Culture, Health & Sexuality An International Journal for Research, Intervention and Care
ISSN: 1369-1058 (Print) 1464-5351 (Online) Journal homepage: http://www.tandfonline.com/loi/tchs20
Service provider perspectives on post-abortion contraception in Nepal Lin-Fan Wang, Mahesh Puri, Corinne H. Rocca, Maya Blum & Jillian T. Henderson To cite this article: Lin-Fan Wang, Mahesh Puri, Corinne H. Rocca, Maya Blum & Jillian T. Henderson (2016) Service provider perspectives on post-abortion contraception in Nepal, Culture, Health & Sexuality, 18:2, 221-232, DOI: 10.1080/13691058.2015.1073358 To link to this article: http://dx.doi.org/10.1080/13691058.2015.1073358
Published online: 15 Sep 2015.
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Date: 17 February 2016, At: 23:14
Culture, Health & Sexuality, 2016 Vol. 18, No. 2, 223–235 http://dx.doi.org/10.1080/13691058.2015.1073358
SHORT REPORT
Service provider perspectives on post-abortion contraception in Nepal Lin-Fan Wanga, Mahesh Purib, Corinne H. Roccac, Maya Blumc and Jillian T. Hendersonc,§ Department of Family and Community Medicine, Thomas Jefferson University Hospital, Mazzoni Center, Philadelphia, USA; bCenter for Research on Environment Health and Population Activities, Kathmandu, Nepal; c Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, USA
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ABSTRACT
The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility’s infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.
ARTICLE HISTORY
Received 3 November 2014 Accepted 13 July 2015 KEYWORDS
Post-abortion; Nepal; contraceptive use; service provider views
Introduction Abortion safety and pregnancy-related morbidity and mortality have improved since abortion was legalised in Nepal in 2002 (Bhandari, Gordon, and Shakya 2011; Henderson et al. 2013). Attention is now increasingly focused on preventing future unintended pregnancy and abortion by providing comprehensive post-abortion contraceptive care (Corbett and Turner 2003; Johnson et al. 2002; Senlet, Cagatay et al. 2001; Senlet, Curtis et al. 2001). Nepal’s National Safe Abortion Policy (National Safe Abortion Policy, Final Draft 2003) explicitly CONTACT Lin-Fan Wang [email protected] § Current affiliation: Kaiser Permanente Center for Health Research Northwest, Portland, USA. © 2015 Taylor & Francis
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recommends the inclusion of family planning services in abortion care, and the Government of Nepal has developed strategies to improve post-abortion contraceptive services (Annual Report Department of Health and Services 2010/2011 2012). Despite government commitment to post-abortion contraceptive care, significant gaps in services remain. Data from public facilities show that approximately 50% of women receiving an abortion in 2009–2011 received a post-abortion contraceptive method (Samandari et al. 2012). In 2011, we conducted a mixed-methods investigation among Nepali women receiving abortions and abortion providers and administrators involved in service delivery. The quantitative study, conducted among 800 women receiving abortions, found that 33.9% of participants had received no information on effective contraceptive methods, defined as pills, contraceptive injections (depot medroxyprogesterone acetate), long-acting reversible contraceptives (intrauterine devices and contraceptive implants) and female or male sterilisation. Over half (55.7%) of patients left facilities without an effective method. The most commonly selected methods were contraceptive injections and pills. Most women selecting contraceptive injections and pills received their chosen method at their abortion visit and continued using the method six months post-abortion. However, 44% of women selecting long-acting reversible contraception had used this method by six months after their abortion visit (Rocca et al. 2014). This early study provided important data on the methods women select, receive, and initiate post-abortion. As a complement to the quantitative investigation on women’s post-abortion contraception, we conducted a qualitative study of the service delivery process to identify structural and facility-level factors that may explain observed patterns of contraceptive selection and use. Such data are needed to develop programmes and interventions to improve post-abortion contraceptive provision and uptake in Nepal, with potential application to other low-income countries where abortion is legal. The purpose of the present study was to examine the perspectives and experiences of abortion providers, counsellors and administrators regarding post-abortion contraceptive provision to understand the strengths and shortcomings of the delivery system.
Methods This study was undertaken between July and September 2012 as part of a larger mixed-methods investigation of post-abortion contraceptive use at four major health facilities in Nepal: two government public hospitals and two non-profit, private clinics. Sites were selected to represent the regional diversity of Nepal. One hospital, in Kathmandu, is the largest maternity hospital in the country and serves clients from districts in the central part of Nepal. The other hospital is located in the central Terai District and receives referrals from surrounding districts. One private clinic is a major abortion service provider for western hilly districts, and the other clinic is located in the eastern region of Nepal. All facilities offered male condoms, combined hormonal contraceptive pills, contraceptive injections, copper intrauterine devices, contraceptive implants and surgical sterilisation services. Same-day, post-abortion intrauterine device insertion was available at all clinics. Methods were available free-of-charge from public sites; private clinics charged small fees for the insertion and removal of long-acting reversible contraceptive devices. Emergency contraceptive pills were not routinely offered. In-depth interviews were conducted with 24 facility providers (physicians, nurses and counsellors) and administrators (family planning supply officers and clinic or hospital
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administrators). Using purposive sampling, potential participants were identified via consultation with key service providers at each site. To obtain a spectrum of perspectives on family planning services within the context of abortion care, at least one physician and one nurse providing family planning services, and a minimum of one facility administrator or one family planning supply officer responsible for maintaining contraceptive supplies, were enrolled from each site. This study was approved by the University of California, San Francisco Institutional Review Board and the Nepal Health Research Council. An informed consent form was reviewed by participants at the start of each interview, and participants were provided the opportunity to ask questions. To protect the confidentiality of the participants, verbal consent was obtained. After informed consent had been obtained, interviews were conducted by two researchers in Nepali or English; the language was selected by the interviewee. A translator was present for interviews in English. A private room at each facility was used for informed consent and interviews. The interview guide was initially developed in English and translated into Nepali. Pilot testing was conducted with four participants recruited from the study facilities to evaluate phrasing, sequence of questions, and comprehension. Modifications were subsequently made to the interview guide based on the results. Topics included: barriers to family planning service delivery and use, contraceptive method availability and challenges to maintenance of supplies, views on contraceptive counselling for abortion patients and recommendations for improving post-abortion contraceptive utilisation. Audio recordings of the interviews were transcribed and Nepali interviews were translated into English. Written notes were taken if the provider did not consent to be recorded. Interviews lasted 50 to 70 minutes. Data analysis was based on the grounded theory approach (Strauss and Corbin 1998), in which constant comparative method was used to develop increasingly more complex groups of codes, leading to theory. A modification of the traditional grounded theory approach was used; memos and codes were applied after approximately half of the interviews were transcribed. Two coders independently reviewed the transcripts line-by-line to generate initial codes, which were used by the first author (LFW) to develop the preliminary codebook. Transcripts were open-coded a second time to develop more detailed codes and assess relationships among codes. A data display was created to examine the frequency and intensity of codes and to combine related and redundant codes. The development of the codebook was initially informed by the conceptual framework proposed by Conteh and Hanson (2003), which identifies determinants of public health product availability in developing countries by delineating influences on demand (e.g. price, income, availability) and supply (e.g. regulation, provider knowledge, perception of patient preferences). While some factors proposed by the conceptual framework, such as the availability of supplies and provider knowledge, arose from the data, new themes emerged, such as concepts related to contraceptive counselling and social norms influencing contraceptive uptake. Related codes were ultimately grouped into: (1) facility factors influencing post-abortion contraceptive services, (2) cultural and normative barriers to post-abortion contraceptive use and (3) contraceptive counselling approaches that influence contraceptive choices. The investigators (LFW, MP and JTH) developed the final codebook through consensus. The software ATLAS.ti (version 5.0, Scientific Software Development, Berlin) was used for coding. Themes were analysed by facility type (public hospital or private clinic).
