Final Baseline Report

Empowering women to access safe abortion service in Gorkha, Nepal

Submitted to: Executive Director Population, Health and Development Group (PHD Group) Indraeni, Dhungakhani, Sanepa, Ring Road, Lalitpur Kathmandu +977-1-5184063

Submitted by Prof. Dr.GajaNandAgrawal – Team Leader Dr.Megha Raj Dhakal – Research Officer Qualitative Mr.PramijThapa – Research Officer Quantitative Metro Apartment, Kuleshwor Kathmandu, Nepal +977-015187341

Email:[email protected]

December 20, 2018

Acknowledgements

We the research team comprising of Prof. Dr. Gaja Nand Agrawal – Team Leader, Dr. Megha Raj Dhakal – Research Officer Qualitative and Pramij Thapa – Research Officer Quantitative would like to express our sincere thanks to Dr. Yagya B. Karki, Project Team Leader, Empowering women to access safe abortion service in Gorkha, Nepal for his support and guidance for the successful completion of the baseline survey work. In the meantime we would also like to thank Mr. Khadaga B. Karki, Admin/Logistics Officer, PHD Group for his overall management when the field work was undertaken for data collection.We are grateful to Ms. Anchal Thapa, Project Assistant, PHD Group for refining the tools of the survey. We would also like to express our sincere thanks to Mr. Deepak Babu Kandel, Mayor, Palungtar Municipality, Mr. Raju Gurung, Mayor, Sirnachok rural municipality and Mr. Phadindra Dhital, Mayor, Ajirkot rural municipality for their for their valuable support and inputs while the baseline data was collected in their localities.

Similarly, on behalf of PHD Group, we wish to thank local health facilities and the Family Welfare Division, Department of Health Services, Ministry of Health and Population, Teku, Kathmandu for their support in carrying out the baseline survey.

We would also like to thank to the survey respondents for their valued time and patience in expressing their interest, understanding and the situation that they have been facing in the current situation.

Research Team .

STUDY TEAM MEMBERS

Prof. Dr. Gaja Nand Agrawal - Team Leader Dr. Megha Raj Dhakal - Research Officer Qualitative Expert Mr. Pramij Thapa - Research Officer Quantitative Expert

Field Supervisors

Mr. Baburam Roka Mr. Sudip Roka

Field Interviewers

Ms. Kavita Bhatta Ms. Manju Thapa Ms. Sushmita BK Ms. Sabitri Dani Ms. Tara Sunar Ms. Niru Pulami

iii

Executive Summary

Background Nepal made great strides in reducing maternal mortality ratio (MMR) of 596 prevalent in early 1990s to 239 by 2016. Nepal’s effort to liberalize abortion in 2002 is reported to be one of the main factors for this achievement. Despite legalization of abortion and expansion of maternal health services, it appears that women are not getting what they are supposed to get. Many are still dying during pregnancy or soon after giving birth and thus contributing to high maternal mortality. Only about 41% women are aware that abortion is legal and this knowledge is lower among older women (35% or less), women living in rural areas (36%), women with primary (33%) or no education (28%) and poor (38%) and very poor (30%) women.

The 2016 NDHS 2016 shows that among women aware of legalization of abortion, much lower proportion (23%) of them know that pregnancy up to 12 weeks’ gestation can be legally aborted and this knowledge is the lowest (19%) among the teen age girls 15-19.

Apparently very few women are accessing safe abortion service in the country; in 2016 it was estimated that only about 9% pregnancies ended in abortion and this low safe abortion rate and nearly stagnant contraceptive prevalence rate (about 50% from 2006-2016) do not support fast declining fertility trend. Nepal’s TFR declined from 4.1 in 2001 to 2.3 by 2016. It appears that women are taking recourse to unsafe abortion which is not reported or there isn’t any study that has captured this unfortunate plight of women contributing to high maternal mortality.

In Nepal, son preference is high and discrimination against girls is persistent and these factors contribute to sex selection. Although sex selective abortion is strictly prohibited by law and punishable it is also possible that people may take advantage of liberal abortion to fulfil their wish. Also the situation of stagnant contraceptive prevalence but declining fertility in the last ten years indicates that women are using abortion as a family planning method.

Nepal comprises of 125 caste/ethnic groups and many of these groups cherish their own cultural, social and religious values and beliefs which when it comes to male female relationship becomes complicated resulting in social conflict, violence and even deaths. This complex socio-cultural value system has its toll on females. Since the Fiscal Year 2016/17, safe abortion service is free but it appears that virtually no woman is aware of this provision.

The objective of the baseline study is to establish the project baseline database that will serve as the basis for quantitative and qualitative assessment of progress towards achieving the defined outcomes and impacts of the project. The sample survey provides baseline indicators of WRA for the project areas. This will help establish SRHR and safe abortion indicators of these populations in working areas.

Methodology The methodology included both qualitative and quantitative approaches such as qualitative approach including desk review; Focus Group Discussions (FGDs) with females aged 15-49 and Key Informant Interviews with school teachers, health facility in-charges and elected local body representatives. The quantitative approach included completion of household rosters of sample households and interview with women, men, adolescents and youth. The quantitative questionnaire was administered to 300 females and males aged 13-49.

Findings From the 300 sample households demographic information was collected of all family members which numbered 1,259 individuals comprising of 47% males and 53% females, yielding a sex ratio of 89. No third gender was found in the sample area.About 26 per cent of the population is under age 15 and 6 per cent are above age 65. The mean age of household population is 29 years.

The proportion of female headed households is estimated at 29 per cent overall and the corresponding figure for the country is 26 per cent. The average household size is 4.2 persons per household which is slightly lower than the national average household size was 4.9. Overall literacy rate (for population aged 5 years and above) is estimated at 86 per cent and it is higher among males (89%) than females (83%). In 2011, the overall national literacy rate was 66 per cent and among the males the literacy rate was 75 per cent and among the females it was 57 per cent. The mean years of schooling completed is7.2 years.

Overall, 30 per cent population aged 10 and above was currently unmarried. By age 24, of all population, the proportion married is 46 per cent.

