Attitudes and Practices Toward Sex-Selective Abortion in an Urban District of Nepal: Findings From a Cross-Sectional Study.

Nepal, a country with deeply ingrained patriarchal values and culture, has limited evidence regarding the practices of sex selection and sex-selective abortion. This study aimed to investigate the attitudes and practices surrounding sex-selective abortion (SSA) and the factors associated with it. A cross-sectional study design was used to collect data from 320 women between the ages of 15 and 49, who had at least one child under the age of 5 and lived in the Bhaktapur district, Nepal. A total of 19.7% of the participants had undergone an abortion, with 39.6% of those being SSAs. Factors like women empowerment and preference for smaller family size are associated with women's favorable attitude toward SSA. In multivariate analysis, women who faced pressure from their families to have a son and those who were aware of Nepal's abortion laws were more likely to abort a female fetus.

Enablers and Barriers Related to Preconception Physical Activity: Insights from Women of Reproductive Age Using Mixed Methods.

Engaging in regular preconception physical activity (PA) is associated with benefits, including improved cardiovascular health and mental well-being. However, most women do not meet PA recommendations in the preconception period. This study aimed to investigate enablers and barriers related to PA in preconception women using a sequential mixed method design. An online survey was followed by Zoom interviews with women of reproductive age (aged 18-45 years). A weaving approach and the Capability Opportunity Motivation Behaviour (COM-B) model were used to integrate and present the data. Seven hundred and eighty-eight non-pregnant women from Australia, India, and the US completed the quantitative survey, and 13 Australian-based women participated in a qualitative interview. Physical activity levels were associated with having social support, a desire to improve body image, and becoming a healthier person. Women encountered barriers such as misconceptions about PA, competing priorities, financial constraints, and a lack of accessibility. Enablers for participation in PA included knowledge of its importance, a desire to be healthier, weight loss, social support, and having goals. The multifaceted and intricate nature of enablers and barriers for preconception PA lays the groundwork for developing tailored interventions and policies aimed at promoting preconception PA among women.

The tide of dietary risks for noncommunicable diseases in Pacific Islands: an analysis of population NCD surveys.

OBJECTIVE: To describe changes over time in dietary risk factor prevalence and non-communicable disease in Pacific Island Countries (PICTs). METHODS: Secondary analysis of data from 21,433 adults aged 25-69, who participated in nationally representative World Health Organization STEPs surveys in 8 Pacific Island Countries and Territories between 2002 and 2019. Outcomes of interest were changes in consumption of fruit and vegetables, hypertension, overweight and obesity, and hypercholesterolaemia over time. Also, salt intake and sugar sweetened beverage consumption for those countries that measured these. RESULTS: Over time, the proportion of adults consuming less than five serves of fruit and vegetables per day decreased in five countries, notably Tonga. From the most recent surveys, average daily intake of sugary drinks was high in Kiribati (3.7 serves), Nauru (4.1) and Tokelau (4.0) and low in the Solomon Islands (0.4). Average daily salt intake was twice that recommended by WHO in Tokelau (10.1 g) and Wallis and Futuna (10.2 g). Prevalence of overweight/obesity did not change over time in most countries but increased in Fiji and Tokelau. Hypertension prevalence increased in 6 of 8 countries. The prevalence of hypercholesterolaemia decreased in the Cook Islands and Kiribati and increased in the Solomon Islands and Tokelau. CONCLUSIONS: While some Pacific countries experienced reductions in diet related NCD risk factors over time, most did not. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia. Population-wide approaches to promote fruit and vegetable consumption and reduce sugar, salt and fat intake need strengthening.

Socioeconomic Determinants of Inequalities in the Use of Modern Contraception among Currently Married Women.

BACKGROUND: Despite interventions for over four decades, the unmet need for family planning is high in Nepal. This study aims to examine the status and the socioeconomic determinants of inequalities in modern contraception among currently married women. METHODS:  We applied a mixed-method design. We interviewed key informants for qualitative information and analyzed secondary data from the Nepal Multiple Indicator Cluster Survey, 2019, and different rounds of Nepal Demographic and Health Surveys. We calculated ratios, differences in percentages, and concentration indices to analyse the inequality. We ran a binary logistic regression model to estimate the adjusted effect of each factor on the use of modern contraception. RESULTS:  The richest-to-poorest difference in using modern contraception has decreased over 13 years. The richest-to-poorest difference decreased from 23.6 percentage points in 2006 to 13.3 percentage points in 2011 and further to 1.2 percentage points in 2016. The richest-to-poorest difference was negative in 2019, indicating poor people are using more contraception than the richest. Multivariate analysis showed the wealth is a significant predictor for using contraception. Women of richer households (aOR=1.29, 95% CI=1.13-1.48), middle (aOR=1.21, 95% CI=1.05-1.40), poorer (aOR=1.36, 95% CI 1.17-1.58) and poorest (aOR=1.18, 95% CI=1.05-1.34) were more likely to use contraception than women from the richest households. CONCLUSIONS: Poor people are increasingly using the modern contraception, and the gap between the poor and rich people has decreased. However, the trend of contraception use in each wealth quintile indicates that Nepal struggles to meet the sustainable development goal target of reducing the unmet need for family planning to less than 10% by 2030.