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Table 1. Profile of study participants (n = 24).
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Characteristic Type of facility Public hospital Private clinic Occupation Physician, non-obstetrician/gynaecologist Obstetrician/gynaecologist Nurse Counsellor Administrator/family planning supply officer Abortion service provider Yes No Responsible for maintaining family planning supplies Yes No Sex Female Male Total
N 17 7 7 6 4 2 5 16 8 8 16 16 8 24
Results The majority of the 24 participants were healthcare providers (seven non-obstetrician/gynaecologist physicians, six obstetrician/gynaecologists, four nurses, and two counsellors) and the remaining five were administrators with varying degrees of involvement in direct patient care (Table 1). Trained health workers provided abortion and family planning counselling at private clinics, while counselling at public hospitals was performed by nurses and/or physicians, who also provided the abortion services. Most participants were directly involved in post-abortion contraceptive services; eight were involved in maintaining family planning supplies. Of the 24, 16 participants were female. Ages ranged from 26 to 57 years. Three key themes emerged from the data: (1) facility factors influencing post-abortion contraceptive services, (2) cultural and normative barriers to post-abortion contraceptive use and (3) contraceptive counselling approaches that influence contraceptive choices.
Facility factors influencing post-abortion contraceptive services Participants pointed to several structural, facility factors that shaped post-abortion services. Providers from all facilities reported shortages in long-acting reversible contraceptive devices, especially implants, which were supplied by the local District Public Health Office. An administrator at a private clinic explained that these shortages impacted method availability: … [the contraceptive implant] has the problem of supply, which we get from the local [District Public Health Office]. In some situations, when there is a shortage [of contraceptive supplies] at [the District Public Health Office], we also face a shortage.
A few service providers, particularly those working at public hospitals, described how changes in staffing improved service delivery by allowing them to provide on-site, sameday contraceptive services. One nurse at a public hospital described how family planning improved after they were integrated with abortion services: There was no manpower specially designated for [family planning], so sometimes we had to provide service from other departments. That led to clients coming late for service, and lack
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of time among hospital staff might have caused some problem for clients … but now there is separate staff designated for that. This has made the service delivery very good.
While, in general, on-site, same-day provision of contraceptive methods was available at all sites, at one public hospital, implant insertions were provided at a unit in a different building. A nurse at the hospital presented this as a significant barrier to contraceptive uptake:
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We send them to [another building] for implant and minilap [bilateral tubal ligation], and it’s not certain whether they get [them] …. Sometimes, the patient party might get puzzled or find it hectic to get the service.
Despite improvements in staffing, the majority of service providers expressed the need for more broadly available, dedicated, well-trained staff, particularly at public hospitals. A few providers at one hospital reported that clinicians who provide abortion and sterilisation services have competing responsibilities, impeding access. Providers consistently reported that contraceptive counselling was provided before, during and after abortion services; providers at private clinics indicated that dedicated counsellors allowed for high-quality counselling. Providers at public hospitals discussed the challenges resulting from not having dedicated counsellors. An obstetrician/gynaecologist at a public hospital asserted: It would be better if there was a counsellor dedicated to counselling only. The people who have more knowledge about that or the ones who have gained training regarding that, such people will have more knowledge.
Service providers at all sites recommended that all staff eligible to provide long-acting reversible contraception undergo training. Perceiving that patients preferred to have female service providers, they also recommended that more female providers be available for the provision of long-acting reversible contraceptives. The need for refresher training was raised by providers from all sites, particularly for contraceptive counselling and provision of long-acting reversible methods. Providers at public hospitals reported limited time and space for contraceptive counselling, especially during times of high patient flow. An administrator at a public hospital described how time limitations would lead to group counselling: When there is excess flow, then we have limited time, and at that time we counsel two to three clients together.
In addition, a few providers noted that patients would sometimes leave the facility quickly after their procedure, without a contraceptive method. Many service providers articulated how healthcare access barriers impacted post-abortion contraceptive provision, particularly in rural areas. Women having medication abortion were perceived to have lower uptake of family planning because they lacked post-abortion contraceptive care. An administrator at a private clinic explained: … people who take [misoprostol] at home, they don’t get the [family planning] counselling at home that they could have gotten here. Like here, we counsel them to take [family planning] anyhow. Our sister tells them here, but in the home, there is no one to tell.
Some providers described the various barriers rural women face in accessing family planning, such as transportation, distance and ability to take time off. An obstetrician/gynaecologist at a public hospital listed: … it’s the transport. They have to go to the family planning clinic … maybe they will get [the method] for free, but they have to get some time [off ]. Social unrest; somebody leaves from one place … suddenly, the traffic is stopped and there’s a traffic jam, and the roads are closed. All women have to do all the agricultural work as well as the household work ….
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One provider, an administrator at a private clinic, stated that it would be irresponsible to provide intrauterine devices if the patient was unable to access post-insertion care: … [for] a woman living five hours away … if we provide the IUCD [intrauterine device] service, and after returning home, she faces a problem and has to come for follow up immediately, if she can follow up at the health post or here, only then should we promote.
Most providers recommended expanding the range of methods and services offered by rural clinics by training more healthcare workers to provide long-acting reversible contraception and increasing opportunities to obtain methods in remote rural areas. An administrator at a private clinic proposed:
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Norplant [contraceptive implants] and IUCD [intrauterine devices] should be made available in the sub-health post of the villages. [The Government and non-governmental organisations] organise camps [for long-acting reversible contraception] two to three times a year, but that is not sufficient.
In summary, service providers at public hospitals expressed more organisational barriers to post-abortion contraceptive services, such as limited time and space to provide counselling, than those at private facilities. Providers observed that on-site, same-day provision of family planning better met the needs of their patients and also recommended training more healthcare workers to provide long-acting reversible contraception. Providers perceived that challenges in follow-up services for long-acting reversible contraception and postmedication abortion impeded family planning uptake, and they recommended expanding services in rural areas.
Cultural and normative barriers to post-abortion contraceptive use Cultural norms, including those around marital status and husband’s absence, were perceived to heavily influence women’s contraceptive choices. Adolescents and unmarried women were perceived to be least likely to initiate a method; infrequent sexual activity was cited as a reason for low uptake among these groups of women. An obstetrician/gynaecologist at a public hospital explained: Unmarried [women] fear that there might be menstrual irregularities. They also think that [sex] won’t happen frequently, this was a one-time mistake and they won’t repeat it again.
