Evaluation of Women’s Knowledge and Practice on
Safe Motherhood, Abortion and the Abortion Law
This evaluation study was aimed at determining
the effectiveness of the PPFA-I/FPAN/CREHPA collaborative
project entitled ‘Creating an enabling environment
for reproductive health and safe abortion services among
women and couples in rural Nepal’ in terms of
enhancing women’s knowledge regarding the abortion
law, availability of safe abortion services, and safe
motherhood including abortion practices.
CREHPA conducted the baseline and the
endline surveys in all six project districts (three
core and three peripheral). The baseline and endline
surveys were conducted in June 2003 and February 2004
respectively. A total of 1,100 married women aged 15-44
years were sampled in both the surveys using multi staged
Probability Proportionate to Size (PPS) sampling technique.
A. Background Characteristics
of the Study Population
The socio-demographic characteristics
of the respondents, such as age and number of living
children are more or less similar between the baseline
and endline samples. However, the endline survey sample
represented a higher proportion of literate respondents
(69%) compared to the baseline survey (55%).
B. Knowledge regarding Safe
Motherhood and Abortion
Women’s knowledge about various
components of safe motherhood practices such as antinatal
care (ANC), nutrition intake and danger signs during
pregnancy and delivery were already high at the time
of the baseline survey (69% to 99%).
Knowledge that abortion is now legal in
the country increased from 15% in the baseline to 26%
in the endline survey. The increase is more pronounced
in the core districts (16% to 31%) compared to peripheral
districts (14% to 22%). Among the women who were aware
of the legal reform, the proportion of those reporting
correctly that abortion is legal up to 12 weeks of gestation
has increased by more than two folds (21% in baseline
to 48% in endline).
The proportion of women citing radio as
the first source of information about legalization of
abortion increased from one third (33%) to two fifths
in the endline survey (40%). Likewise, those mentioning
community based volunteers of FPAN [e.g. female community
health volunteers (FCHVs), reproductive health volunteers
(RHVs)] increased from a low 6.7% in the baseline to
high 16.4% in the endline survey. On the other hand,
the proportion of women citing friends/neighbours as
their first source of information about the law declined
from 26% in baseline to 15% in the endline.
Women’s knowledge about gestation
period considered to be ‘safe’ for pregnancy
termination (up to 12 weeks or 3 months) was already
high at the time of the baseline survey and it improved
marginally over time from 81% to 87% in the endline.
Similarly, the proportion of women having incorrect
knowledge about safe gestation age for abortion (citing
4 months and above) have reduced by half, i.e. from
14.2% in the baseline to 6.5% in the endline survey.
The proportion of respondents who cited
‘doctors’ as safe abortion service providers
increased significantly from 38% in baseline to 51%
in endline. On the other hand, the proportion of respondents
mentioning trained health providers decreased from 53%
to 40%. In both the surveys, the majority of the respondents
cited hospital as the appropriate place for obtaining
safe abortion services (86% in the baseline and 83%
in endline). The proportion of those mentioning private
clinics has increased from 10% in the baseline to 21%
in the endline survey.
Knowledge about unsafe abortion practices
among women has increased significantly. Most respondents
(87% in endline vs. 78% in baseline) mentioned that
it is unsafe to terminate any pregnancy over three months.
Similarly, the larger portion of them also perceived
that the use of medicines without a doctor’s prescription
(64% vs. 61% in baseline), in-take of herbal medicines
(52% vs. 42% in baseline), abortion conducted by untrained
providers (79% vs. 76% in baseline) would make abortion
Women’s approval to abortion was
very high. Nearly all of the endline respondents (92%)
as compared to 82 percent of the baseline respondents
replied positively (gave “Yes” response)
saying that it was necessary to legalise abortion in
the country. Moreover, almost all of them (91% vs. 82%
in baseline) would approve if anyone in their family
members sought safe abortion services within the legal
C. Knowledge about Service
Knowledge about availability of safe motherhood
services in the district is universal among the women
(98-100%). A considerable proportion of the respondents
in the endline as compared to the baseline mentioned
that Health Post/Primary Health Center/Sub Health Post
(HP/PHC/SHP)provides safe motherhood services (73% vs.