Of the total 300 survey respondents, 240 were females and 60 were males. Respondents’ age ranges from age 13 to age 49. Of the total female respondents, 39 per cent belong to Janajati group followed by Dalit (24%), Chhetri (17%), Bahun (16%) and Newar (4%). Most respondents (39%) are engaged in agricultural occupation while 23 per cent are students and 14 per cent are housewives. Ten per cent respondents reported business as their main occupation, 4 per cent each engaged in service sector and wage labouring. Wage labouring is another important occupation especially for males as 18 per cent do wage labouring while among females it is about 5 per cent.

According to female respondents, their family’s (household) average annual income was Rs. 340,821 and the corresponding amount reported by male respondents was more than double (Rs. 873,250). The average annual household income was highest (Rs. 867,968) in Siranchok rural municipality followed by Palungtar municipality (Rs. 293,695) and the lowest was found in Ajirkot rural municipality (Rs. 150,091).

Overall, only about 64 per cent families have 12 months food security and the corresponding figures for Ajirkot rural municipality, Siranchok rural municipality and Palungtar municipality are respectively 15 per cent, 74 per cent and 78 per cent.

Of the total survey respondents, 22 per cent were unmarried and 78 per cent were married and by sex more (80%) female respondents were married than male respondents (68%).

Compared to male, only 16 per cent of females make important decision in the family while more males (43%) do so. Female respondents said decisions are made mostly (nearly 75%) by male members of the family such as husband, father/father-in-law, grandfather or any male member of the family. About 10 per cent female respondents said decisions are made by mother or mother-in- law. Thirty four per cent of married females said they decided themselves about their marriage while this proportion is much higher for male respondents (59%). Nearly three in four (71%) female respondents said that they have to ask someone in the family to spend the money they earn and this proportion is much lower for male respondents (31%).

For 66 per cent of female respondents aged 13-49 years reproductive health is child bearing. Over half (55%) of females said that reproductive health is the development of reproductive organs. About 33 per cent females said becoming mentally matured is reproductive health. Good health of mother and child was mentioned by a quarter of female respondents. Use of FP methods for birth

v spacing is RH for 21 percent female respondents. Male respondents emphasized mainly childrearing, development of reproductive organs, child care, good health of mother and child, becoming mentally mature, birth spacing by using FP methods, health care, reproductive hygiene, personal hygiene and female diseases to mean RH.

During adolescence most (82%) girls experienced pain in the stomach and back while menstruating, heavy bleeding (51%), irregular menses (38%), emotional and mental problem (14%), felt shame to go to school when menstruating (11%), social stigma (7%), and 6 per cent each were embarrassed to see organs growing and lacked sufficient information. Overall, the perceived age at menarche was reported as 12.7 years which was lower than their actual age (13.9 years) at menarche .

In the last six months before the survey, more female respondents (20%) visited health facility for RH services than their male counterparts (7%). Among the respondents who visited health facility in the last 6 months, 26 per cent each visited for RH education and because of irregular menstruation while 19 per cent went to obtain FP methods and 15 per cent went for HIV&AIDS counselling/ blood test. Most (53%) female respondents went to HPs for RH service in the last 6 months, 34 per cent went to hospital, 6 per cent went to private clinics, 4 per cent went to pharmacies and 2 per cent went to. For 61 per cent of female respondents the nearest health facility is HP. Primary Health Care Centre is nearest for about 17 per cent of women. About equal proportion (17%) women also have private facilities like pharmacies and private clinics nearest to them. In the nearby health facilities all have general treatment services and FP services are available in over two in three (68%) facilities while abortion facility is available in 24 per cent centres. Over 9 in 10 female respondents said that practicing family planning methods can prevent pregnancy.

Knowledge of family planning method is universal in the project operational areas with all women and men knowing at least one method of contraception. The most well-known method among women is pill (97%), followed by injectables (95%), condom (94%), Implant/ Norplant (85%), Male sterilization (84%), Female sterilization (83%), IUCD (83%) and Emergency contraception pill (56%). The contraceptive prevalence rate (CPR) among currently married women age 15-49 is 44.5 per cent with 44 per cent using modern methods. Among married women, injectables is the most commonly used method (17.3%), followed by the pill (5.8%), Male Sterilization and Implant/ Norplant (5.2% each), IUCD and condom (3.7% each ) and Female Sterilization (3.1%).

In Ajirkot rural municipality the most common sexual and reproductive health and abortion related problems are the lack of sex education (95%), followed by lack of FP services (80%), adolescent pregnancy (42%), child/early marriage (20%), rape (9%) and sexual violence (2%). Similar problems are reported in other two municipalities. In Siranchok rural municipality a few respondents also mentioned uterine problem, stomach ache during menses and lack of RH knowledge. Highest proportion (98%) of Ajirkot respondents said that abortion is unsafe there and this proportion is lower in Palungtar (48%) and Siranchok municipalities (34%). Lack of sex education is another important barrier in Ajirkot as 93 per cent respondents mentioned it and in Palungtar 58 per cent mentioned it while in Siranchok this proportion is lowest at 30 per cent. Lack of FP service, adolescent pregnancy, child/ early marriage and sexual violence are also reported as barriers to accessing SRH and safe abortion services.In Ajirkot the main problems related to the use and access of SRH services faced by WRA and adolescents are lack of proper physical facility at health facility (90.9%), untrained HWs (76.4%), very low knowledge about Sexual Health (69%), irregular supply of drugs, HP building being unfriendly. This pattern is similar in Palungtar municipality while in Siranchok low knowledge about Sexual Health tops the list (70%) followed by untrained HWs (62%). In Ajirkot main problems related to the use and access of safe abortion services faced by WRA and adolescents are lack of equipment at health facility (76%), irregular supply of drugs (71%), untrained

vi health workers (66%), etc and this pattern is similar in other two municipalities but very low knowledge about Sexual Health tops the list in these municipalities.

Most (96%) adolescent and youth and other women and men of reproductive age go to government facilities such as hospital and HP for abortion counselling and service in Ajirkot and this is highest (88% visiting HP) in Siranchok rural municipality while in Palungtar the proportion of people going to government hospital is highest (62%). High proportion (62%) of people from Siranchok rural municipality also visit pharmacy for abortion counselling and service. In Ajirkotapart from regular RH services, one quarter (24%) respondents said abortion service is also available and the corresponding figure for Palungtar is 54 per cent and for Siranchok it is 34 per cent.