Women not living with their husbands while they migrate for work were perceived as less likely to use contraception. A counsellor at a private clinic observed that there may be stigma around using contraception when the husband is away: Most [married women] do not use [contraception] as their husbands are abroad for three years, and our society has a concept that she doesn’t need to use it because she won’t be engaged with someone else. We cannot change society, regardless of how much effort we put. Out of fear, women do not want to use [contraception] when their husbands are not around.
A few providers observed that women sometimes initiate a method too late for it to be effective. For example, an obstetrician/gynaecologist at a public hospital recalled: When the women come to us, and if we ask them, ‘How do you use pills?’ Then they say, ‘Consumed from the day of husband’s arrival and stopped consuming after his departure.’
Most providers noted challenges while counselling women from rural areas, such as low education and language differences, which hindered understanding during counselling, even when providers used flip charts with pictures and translators. Rural women were also
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perceived to have more side-effect fears and misinformation about contraceptives, particularly intrauterine devices. Concerns regarding bleeding disorders, weight gain and infertility were provided as examples. For instance, as articulated by a nurse at a private clinic: Most of them do not use [contraception] due to being fearful about side-effects, like irregular menstruation or Depo [contraceptive injection] causing them to put on weight. Among the married people, they have a wrong impression that by using contraceptives, they will not be able to get pregnant.
Some providers remarked that rumours about side-effects were easily spread in rural areas. A counsellor at a private clinic explained:
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… in the rural areas, people usually talk about the negative effects of contraceptive. Such as, if one uses the Copper-T [intrauterine device] it will get stuck, it might spread, [or] Norplant might get covered and it would be impossible to take it out …. They think if one takes medicine, then it will only accumulate in the stomach ….
While providers mostly focused on the negative effects of social influences on contraceptive uptake, a nurse at a private clinic observed that peers and the broader community could also have a positive effect: [However,] a lot of such negative perspectives have changed [over the past several years]. Women have started to share their [contraceptive] experiences with each other, which changed negative thoughts ….
Gender power barriers were repeatedly raised as influencing contraceptive use. Some providers noted that women needed to consult with their family or husband prior to choosing a method. An obstetrician/gynaecologist at a public hospital explained: Females alone cannot decide. They need to obey the decision of their male partner, other family member, like their mother-in-law. Due to this, females don’t have decision power. They don’t have that much strong decision power.
A male-dominated power structure along with misinformation was repeatedly raised as a barrier to male sterilisation. An obstetrician/gynaecologist at a public hospital elaborated: Males think they will lose puruswartha [masculinity/power to produce children and carry out heavy work]. They have to do a lot of work, have to carry loads, so they don’t do vasectomy …. Most of the people think that it causes loss in erection and it’s hard to tell them that it does not bring changes in them.
In summary, cultural norms and gender power differences were perceived to strongly influence post-abortion contraceptive use. Young women, unmarried women and women whose husbands had migrated for work were perceived to be least likely to use contraception. Service providers also described multiple challenges faced by rural women, such as language barriers and misinformation.
Contraceptive counselling approaches that influence contraceptive choices Providers’ advice regarding contraceptive options was sometimes based on their own opinions about appropriate childbearing. Some reported that it was best for women to have two or three children, with a few years between each birth. For example, an administrator at a public hospital asserted: … we can explain to them, at least, the gap [between births] must be five years so it will be better for the development of the child also. … if you have two children, then it’s ok to stop further
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pregnancies. We have to counsel them … because they have to give [their children] education and everything, so [it’s] better if they don’t become pregnant.
Some providers therefore recommended condoms or pills for unmarried women or women without children, and sterilisation or long-acting reversible contraception for married women with at least two children. A physician at a private clinic believed that long-acting methods should not be provided to unmarried women:
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There are some who are unmarried but ask for long-term methods, which is not applicable as she is not married, she has no child. In such a case, how can we provide such a measure?
Some providers expressed that teenagers, women over 40, women who regularly have unsafe sex and women with medical conditions that could cause pregnancy complications required extra counselling regarding contraception. Providers’ personal views on specific methods appeared to shape their counselling practices. Most held positive views about the copper intrauterine device as the only reversible method without hormones. A few reported that intrauterine devices were prioritised during counselling. For example, a physician at a private clinic stated: I prioritise the Copper-T [intrauterine device], as it is non–hormonal and the rest of the others are hormonal, except condoms. It is hard to say about the possible effects of hormones, and it differs according to the individual … and the clients might complain regarding the changes. So the safest is the Copper-T [intrauterine device] and the condom.
Some providers considered specific methods to be suitable only for certain women. For example some stated that long-acting reversible contraception is only appropriate for women with at least one child or women with repeat abortions, or that the contraceptive injections are unsuitable for unmarried women. For example, an obstetrician/gynaecologist at a public hospital asserted: For married women with no baby, then we don’t provide Depo because of [the delayed return of fertility].
A few providers expressed judgment of abortion patients. Some believed that women with prior abortions required extra counselling to accept a method, and some counselled women about the health risk of having multiple abortions. A few remarked that women with repeat abortions were lazy or careless or that they were using abortion as a family planning method. For example, an administrator at a public hospital declared: But the hidden reason behind [the repeat abortion] is the easy accessibility of abortion services. You can find the service everywhere so it makes the client negligent to use [family planning] methods.
During contraceptive counselling, one provider described telling a couple that an abortion would not be provided if she had another unplanned pregnancy: One client … came to meet me … and then I came to know that his wife had [a medical abortion] one year back…. This is the result of improper use of family planning devices, so I told them, ‘If you come again, I will not do it.’
Some providers recommended involving male partners and providing contraceptive education to men in order to improve contraceptive uptake. They observed that some women either want their partner’s input on family planning or are influenced by partner disapproval of contraception. An obstetrician/gynaecologist at a public hospital suggested: We are going to give the counselling with the partner or husband. … We think that with partner counselling, if the partner is convinced, she is also going to be convinced [to use family planning].
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In summary, providers’ opinions about appropriate childbearing and personal views on specific methods appeared to shape their counselling practices. A few providers expressed judgment of abortion patients, particularly women with prior abortions. Some providers recommended including men in contraceptive education to improve family planning use.
