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Knowledge on legislation of abortion and experience of abortion among female youth in Nepal: A cross sectional study

Reproductive Health201613:48

https://doi.org/10.1186/s12978-016-0166-4

Received: 24 January 2015

Accepted: 18 April 2016

Published: 27 April 2016

Abstract

Background

Abortion has been legal in Nepal since 2002 and the country has made striking progress in rolling out induced abortion services. It led to well-known changes in reproductive behavior, however knowledge about legislation and abortion experience by female youth has been least investigated. This paper is an attempt to examine knowledge about legislation of abortion and abortion experiences among female youth in Nepal.

Methods

This paper uses data from the Nepal Demographic and Health Survey (NDHS 2011). The analysis is confined to female youth aged 15-24 (n = 5050). Both bivariate and multivariate analyses have been performed to describe the knowledge about law and experience of abortion. The bivariate analysis (chi-square test) was applied to examine the association between dependent variables and female youth’s demographic, socioeconomic, and cultural characteristics. Besides bivariate analysis, the net effect of each independent variable on the dependent variable after controlling for the effect of other predictors has also been measured through multivariate analysis (logistic regression).

Results

Only two-fifth (41 %) female youth was aware of abortion legislation in the country. Knowledge on at least one condition of abortion law is even lower (21 %). Less than two percent (1.5 %) female youth reported that they ever had an abortion. The multivariate analysis found that the knowledge and experience of abortion varied with different settings. Youth aged 20-24 [adjusted odds ratio (aOR) = 1.3; 95 % CI 1.7-5.0)], who have higher education (primary aOR = 1.89, ; 95 % CI 1.5-2.5 secondary aOR = 4.6; 95 % CI 3.7-5.9), who were from rich households (aOR = 1.5; 95 % CI 1.2-1.7), who had high autonomy (aOR = 1.29; 95 % CI 1.02-1.64) were more likely to be aware compared to their counterparts about legislation of abortion. In the other hand, female from Dalit (aOR = 0.55; 95 % CI 0.5-0.7 and Janajati aOR = 0.72; 95 % CI 0.6-0.8) caste, who were married (aOR = 0.80; 95 % CI 0.7-0.9), who were from Muslim (aOR = 0.54; 95 % CI 0.3-0.9) and who resided in Hill (aOR = 0.63 ; 95 % CI 0.5-0.8) and Terai/plain area (aOR = 0.74; 95 % CI 0.6-0.9) were less likely to be aware about the law. Similarly, female youth who have knowledge on abortion law (aOR = 2.8; ; 95 % CI 1.6-4.8), who have primary (aOR = 5.2; 95 % CI 1.6-16.9) and secondary education (aOR = 3.8; 95 % CI 1.2-12.8), married (aOR = 7.7; 95 % CI 3.8-12.9), who had higher number of children ever born [1-2 children aOR = 1.9; 95 % CI 1.1-3.6 and 3 or more children aOR = 3.4; 95 % CI 1.1-10.9), who were from rich households (aOR = 2.62 ;95 % CI 1.3-5.4), who have high autonomy (aOR = 3.0; 95 % CI 1.6-5.8), who had experienced sexual violence (aOR = 1.91; 95 % CI 1.1-8.7) were more likely to undergone abortion compared to their counterparts.

Conclusion

Knowledge about legislation of abortion and conditions of abortion law is low among female youth. Awareness program should target these youth as they are more likely to be sexually active. There is a need of comprehensive education about abortion to these youth which can help eventually reduce unsafe abortion that take a large toll on women’s life.

Keywords

Abortion Legislation Knowledge Female Youth Nepal

Background

Abortion has been legal in Nepal since 2002 and the country has made striking progress in rolling out induced abortion services, establishing comprehensive abortion care (CAC) at 100 % of public-sector sites at the regional, zonal, and district level and 46 % of primary health-care centers. As a result, more than 500,000 Nepali women have been served with safe abortion care since 2002 [1].