Overall, in three municipalities combined, the quality of FP and abortion services was rated as being of good quality by about 20 per cent respondents, in Palungtar the respective figure was 35 per cent and no respondent reported good quality service in Siranchok. Overall, only 36 per cent respondents rated the services as satisfactory.

Of the total 300 respondents, 78 per cent were married and by sex more (80.4%) females were married than males (68.3%). Among the married women, the mean age at marriage was 17.9 years and for males it was 22.1 years. Over 6 in 10 women got married between age 15-19. The average age at first birth was 20 years for all three municipalities combined and it was highest (20.5 years) in Siranchok, followed by Ajirkot (21 years) and Palungtar (19.3 years). Among the different caste/ethnic groups, Dalit had their first child the earliest (19 years), followed by Chhetri (19.8 years), Janajati (20.5 years) and Bahun (22.7 years). Some Janajati women had their first child even before age 15.The TFR estimated from the data is 3 per woman which is higher than the national rate of 2.3 estimated in 2016.

Age specific fertility rate shows that the fertility rate peaks at age 25-29 and declines steadily thereafter. Fertility peaking is later in sample areas than the national rate which showed fertility peaking at age 20-24. Nearly 10 per cent women had an abortion and this was highest (15.3%) in Siranchok rural municipality followed by Palungtar municipality (8.1%) while in Ajirkot rural municipality this proportion was only 4.4 per cent. Mostly older women above 20 years of age reported having had an abortion but in Palungtar even younger women aged 15-19 reported having had an abortion. Most important reason for abortion (70%) mentioned was that women “did not want any more children” and second most important reason was “wanted to delay child bearing” or “wanted to space child birth”. Of the 23 abortions reported, 13 per cent were miscarriages and of the remaining abortions most (52%) were performed using MVA method, 30 per cent were medical abortions and 4 per cent were D&E/ D&C. Only 17 out of 23 women who had an abortion reported that they were counselled about family planning after abortion and 11 of them adopted FP method and only 10 women visited health facility after abortion. Knowledge that abortion is legal in Nepal is known to 43.3 per cent of the survey respondents and more (53.3%) males know about it than their female counterparts (40.8%).

Among women having knowledge that abortion is legal, 80 per cent said that abortion is allowed for pregnancy of any duration if life of mother is at risk. Sixty per cent females said if mother's physical or mental health is at risk abortion would be allowed. Thirty nine per cent females said abortion would be allowed for pregnancy of 18 weeks if it is a result of rape or incest and about one in three females said abortion would be allowed if foetus is deformed. About half of all female respondents said that abortion would be allowed if pregnancy is of 9 weeks’ gestation.

Respondents who had completed at least 8 years of schooling were asked whether their school curriculum included SRH education and over 90 per cent said it is. Among the survey respondents

vii interested in improving the SRH curriculum, most of them suggested to include SRH and abortion information followed by health information/education, awareness.

Qualitative findings are based on analysis of three FGDs (all women) and KIIs conducted in Palungtar municipality, Siranchok and Ajirkot rural municipalities. Key Informant Interviews were conducted with 27 respondents comprising of elected representatives, health facility in-charges, health and education coordinators and school teachers.

The FGD participants discussed about general health conditions, marriage and family size, sources of knowledge on SRH and safe abortion, places visited by people when they have SRH problems, legalization of abortion, conditions of SRH and abortion services, status of access to SRH and abortion services, actions taken to improve access and services for SRH and SA, knowledge of FP, recommendations/suggestions.

The FGD discussants concluded that early marriage and early pregnancy is still the norm in all the municipalities. Generally WRA are not much knowledgeable about legality of abortion and conditions under which abortion can take place legally. For most, abortion service is not readily available although it is free. Abortion is stigmatized and therefore it is not generally talked about. Women seek abortion service when they have sufficient number of children.

The key informants also dealt on SRHR issues, related services and information and sexuality education. They were of the view that SRHR services need to be improved and more health facilities should be able to provide abortion service in the nearest health facility possible. The local community need to be imparted with SRHR and abortion education to prevent unsafe abortion incidents. Local health authorities, elected representatives and educationists all support the idea of introducing CSE in schools although currently health education is there.

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CONTENTS Page

Acknowledgement ii Study team members iii Executive summary iv Contents ix

Chapter One: Introduction ...... ………...... 1 1.1 Project background ...... …………...... 1 1.2 Overall goal of the project...... 2 1.3 Objectives of the project …………...... 2 1.4 Baseline survey...... ……………………...... 2 Chapter Two: Methodology ...... …………………...... 4 2.1 Methods and tools ...... …………...... 4 2.2 Desk review...... ………………………...... 4 2.3 Sample of adolescents, youth and adults...... 4 2.3.1 Sample size ...... 4 2.3.2 Sample selection strategy...... ………………………………………………...... 5 2.4 Field preparation...... 5 2.5 Quantitative questionnaire...... …………………...... 5 2.6 Qualitative questionnaire – guides...... 6 2.7 Data processing...... 6 2.8 Data analysis ...... ……………...... 6 2.9 Ethical considerations ...... 6 2.10 Fieldwork and study duration ...... 7 2.11 Limitations and constraints of the study ...... …...... 7 Chapter Three: Household population ………………………………………………………...... 8 Chapter Four: Characteristics of survey respondents …………………...... ……………………………...... 11 4.1 Characteristics of survey respondents...... ……………………...... 11 Chapter Five: women’s empowerment …………………...... …………………………………...... 17 Chapter Six: Knowledge, attitude and behaviour on SRH, safe abortion and family planning……………... 21 6.1 Understanding of reproductive health...... ……………………...... 21 Chapter Seven: Safe abortion and SRH problems and access to services …………………………..……………... 31 Chapter Eight: Marriage, fertility, abortion and sexuality education …………………………………..……….…... 41 Chapter Nine: Findings of qualitative study...... ………………...... 58 FGD findings: Female FGDs...... 58 KII findings:………………………...... 61 References...... 66 ABBREVIATIONS AND ACRONYMS...... 67