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Discussion The providers and abortion facility administrators in this study articulated a range of practical and attitudinal barriers to providing post-abortion contraceptive services. While our findings are consistent with research showing that clinic logistics impact contraceptive counselling and provision (Mohammad-Alizadeh et al. 2009; Mugisha and Reynolds 2008), cultural norms around women’s contraceptive decision-making autonomy and use when sex is infrequent were noted as reasons for low contraceptive use among Nepali patients. In general, participants were dedicated to providing comprehensive abortion and contraceptive services, sensitive to their patients’ needs and frustrated at practical barriers that hindered contraceptive service provision. At the same time, however, interviews disclosed biases and counselling approaches that may compromise patient trust and women’s ability to select and use a method that best meets their needs. Compared to private clinics, service providers at public hospitals identified a larger number of organisational barriers to post-abortion contraceptive services, such as limited time and space to provide counselling. Healthcare workers specifically trained to provide abortion and contraceptive counselling were not available at public hospitals, and this was perceived as an additional barrier to family planning provision. These barriers may partly explain our quantitative study finding that women seeking services at two private clinics were significantly more likely (82 and 97%) to receive contraceptive information when compared to two public hospitals (67 and 40%). The quantitative study also revealed that women who received contraceptive information were over twice as likely to choose an effective method (Rocca et al. 2014). Providing more organisational support, such as appointing trained healthcare workers to provide counselling, may help ensure that women receive contraceptive counselling during their abortion visits. While patients at one public hospital were referred to a separate unit for post-abortion contraceptive implant insertion, overall, providers at all sites reported that on-site same-day provision of family planning methods was available. Providers at all facilities also expressed the need for more trained providers able to provide immediate post-abortion long-acting reversible contraception. Data from the quantitative study found that most women who chose pills or contraceptive injections received their method of choice the day of the abortion visit, while fewer than half of women who chose intrauterine devices or contraceptive implants received their chosen method on the day of their abortion (Rocca et al. 2014). Providing more training and organisational support may improve contraceptive uptake and better meet the needs of women choosing long-acting reversible contraception. Investing in immediate post-abortion insertion of intrauterine devices and contraceptive implants may have the most impact on unintended pregnancy rates. Longitudinal data from the quantitative study found that one-year contraceptive discontinuation and pregnancy rates were significantly lower among women using long-acting reversible contraception when compared to women using pills, contraceptive injections or condoms (Puri et al. 2015).
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Service providers at all facilities articulated barriers rural women face in accessing contraception. They perceived more difficulties in dispelling myths and addressing fears when counselling women from rural areas. Previous research has found that side-effect fears and misinformation are important barriers to contraceptive use in Nepal (Diamond-Smith, Campbell, and Madan 2012; Menger et al. 2015). A nurse at a private clinic observed that women sharing positive experiences may help to dispel fear and misinformation. Further research on peer education as a way to address side-effect fears may identify strategies to improve access to more effective contraceptive methods. Providers also described logistic barriers women face in accessing family planning service, such as ability to take time off work, travel distance and transportation. An administrator at a private clinic considered it important to ensure that patients requesting intrauterine devices had access to appropriate follow-up care before providing the method. Despite the potentially unique challenges to access for rural women, our quantitative study did not find that rural and urban women differed in choosing an effective contraceptive method at the time of their abortion visit, using an effective method within six months of their abortion visit or experiencing a pregnancy one year post-abortion (Puri et al. 2015). Education may play a stronger role – the quantitative study found that women with greater than primary education were more likely to choose and receive an effective contraceptive method and to report use of an effective method within six months of their abortion visit (Rocca et al. 2014). Our findings highlight the challenge of addressing gender power norms in post-abortion counselling practices. Many providers speculated that low rates of male sterilisation resulted from fear of a loss of masculinity or fertility. Some providers observed that some female patients did not have the authority to decide on a contraceptive method independently, which is consistent with previous research revealing that the views of husbands and mother-in-laws regarding family planning side-effects influenced Nepali women’s decision-making (Diamond-Smith, Campbell, and Madan 2012). Therefore, providers recommended family planning education targeting men. While involving partners in post-abortion counselling may improve contraceptive uptake (Beenhakker et al. 2004; Dhillon et al. 2004; Rasch and Lyaruu 2005), careful consideration of gender dynamics and further study would be needed in Nepal. Notably, one service provider reported harnessing this power imbalance by involving the male partner in counselling so that he might ‘convince’ the patient to use family planning. Counselling approaches that support women to select a method that meets her needs, while acknowledging the limitations in women’s decision-making ability and autonomy, are important in this setting. Young women, unmarried women and women whose husbands were abroad for work were perceived as less likely to choose an effective contraceptive method when compared to older women living with their husbands. This finding correlates with quantitative data from this mixed-methods study – women not living with their husbands were far less likely to receive counselling or select and use a method post-abortion (Rocca et al. 2014). Stigma and other social consequences may contribute to these differences in contraceptive uptake. A counsellor at a private clinic observed that women fear using contraception when their husbands are abroad, as others may assume that they are having extramarital intercourse. While the impact of stigma on younger or unmarried women did not emerge from the data, prior research suggest that young people in Nepal, particularly in rural areas, are embarrassed and fearful of accessing reproductive health
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services, and premarital sex is highly stigmatised (Regmi et al. 2010). Further research exploring the role of stigma on contraceptive use among adolescents, unmarried women and women whose husbands are abroad may identify strategies to better meet their reproductive health needs. This study found that some service providers hold negative judgments about the appropriateness of women’s contraceptive use. On the one hand, providers voiced the concern that easy availability of abortion in Nepal makes women ‘negligent’ about using contraception, an attitude found among Nepali abortion providers in previous studies (Moller, Ofverstedt, and Siwe 2012; Puri et al. 2012). On the other hand, some providers suggested that effective contraceptive use was discouraged among women deemed inappropriate candidates, including unmarried women and women without children. Notably, some providers suggested that long-acting methods may not be appropriate for certain patients based on marital status or parity, contradicting the World Health Organization (2009) medical eligibility criteria for contraceptive use, and unnecessarily limiting access to effective methods for some women. Values clarification exercises for contraceptive providers may help improve the quality of patient care and voluntary contraceptive use among all groups of women in Nepal. As concerns about ‘repeat’ abortion in Nepal become more prevalent (Thapa and Neupane 2013), particular attention to the balance between providing post-abortion contraceptive services and ensuring women’s autonomy and choice will be important. The results of this qualitative study cannot be generalised to all abortion providers in Nepal. While broad themes may be applicable to other sites and settings, there could be unique, site-specific issues and viewpoints observed only in urban facilities in Nepal. The themes we identified, however, highlight areas for quantitative inquiry that may further understanding of post-abortion contraceptive delivery in Nepal and elsewhere. Further research is needed regarding abortion patients’ perspectives on selecting and utilising post-abortion contraception.
Conclusion This small-scale study highlights current strengths and shortcomings of post-abortion contraceptive provision from the perspectives of service providers and administrators. Providers were dedicated to providing comprehensive contraceptive services in the setting of abortion care, but identified practical, facility factors impacting on contraceptive services. Women’s limited contraceptive decision-making autonomy, the stigma of contraceptive use during a husband’s absence or when sex is infrequent and provider biases and misinformation about eligibility criteria likely influence counselling approaches and method use. Interventions aimed at addressing both structural and cultural barriers to effective contraceptive provision in the post-abortion setting may be informed by the joint findings of the present study and an earlier complementary quantitative investigation into post-abortion contraceptive provision in Nepal. Further research regarding culturally sensitive approaches to contraceptive counselling is needed to improve access to family planning for the women at greatest risk for unintended pregnancy.
Disclosure statement The authors declare that they have no competing interests, financial or otherwise.
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Funding This work was supported by a grant from the Society of Family Planning [grant number SFP4-8].