Effect of overseas parental employment migration on healthcare seeking for common childhood illnesses and nutritional status among left-behind young children: A systematic review.

We aimed to examine the available evidence on the impact of overseas parental migration on healthcare seeking for common childhood illnesses and the nutritional status of children left-behind under five years of age. A systematic review of English language articles was conducted on PubMed, MEDLINE and EMBASE, supplemented by a manual search of grey literature and reference lists. There were no studies examining the association between overseas parental migration and healthcare seeking for common childhood illnesses. We found three cross-sectional surveys examining the association with an indicator of nutritional status. We observed mixed findings from the available studies. The results indicated that children left-behind may have positive, negative or null effects on their nutritional status. There was insufficient information available to draw conclusions on the magnitude and direction of the association between overseas parental migration and its effect on either healthcare seeking for common childhood illnesses or the nutritional status of left-behind children. The association, if any, may be context or country dependent. Prospective studies are needed to address this important knowledge gap.

What young Australians think about a tax on sugar-sweetened beverages.

OBJECTIVE: To determine support for a tax on sugar-sweetened beverages (SSBs) among young Australian adults and the potential impact on SSB consumption if a tax is introduced. METHODS: Cross-sectional convenience survey of Australians aged 18-30 years sampled in the City of Greater Geelong, Australia, in November-December 2017. RESULTS: A total of 1,793 responses were recorded. Overall, 48% supported a tax on SSBs, which increased to 74% and 72% if tax revenue was allocated to subsidising fruit and vegetables or funding community exercise facilities, respectively. If a tax of $0.40/100g of sugar were introduced, 53% of participants would reduce their SSB consumption and most of this group (63%) reported that they would consume more water instead. Participants who consumed SSBs more frequently were less likely to support a tax or reduce their consumption. Gender, obesity and SES were not associated with support for a tax. CONCLUSIONS: Most young adults supported the idea of a tax on SSBs if tax revenue would be used to support healthy eating or physical activity. If a tax was introduced, most indicated that they would reduce their SSB consumption and substitute water for SSBs. Implications for public health: Policymakers can expect support from young people should an SSB tax be introduced in Australia.

Does safe disposal of child faeces matter? An assessment of access to improved sanitation and child faeces disposal behaviour and diarrhoea in rural Nepal.

Background: Improper disposal of child faeces is a major source of faecal pathogens that cause diarrhoeal disease. However, this has received relatively less attention in sanitation evaluation literature, which has tended to focus on sanitation provision, implicitly assuming that child faeces disposal behaviour also improves with sanitation. We examined the impact of improved sanitation without safe disposal (households with improved sanitation but not disposing of child faeces in improved sanitation) and improved sanitation with safe disposal (households with improved sanitation and disposal of child faeces in improved sanitation) on diarrhoeal prevalence in rural Nepal. Methods: Data from the Nepal Demographic Health Survey 2011 for 3377 children <5 y of age were used to answer the research question using quasi-experimental methods. Results: Improved sanitation with safe disposal was associated with a 3.3 percentage point (standard error [SE] 0.016) to 6.6 percentage point (SE 0.023) lower prevalence of diarrhoea among children <5 y of age compared with matched households without access to improved sanitation. No effect was observed for households having improved sanitation without safe disposal compared with matched households without access to improved sanitation. Improved sanitation with safe disposal was also associated with a 4.0 percentage point (SE 0.023) lower prevalence of diarrhoea in low economic status households (bottom two quintiles). Conclusions: Our results suggest that sanitation programmes need to focus on behavioural interventions as well as increasing access to sanitation facilities.

Depression and anxiety among war-widows of Nepal: a post-civil war cross-sectional study.