Chapter One: Introduction

1.1 Project background

According to Nepal Demographic and Health Survey (NDHS) 1996, Nepal had one of Asia’s highest maternal mortality ratio (MMR) of 596 (Pradhan et al 1997). In 2006 this came down to 281 per 100,000 live births – an astonishing 53% reduction within just 10 years (MOHP, New ERA and MII 2007). Liberalisation of abortion legislation is thought to be one of the main factors for the reduction in maternal mortality in Nepal. However, NDHS 2016 reported an estimate of 239 MMR (MOHP, New ERA and ICF 2017) indicating a slow pace of improvements in maternal health and mortality in recent years. Despite legalization of abortion and expansion of maternal health services such as increased access to safe motherhood services including abortion service in the country, it appears that women of reproductive age are not getting what they are supposed to get. Many are still dying during pregnancy or soon after giving birth and thus contributing to high maternal mortality.

Nepal made abortion legal in September 2002 (MOH. 2004. Annual Report 2002/2003) and the Ministry of Health began providing comprehensive abortion care services since March 2004 (MOH. 2005). However, the effect of legalization of abortion does not seem to have percolated fast to women of reproductive age; the proportion of women age 15-49 who are aware that abortion is legal in Nepal has increased by only 3 percentage points in the last five years from 38% in 2011 (NDHS 2011) to 41% in 2016 (MOHP, New ERA and ICF 2012). According to NDHS 2016, this knowledge is lower among older women (35% or less), women living in rural areas (36%), women with primary (33%) or no education (28%) and poor (38%) and very poor (30%) women. By caste/ethnic groups, this knowledge is highest among highly advantaged group (48%), followed by disadvantaged group (40%), advantaged group (35%, Terai castes) and lowest among the Dalit (34%).

Surprisingly NDHS 2016 shows that among women aware of legalization of abortion, much lower proportion (23%) of them know that pregnancy up to 12 weeks’ gestation can be legally aborted while the corresponding figure in 2011 was 36%. Furthermore, among all women who are aware of legalization of abortion, the knowledge that pregnancy up to 12 weeks’ gestation can be legally aborted is the lowest (19%) among the teen age girls 15-19. Data on 10-14 adolescent sexual activities of NDHS 2011 and 2016 show that about 3 per cent males had their first sex between age 10-14 both in 2011 and 2016 while among the girls this proportion declined from 15 per cent in 2011 to 9 per cent by 2016.

Apparently very few women are accessing safe abortion service in the country; in 2011 it was estimated that only about 7.5% pregnancies ended in abortion and this increased slightly to 9% by 2016 (MOHP, New ERA and ICF 2017). This low safe abortion rate and nearly stagnant contraceptive prevalence rate (48% in 2006, 49.7% in 2011 and 52.6% in 2016) do not support fast declining fertility trend. Nepal’s Total Fertility Rate (TFR) declined from 4.1 in 2001 to 3.1 in 2006, further to 2.6 by 2011 and still further to 2.3 by 2016. It appears that women are taking recourse to unsafe abortion which is not reported or there isn’t any study that has captured this unfortunate plight of women which has perhaps contributed to slow pace of maternal mortality decline.

Gender-biased sex selection (GBSS) in favour of boys is a symptom of pervasive social, cultural, political and economic injustices against girls and women. GBSS can be measured using sex ratio at birth (SRB), a comparison of the number of boys born versus the number of girls born in a given period. According to WHO, when many more boys are born than girls, it is a sign that sex selection is taking place (WHO. 2011). In Nepal, son preference is high and discrimination against girls is persistent and these factors contribute to sex selection. Although sex selective abortion is strictly prohibited by law and punishable it is also possible that people may take advantage of liberal

1 abortion to fulfil their wish. Also the situation of stagnant contraceptive prevalence but declining fertility in the last ten years indicates that women are using abortion as a family planning method.

Despite being a relatively small country landmass wise, Nepal is comprised of 125 caste/ethnic groups as reported in the 2011 population census (CBS. 2012). Broadly they can be categorized as highly advantageous, advantageous and marginalized groups and Dalit. Many of these groups cherish their own cultural, social and religious values and beliefs which when it comes to male female relationship becomes complicated resulting in social conflict, violence and even deaths. This complex socio-cultural value system has its toll on females. For instance, if a girl elopes with a boy from another group and becomes pregnant she is likely to end up in committing suicide. Such anecdotes are reported in local newspapers quite frequently.

Until the end of Fiscal Year 2015/16 (middle July), safe abortion service charge was Rs. 1,000/- or US$10 and this amount was far too expensive for most rural women. Government of Nepal made abortion free from FY 2016/17 (MOH. 2016) but it appears that virtually no woman is aware of this provision. There is therefore a need to educate women that they can access abortion service free of charge. Clearly, there is high prevalence of unsafe abortion in Nepal.

1.2 Overall goal of the project

Women and girls in Nepal are able to realize their rights to sexual and reproductive health and are informed and able to access contraception and safe abortion when needed.

1.3 Objectives of the project

Objective 1: Raise awareness of community members, programme implementers and policy makers about the consequences of unsafe abortion in project operational areas, i.e., Siranchok and Ajirkot rural municipalities and Palungtar municipality, Gorkha by the end of 8th month of the project period.

Objective 2: Strengthen the capacity of 20 local Government health facilities to provide counselling and medical abortion services to girls/women seeking information and services by the end of 8th month of the project period.

Objective 3: Empower/educate women / girls on SRHR and safe abortion that it is their right to decide to access and use contraceptive methods and make use of safe abortion service whenever needed.

Objective 4: Improve knowledge of young girls and boys of grades 9-12 of project operational areas on comprehensive sexuality by the end of the programme period.