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Senlet, P., L. Cagatay, J. Ergin, and J. Mathis. 2001. “Bridging the Gap: Integrating Family Planning with Abortion Services in Turkey.” International Family Planning Perspectives 27 (2): 90–95. Senlet, P., S. L. Curtis, J. Mathis, and H. Raggers. 2001. “The Role of Changes in Contraceptive Use in the Decline of Induced Abortion in Turkey.” Studies in Family Planning 32 (1): 41–52. Strauss, A., and J. Corbin. 1998. Basics of Qualitative Research Techniques and Procedures for Developing Grounded Theory. 2nd ed. London: Sage Publications. Thapa, S., and S. Neupane. 2013. “Risk Factors for Repeat Abortion in Nepal.” International Journal of Gynaecology & Obstetrics 120 (1): 32–36. World Health Organization. 2009. Medical Eligibility Criteria for Contraceptive Use. 4th ed. Geneva: World Health Organization. http://www.who.int/reproductivehealth/publications/family_planning/ 9789241563888/en/
ISSN: 1369-1058 (Print) 1464-5351 (Online) Journal homepage: http://www.tandfonline.com/loi/tchs20
Service provider perspectives on post-abortion contraception in Nepal Lin-Fan Wang, Mahesh Puri, Corinne H. Rocca, Maya Blum & Jillian T. Henderson To cite this article: Lin-Fan Wang, Mahesh Puri, Corinne H. Rocca, Maya Blum & Jillian T. Henderson (2016) Service provider perspectives on post-abortion contraception in Nepal, Culture, Health & Sexuality, 18:2, 221-232, DOI: 10.1080/13691058.2015.1073358 To link to this article: http://dx.doi.org/10.1080/13691058.2015.1073358
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Culture, Health & Sexuality, 2016 Vol. 18, No. 2, 223–235 http://dx.doi.org/10.1080/13691058.2015.1073358
SHORT REPORT
Service provider perspectives on post-abortion contraception in Nepal Lin-Fan Wanga, Mahesh Purib, Corinne H. Roccac, Maya Blumc and Jillian T. Hendersonc,§ Department of Family and Community Medicine, Thomas Jefferson University Hospital, Mazzoni Center, Philadelphia, USA; bCenter for Research on Environment Health and Population Activities, Kathmandu, Nepal; c Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, USA
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a
ABSTRACT
The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility’s infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.
ARTICLE HISTORY
Received 3 November 2014 Accepted 13 July 2015 KEYWORDS
Post-abortion; Nepal; contraceptive use; service provider views
Introduction Abortion safety and pregnancy-related morbidity and mortality have improved since abortion was legalised in Nepal in 2002 (Bhandari, Gordon, and Shakya 2011; Henderson et al. 2013). Attention is now increasingly focused on preventing future unintended pregnancy and abortion by providing comprehensive post-abortion contraceptive care (Corbett and Turner 2003; Johnson et al. 2002; Senlet, Cagatay et al. 2001; Senlet, Curtis et al. 2001). Nepal’s National Safe Abortion Policy (National Safe Abortion Policy, Final Draft 2003) explicitly CONTACT Lin-Fan Wang [email protected] § Current affiliation: Kaiser Permanente Center for Health Research Northwest, Portland, USA. © 2015 Taylor & Francis
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recommends the inclusion of family planning services in abortion care, and the Government of Nepal has developed strategies to improve post-abortion contraceptive services (Annual Report Department of Health and Services 2010/2011 2012). Despite government commitment to post-abortion contraceptive care, significant gaps in services remain. Data from public facilities show that approximately 50% of women receiving an abortion in 2009–2011 received a post-abortion contraceptive method (Samandari et al. 2012). In 2011, we conducted a mixed-methods investigation among Nepali women receiving abortions and abortion providers and administrators involved in service delivery. The quantitative study, conducted among 800 women receiving abortions, found that 33.9% of participants had received no information on effective contraceptive methods, defined as pills, contraceptive injections (depot medroxyprogesterone acetate), long-acting reversible contraceptives (intrauterine devices and contraceptive implants) and female or male sterilisation. Over half (55.7%) of patients left facilities without an effective method. The most commonly selected methods were contraceptive injections and pills. Most women selecting contraceptive injections and pills received their chosen method at their abortion visit and continued using the method six months post-abortion. However, 44% of women selecting long-acting reversible contraception had used this method by six months after their abortion visit (Rocca et al. 2014). This early study provided important data on the methods women select, receive, and initiate post-abortion. As a complement to the quantitative investigation on women’s post-abortion contraception, we conducted a qualitative study of the service delivery process to identify structural and facility-level factors that may explain observed patterns of contraceptive selection and use. Such data are needed to develop programmes and interventions to improve post-abortion contraceptive provision and uptake in Nepal, with potential application to other low-income countries where abortion is legal. The purpose of the present study was to examine the perspectives and experiences of abortion providers, counsellors and administrators regarding post-abortion contraceptive provision to understand the strengths and shortcomings of the delivery system.
Methods This study was undertaken between July and September 2012 as part of a larger mixed-methods investigation of post-abortion contraceptive use at four major health facilities in Nepal: two government public hospitals and two non-profit, private clinics. Sites were selected to represent the regional diversity of Nepal. One hospital, in Kathmandu, is the largest maternity hospital in the country and serves clients from districts in the central part of Nepal. The other hospital is located in the central Terai District and receives referrals from surrounding districts. One private clinic is a major abortion service provider for western hilly districts, and the other clinic is located in the eastern region of Nepal. All facilities offered male condoms, combined hormonal contraceptive pills, contraceptive injections, copper intrauterine devices, contraceptive implants and surgical sterilisation services. Same-day, post-abortion intrauterine device insertion was available at all clinics. Methods were available free-of-charge from public sites; private clinics charged small fees for the insertion and removal of long-acting reversible contraceptive devices. Emergency contraceptive pills were not routinely offered. In-depth interviews were conducted with 24 facility providers (physicians, nurses and counsellors) and administrators (family planning supply officers and clinic or hospital
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administrators). Using purposive sampling, potential participants were identified via consultation with key service providers at each site. To obtain a spectrum of perspectives on family planning services within the context of abortion care, at least one physician and one nurse providing family planning services, and a minimum of one facility administrator or one family planning supply officer responsible for maintaining contraceptive supplies, were enrolled from each site. This study was approved by the University of California, San Francisco Institutional Review Board and the Nepal Health Research Council. An informed consent form was reviewed by participants at the start of each interview, and participants were provided the opportunity to ask questions. To protect the confidentiality of the participants, verbal consent was obtained. After informed consent had been obtained, interviews were conducted by two researchers in Nepali or English; the language was selected by the interviewee. A translator was present for interviews in English. A private room at each facility was used for informed consent and interviews. The interview guide was initially developed in English and translated into Nepali. Pilot testing was conducted with four participants recruited from the study facilities to evaluate phrasing, sequence of questions, and comprehension. Modifications were subsequently made to the interview guide based on the results. Topics included: barriers to family planning service delivery and use, contraceptive method availability and challenges to maintenance of supplies, views on contraceptive counselling for abortion patients and recommendations for improving post-abortion contraceptive utilisation. Audio recordings of the interviews were transcribed and Nepali interviews were translated into English. Written notes were taken if the provider did not consent to be recorded. Interviews lasted 50 to 70 minutes. Data analysis was based on the grounded theory approach (Strauss and Corbin 1998), in which constant comparative method was used to develop increasingly more complex groups of codes, leading to theory. A modification of the traditional grounded theory approach was used; memos and codes were applied after approximately half of the interviews were transcribed. Two coders independently reviewed the transcripts line-by-line to generate initial codes, which were used by the first author (LFW) to develop the preliminary codebook. Transcripts were open-coded a second time to develop more detailed codes and assess relationships among codes. A data display was created to examine the frequency and intensity of codes and to combine related and redundant codes. The development of the codebook was initially informed by the conceptual framework proposed by Conteh and Hanson (2003), which identifies determinants of public health product availability in developing countries by delineating influences on demand (e.g. price, income, availability) and supply (e.g. regulation, provider knowledge, perception of patient preferences). While some factors proposed by the conceptual framework, such as the availability of supplies and provider knowledge, arose from the data, new themes emerged, such as concepts related to contraceptive counselling and social norms influencing contraceptive uptake. Related codes were ultimately grouped into: (1) facility factors influencing post-abortion contraceptive services, (2) cultural and normative barriers to post-abortion contraceptive use and (3) contraceptive counselling approaches that influence contraceptive choices. The investigators (LFW, MP and JTH) developed the final codebook through consensus. The software ATLAS.ti (version 5.0, Scientific Software Development, Berlin) was used for coding. Themes were analysed by facility type (public hospital or private clinic).