Thousands of Nepalese women were widowed as a consequence of a decade (1996-2006) long civil war in Nepal. These women are at grave risk of mental health problems due to both traumatic experiences and violation of natural order of widowhood. The present study explores the depression and anxiety among war-widows. In 2012, a cross-sectional study was designed to interview 358 war-widows using validitated Beck Depression Inventory and Beck Anxiety Inventory in four districts of Nepal - Bardiya, Surkhet, Sindhupalchowk and Kavrepalanchowk with history of high conflict intensity. The prevalence of depression and anxiety was 53% and 63% respectively. Financial stress was significantly associated with depression (2.67, 95% CI: 1.40-5.07) and anxiety (2.37, 95% CI: 1.19-4.72). High autonomy of women as compared to low autonomy, high social support as compared to low social support and literacy as opposed to illiteracy was associated with less likelihood of depression and anxiety. Our results suggest high magnitude of depression and anxiety among war-widows in Nepal. Future policy efforts should be directed at providing mental health services to identify mental health issues among conflict affected individuals with focus on education, employment and activities to promote social support and autonomy at community.

Impact of cleaner fuel use and improved stoves on acute respiratory infections: evidence from India.

Background: The use of cleaner fuel and improved stoves has been promoted as a means to lower harmful emissions from solid fuels. However, little is known about how exclusive use of cleaner fuels, mixed fuel use and improved stoves influences children's health. Methods: We compared the impact of using liquefied petroleum gas (LPG) exclusively with mixed fuel use (LPG plus polluting fuels) and with exclusive use of polluting fuels on acute respiratory infections (ARI) among 16 157 children 0-4 years of age from households in the 2012 Indian Human Development Survey. Inverse probability weighting (IPW) procedures for multiple treatments were used for this evaluation. Results: Children from households using LPG had a 5.0% lower probability of reporting ARI relative to exclusive users of polluting fuels, with larger effects (10.7%) in rural households. The probability of ARI in households using improved stoves and mixed fuel use was also lower in rural households, by 2.9% and 2.8%, respectively. The magnitude of effect varied across population subgroups, with the highest effects for children living in households living in kachha (low quality material) houses households identified as poor. Conclusion: Use of LPG and improved stoves lowered the probability of ARI among children younger than 5 years.

Impact evaluation of free delivery care on maternal health service utilisation and neonatal health in Nepal.

Nepal introduced free delivery services for births in public facilities in 2005 in 25 districts with the intervention initially restricted to women with less than two living children and/or women with obstetric complications. After November 2007, eligibility conditions were relaxed to include all women, and the programme was later expanded to cover an additional 50 districts in December 2008. We exploit the phased expansion of the free birth delivery programme to identify its impact on place of delivery, the presence of skilled birth attendants (SBAs) and neonatal mortality using difference-in-difference methods, on data for 4457 live-births reported between 2001 and 2008 from Nepal Demographic and Health Surveys for 2006 and 2011. Programme impacts were estimated for: (1) initial implementation until the relaxation of eligibility criteria to include all women in November 2007 (early phase); and (2) initial implementation until the programme was expanded nationwide in December 2008 (longer phase). Early implementing districts were treatment districts, while late implementing hill districts were control districts. In the early phase, the likelihood of delivery by SBAs was 5.6 percentage points higher (95%CI 0.002, 0.111) and the likelihood of delivery in a public facility was 5.1 percentage points higher (95%CI -0.003, 0.106) in treatment districts compared with control districts. The programme lowered the likelihood of neonatal mortality by 4.0 (-0.072, -0.009) percentage points for women with less than two living children and by 6.9 percentage points (95%CI -0.104, -0.035) for women from lower castes and indigenous groups in treatment districts compared with women in control districts, during the early phase. Programme effects on use of public facilities for births and deliveries attended by SBAs were not sustained over a longer exposure period. The results on neonatal mortality persisted with longer programme exposure, although the effects were smaller in magnitude.

Extent of Fecal Contamination of Household Drinking Water in Nepal: Further Analysis of Nepal Multiple Indicator Cluster Survey 2014.

Water sources classified as "improved" may not necessarily provide safe drinking water for householders. We analyzed data from Nepal Multiple Indicator Cluster Survey 2014 to explore the extent of fecal contamination of household drinking water. Fecal contamination was detected in 81.2% (95% confidence interval [CI]: 77.9-84.2) household drinking water from improved sources and 89.6% (95% CI: 80.4-94.7) in water samples from unimproved sources. In adjusted analysis, there was no difference in odds of fecal contamination of household drinking water between improved and unimproved sources. We observed significantly lower odds of fecal contamination of drinking water in households in higher wealth quintiles, where soap and water were available for handwashing and in households employing water treatment. The extent of contamination of drinking water as observed in this study highlights the huge amount of effort required to ensure the provision of safely managed water in Nepal by 2030 as aimed in sustainable development goals.

