Women empowerment for abortion and family planning decision making among marginalised women in Nepal: a mixed method study

Background Women empowerment is multidimensional. Women’s education, employment, income, reproductive healthcare decision making, household level decision making and social status are vital for women empowerment. Nepal is committed to achieving women empowerment and gender equality, which directly affects the reproductive health issues. This can only be achieved by addressing the issues of the poor and marginalised communities. In this context, we aimed to find the association of women empowerment with abortion and family planning decision making among marginalised women in Nepal. A mixed-method study was conducted at selected municipalities of Morang district of Nepal from February 2017 to March 2018. Cross sectional study was conducted among 316 married marginalised women of reproductive age (15–49 years) and key informants interview was conducted among 15 representative healthcare providers and local leaders. From key informants, data were analysed using the thematic framework method. Findings obtained from two separate analyses were drawn together and meta inferences were made.


Abstract Background
Women empowerment is multidimensional. Women's education, employment, income, reproductive healthcare decision making, household level decision making and social status are vital for women empowerment. Nepal is committed to achieving women empowerment and gender equality, which directly affects the reproductive health issues. This can only be achieved by addressing the issues of the poor and marginalised communities. In this context, we aimed to find the association of women empowerment with abortion and family planning decision making among marginalised women in Nepal.

Methods
A mixed-method study was conducted at selected municipalities of Morang district of Nepal from February 2017 to March 2018. Cross sectional study was conducted among 316 married marginalised women of reproductive age (15-49 years) and key informants interview was conducted among 15 representative healthcare providers and local leaders. From key informants, data were analysed using the thematic framework method. Findings obtained from two separate analyses were drawn together and meta inferences were made.

Results
Women empowered above average were 50.6%. Current use of modern contraceptives were more among below average empowerment groups (p 0.041, OR 0.593 C.I. 0.36-0.98). We could not find any statistical significant differences among women empowerment with abortion knowledge (p 0.549); family planning knowledge (p 0.495) and women's' decision for future use of modern contraceptives (p 0.977). Most of key informants reported that unsafe abortion was into practice.

Conclusions
Women empowerment has no direct role for family planning and abortion decision making at marginalised communities of Morang district of Nepal. There was direct influence of different organisations for seeking healthcare services on abortion and family planning despite having women empowerment.

Plain English Summary
Sustainable Development Goal (SDG-5) addresses women and girls with equal access to education, healthcare, decent works, and their representation in political and economic decision-making processes that fuel sustainable economies and benefit societies and humanity. Women's empowerment, abortion and family planning are inter related. Easy access to contraceptive devices help reduce unsafe abortion, unintended pregnancy, reduce maternal and child health morbidity and mortality. Nepal is committed to achieving women empowerment and gender equality; fifth goal of SDG. To achieve this, there needs to be equitable involvement of all women in reproductive health service. Hence, we conducted our study among marginalised married women of reproductive age group in a district of Nepal. Our objective was to find the association of women empowerment with abortion and family planning decision making. First, we collected data on women empowerment measures, knowledge and practices on abortion and family planning methods from the marginalised women and concurrently from the same locality, we conducted key informants interview to explore further. We found that women empowerment has no significant association on abortion and family planning decision making among marginalised women. Illegal practices of abortion was reported from key informants. Current use of contraceptives devices were more in women who were below average women empowerment than above average women empowerment. Our result concluded that availability and easy access to healthcare facilities support from different governmental and nongovernmental organisations and transportation facility can influence the abortion and family planning decisions even if women are empowered or not.