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Table 1. Profile of study participants (n = 24).
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Characteristic Type of facility Public hospital Private clinic Occupation Physician, non-obstetrician/gynaecologist Obstetrician/gynaecologist Nurse Counsellor Administrator/family planning supply officer Abortion service provider Yes No Responsible for maintaining family planning supplies Yes No Sex Female Male Total
N 17 7 7 6 4 2 5 16 8 8 16 16 8 24
Results The majority of the 24 participants were healthcare providers (seven non-obstetrician/gynaecologist physicians, six obstetrician/gynaecologists, four nurses, and two counsellors) and the remaining five were administrators with varying degrees of involvement in direct patient care (Table 1). Trained health workers provided abortion and family planning counselling at private clinics, while counselling at public hospitals was performed by nurses and/or physicians, who also provided the abortion services. Most participants were directly involved in post-abortion contraceptive services; eight were involved in maintaining family planning supplies. Of the 24, 16 participants were female. Ages ranged from 26 to 57 years. Three key themes emerged from the data: (1) facility factors influencing post-abortion contraceptive services, (2) cultural and normative barriers to post-abortion contraceptive use and (3) contraceptive counselling approaches that influence contraceptive choices.
Facility factors influencing post-abortion contraceptive services Participants pointed to several structural, facility factors that shaped post-abortion services. Providers from all facilities reported shortages in long-acting reversible contraceptive devices, especially implants, which were supplied by the local District Public Health Office. An administrator at a private clinic explained that these shortages impacted method availability: … [the contraceptive implant] has the problem of supply, which we get from the local [District Public Health Office]. In some situations, when there is a shortage [of contraceptive supplies] at [the District Public Health Office], we also face a shortage.
A few service providers, particularly those working at public hospitals, described how changes in staffing improved service delivery by allowing them to provide on-site, sameday contraceptive services. One nurse at a public hospital described how family planning improved after they were integrated with abortion services: There was no manpower specially designated for [family planning], so sometimes we had to provide service from other departments. That led to clients coming late for service, and lack
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of time among hospital staff might have caused some problem for clients … but now there is separate staff designated for that. This has made the service delivery very good.
While, in general, on-site, same-day provision of contraceptive methods was available at all sites, at one public hospital, implant insertions were provided at a unit in a different building. A nurse at the hospital presented this as a significant barrier to contraceptive uptake:
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We send them to [another building] for implant and minilap [bilateral tubal ligation], and it’s not certain whether they get [them] …. Sometimes, the patient party might get puzzled or find it hectic to get the service.
Despite improvements in staffing, the majority of service providers expressed the need for more broadly available, dedicated, well-trained staff, particularly at public hospitals. A few providers at one hospital reported that clinicians who provide abortion and sterilisation services have competing responsibilities, impeding access. Providers consistently reported that contraceptive counselling was provided before, during and after abortion services; providers at private clinics indicated that dedicated counsellors allowed for high-quality counselling. Providers at public hospitals discussed the challenges resulting from not having dedicated counsellors. An obstetrician/gynaecologist at a public hospital asserted: It would be better if there was a counsellor dedicated to counselling only. The people who have more knowledge about that or the ones who have gained training regarding that, such people will have more knowledge.
Service providers at all sites recommended that all staff eligible to provide long-acting reversible contraception undergo training. Perceiving that patients preferred to have female service providers, they also recommended that more female providers be available for the provision of long-acting reversible contraceptives. The need for refresher training was raised by providers from all sites, particularly for contraceptive counselling and provision of long-acting reversible methods. Providers at public hospitals reported limited time and space for contraceptive counselling, especially during times of high patient flow. An administrator at a public hospital described how time limitations would lead to group counselling: When there is excess flow, then we have limited time, and at that time we counsel two to three clients together.
In addition, a few providers noted that patients would sometimes leave the facility quickly after their procedure, without a contraceptive method. Many service providers articulated how healthcare access barriers impacted post-abortion contraceptive provision, particularly in rural areas. Women having medication abortion were perceived to have lower uptake of family planning because they lacked post-abortion contraceptive care. An administrator at a private clinic explained: … people who take [misoprostol] at home, they don’t get the [family planning] counselling at home that they could have gotten here. Like here, we counsel them to take [family planning] anyhow. Our sister tells them here, but in the home, there is no one to tell.
Some providers described the various barriers rural women face in accessing family planning, such as transportation, distance and ability to take time off. An obstetrician/gynaecologist at a public hospital listed: … it’s the transport. They have to go to the family planning clinic … maybe they will get [the method] for free, but they have to get some time [off ]. Social unrest; somebody leaves from one place … suddenly, the traffic is stopped and there’s a traffic jam, and the roads are closed. All women have to do all the agricultural work as well as the household work ….
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One provider, an administrator at a private clinic, stated that it would be irresponsible to provide intrauterine devices if the patient was unable to access post-insertion care: … [for] a woman living five hours away … if we provide the IUCD [intrauterine device] service, and after returning home, she faces a problem and has to come for follow up immediately, if she can follow up at the health post or here, only then should we promote.
Most providers recommended expanding the range of methods and services offered by rural clinics by training more healthcare workers to provide long-acting reversible contraception and increasing opportunities to obtain methods in remote rural areas. An administrator at a private clinic proposed:
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Norplant [contraceptive implants] and IUCD [intrauterine devices] should be made available in the sub-health post of the villages. [The Government and non-governmental organisations] organise camps [for long-acting reversible contraception] two to three times a year, but that is not sufficient.
In summary, service providers at public hospitals expressed more organisational barriers to post-abortion contraceptive services, such as limited time and space to provide counselling, than those at private facilities. Providers observed that on-site, same-day provision of family planning better met the needs of their patients and also recommended training more healthcare workers to provide long-acting reversible contraception. Providers perceived that challenges in follow-up services for long-acting reversible contraception and postmedication abortion impeded family planning uptake, and they recommended expanding services in rural areas.