Worldwide, about 287,000 women die annually from pregnancy related causes [2]. Ninety percent of maternal deaths occur in less developed countries [3]. A large number of women (approx. 47000) died each year due to unsafe abortion [4]. It is also estimated that five million adolescents between the ages of 15 and 18 have unsafe abortion each year [5] and 70,000 abortion-related deaths occur among this age group every year [6]. In Nepal, the data suggest that more than a quarter (26 %) of all pregnancies [7] and 41 percent of the last pregnancy among currently pregnant women [8] are unintended.

About a fifth of the total population of Nepal comprise youth (between the ages of 15-24) [9]. While a majority of adolescents (64 %) have their first sexual intercourse between 15 to 17 years of age, only 4.5 percent of adolescent women use a modern form of contraception [10]. Less than two-fifth adolescent aged 15-19 thought that abortion is legal in the country. Less than three percent pregnancy had abortion before the age of 20 years [11]. Overall, unsafe abortion remains a leading cause of maternal morbidity and mortality in Nepal, accounting for an estimated 54 % of gynecological and obstetric hospital admissions and 42 % of maternal deaths in health sites [12].

Knowledge about abortion law among female youth is very important because it has implications for access to legal abortion services. Even when safe, legal abortion services are available, women who lack accurate information about the law may seek unsafe abortion because they do not know that they are eligible for the service or do not know the legal requirements for obtaining an abortion [13]. It is hypothesized that older female, who have higher education, who have higher level of autonomy in household decision, lead to high knowledge of abortion law and higher experience of abortion.

Research on awareness of abortion law and experience of abortion among female youth may help to inform policy makers and education planners in Nepal. Unfortunately, not much research has been conducted in this area among the female youth in the country. The aims of this study are to investigate awareness levels and factors influencing awareness of the abortion legislation among female youth in Nepal. Furthermore this study also explores the prevalence of abortion incidence among female youth in Nepal.

Methods

Data for this paper were drawn from the Nepal Demographic and Health Survey, 2011. The primary purpose of the 2011 NDHS, a nationally representative sample survey,was to provide current and reliable data on fertility and family planning, child mortality, children’s nutritional status, utilization of maternal and child health services, domestic violence, and knowledge of HIV/AIDS. The 2011 NDHS was carried out under the aegis of the Population Division of the Ministry of Health and Population.

Interviews were completed for 12,674 women of reproductive age. The detail methods can be found in the NDHS report. [11] However, this analysis is confined to youth aged 15-24 women (n = 5050). Association between exploratory variables and knowledge on abortion law was assessed via bivariate analysis using chi-square tests. Then logistic regression was used to assess the net effect of each exploratory variable on knowledge on abortion law after controlling for several other independent variables.

Results

Majority of the respondents were adolescent aged 15-19 (55 %). Almost two thirds had secondary or above education. Similarly, more than a half of youth were married. An overwhelming majority of youth lived in rural area (86 %). Almost three-fourth had no autonomy in household decision. Less than five percentages of female youth had experienced of physical, emotional and sexual violence by their husband/partner (Table 1).
Table 1

Background characteristic of female youth

 

%

N

Age group

 15-19

54.5

2753

 20-24

45.5

2297

Ethnicity

 Brahmin/Chhetri

31.9

1611

 Janajati

40.6

2053

 Dalit

15.1

762

 Other

12.4

625

Education level

 No education

17.1

866

 Primary

17.6

887

 Secondary or above

65.3

3298

Marital status

 Never married

49.0

2476

 Ever married

51.0

2575

Number of children ever born (CEB)

 None

65.7

3318

 1-2

30.4

1534

 3 or more

3.9

198

Religion

 Hindu

83.8

4231

 Buddhist

9.1

458

 Muslim

4.1

207

 Kirat/Christian

3.1

155

Ecological zone

 Mountain

6.3

316

 Hill

39.5

1996

 Terai

54.2

2738

Place of residence

 Urban

13.7

692

 Rural

86.3

4358

Wealth index

 Poor

35.5

1794

 Middle

21.7

1095

 Rich

42.8

2162

Autonomy in household decision

 No autonomy

72.6

3667

 Moderate autonomy (involved in 1-2 issues)