80%). A marginal increase in awareness regarding FPAN
clinic providing safe motherhood services was also evident
from the endline survey (13% in baseline to 20% in endline).
Majority of the women were aware of the
availability of safe abortion services in their districts.
Government hospitals (57%) and private clinics (55%)
were the two often cited health facilities to be providing
safe abortion services. Knowledge of FPAN clinic providing
safe abortion services has also increased by two-fold
in the endline survey (5% in baseline to 10% in endline).
D. Utilization of Maternal
Health Care Services
Utilization of facilities providing maternal
care or safe motherhood services has slightly declined
among the respondents in the endline survey (60% to
57%). However, a slightly higher proportion of the respondents
in the core districts (60%) in comparison to the peripheral
districts (54%) mentioned that they had been to such
a facility during 12 months preceding the endline survey.
Proportion of the women who utilized hospital
facility at the time of their delivery during the year
preceding the endline survey increased especially in
the core districts (64%). Among those women who delivered
at home, a higher proportion of those residing in the
core districts (36% vs. 21% in peripheral) had used
safe delivery kit (SDK).
E. Utilization of Safe Abortion
Among the 173 women (16%) who were pregnant
during the 12 months preceding the endline survey, only
7 women (4.6%) had induced abortion. It was encouraging
to note that all of them had sought safe abortion services
(four women utilized abortion services from Marie Stopes
Clinics (MSI) and the rest from FPAN clinic, private
clinic and nursing home).
F. Utilization of FPAN Services
Utilization of FPAN services by the respondents
was low. Few respondents visited FPAN clinics for receiving
family planning contraceptives, antenatal care and very
few for induced abortions. A baseline-endline comparison
reveals that there has been a significant increase among
pregnant women visiting FPAN clinic for ANC check-ups
(5% in baseline vs. 25% in endline). Less than 2% of
the women had sought induced abortion from FPAN clinic
during the year preceding the endline survey.
G. Participation in Community
Almost a quarter of the respondents in
both the baseline (26%) and endline survey (26%) were
of organising community level educational programs on
safe motherhood and safe abortion in their villages.
The level of participation in such programs by the respondents
has increased significantly from 26% in the baseline
to 35% in the endline survey.
The endline survey shows a modest increase
in knowledge and practices of women regarding safe motherhood
and safe abortion. The low level of awareness among
women on legalization of abortion in the country is
not surprising. The public opinion polls conducted in
the urban areas of the country in Nov. 2003 (26%) and
survey of married men in July 2003 (31%) had also documented
low level of awareness about the legalization of abortion.
Knowledge about safe motherhood practices,
service availability and unsafe abortion was already
high among married women at the time of the baseline
survey and this might be due to the previous community
education and advocacy efforts of FPAN and partner NGOs
in the districts.
Utilization of safe motherhood services
like ANC has increased especially in FPAN clinics. Among
the few who had terminated their pregnancies during
one year, all sought abortion services from safe but
yet legally unapproved places such as MSI, FPAN and
private clinics. Government hospitals did not obtain
the approval to provide abortion services at the time
of the endline survey.
The impact of the Project in terms of
increasing women’s knowledge regarding and practices
of safe abortion and safe motherhood has not been very
high as envisaged. This may be due to the fact that
the larger chunk of the project focus was on community-based
stakeholders and change agents (village opinion leaders
and RHVs) with no direct intervention activity for the
married women. The short time gap between baseline and
the endline surveys (9 months) and inadequate program
activities could also be additional factors. Nevertheless,
the present findings serve as a good benchmark for designing
future woman-focussed interventions to increase knowledge,
gain community support and ensure access to safe abortion