Cultural and normative barriers to post-abortion contraceptive use Cultural norms, including those around marital status and husband’s absence, were perceived to heavily influence women’s contraceptive choices. Adolescents and unmarried women were perceived to be least likely to initiate a method; infrequent sexual activity was cited as a reason for low uptake among these groups of women. An obstetrician/gynaecologist at a public hospital explained: Unmarried [women] fear that there might be menstrual irregularities. They also think that [sex] won’t happen frequently, this was a one-time mistake and they won’t repeat it again.
Women not living with their husbands while they migrate for work were perceived as less likely to use contraception. A counsellor at a private clinic observed that there may be stigma around using contraception when the husband is away: Most [married women] do not use [contraception] as their husbands are abroad for three years, and our society has a concept that she doesn’t need to use it because she won’t be engaged with someone else. We cannot change society, regardless of how much effort we put. Out of fear, women do not want to use [contraception] when their husbands are not around.
A few providers observed that women sometimes initiate a method too late for it to be effective. For example, an obstetrician/gynaecologist at a public hospital recalled: When the women come to us, and if we ask them, ‘How do you use pills?’ Then they say, ‘Consumed from the day of husband’s arrival and stopped consuming after his departure.’
Most providers noted challenges while counselling women from rural areas, such as low education and language differences, which hindered understanding during counselling, even when providers used flip charts with pictures and translators. Rural women were also
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perceived to have more side-effect fears and misinformation about contraceptives, particularly intrauterine devices. Concerns regarding bleeding disorders, weight gain and infertility were provided as examples. For instance, as articulated by a nurse at a private clinic: Most of them do not use [contraception] due to being fearful about side-effects, like irregular menstruation or Depo [contraceptive injection] causing them to put on weight. Among the married people, they have a wrong impression that by using contraceptives, they will not be able to get pregnant.
Some providers remarked that rumours about side-effects were easily spread in rural areas. A counsellor at a private clinic explained:
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… in the rural areas, people usually talk about the negative effects of contraceptive. Such as, if one uses the Copper-T [intrauterine device] it will get stuck, it might spread, [or] Norplant might get covered and it would be impossible to take it out …. They think if one takes medicine, then it will only accumulate in the stomach ….
While providers mostly focused on the negative effects of social influences on contraceptive uptake, a nurse at a private clinic observed that peers and the broader community could also have a positive effect: [However,] a lot of such negative perspectives have changed [over the past several years]. Women have started to share their [contraceptive] experiences with each other, which changed negative thoughts ….
Gender power barriers were repeatedly raised as influencing contraceptive use. Some providers noted that women needed to consult with their family or husband prior to choosing a method. An obstetrician/gynaecologist at a public hospital explained: Females alone cannot decide. They need to obey the decision of their male partner, other family member, like their mother-in-law. Due to this, females don’t have decision power. They don’t have that much strong decision power.
A male-dominated power structure along with misinformation was repeatedly raised as a barrier to male sterilisation. An obstetrician/gynaecologist at a public hospital elaborated: Males think they will lose puruswartha [masculinity/power to produce children and carry out heavy work]. They have to do a lot of work, have to carry loads, so they don’t do vasectomy …. Most of the people think that it causes loss in erection and it’s hard to tell them that it does not bring changes in them.
In summary, cultural norms and gender power differences were perceived to strongly influence post-abortion contraceptive use. Young women, unmarried women and women whose husbands had migrated for work were perceived to be least likely to use contraception. Service providers also described multiple challenges faced by rural women, such as language barriers and misinformation.
Contraceptive counselling approaches that influence contraceptive choices Providers’ advice regarding contraceptive options was sometimes based on their own opinions about appropriate childbearing. Some reported that it was best for women to have two or three children, with a few years between each birth. For example, an administrator at a public hospital asserted: … we can explain to them, at least, the gap [between births] must be five years so it will be better for the development of the child also. … if you have two children, then it’s ok to stop further
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pregnancies. We have to counsel them … because they have to give [their children] education and everything, so [it’s] better if they don’t become pregnant.
Some providers therefore recommended condoms or pills for unmarried women or women without children, and sterilisation or long-acting reversible contraception for married women with at least two children. A physician at a private clinic believed that long-acting methods should not be provided to unmarried women:
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There are some who are unmarried but ask for long-term methods, which is not applicable as she is not married, she has no child. In such a case, how can we provide such a measure?
Some providers expressed that teenagers, women over 40, women who regularly have unsafe sex and women with medical conditions that could cause pregnancy complications required extra counselling regarding contraception. Providers’ personal views on specific methods appeared to shape their counselling practices. Most held positive views about the copper intrauterine device as the only reversible method without hormones. A few reported that intrauterine devices were prioritised during counselling. For example, a physician at a private clinic stated: I prioritise the Copper-T [intrauterine device], as it is non–hormonal and the rest of the others are hormonal, except condoms. It is hard to say about the possible effects of hormones, and it differs according to the individual … and the clients might complain regarding the changes. So the safest is the Copper-T [intrauterine device] and the condom.
Some providers considered specific methods to be suitable only for certain women. For example some stated that long-acting reversible contraception is only appropriate for women with at least one child or women with repeat abortions, or that the contraceptive injections are unsuitable for unmarried women. For example, an obstetrician/gynaecologist at a public hospital asserted: For married women with no baby, then we don’t provide Depo because of [the delayed return of fertility].
A few providers expressed judgment of abortion patients. Some believed that women with prior abortions required extra counselling to accept a method, and some counselled women about the health risk of having multiple abortions. A few remarked that women with repeat abortions were lazy or careless or that they were using abortion as a family planning method. For example, an administrator at a public hospital declared: But the hidden reason behind [the repeat abortion] is the easy accessibility of abortion services. You can find the service everywhere so it makes the client negligent to use [family planning] methods.
During contraceptive counselling, one provider described telling a couple that an abortion would not be provided if she had another unplanned pregnancy: One client … came to meet me … and then I came to know that his wife had [a medical abortion] one year back…. This is the result of improper use of family planning devices, so I told them, ‘If you come again, I will not do it.’
Some providers recommended involving male partners and providing contraceptive education to men in order to improve contraceptive uptake. They observed that some women either want their partner’s input on family planning or are influenced by partner disapproval of contraception. An obstetrician/gynaecologist at a public hospital suggested: We are going to give the counselling with the partner or husband. … We think that with partner counselling, if the partner is convinced, she is also going to be convinced [to use family planning].
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In summary, providers’ opinions about appropriate childbearing and personal views on specific methods appeared to shape their counselling practices. A few providers expressed judgment of abortion patients, particularly women with prior abortions. Some providers recommended including men in contraceptive education to improve family planning use.