16.0

809

 High autonomy (involved in all 3 issues)

11.4

575

Physical violence by husband/partner

  

 No

96.0

4847

 Yes

4.0

204

Emotional violence by husband/partner

  

 No

97.0

4898

 Yes

3.0

152

Sexual violence by husband/partner

  

 No

97.7

4936

 Yes

2.3

115

Total

100.0

5050

Only two fifths female youth (41 %) were aware about the law. However, only a fifth (21 %) was aware at least one condition of abortion law (Table 2). Awareness about abortion legislation varied with different settings. A significantly higher proportion of youth from Brahmin/Chhetri (55 %) than Janajati (43 %) and Dalit (28 %) were aware about the law. Similarly, significantly higher proportions of the youth who had secondary or above education (52 %) than those who had primary (26 %) or no education (13 %) were aware about the law. It is found that a higher percentage of never married youth (45 %) compared with ever married (37 %) were aware of abortion legislation. Similarly, a significant proportion of youth who lived in urban area, who were from rich family, who did not experience physical, emotional and sexual violence were aware about the law than other groups. In regards to experience of abortion, significantly higher youth aged 20-24, who had primary level education, who were ever married, who were from rich family, who had high autonomy, who had experienced sexual violence had abortion than other group (Table 3).
Table 2

Knowledge about abortion law and conditions

 

%

N (5050)

Abortion is legal in Nepal

 Yes

41.0

2070

 No

34.1

1720

 Don’t know

25.0

1261

Conditions of Abortion law

 Pregnancy of 12 weeks or less gestation for any woman

13.0

659

 Pregnancy of 18 weeks if it is a result of rape or incest

7.9

401

 Pregnancy of any duration if life of mother is at risk

2.8

143

 Pregnancy of any duration if mother’s physical and mental health at risk

3.8

192

 Fetus is deformed

2.3

115

At least one condition of abortion law

21.0

1059

Table 3

Knowledge of legalization of abortion law and experience of abortion by background characteristic of female youth

 

Knowledge on abortion law (%)

Have an abortion (%)

Total N

No

Yes

No

Yes

 

Age group

-

  

***

 

 15-19

60.2

39.8

99.5

0.5

2753

 20-24

57.7

42.3

97.2

2.8

2297

Ethnicity

 

***

 

-

 

 Brahmin/Chhetri

45.4

54.6

98.4

1.6

1611

 Janajati

57.4

42.6

98.3

1.7

2053

 Dalit

72.3

27.7

98.4

1.6

762

 Other

83.2

16.8

99.5

0.5

625

Education level of youth

 

***

 

**

 

 No education

86.8

13.2

99.6

0.4

866

 Primary

74.0

26.0

97.7

2.3

887

 Secondary or above

47.7

52.3

98.4

1.6

3298

Marital status

 

***

 

***

 

 Never married

54.6

45.4

100.0

0.1

2476

 Ever married

63.3

36.7

97.1

2.9

2575

Number of children ever born (CEB)

 

***

 

***

 

 None

56.6

43.4

99.5

0.5

3318

 1-2

61.6

38.4

96.3

3.7

1534

 3 or more

79.0

21.0

97.4

2.6

198

Religion

 

***

 

-

 

 Hindu

57.5

42.5

98.5

1.5

4231

 Buddhist

60.3

39.7

98.2

1.8

458

 Muslim

90.7

9.3

99.4

0.6

207

 Kirat/Christian

54.8

45.2

98.4

1.6

155

Ecological zone

 

*

 

-

 

 Mountain

54.3

45.7

99.0

1.0

316

 Hill

57.9

42.1

98.4

1.6

1996

 Terai

60.4

39.6

98.5

1.5

2738

Place of residence

 

***

 

-

 

 Urban

52.0

48.0

97.6

2.4

692

 Rural

60.1

39.9

98.6

1.4

4358

Wealth index

 

