Creating an Enabling Environment for Reproductive Health and Safe Abortion Services among Women and Couples in Rural Nepal

CREHPA, FPAN, PPFA-I Collaboration

PROJECT SUMMARY

THE CONTEXT

In March 2002, the Lower House of Parliament approved the 11th Amendment of the Civil Code Bill that permits women to seek abortion on certain grounds. The bill received Royal Assent in September 2002. The new legal provisions allow abortion on request during the first 12 weeks of pregnancy for any reason, and up to 18 weeks of pregnancy in cases of rape or incest, and at any time during pregnancy in case of fetal malformation or risk to the woman’s life. The National Safe Abortion Policy drafted by the Ministry of Health in 2002 encourages NGOs and private sectors to contribute towards creating awareness on, and expanding access to, safe abortion services in the country. Awareness, advocacy and education on the legal provisions, consequences of unsafe abortions and sources of safe abortion care are fundamental to enable women to seek the appropriate services they may need. Unless the advocacy and awareness campaign reaches women, women are not likely to benefit from the legal reform and services.

THE PROJECT

This one-year project was a collaborative effort of CREHPA, FPAN and PPFA-I. The project aimed at contributing towards creating an enabling environment for reproductive and safe abortion services among women and couples to be served by FPAN, through empowerment of community-based FPAN volunteers of FPAN and sensitization of community-level stakeholders. community-level

STRATEGIES

The project was implemented in three core districts (where FPAN clinics are established) and in three peripheral districts (catchment districts of the FPAN clinics). The three core districts are: Kathamandu (valley), Chitwan and Sunsari and the three peripheral districts are: Makwanpur, Nawalparasi and Morang. A total of 113 VDCs having FPAN RHVs in place were covered under the project.

CREHPA empowered its partner NGOs located in these districts for the purpose of organizing community-level sensitization/advocacy workshops, that includeda advantages of the new abortion law (as reproductive rights of women), reducing stigmatization towards abortion, and creating a supportive environment to women for access safe abortion services. Similarly, it trained reproductive health volunteers (RHVs) of FPAN to generate awareness among married women of reproductive age (MWRAs) about the abortion law, health implications of unsafe abortion, signs of pregnancy complications and places where safe abortion services are available. In addition, District level elected volunteers of FPAN were also sensitised to enable them to play pro-active roles in expanding safe abortion services and prevention of unsafe abortion practices in their respective districts.

A pre- and post-test was conducted among all the participants of the RHV training to measure their knowledge about the topics covered in the training.

LOCAL PARTNERS IN PROJECT

The district-level NGOs based in the six project districts acted as local partners in the project. These NGOs are: Aamaa Milan Kendra (Kathmandu), ASMITA Nepal (Makwanpur), Adarsha Nari Bikash Kendra (Chitwan), Nari Kalyan Bikash Kendra (Nawalparasi), Nari Bikash Sangh (Sunsari) and Nari Bikash Sangh (Morang).

COORDINATION

The project being a collaborative venture, CREHPA executed the project in a close collaboration with PPFA-I regional staff based in Bangkok and FPAN staff based both at the centre (Kathmandu) and at the districts. Sharing of the project activities and experiences was done at quarterly meetings with PPFA-I, FPAN and FWLD (another collaborating partner of PPFA-I in Nepal).

MAJOR ACTIVITIES

The following were the major intervention activities under the project:

1. Orientation training to master trainers of district-level partner NGOs;
2. Basic orientation training of FPAN RHVs;
3. One-day advocacy workshop for community leaders at VDC level;
4. Observation and monitoring the village development committee (VDC) level activities of partner NGOs;
5. One-day sensitization workshop for FPAN's district-level elected volunteers;
6. Reprinting and distribution of IEC material published by CREHPA, FWLD and FPAN;
7. Baseline and endline evaluation surveys in the core and peripheral districts.