Background
Women's empowerment is determined by women's sense of self-worth, their right to determine choices; right to have access to opportunities and resources; right to have power to control their own lives within and outside the home; and their ability to influence the direction of social change[1] [2].
Nepal became the signatory of International Conference on Population and Development (ICPD) in Cairo, Egypt in 1994, which emphasized women empowerment and reproductive rights issues. Since then, it has been a key part in Millennium Development Goal 3 (MDGs) and now on Sustainable Development Goal 5 (SDG) [3]. SDG 5 addresses women and girls with equal access to education, healthcare, decent works, and their representation in political and economic decision-making processes that fuel sustainable economies and benefit societies and humanity [4]. Nepal Demographic and Health Survey (NDHS) measures women empowerment in terms of employment, earnings, control over earnings, and magnitude of earnings relative to those of partners, participation in household decision-making and attitudes towards wife beating [5]. According to 2011 Nepal census, Dalit constitutes 13.6 percent of the total population [6]. Dalit by virtue of caste based discrimination and untouchability, are most backward in social, economic, educational, political and religious fields, and are deprived of human dignity and social justice [7]. Dalit women need to be included in order to achieve the country's commitments to global family planning goals and to reach a modern contraceptive prevalence rate of 52% by 2020, the target set by the National Health Sector Strategy 2016-2021 [8]. Evidence shows that improvement in the welfare of women and closing inequality gaps can improve maternal and child health reduce mortality and contribute to socio economic development [9]. Nepal is committed to achieving women empowerment and gender equality as per SDG 5 of the United Nation [10]. This goal can be achieved by addressing the issues of the poor and marginalised community. Women's empowerment, abortion and family planning are inter realted. Empowering women help exercise free choices, right to control fertility, right to take an autonomous decision on healthcare seeking behaviour, mobility, reproductive rights, ownership of assets, participation in social group and increase awareness [11] [12]. However, there is a significant barrier on knowledge on abortion laws and access to safe abortion practices. Safe abortion practices and family planning methods are powerful tools to monitor women's status within the community.
Easy access to contraceptive devices help reduce unsafe abortion, unintended pregnancy, reduce maternal and child health morbidity and mortality. Women would be able to take full advantage of the broader life opportunities as they move beyond their roles of wives and mothers [11]. In order to have this type of decision-making power, women empowerment is an essential precondition [11] [13].
Factors of woman empowerment contributing to abortion and family planning decision making is of paramount importance to reduce morbidity and mortality related to unsafe abortion and to increase access to family planning services. In this context, we aimed to find the association of women empowerment with abortion and family planning decision making among marginalised women in Nepal.

Methods
A concurrent mixed-method (QUAN + qual) design was used to collect information from 11 municipalities of Morang district of Nepal from Feb 2017 to March 2018. For cross sectional study, 316 married marginalised women of reproductive age (15-49 years) and for key informants interviews, 15 healthcare providers and local leaders of same communities were taken. Multistage sampling method was used to select participants from Morang district, which has 17 municipalities. In first stage, 18 marginalised communities from 11 municipalities were included based on recommendation of the District Public Health Office, Morang. In the second stage, households were selected. First household was selected from one corner of the community and then each alternate household were selected. If the participants were not available, then an adjacent household was taken. In the third stage, one participant from a selected household available at the time of data collection, meeting the eligibility criteria was taken. In case of more than one eligible participant in a household, the youngest eligible participant was selected. For key informants, representatives key persons such as local leaders, female community health volunteers, health post in charges, primary health center auxiliary nurse midwives were selected purposively. The total time taken for each key informant interview was 25-30 minutes. The interview conduct and reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ). [14] The independent variable was women empowerment. Generally, proxy indicators are commonly used to measure empowerment due to its multifaceted nature [15]. As there is not a standard tool to measure women empowerment, consensus was made to measure women empowerment in terms of women's biodemographic and reproductive health measures. Women empowerment score was calculated based on fifteen different variables which includes education, occupation, socioeconomic status, age at marriage, child mortality of participant, intended pregnancy, desire for future pregnancy, sex preference, ideal number of children, contraception use decision making, able to refuse sexual intercourse, ask husband to use condom during intercourse, general healthcare decision making, decision over use of income and involvement in any social group (mothers group/saving group/women group). Maximum score for each variable was given 1 and the possible highest score was 15. The median score of all the variables of women empowerment was calculated to be 7.5. Accordingly, it was categorised into two groups after statistical consultations. Women empowerment was considered above average if the score was more than or equal to 7.5(median value) and below average if it was below the median value. Dependent variables were abortion knowledge, abortion practice, family planning knowledge and family planning practice. The two variables (knowledge on fertile period and knowledge on abortion law: scored 1 for each right response) were used to calculate abortion knowledge where median value for abortion knowledge was 1. Above or equal to median value was considered as having abortion knowledge and below it was considered having no abortion knowledge. The single variable was used to assess the abortion practice. It was scored 1 for good practice and 0 if not. The family planning knowledge was calculated asking patients about their knowledge on modern contraceptives methods: female sterilisation, male sterilisation, intrauterine contraceptive devices (IUCD), depo-provera, implant, oral contraceptive pills (OCPs) and male condom. Participants responding yes were scored 1 for each method; of which the total score came to be 7 and 0 for wrong response. The median score for family planning knowledge was 6.
Participants scoring above and equal to median value were considered having knowledge of family planning and below having no knowledge. For practices of family planning methods two variables: currently practicing any modern contraceptive methods and thinking of using contraception in the near future were used separately. The good practice was scored one and bad practice scored 0 in each variable.