***

 

***

 

 Poor

69.1

30.9

99.1

0.9

1794

 Middle

64.4

35.6

99.2

0.8

1095

 Rich

47.9

52.1

97.6

2.4

2162

Autonomy in household decision

 

-

 

***

 

 No autonomy

59.7

40.3

99.6

0.4

3667

 Moderate autonomy (involved in 1-2 issues)

58.3

41.7

96.9

3.1

809

 High autonomy (involved in all 3 issues)

55.9

44.1

93.8

6.2

575

Physical violence by husband/partner

 

***

 

-

 

 No

58.1

41.9

98.5

1.5

4847

 Yes

81.2

18.8

97.8

2.2

204

Emotional violence by husband/partner

 

***

 

-

 

 No

58.5

41.5

98.5

1.5

4898

 Yes

77.2

22.8

96.9

3.1

152

Sexual violence by husband/partner

 

***

 

*

 

 No

58.5

41.5

98.5

1.5

4936

 Yes

79.4

20.6

96.0

4.0

115

Total

59.0

41.0

98.5

1.5

5050

Note *** Significant at Chi-square test p < 0.001, ** = p < 0.01, and * = p < 0.05

Logistic regression was conducted to examine the net effect of exploratory variables on awareness on abortion law. Crude and adjusted odds ratio are presented in the Tables 4 and 5. It is found that the variables age, ethnicity, education, marital status, religion, ecological zone, wealth index, autonomy in household decision were strong predictors for having awareness on abortion law. Those youth who had an abortion were almost 3 times more likely (aOR = 2.94; 95 % CI 1.72-5.0) to be aware of abortion law compared with those who never had an abortion. Similarly, respondents aged 20-24 were more likely to be aware about law (aOR = 1.28; 95 % CI 1.11-1.43) compared with respondents aged 15-19. Respondents from Janajati and Dalit were 28 percent and 45 percent respectively less likely to be aware about law compared with respondents from Brahmin/Chhetri. Similarly, youth who have secondary and above education were about 5 times more likely (aOR = 4.6, 95 % CI 3.65-5.92) than those who had no education. On the other hand, ever married female were less likely to be aware on abortion law (aOR = 0.80; 95 % CI 0.66-0.98) than unmarried female. Female from rich household were more likely to be aware about law (aOR = 1.5; 95 % CI 1.23-1.74) than female from poor household. Female who had high autonomy in household decision were more likely to be aware about law than those who did not have autonomy in household decision (Table 4).
Table 4

Adjusted odds ratio (aOR) and 95 % confidence interval (CI) for having awareness on abortion law of the country among female youth by selected predictors

Predictors

Crude

Adjusted

OR

95 % CI

OR

95 % CI

Lower

Upper

Lower

Upper

Had an abortion

 No

1.00

  

1.00

  

 Yes

3.6***

2.2

5.9

2.938***

1.724

5.004

Age group

 15-19

1.00

  

1.00

  

 20-24

1.11

0.99

1.24

1.283**

1.105

1.489

Ethnicity

 Brahmin/Chhetri

1.00

  

1.00

  

 Janajati

.616***

.540

.702

.719***

.619

.836

 Dalit

.318***

.264

.384

.552***

.450

.678

 Other

.168***

.134

.212

.332***

.250

.441

Education level

 No education

1.00

  

1.00

  

 Primary

2.3***

1.796

2.945

1.894***

1.460

2.457

 Secondary or above

7.18***

5.835

8.848

4.651***

3.654

5.920

Marital status

 Never married

1.00

  

1.00

  

 Ever married

0.69***

0.62

0.78

.801*

.658

.975

Number of children ever born (CEB)

 None

1.00

  

1.00

  

 1-2

.812**

.718

.919

1.155

.946

1.410

 3 or more

.348***

.246

.493

1.081

.706

1.654

Religion

 Hindu

1.00

  

1.00

  