1.4 Baseline survey

The objective of the baseline study is to establish the project baseline database that will serve as the basis for quantitative and qualitative assessment of progress towards achieving the defined outcomes and impacts of the “Empowering women to access safe abortion service in Gorkha, Nepal” project. The sample survey will provide baseline indicators of WRA for the project areas. This will help establish SRHR and safe abortion indicators of these populations in working areas. In order to explore beliefs, value system and norms of local communities, qualitative study especially Focus

Group Discussions (FGDs) have been conducted with WRAs in sample areas. Because this project is focusing on marginalised and Dalit communities, it might as well be that age old norms that are discriminatory to females will come out strongly at the baseline. This basic tenet that the community holds needs to be changed. Opinions of local key informants such as school teachers, health facility in-charges and elected local body representatives have been collected by conducting Key Informant Interviews. Furthermore, the Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) tool designed by IPAS and adapted by IPPF to measure abortion stigma has been included in the baseline questionnaire. The baseline was conducted in the first six months of the project.

Chapter Two: Methodology

2.1 Methods and tools

PHD Group in consultation with local research experts has improved the study design and methods which were eventually finalised. The design includes qualitative and quantitative information:

Qualitative information: • Desk review of the relevant documents • Focus Group Discussions (FGDs) with females aged 15-49. • Key Informant Interviews with school teachers, health facility in-charges and elected local body representatives.

Quantitative information: • Interview with women, men, adolescents and youth

2.2 Desk review

For this survey work, a number of Government project documents and other relevant research/evaluation reports were reviewed. Research reports and government policy documents and protocols on sexual and reproductive health including abortion were reviewed.

2.3 Sample of adolescents, youth and adults

The study aimed at establishing project baseline database that will serve as the basis for qualitative and quantitative assessment through schedule interview, FGDs and Key Informant Interviews. The primary information for the baseline has been collected from the field survey.

2.3.1 Sample Size

The baseline study was conducted in project operational areas of Gorkha district where PHD Group is implementing SAAF funded ‘‘Empowering women to access safe abortion service”. The sampling frame for the study were the households of the three municipalities which are the project operational areas. For sampling purposes, ward-wise total household population was used from the National Population Census – 2011 Nepal (CBS. 2012).

The estimate of the sample size for WRA is obtained from the following formula: n = D* [(Zά +Zβ)2 * (P1* (1-P1) + P2 *(1-P2)) / (P2-P1)2] Where, n = sample size D = Design effect. Default value of 2. Zά = probability to conclude that the observed change of size (P2-P1) would not have occurred by chance. Set at 95 % level of significance (1.645 for one tailed test) Zβ = degree of confidence to detect a change of size (P2-P1) if one actually occurred. Set as 80% 0.84 for one tailed test. P1= the estimated proportion among women who know abortion is legal percentage who know pregnancy of 12 weeks' duration or less allowed legal abortion at the time of baseline (estimated to be 23% 1). P2 = the expected proportion by the endline would be such that the quantity (P2-P1) is the size of magnitude of change, expected to be 37%. (P2-P1) = the size of magnitude of change which in this case is 14%

1 Among women who know abortion is legal percentage who knows pregnancy of 12 weeks' duration or less allowed legal abortion increased by 60% from baseline (indicator from NDHS 2016). Gorkha district belongs to western hill region and therefore indicator for western hill region is taken because NDHS does not have single district level data.

Since the multi-stage (two-stage) clustering method is proposed, the design effect is minimized by keeping the effect at 2. The statistical power, the ability to detect a change in the indicator if one has actually occurred, has been set to 80%, while the level of confidence to test whether the observed change has actually occurred by the intervention is set at 95%. The estimated proportion among women who know abortion is legal percentage who knows pregnancy of 12 weeks' duration or less allowed legal abortion at the time of baseline (estimated to be 23%). It is assumed that the base figure would increase by 60% that is by the end of the project the base figure would increase to 37%. Based on the above formula, the estimated sample size would be 257 WRA and by rounding it the final sample size comes to 260 WRA. In order to allow for attrition and other possible omissions of women respondents the sample size is raised to 300 in all.

2.3.2 Sample selection strategy

In order to select survey respondents, the number of households of wards of each municipality were cumulated and using a sampling interval 300 households2 were selected with probability proportional to census population of 2011. A ward of a municipality was considered a cluster and served as the Primary Sampling Unit (PSU). From the selected 300 households, a male respondent was selected from every fifth household. If in the sampled household only one respondent was found then that individual was interviewed but if more than one individual was eligible for interview only the youngest individual was interviewed.

2.4 Field preparation

Training: Prior to the field survey, 2- day long training was organized for field enumerators. The field enumerators were provided with knowledge about survey design, sampling procedure, questionnaire administration/ interview techniques, field management and issues related to the project. During the training session, questionnaires and checklists (FGD guidelines and Key Informant Interview checklists) were thoroughly discussed. Participants conducted mock interviews and got well familiarized with the subjects of the survey. The training was facilitated by PHD Group senior staff.

On the last day of the training, following the mock testing, the questionnaire and check lists were reviewed. Irrelevant questions, skipping pattern and wording were corrected to make questionnaires suitable to administer. Only female enumerators were recruited from the project operational areas.

Field mobilization: Six female enumerators were mobilized to different areas of the project operational areas for data collection.

2.5 Quantitative questionnaire

The consultant group developed draft quantitative questionnaires (household roster and individual questionnaire), shared them with the senior PHD Group staff and finalized the questionnaires. The household roster recorded data (age, sex, marital status for member 10 years of age or more, literacy and school attendance for members five years of age or more, caste/ethnicity and pregnancy status of women) of all members of the household who are de jure members of the family. However, any member of the family who was away from home for 6 months or more was excluded.

2It was decided that from each selected household one woman or man of reproductive age was selected from the household.

The individual questionnaire comprises of sections like Introduction and Consent, Demographics and Socio-economic background, Gender role in family and community, Knowledge, attitude and behaviour on SRH, Safe abortion and Family planning, Knowledge of contraceptive methods, Safe abortion and SRH problems and access to services, Sources of safe abortion and SRH information and Stigmatizing attitudes, beliefs and actions scale (SABAS) tool.

Respondent types: The types of respondents were- females aged 13-49 and males 15-49. In all, 300 respondents were interviewed of which 80% were females and the rest males.