Effects of abortion legalization in Nepal, 2001-2010.

BACKGROUND: Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion. METHODS: We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010). RESULTS: 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75). CONCLUSION: Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

The prevalence and determinants of sexual violence against young married women by husbands in rural Nepal.

BACKGROUND: Sexual violence within marriage is a public health and human rights issue; yet it remains a much neglected research area, especially in Nepal. This paper represents one of the first attempts to quantify the extent of sexual violence and its determinants among young married women in Nepal. METHODS: A cross-sectional survey was conducted among 1,296 married women aged 15-24 years in four major ethnic groups in rural Nepal. The survey data were used to estimate the prevalence and identify determinants of sexual violence. The relative importance of different correlates of sexual violence in the past 12 months at the individual, household and community levels were examined by using a multi-level multivariate statistical approach. RESULTS: Of the young women surveyed 46% had experienced sexual violence at some point and 31% had experienced sexual violence in the past 12 months. Women's autonomy was found to be particularly protective against sexual violence both at the individual and community level. Women's educational level was not found to be protective, while the educational level of the husband was found to be highly protective. CONCLUSIONS: The high prevalence of sexual violence against young women by husbands found in this study is a matter for serious concern and underscores the need for a comprehensive response by policymakers.

"Sometimes they used to whisper in our ears": health care workers' perceptions of the effects of abortion legalization in Nepal.

BACKGROUND: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers' views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care. METHODS: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data. RESULTS: Overall, participants had positive views of abortion legalization - many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment. CONCLUSIONS: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

Women's status and violence against young married women in rural Nepal.

BACKGROUND: Studies conducted around the world consistently show the existence of violence against women. Despite the increasing number of studies being conducted on violence against young married women elsewhere, this subject has received little attention from researchers and policy makers in Nepal. This paper assesses the prevalence of violence among young married women in rural Nepal. Specifically, it examines [factors related to] women's status in order to better understand the risk of violence. METHODS: A cross-sectional study was conducted in 2009 among 1,296 young married women aged 15-24 years in four major ethnic groups. Bivariate analysis and multivariate logistic regression were used to examine the association between selected risk factors and violence. RESULTS: More than half the women (51.9%) reported having experienced some form of violence in their lifetime. One-fourth (25.3%) reported physical violence and nearly half (46.2%) reported sexual violence. Likewise, one-third (35.8%) of women reported experiencing some form of violence in the past 12 months. No or little inter-spousal communication and low autonomy of women significantly increases the odds of experiencing violence among married women. CONCLUSIONS: The violence against women is quite common among young married women in rural Nepal. Although the Domestic Violence and Punishment Act 2066 has been enacted, equal attention needs to be given to increasing women's autonomy and activities that encourage inter-spousal communication. Furthermore, more research is required in Nepal that examines dynamics of violence perpetrated by husbands.

Sex-selective abortion in Nepal: a qualitative study of health workers' perspectives.

BACKGROUND: Sex-selective abortion is expressly prohibited in Nepal, but limited evidence suggests that it occurs nevertheless. Providers' perspectives on sex-selective abortion were examined as part of a larger study on legal abortion in the public sector in Nepal. METHODS: In-depth interviews were conducted with health care providers and administrators providing abortion services at four major hospitals (n = 35), two in the Kathmandu Valley and two in outlying rural areas. A grounded theory approach was used to code interview transcripts and to identify themes in the data. RESULTS: Most providers were aware of the ban on sex-selective abortion and, despite overall positive views of abortion legalization, saw sex selection as an increasing problem. Greater availability of abortion and ultrasonography, along with the high value placed on sons, were seen as contributing factors. Providers wanted to perform abortions for legal indications, but described challenges identifying sex-selection cases. Providers also believed that illegal sex-selective procedures contribute to serious abortion complications. CONCLUSION: Sex-selective abortion complicates the provision of legal abortion services. In addition to the difficulty of determining which patients are seeking abortion for sex selection, health workers are aware of the pressures women face to bear sons and know they may seek unsafe services elsewhere when unable to obtain abortions in public hospitals. Legislative, advocacy, and social efforts aimed at promoting gender equality and women's human rights are needed to reduce the cultural and economic pressures for sex-selective abortion, because providers alone cannot prevent the practice.