 Buddhist

0.89

0.73

1.08

.875

.700

1.093

 Muslim

0.14**

0.86

0.22

.540*

.312

.934

 Kirat/Christian

1.12

0.81

1.54

.976

.694

1.373

Ecological zone

 Mountain

1.00

  

1.00

  

 Hill

.863

.680

1.096

.632**

.487

.819

 Terai

.777*

.615

.982

.744*

.568

.973

Place of residence

 Urban

1.00

  

1.00

  

 Rural

0.72***

0.61

0.85

1.104

.916

1.331

Wealth index

 Poor

1.00

  

1.00

  

 Middle

1.235**

1.053

1.448

1.067

.892

1.276

 Rich

2.426***

2.128

2.765

1.467***

1.234

1.743

Autonomy in household decision

 No autonomy

1.00

  

1.00

  

 Moderate autonomy (involved in 1-2 issues)

1.060

.908

1.237

1.015

.823

1.250

 High autonomy (involved in all 3 issues)

1.169*

1.092

1.396

1.295*

1.023

1.640

Physical violence by husband/partner

 No

1.00

  

1.00

  

 Yes

.320***

.224

.457

.543

.266

1.108

Emotional violence by husband/partner

 No

1.00

  

1.00

  

 Yes

.416***

.284

.610

.923

.481

1.771

Sexual violence by husband/partner

 No

1.00

  

1.00

  

 Yes

.367***

.233

.579

.768

.390

1.512

Constant

 

.297***

-2 Log likelihood

6023.9

Cox & Snell R Square

.149

Note *** p < 0.001, ** = p < 0.01, and * = p < 0.05

Table 5

Adjusted odds ratio (aOR) and 95 % confidence interval (CI) for having had an abortion among female youth by selected predictors

Predictors

Crude

Adjusted

OR

95 % CI

OR

95 % CI

lower

Upper

lower

Upper

Knowledge on abortion law

 No

1.00

  

1.00

  

 Yes

3.626**

2.204

5.967

2.771***

1.610

4.771

Age group

 15-19

1.00

  

1.00

  

 20-24

5.883***

3.242

10.675

1.142

.589

2.214

Ethnicity

 Brahmin/Chhetri

1.00

  

1.00

  

 Janajati

1.082

.649

1.804

1.374

.768

2.459

 Dalit

.986

.495

1.965

1.428

.668

3.055

 Other

.303*

.092

.993

.392

.082

1.861

Education level

 No education

1.00

  

1.00

  

 Primary

5.655**

1.818

17.587

5.186**

1.584

16.978

 Secondary or above

3.973*

1.349

11.694

3.823*

1.146

12.752

Marital status

 Never married

   

1.00

  

 Ever married

8.356

5.378

13.227

7.709***

3.762

12.964

Number of children ever born (CEB)

 None

1.00

  

1.00

  

 1-2

8.243***

4.663

14.569

1.957*

1.051

3.644

 3 or more

5.698**

2.064

15.729

3.462**

1.092

10.970

Religion

 Hindu

1.00

  

1.00

  

 Buddhist

1.175

.564

2.448

1.154

.503

2.647

 Muslim

.370

.059

2.298

2.374

.226

24.890

 Kirat/Christian

1.073

.303

3.805

.903

.237

3.439

Ecological zone

 Mountain

1.00

  

1.00

  

 Hill

1.569

.500

4.928

1.144

.343

3.811

 Terai

1.456

.469

4.521

1.094

.324

3.689

Place of residence

 Urban

1.00

  

1.00

  

 Rural

.572*

.330

.993

.702

.375

1.313

Wealth index

 Poor

1.00

  

1.00

  

 Middle

.945

.412

2.169

.982

.406

2.374

 Rich

2.871***

1.619

5.089

2.617**

1.254

5.460

Autonomy in household decision

 No autonomy

1.00

  

1.00

  

 Moderate autonomy (involved in 1-2 issues)

7.539***

3.999

14.216

1.624

.828

3.183

 High autonomy (involved in all 3 issues)