2.6 Qualitative questionnaire – guides

Qualitative questionnaire included development of Focus Group Discussion (FGD) guidelines and Key Informant Interview check lists. The consultant group drafted FGD guidelines and KII check lists and submitted to PHD Group for comments. Qualitative method such as FGD was used to obtain information about socio-cultural norms, views, attitudes to sexual and reproductive health and behaviour. Detailed issues were finalized after reviewing the relevant literature. FGD and KIIs were conducted by the PHD Group senior staff.

2.7 Data processing

Upon completion of the field activities, secondary checking of the quantitative survey questionnaires was performed at the PHD Office in Kathmandu. In the meantime data entry template was prepared to computer enter quantitative data. The edited questionnaires were coded for computer entry. The data have been computer entered and cleaning has been conducted.

The qualitative data were transcribed in Nepali. Information collected through FGDs and KIIs have been manually processed.

2.8 Data analysis

Quantitative data were analysed using simple frequency tables and two/three way cross tables. Basic statistical tools including percentage, measures of central tendency, measures of dispersion and degree of relationship between the selected variables were used in the analysis. The quantitative indicators required for the baseline were derived from the analysis. The quantitative analysis was conducted using SPSS software version 21.

The senior PHD Group staff critically reviewed and triangulated data to cross check quantitative and qualitative data from different types of data sources. The collated information were helpful in generating factual qualitative data and meaningful conclusions.

Both primary and secondary quantitative data and qualitative information from different sources collected by consultants and field researchers were used to establish benchmark information.

2.9 Ethical considerations

Prior to conducting interviews the interviewers obtained informed consent from the respondents. Every respondent was told about the purpose of the study and convinced about the confidentiality of the data. The participants were explained about the purpose of the study and their consent to participate in it was sought. During the training the client rights issues such as right to share or not to share personal information, emotional problems, etc. were discussed and the field researchers were instructed to act accordingly.

2.10 Fieldwork and study duration

Field work was started soon after the training of the research team members. One enumerator was responsible for covering Ajirkot rural municipality, two enumerators took care of Siranchok rural municipality and three enumerators conducted field work in Palungtar municipality. PHD Group field coordinator and one central office staff maintained regular communication among them to ensure uniformity of data collection and sharing of field experiences. Field researchers spent 21 days for field work. Despite the seasonal religious festivals, the field work was completed as planned.

2.11 Limitations and constraints of the study

There are no major limitations in the study that affected the quality and outcomes of the study considerably. However, there were few minor limitations. One limitation of the study was that the field work was conducted during the time when Nepalese biggest festival, i.e., Dashain was just beginning which made it difficult to find respondents as they had to be busy preparing for the festival. However, this did not affect the study results at all.

Chapter Three: Household Population

In this survey a household is defined as a person or group of related or unrelated persons who live together in the same dwelling unit(s), who acknowledge one adult male or female as the head of the household, who share the same housekeeping arrangements, and who are considered a single unit. Information was collected from all usual residents (de jure population) of a selected household, whether or not they stayed in the household the night before the interview but have been living together for six months or more.

The total survey population is 1,259; 47% of these individuals are males and 53% are females, yielding a sex ratio (number of males per 100 females) of 89 (Table 3.1). No third gender was reported in the sample area. Sex ratio is lowest (81) in Palungtar municipality compared to other two rural municipalities where it is 98.

Table 3.1 Per cent distribution of household survey population by residence, according to sex and households, Gorkha, Nepal 2018 Household population Total Households Rural/ urban municipality Male Female % n % n Ajirkot rural municipality 49.57 50.43 100.00 232 18.33 55 Siranchok rural municipality 49.39 50.61 100.00 411 31.33 94 Palungtar municipality 44.64 55.36 100.00 616 50.33 151 Total 47.10 52.90 100.00 1,259 100.00 300

About 26 per cent of the population is under age 15 and 6 per cent are above age 65 (Table 3.2). The mean age of household population is 29 years and it is slightly higher (29 years) for males than for females (28 years, Table 3.2).

Table 3.2 Per cent distribution of household survey population by age, according to sex, Gorkha, Nepal 2018 Sex of household members Age Male Female Both sexes <15 27.82 23.87 25.73 15-24 23.10 29.13 26.29 25-49 32.55 33.93 33.28 50-64 9.95 7.36 8.58 65+ 6.58 5.71 6.12 Total % 100.00 100.00 100.00 Total n 593 666 1,259 Mean 29.33 28.13 28.70 Median 24 23 24 Maximum 95 89 95

Among the 300 households surveyed the proportion of female headed households is estimated at 29 per cent overall and among the caste/ethnic groups it is highest (35%) among Chhetri caste followed by Janjati ethnic group (34%), Dalit (26%), Bahun and Newar (17%) in that order (Table 3.3). Nationally the proportion of female headed households was 26 per cent in 2011 (CBS. 2012).

The sample survey data shows average household size of 4.2 persons per household and it is highest among Janajati (4.4), followed by Dalit (4.3), Newar (4.2), Chhetri (4.0) and the lowest size was found

8 for Bahun (3.8, Table 3.3). According to the population census of 2011 the average household size was 4.9 in 2011 (CBS. 2012).

Table 3.3 Per cent distribution of household head by caste/ethnicity, according to sex and household size, Gorkha, Nepal 2018 Sex of household head Caste/ethnicity Male Female Total % Household size Total n Chhetri 64.71 35.29 100.00 3.98 51 Bahun 82.98 17.02 100.00 3.81 47 Janajati 65.79 34.21 100.00 4.37 114 Newar 83.33 16.67 100.00 4.17 12 Dalit 73.68 26.32 100.00 4.33 76 Total 71.00 29.00 100.00 4.20 300

Overall literacy rate (for population aged 5 years and above) is estimated at 86 per cent and it is higher among males (89%) than females (83%, Table 3.4). Among the caste/ethnic groups, literacy rate is highest among the Bahun and lowest among Newar. In 2011, the overall literacy rate was 66 per cent and among the males the literacy rate was 75 per cent and among the females it was 57 per cent (CBS. 2012).