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Discussion The providers and abortion facility administrators in this study articulated a range of practical and attitudinal barriers to providing post-abortion contraceptive services. While our findings are consistent with research showing that clinic logistics impact contraceptive counselling and provision (Mohammad-Alizadeh et al. 2009; Mugisha and Reynolds 2008), cultural norms around women’s contraceptive decision-making autonomy and use when sex is infrequent were noted as reasons for low contraceptive use among Nepali patients. In general, participants were dedicated to providing comprehensive abortion and contraceptive services, sensitive to their patients’ needs and frustrated at practical barriers that hindered contraceptive service provision. At the same time, however, interviews disclosed biases and counselling approaches that may compromise patient trust and women’s ability to select and use a method that best meets their needs. Compared to private clinics, service providers at public hospitals identified a larger number of organisational barriers to post-abortion contraceptive services, such as limited time and space to provide counselling. Healthcare workers specifically trained to provide abortion and contraceptive counselling were not available at public hospitals, and this was perceived as an additional barrier to family planning provision. These barriers may partly explain our quantitative study finding that women seeking services at two private clinics were significantly more likely (82 and 97%) to receive contraceptive information when compared to two public hospitals (67 and 40%). The quantitative study also revealed that women who received contraceptive information were over twice as likely to choose an effective method (Rocca et al. 2014). Providing more organisational support, such as appointing trained healthcare workers to provide counselling, may help ensure that women receive contraceptive counselling during their abortion visits. While patients at one public hospital were referred to a separate unit for post-abortion contraceptive implant insertion, overall, providers at all sites reported that on-site same-day provision of family planning methods was available. Providers at all facilities also expressed the need for more trained providers able to provide immediate post-abortion long-acting reversible contraception. Data from the quantitative study found that most women who chose pills or contraceptive injections received their method of choice the day of the abortion visit, while fewer than half of women who chose intrauterine devices or contraceptive implants received their chosen method on the day of their abortion (Rocca et al. 2014). Providing more training and organisational support may improve contraceptive uptake and better meet the needs of women choosing long-acting reversible contraception. Investing in immediate post-abortion insertion of intrauterine devices and contraceptive implants may have the most impact on unintended pregnancy rates. Longitudinal data from the quantitative study found that one-year contraceptive discontinuation and pregnancy rates were significantly lower among women using long-acting reversible contraception when compared to women using pills, contraceptive injections or condoms (Puri et al. 2015).
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Service providers at all facilities articulated barriers rural women face in accessing contraception. They perceived more difficulties in dispelling myths and addressing fears when counselling women from rural areas. Previous research has found that side-effect fears and misinformation are important barriers to contraceptive use in Nepal (Diamond-Smith, Campbell, and Madan 2012; Menger et al. 2015). A nurse at a private clinic observed that women sharing positive experiences may help to dispel fear and misinformation. Further research on peer education as a way to address side-effect fears may identify strategies to improve access to more effective contraceptive methods. Providers also described logistic barriers women face in accessing family planning service, such as ability to take time off work, travel distance and transportation. An administrator at a private clinic considered it important to ensure that patients requesting intrauterine devices had access to appropriate follow-up care before providing the method. Despite the potentially unique challenges to access for rural women, our quantitative study did not find that rural and urban women differed in choosing an effective contraceptive method at the time of their abortion visit, using an effective method within six months of their abortion visit or experiencing a pregnancy one year post-abortion (Puri et al. 2015). Education may play a stronger role – the quantitative study found that women with greater than primary education were more likely to choose and receive an effective contraceptive method and to report use of an effective method within six months of their abortion visit (Rocca et al. 2014). Our findings highlight the challenge of addressing gender power norms in post-abortion counselling practices. Many providers speculated that low rates of male sterilisation resulted from fear of a loss of masculinity or fertility. Some providers observed that some female patients did not have the authority to decide on a contraceptive method independently, which is consistent with previous research revealing that the views of husbands and mother-in-laws regarding family planning side-effects influenced Nepali women’s decision-making (Diamond-Smith, Campbell, and Madan 2012). Therefore, providers recommended family planning education targeting men. While involving partners in post-abortion counselling may improve contraceptive uptake (Beenhakker et al. 2004; Dhillon et al. 2004; Rasch and Lyaruu 2005), careful consideration of gender dynamics and further study would be needed in Nepal. Notably, one service provider reported harnessing this power imbalance by involving the male partner in counselling so that he might ‘convince’ the patient to use family planning. Counselling approaches that support women to select a method that meets her needs, while acknowledging the limitations in women’s decision-making ability and autonomy, are important in this setting. Young women, unmarried women and women whose husbands were abroad for work were perceived as less likely to choose an effective contraceptive method when compared to older women living with their husbands. This finding correlates with quantitative data from this mixed-methods study – women not living with their husbands were far less likely to receive counselling or select and use a method post-abortion (Rocca et al. 2014). Stigma and other social consequences may contribute to these differences in contraceptive uptake. A counsellor at a private clinic observed that women fear using contraception when their husbands are abroad, as others may assume that they are having extramarital intercourse. While the impact of stigma on younger or unmarried women did not emerge from the data, prior research suggest that young people in Nepal, particularly in rural areas, are embarrassed and fearful of accessing reproductive health
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services, and premarital sex is highly stigmatised (Regmi et al. 2010). Further research exploring the role of stigma on contraceptive use among adolescents, unmarried women and women whose husbands are abroad may identify strategies to better meet their reproductive health needs. This study found that some service providers hold negative judgments about the appropriateness of women’s contraceptive use. On the one hand, providers voiced the concern that easy availability of abortion in Nepal makes women ‘negligent’ about using contraception, an attitude found among Nepali abortion providers in previous studies (Moller, Ofverstedt, and Siwe 2012; Puri et al. 2012). On the other hand, some providers suggested that effective contraceptive use was discouraged among women deemed inappropriate candidates, including unmarried women and women without children. Notably, some providers suggested that long-acting methods may not be appropriate for certain patients based on marital status or parity, contradicting the World Health Organization (2009) medical eligibility criteria for contraceptive use, and unnecessarily limiting access to effective methods for some women. Values clarification exercises for contraceptive providers may help improve the quality of patient care and voluntary contraceptive use among all groups of women in Nepal. As concerns about ‘repeat’ abortion in Nepal become more prevalent (Thapa and Neupane 2013), particular attention to the balance between providing post-abortion contraceptive services and ensuring women’s autonomy and choice will be important. The results of this qualitative study cannot be generalised to all abortion providers in Nepal. While broad themes may be applicable to other sites and settings, there could be unique, site-specific issues and viewpoints observed only in urban facilities in Nepal. The themes we identified, however, highlight areas for quantitative inquiry that may further understanding of post-abortion contraceptive delivery in Nepal and elsewhere. Further research is needed regarding abortion patients’ perspectives on selecting and utilising post-abortion contraception.
Conclusion This small-scale study highlights current strengths and shortcomings of post-abortion contraceptive provision from the perspectives of service providers and administrators. Providers were dedicated to providing comprehensive contraceptive services in the setting of abortion care, but identified practical, facility factors impacting on contraceptive services. Women’s limited contraceptive decision-making autonomy, the stigma of contraceptive use during a husband’s absence or when sex is infrequent and provider biases and misinformation about eligibility criteria likely influence counselling approaches and method use. Interventions aimed at addressing both structural and cultural barriers to effective contraceptive provision in the post-abortion setting may be informed by the joint findings of the present study and an earlier complementary quantitative investigation into post-abortion contraceptive provision in Nepal. Further research regarding culturally sensitive approaches to contraceptive counselling is needed to improve access to family planning for the women at greatest risk for unintended pregnancy.
Disclosure statement The authors declare that they have no competing interests, financial or otherwise.
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Funding This work was supported by a grant from the Society of Family Planning [grant number SFP4-8].
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