Data analysis
Quantitative: We performed univariate analysis to find the sociodemographic characteristics. For bivariate analysis, chi square test was used to find the association between dependent and independent variables. Odds ratio and confidence interval were calculated and p value less than 0.05 at 95% confidence interval was considered as statistically significant.

Key informants interviews
Consensus on selecting 15 key informants was made when saturation point was received at 12 th key informant. Thematic approach was used to analyse the data. The audiotaped interviews were transcribed verbatim independently by two investigators (HKC and SP). The investigators (HKC and SP) reread through the transcripts several times to familiarise themselves with the data. The text was then divided into meaningful units, such as phrases and quotes, and the meaningful units were then condensed. The condensed meaningful units were then abstracted and labelled with codes independently and checked for agreement. Then the codes were compared based on similarities and differences and categorized. The categories were further discussed by all the investigators for identification, formulation and finalisation of themes and subthemes related to women empowerment, abortion and family planning knowledge and practices. The findings obtained from two separate analyses were drawn together to form meta inferences.    women's decision for future use of modern contraceptives. (p 0.977) ( Table 4).

Key informant interviews
Characteristics of participants We have copper-T, male condom, injection, one is electric operation and one is hand operation. Some are using these methods and some not. We still have a lack of public awareness on these methods.

Discussion
This study employed the relationship of women empowerment with abortion and family planning decision making among marginalised women in a district of eastern part of Nepal. Though Nepal is continuously striving to improve women's status within the society, there remains a disparity and inequality among ethnically, socially, politically, economically and geographically disadvantaged groups. In our study, we defined marginalised women as those women who are socially, economically, politically and by ethnicity deprived. Majority of marginalised women belongs to terai dalit and terai madhesi. It is very essential to cover all spectrums of women in order to improve women's' status within the country. Hence, an effort has been made to study the association of women empowerment among marginalised women in abortion and family planning knowledge and practices quantitatively and key informants interviews were taken from same communities to support quantitative findings.
Generally, proxy indicators are commonly used to measure empowerment due to its multifaceted nature [15]. We measured women empowerment in terms of different factors i.e. education, occupation, socio-economic status, marital age, fertility choices, reproductive healthcare decision making, general healthcare decision making, decision for income use, and involvements of the women in social groups. Our study found that more than three fourth (76.9%) are literate women, but only 11.4% are working, nearly two third (62.7%) with upper lower socioeconomic status followed by lower middle socio-economic status ( 37.3%) and every four in five women with early marital history (12-19 years). In contrast to our findings, further analysis of the report NDHS 2011, identified terai/ madhesi dalit and muslim community having highest illiteracy rate (83% and 76%, respectively) compared to brahmin chhetri (27.3%), a geographical variation among terai/madhesi dalit women (83%) versus hill dalit women ( 43%) [17]. The differences may be due to improvement in the literacy rate over the time as the government has given priority over improvement in girls' education, especially those of poorer communities. Findings from our study was similar to where majority of terai/madhesi, muslim, and terai/madhesi dalit women were unemployed (48.6%, 57% and 19.3% respectively). The report also supports our findings, which states dalit to be the poorest community as compared to other ethnic groups [17].  [23]. Women's autonomy in decision making over consensual sexual relations, contraception use and access to sexual and reproductive health services is key to their empowerment and the full exercise of their reproductive rights [24]. A woman's ability to say "no" to her husband/partner if she does not want to have sexual intercourse, decisions being made "mainly by the partner", as opposed to decision being made "by the husband or wife alone on contraceptives use is well aligned with the concept of sexual autonomy and women's empowerment [24]. Hence, we included women's ability to reproductive healthcare decision making as a measure of women empowerment. In this study, more than four out of five (83.7%) couples decided jointly on using contraception, three fifth (61.1%) women were able to refuse sexual intercourse with their husbands, but in Province 1 it was 92.8% [18] and terai women being the least (85.4%) compared to hills and mountain women (95.5% and 91.4%) respectively; half (50.8%) women were able to ask their husband to use condoms during intercourse compared to province 1 (86.1%) and terai women were least(73.4%) compared to mountain and hill (79.6 and 88.3%) [18]. In contrast to our findings, one-fifth women could not refuse their partners' request for sexual intercourse while one out of four could not demand the use of condoms by their partners [25].