Table 3.4 Per cent distribution of literate population by caste/ethnicity, according to sex, Gorkha, Nepal 2018 Sex Caste/ethnicity Male Female Total Chhetri 90.12 79.25 83.96 Bahun 90.79 86.21 88.34 Janajati 89.29 82.48 85.81 Newar 81.25 85.19 83.72 Dalit 88.89 84.18 86.42 All % 89.28 83.01 85.95 Total n 541 612 1,153

In the project operation areas, the proportion of population 5 years of age and over ever attended school is estimated at 79 per cent and it is higher among males (83%) than among females (76%, Table 3.5).More Bahun (82%) and Janajati (80%) ever attend schools than Chhetri (78%), Neewar (77%) or Dalit (77%).

The mean years of schooling completed is highest for Newar (8.3 years), followed by Bahun and Chhetri (7.8 years), 6.9 years Janajati and the least numbers of years was found for Dalit (6.8 years, Table 3.5). Interestingly years of schooling completed is slightly higher for females (7.3 years) than for males (7.2 years).

Table 3.5 Per cent distribution of population 5 years of age and above by caste/ethnicity, according school attendance, years of schooling completed and sex, Gorkha, Nepal 2018 Per cent ever attended school Mean years of schooling completed Male Female Both sexes Caste/ethnicity (n=541) (n=612) (n=1153) Male Female Both sexes Chhetri 81.48 74.53 77.54 8.11 7.51 7.78 Bahun 82.89 81.61 82.21 7.92 7.76 7.84 Janajati 85.27 75.64 80.35 6.75 7.13 6.93 Newar 75.00 77.78 76.74 9.17 8.29 8.61 Dalit 81.25 73.42 77.15 6.69 6.81 6.75 Total 82.99 75.82 79.18 7.16 7.26 7.21

Information on marital status was sought for all household members aged 10 and above and one girl aged 14 was currently married while none of the boys aged less than 15 was married. Overall, 30 per cent population aged 10 and above was currently unmarried. By age 24, of all population, the proportion married is 46 per cent while by caste/ethnicity this proportion is lowest for Dalit (40%), followed by Janjati (47%), Chhetri (49%) and for Bahun and Newar it is 50 per cent (Table 3.6).

Table 3.6 Per cent distribution of population 10 years of age and above by caste/ethnicity, according marital status and age, Gorkha, Nepal 2018 Marital status of member Caste/ Widow/ Divorced/ ethnicity Age Unmarried Married Widower Separated Total Chhetri 10-14 100.0 - - - 100.0 23 15-24 51.1 48.9 - - 100.0 45 25-49 3.0 97.0 - - 100.0 66 50+ - 79.5 17.9 2.6 100.0 39 Total 27.7 67.6 4.0 0.6 100.0 173 Bahun 10-14 100.0 - - - 100.0 16 15-24 50.0 47.2 - 2.8 100.0 36 25-49 1.6 98.4 - - 100.0 64 50+ - 88.2 8.8 2.9 100.0 34 Total 23.3 73.3 2.0 1.3 100.0 150 Janajati 10-14 98.1 1.9 - - 100.0 52 15-24 52.5 46.1 - 1.4 100.0 141 25-49 1.9 95.5 1.3 1.3 100.0 156 50+ 1.3 84.4 13.0 1.3 100.0 77 Total 30.3 65.7 2.8 1.2 100.0 426 Newar 10-14 100.0 - - - 100.0 4 15-24 50.0 50.0 - - 100.0 10 25-49 4.8 95.2 - - 100.0 21 50+ - 83.3 16.7 - 100.0 6 Total 24.4 73.2 2.4 - 100.0 41 Dalit 10-14 100.0 - - - 100.0 45 15-24 60.6 38.4 - 1.0 100.0 99 25-49 - 95.5 1.8 2.7 100.0 112 50+ - 79.3 20.7 - 100.0 29 Total 36.8 58.9 2.8 1.4 100.0 285 Total 10-14 99.3 0.7 - - 100.0 140 15-24 54.4 44.4 - 1.2 100.0 331 25-49 1.7 96.2 1.0 1.2 100.0 419 50+ 0.5 83.2 14.6 1.6 100.0 185 Total 30.4 65.6 2.9 1.1 100.0 1075

Chapter Four: Characteristics of survey respondents

4.1 Characteristics of survey respondents

Table 4.1 shows age and sex distribution of sample respondents. Overall, respondents’ age ranges from age 13 to age 49. Of all the age groups, highest proportion (24%) belongs to age 20-24and this varies by sex. Among the females the highest proportion (26%) is seen for age group 20-24.

Table 4.1 Per cent distribution of respondents by sex, according municipality and age, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Age municipality municipality municipality Total Female 13-14 2.2 8.9 1.4 5.4 15-19 15.6 24.4 19.4 21.3 20-24 31.1 22.0 29.2 25.8 25-29 11.1 15.4 12.5 13.8 30-34 4.4 8.1 11.1 8.3 35-39 8.9 7.3 16.7 10.4 40-44 8.9 6.5 8.3 7.5 45-49 17.8 7.3 1.4 7.5 Total % 100.0 100.0 100.0 100.0 Total n 45 123 72 240 Male 13-14 0.0 3.6 0.0 1.7 15-19 30.0 32.1 27.3 30.0 20-24 20.0 21.4 9.1 16.7 25-29 0.0 7.1 9.1 6.7 30-34 20.0 3.6 18.2 11.7 35-39 0.0 7.1 9.1 6.7 40-44 30.0 0.0 13.6 10.0 45-49 0.0 25.0 13.6 16.7 Total % 100.0 100.0 100.0 100.0 Total n 10 28 22 60 Both sexes 13-14 1.8 7.9 1.1 4.7 15-19 18.2 25.8 21.3 23.0 20-24 29.1 21.9 24.5 24.0 25-29 9.1 13.9 11.7 12.3 30-34 7.3 7.3 12.8 9.0 35-39 7.3 7.3 14.9 9.7 40-44 12.7 5.3 9.6 8.0 45-49 14.5 10.6 4.3 9.3 Total % 100.0 100.0 100.0 100.0 Total n 55 151 94 300

Of the total respondents, 38 per cent belong to Janajati group followed by Dalit (25%), Chhetri 17 per cent, Bahun 16 per cent and Newar 4 per cent (Table 4.2). Similar pattern of caste/ethnic distribution is seen for males and female respondents.