ACHIEVEMENTS

Twelve master trainers of partner NGOs of CREHPA (two from each NGO) received orientation training about the project intervention. These master trainers assisted the CREHPA project team in successfully providing basic training to a total of 337 RHVs of FPAN from 113 VDCs. Likewise, the master trainers organized 220 VDC level workshops attended by 5,280 community-based stakeholders comprising of elected VDC and ward representatives, political party leaders, school teachers, social workers, leaders of community based organizations/clubs, mother's group members, health workers and female community health volunteers (FCHVs).

The sensitization workshops for elected volunteers of FPAN were conducted in five out of six districts and attended by 77 participants (average 15 elected volunteers per workshop per district). The baseline survey was conducted among 1,100 MWRAs prior to the launching of the intervention in June 2003. The endline survey was conducted towards the end of the intervention phase in February 2004 to measure the effectiveness of the project in increasing knowledge and practice of safe reproductive health including safe abortion practices among women and couples.

Pre- and Post-test Results: The pre- and post-tests were conducted with all the 337 RHVs participating the basic orientation training. A self-administered questionnaire was used to obtain the knowledge of the participants (RHVs) before and immediately after the three-days training program. The three key questions asked in the pre- and post-tests were on: (i) three legal conditions for abortion; (ii) three health risks of unsafe abortion and (iii) three potential Comprehensive Abortion Care (CAC) centres. The results showed a remarkable increase in knowledge among the participants in all the three topics asked. Whereas only 8% participants could cite three legal conditions of abortion in the pre-test, 73% of them could do so in the post-test. Participants' knowledge regarding the three health risks of unsafe abortion was already high in the pre-test (65%), which increased to 91% in the post-test. Similarly, participants' knowledge about the three potential CAC centres increased from 55% in the pre-test to 90% in the post-test.

CONCLUSIONS AND LESSONS LEARNED

The project has been successful in empowering 337 RHVs of FPAN to conduct community-level interaction programs on abortion, abortion law and safe motherhood in their respective districts. It has also been successful in sensitizing over 5,000 community-level stakeholders about the abortion law, which grants women the right to abortion and the need to create a supportive environment so that they can exercise their reproductive rights. Other outcomes included sensitization of 77 elected volunteers of FPAN to enable them to have a pro-active role and enhancing the capacity of 12 master trainers of six partner NGOs to conduct community-level advocacy.

However, the implementation of the proposed activities at the district and community-levels took slightly longer time than planned due to factors like Maoists insurgency and natural disaster, notably the occurrence of heavy land slides along the national highways connecting Kathmandu valley that obstructed the traffic for a long period. Although, all planned activities were completed by March 2004, PPFA-I agreed to provide a two-month extension to the project to enable CREHPA to analyze the endline survey data, publish policy briefs and organize dissemination workshop in May, 2004.

Despite the prolonged delay in approval of the Safe Abortion Service Process, FPAN was able to introduce CAC services by their qualified and trained doctors in two out of three clinics. It may be pointed out that, although the population-based survey conducted by CREHPA to evaluate this project did not capture many of those women utilizing FPAN clinics for abortion services, there was a high turnover of abortion clients at the two FPAN clinics who were aware about the clinic services and probably they were referred by the trained RHVs, FCHVs and NGO volunteers.

Lessons learned: During this project period, NGOs and the volunteers were quite hesitant to publicly convey the message about CAC services provided by FPAN since the Safe Abortion Service Process had not yet been approved. This was one of the main constraints affecting advocacy and referral services.

Another important lessons learnt was about the limitation in the project design with regards to project monitoring. We realized that the project would have been more effective if community-level facilitators of partner NGOs were also equally utilized for reaching MWRAs in the community. In the present project design, only the RHVs (2-3 RHVs per VDC) were the sole agents to reach MWRAs in the villages.

It was also necessary to increase the number of community-level advocacy workshops to enable the partner NGOs to cover one workshop for each ward instead of restricting to two workshops per VDC. Furthermore, it was essential to provide refresher training to all 337 RHVs during the mid-project period to encourage them to conduct project activities.