Women who make their own decision regarding seeking healthcare for themselves are considered empowered to exercise their reproductive rights [24], So we included women's response to general healthcare seeking behaviour as a measure of women empowerment. In Nepal, decision-making in most aspects of life has been men's domain, one-fourth of women (26%) make their own decisions on healthcare, but a greater percentage (35%) do not participate in decisions in Nepal [17]: but our findings gave a satisfying result that more than four fifth couples (88.9%) jointly made decisions about general healthcare seeking behaviours and most couples (90.5%) jointly decided on using income. Exception to our findings, a national survey reported majority of Terai/Madhesi and Muslim women, did not participate in decisions about their own healthcare; where nearly all caste, ethnic, and religious groups decisions on women's healthcare are made by women themselves or jointly with their partners [17]. More than half (51.6%) did not belong to any social group in our study. Evidence suggests that women's involvement in social groups, women's mobilization and interaction with others help them to communicate their issues with their friends. Friends and communities can be the source of information on various reproductive health issues like access to family planning methods [17], abortions knowledge and practices. Hence, women's involvement in social groups has been kept as an affirmative response to women empowerment.
Our study found that there was almost similar outcome on above average women empowered vs below average women empowered (50.6% Vs 49.4% respectively). Knowledge on abortion was more among above average empowered women compared to those who were below averaged but there was no statistical significant association. Only 29.1% women had knowledge on abortion laws in our study. Most of key informants reported that induced illegal abortion was quite common among teenagers and factory workers and they often present in health post with post abortion complications; though 13.6% reported abortion history. The contradictory findings in our study may be because abortion practice is linked with issues of morality and stigma. A national survey of Nepal stated that only two-fifths of women aged 15-49 years had knowledge on abortion law; every one in four women had experienced post-abortion complications: but no abortion complications was reported from terai dalit/ madhesi and muslim [17].  [29]. Studies reported that caste based discrimination and continuing social exclusion resulted in not visiting health facilities by ethnical minorities to avoid potential discrimination and poor quality care [30][31] [32]. In contrast to our study, increased use of family planning was found with increased education and higher economic status [32]. In another study from Nepal, currently not working, poor, muslim and janajati ethnicity and women who have no autonomy in household decision were non-users of family planning method [33]. Another study reported that various women factors like higher education, good socioeconomic status, involvement in household decision making, autonomy on their health seeking behaviour, participation in fertility choices, participation in income generating activities, access to information and country's socio-cultural and health system context are more likely to decide and use contraceptive methods [34][35] [36]. We did not find any significant difference between women empowerment with knowledge and practice of family planning methods. In contrary, we found below averaged empowered women currently practicing family planning methods than women of above average. Similar to our finding, a DHS report from Sub Saharan Africa found that women empowerment was less important in determining contraceptive use; attaining higher education was not much important in choosing method effectiveness and a country-specific norms and institutions may restrict women in their decisionmaking capacities, as evidenced from the report of Kenya [37]. Possible explanation for this may be because there was not a major difference between below average women empowered versus above averaged women empowered, the societal influences, geographical feasibility (terai region) for easy transportation, prime focused of various governmental and non governmental organization on reproductive health programmes, accessibility of safe abortion and family planning methods, nearby health centers, mobile camps and practising sterilization because of their early age reproduction and fulfilment of desired children. Many issues of family planning and abortion are couple decision. Failure to include the husband's perspective limits this study's findings.

Conclusions
Our study concluded that Women empowerment has no direct role for family planning and abortion decision making at marginalised communities of Morang district of Nepal. There was direct influence of different organisations for seeking healthcare services on abortion and family planning despite having women empowerment.

Recommendations
Further study in a larger context, husband and community women involvement in the research group is recommended. Abortion is still linked with stigma and social isolation hence priority must be given on improvement of knowledge on abortion law and safe abortion practices by local governments.