proportion of women citing friends/neighbours as their first source of information about the law declined from 26% in baseline to 15% in the endline.

Women’s knowledge about gestation period considered to be ‘safe’ for pregnancy termination (up to 12 weeks or 3 months) was already high at the time of the baseline survey and it improved marginally over time from 81% to 87% in the endline. Similarly, the proportion of women having incorrect knowledge about safe gestation age for abortion (citing 4 months and above) have reduced by half, i.e. from 14.2% in the baseline to 6.5% in the endline survey.

The proportion of respondents who cited ‘doctors’ as safe abortion service providers increased significantly from 38% in baseline to 51% in endline. On the other hand, the proportion of respondents mentioning trained health providers decreased from 53% to 40%. In both the surveys, the majority of the respondents cited hospital as the appropriate place for obtaining safe abortion services (86% in the baseline and 83% in endline). The proportion of those mentioning private clinics has increased from 10% in the baseline to 21% in the endline survey.

Knowledge about unsafe abortion practices among women has increased significantly. Most respondents (87% in endline vs. 78% in baseline) mentioned that it is unsafe to terminate any pregnancy over three months. Similarly, the larger portion of them also perceived that the use of medicines without a doctor’s prescription (64% vs. 61% in baseline), in-take of herbal medicines (52% vs. 42% in baseline), abortion conducted by untrained providers (79% vs. 76% in baseline) would make abortion unsafe.

Women’s approval to abortion was very high. Nearly all of the endline respondents (92%) as compared to 82 percent of the baseline respondents replied positively (gave “Yes” response) saying that it was necessary to legalise abortion in the country. Moreover, almost all of them (91% vs. 82% in baseline) would approve if anyone in their family members sought safe abortion services within the legal gestational limits.

C. Knowledge about Service Availability

Knowledge about availability of safe motherhood services in the district is universal among the women (98-100%). A considerable proportion of the respondents in the endline as compared to the baseline mentioned that Health Post/Primary Health Center/Sub Health Post (HP/PHC/SHP)provides safe motherhood services (73% vs. 80%). A marginal increase in awareness regarding FPAN clinic providing safe motherhood services was also evident from the endline survey (13% in baseline to 20% in endline).

Majority of the women were aware of the availability of safe abortion services in their districts. Government hospitals (57%) and private clinics (55%) were the two often cited health facilities to be providing safe abortion services. Knowledge of FPAN clinic providing safe abortion services has also increased by two-fold in the endline survey (5% in baseline to 10% in endline).

D. Utilization of Maternal Health Care Services

Utilization of facilities providing maternal care or safe motherhood services has slightly declined among the respondents in the endline survey (60% to 57%). However, a slightly higher proportion of the respondents in the core districts (60%) in comparison to the peripheral districts (54%) mentioned that they had been to such a facility during 12 months preceding the endline survey.

Proportion of the women who utilized hospital facility at the time of their delivery during the year preceding the endline survey increased especially in the core districts (64%). Among those women who delivered at home, a higher proportion of those residing in the core districts (36% vs. 21% in peripheral) had used safe delivery kit (SDK).

E. Utilization of Safe Abortion Services

Among the 173 women (16%) who were pregnant during the 12 months preceding the endline survey, only 7 women (4.6%) had induced abortion. It was encouraging to note that all of them had sought safe abortion services (four women utilized abortion services from Marie Stopes Clinics (MSI) and the rest from FPAN clinic, private clinic and nursing home).

F. Utilization of FPAN Services

Utilization of FPAN services by the respondents was low. Few respondents visited FPAN clinics for receiving family planning contraceptives, antenatal care and very few for induced abortions. A baseline-endline comparison reveals that there has been a significant increase among pregnant women visiting FPAN clinic for ANC check-ups (5% in baseline vs. 25% in endline). Less than 2% of the women had sought induced abortion from FPAN clinic during the year preceding the endline survey.

G. Participation in Community Level Activities

Almost a quarter of the respondents in both the baseline (26%) and endline survey (26%) were of organising community level educational programs on safe motherhood and safe abortion in their villages. The level of participation in such programs by the respondents has increased significantly from 26% in the baseline to 35% in the endline survey.

CONCLUSIONS

The endline survey shows a modest increase in knowledge and practices of women regarding safe motherhood and safe abortion. The low level of awareness among women on legalization of abortion in the country is not surprising. The public opinion polls conducted in the urban areas of the country in Nov. 2003 (26%) and survey of married men in July 2003 (31%) had also documented low level of awareness about the legalization of abortion.

Knowledge about safe motherhood practices, service availability and unsafe abortion was already high among married women at the time of the baseline survey and this might be due to the previous community education and advocacy efforts of FPAN and partner NGOs in the districts.

Utilization of safe motherhood services like ANC has increased especially in FPAN clinics. Among the few who had terminated their pregnancies during one year, all sought abortion services from safe but yet legally unapproved places such as MSI, FPAN and private clinics. Government hospitals did not obtain the approval to provide abortion services at the time of the endline survey.

The impact of the Project in terms of increasing women’s knowledge regarding and practices of safe abortion and safe motherhood has not been very high as envisaged. This may be due to the fact that the larger chunk of the project focus was on community-based stakeholders and change agents (village opinion leaders and RHVs) with no direct intervention activity for the married women. The short time gap between baseline and the endline surveys (9 months) and inadequate program activities could also be additional factors. Nevertheless, the present findings serve as a good benchmark for designing future woman-focussed interventions to increase knowledge, gain community support and ensure access to safe abortion services.