15.281***

8.375

27.881

3.005**

1.568

5.759

Physical violence by husband/partner

 No

1.00

  

1.00

  

 Yes

1.508

.577

3.938

.481

.108

2.133

Emotional violence by husband/partner

 No

1.00

  

1.00

  

 Yes

2.160

.839

5.557

.827

.184

3.708

Sexual violence by husband/partner

 No

1.00

  

1.00

  

 Yes

2.833*

1.084

7.402

1.906*

1.017

8.722

Constant

 

0.01***

-2 Log likelihood

595.17

Cox & Snell R Square

.038

Note *** p < 0.001, ** = p < 0.01, and * = p < 0.05

Female youth who had knowledge on abortion law were almost 3 times (aOR = 2.8; 95 % CI 1.61-4.77) more likely to have an abortion than those who were not aware about the law. Similarly, those who have primary (aOR = 5.2; 95 % CI 1.58-16.9) and secondary or above (aOR = 3.8, 95 % CI 1.15-12.75) education, who had higher number of children (aOR = 1.9; 95 % CI 1.05-3.64 for those who had 1-2 children and aOR = 3.5, 95 % CI 1.09-10.97 for those who had 3 or more), who had higher autonomy in household decision (aOR = 3.01; 95 % CI 1.56-5.76) were more likely to have an abortion than their comparison group. It is found that women who had experienced of sexual violence from their husbands/partners were about twice (aOR = 1.9; 95 % CI 1.02-8.72) more likely to have an abortion than those who did not face sexual violence from their intimate partners (Table 5).

Discussion

This study explored the awareness level and factors influencing awareness about abortion legislation among female youth in Nepal and their experience on abortion. In order to ensure that legalized abortion in Nepal improves reproductive health, people must know that abortion is a legal option in case of unintended pregnancy. Research shows that most youth had experienced unprotected sex and unintended pregnancy [8, 14]. In such cases, awareness about abortion law could play a critical role in reducing unintended birth and unsafe abortion.

Safe abortion is an effective means of preventing unintended birth, but unfortunately the large numbers of youth are unaware of it. The awareness of law among female youth was 41 %, which is low compare to study conducted in South African women (69 %) [15], slightly higher than Mexican youth (45 %) [16] and Latvia (57 %) [17].

Similarly, our study found that older youth were more aware about the law. It could be due to that older youth feel comfortable to talk about reproductive health issues than younger female. On the other hand, female youth from Janajati and Dalit were less likely to be aware about the law compared with Brahmin/Chhetri.

As expected, youth with higher education were more likely to be aware about the abortion law than those who did not have education. This could be due to these students could talk the issues such as about family planning methods, abortion, or sex-related issues with their friends and colleague without reluctant [18]. However, married youth were less likely to be aware about the abortion law than those unmarried.

Ecological differences in awareness level can be found in this study. Youth from hill and terai region were less likely to be aware about the abortion law than those who live in mountain region. Those who were rich and who had higher level of autonomy were more likely to be aware about the law than their comparison group. However, this finding also requires further investigation.

There are some limitations in the interpretation of the results of this study. First, as pointed out previously, we restricted our subjects to only female youth, so our results regarding the awareness about the abortion law and the prevalence of abortion incidence should not be generalized to all women in Nepal. Second, because the cross-sectional design of the study and all of the items analyzed in the logistic regression analysis came from information at the time of survey, the analysis can only provide evidence of statistical association between those items and knowledge on abortion law and cannot show cause-effect relationships.

Conclusion

Awareness about abortion legislation among female youth was low which indicates that there is a need among female youth for information on abortion. Health education initiatives should target such youth as they are more likely to be sexually active. It can help to reduce unintended birth, many of which result in unsafe abortion and take a large toll on women’s health.

Declarations

Acknowledgement

The authors thanks MEASURE DHS + for providing access to the data. The authors would also like to thank to all the reviewers for their valuable comments and very useful suggestions

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University

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Copyright

© Adhikari. 2016

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