By municipality, more than half (53%) of the respondents belong to Janajati group, followed by Dalit (24%), Bahun 20 per cent, and the smallest group is Newar (4%, Table 4.2)in Ajirkot. Similar pattern of caste/ethnic distribution is seen for respondents from Palungtar municipality, namely, 34 per cent belong to Janajati, 25 per cent Dalit, 22 per cent Chhetri, 13 per cent Bahun and 6 per cent Newar. Distribution of respondents by caste/ethnicity for Siranchok rural municipality is similar.

Table 4.2 Per cent distribution of respondents by sex, according municipality and caste/ethnicity, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Caste/ethnicity municipality municipality municipality Total Female Chhetree 4.4 22.0 15.3 16.7 Bahun 22.2 13.0 18.1 16.3 Janajati 53.3 35.0 36.1 38.8 Newar 0.0 6.5 4.2 4.6 Dalit 20.0 23.6 26.4 23.8 Total % 100.0 100.0 100.0 100.0 Total n 45 123 72 240 Male Chhetree 0.0 21.4 22.7 18.3 Bahun 10.0 14.3 18.2 15.0 Janajati 50.0 32.1 27.3 33.3 Newar 0.0 3.6 0.0 1.7 Dalit 40.0 28.6 31.8 31.7 Total % 100.0 100.0 100.0 100.0 Total n 10 28 22 60 Both sexes Chhetree 3.6 21.9 17.0 17.0 Bahun 20.0 13.2 18.1 16.0 Janajati 52.7 34.4 34.0 37.7 Newar 0.0 6.0 3.2 4.0 Dalit 23.6 24.5 27.7 25.3 Total % 100.0 100.0 100.0 100.0 Total n 55 151 94 300

Most respondents (39%) are engaged in agricultural occupation while 23 per cent are students and 14 per cent are housewives (Table 4.3).

Table 4.3 Per cent distribution of respondents by sex, according municipality and main occupation, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Main occupation municipality municipality municipality Total Female Agriculture 68.9 32.5 29.2 38.3 Business 6.7 9.8 16.7 11.3 Service 2.2 2.4 2.8 2.5 Wage labouring (domestic) 2.2 1.6 4.2 2.5 Wage labouring (outside) 2.2 3.3 1.4 2.5 Student 17.8 22.8 19.4 20.8 Dependent 0.0 1.6 0.0 0.8 Unemployed 0.0 4.1 0.0 2.1 Housewife 0.0 17.9 26.4 17.1 Domestic Labour 0.0 4.1 0.0 2.1 Total % 100.0 100.0 100.0 100.0 Total n 45 123 72 240 Male Agriculture 60.0 35.7 36.4 40.0 Business 0.0 3.6 9.1 5.0 Service 0.0 17.9 9.1 11.7 Wage labouring (domestic) 0.0 7.1 13.6 8.3 Wage labouring (outside) 0.0 0.0 4.5 1.7 Student 40.0 35.7 22.7 31.7 Unemployed 0.0 0.0 4.5 1.7 Total % 100.0 100.0 100.0 100.0 Total n 10 28 22 60

Ten per cent respondents reported business as their main occupation, 4 per cent respondents are engaged in service sector and equally, i.e., 4 per cent work as wage labourers. By gender, 38 per cent females are engaged in agricultural occupation while slightly higher proportions (40%) of males are engaged in agricultural occupation (Table 4.3).Wage labouring is another important occupation especially for males as 18 per cent do wage labouring while among females it is about 5 per cent.

In the survey respondents were asked about their family’s (household) annual income and the average annual income of 300 households was Rs.447,307 and the corresponding amount reported by male respondents was more than double (Rs.873,250) that of females (Rs.340,821, Table 4.4). The average annual household income was highest (Rs.867,968) in Siranchok rural municipality followed by Palungtar municipality (Rs.293,695) and the lowest was found in Ajirkot rural municipality (Rs.150,091).

Table 4.4 Per cent distribution of respondents by municipality, according sex and annual household income, Gorkha, Nepal 2018 Sex Municipality Household income Female Male Total Ajirkot rural municipality Rs.10,000-Rs.135,000 55.6 80.0 60.0 Rs.135,100-Rs.240,000 22.2 20.0 21.8 Rs.240,100-Rs.380,000 13.3 - 10.9 Rs.381000+ 8.9 - 7.3 Total % 100.0 100.0 100.0 Total n 45 10 55 Mean annual income 163,889 88,000 150,091 Palungtar municipality Rs.10,000-Rs.135,000 13.0 14.3 13.2 Rs.135,100-Rs.240,000 33.3 25.0 31.8 Rs.240,100-Rs.380,000 25.2 42.9 28.5 Rs.381000+ 28.5 17.9 26.5 Total % 100.0 100.0 100.0 Total n 123 28 151 Mean annual income 297,626 276,429 293,695 Siranchok rural municipality Rs.10,000-Rs.135,000 20.8 22.7 21.3 Rs.135,100-Rs.240,000 16.7 18.2 17.0 Rs.240,100-Rs.380,000 25.0 22.7 24.5 Rs.381000+ 37.5 36.4 37.2 Total % 100.0 100.0 100.0 Total n 72 22 94 Mean annual income 525,194 1,989,773 867,968 All three Rs.10,000-Rs.135,000 23.3 28.3 24.3 Rs.135,100-Rs.240,000 26.3 21.7 25.3 Rs.240,100-Rs.380,000 22.9 28.3 24.0 Rs.381000+ 27.5 21.7 26.3 Total % 100.0 100.0 100.0 Total n 240 60 300 Mean annual income 340,821 873,250 447,307

The survey respondents were also inquired about food security, i.e. duration of time household income supports the family and it is found that nearly two in three families have 12 months food security and about one fourth respondents are supported by their income for up to 6 months only

(Table 4.5). Food security is low in Ajirkot rural municipality while in Palungtar municipality and Siranchok rural municipality about 3 in 4 respondents have food security.

Table 4.5 Per cent distribution of respondents by municipality, according sex and food security, Gorkha, Nepal 2018 Sex Municipality Food security Female Male Total Ajirkot rural municipality 1-6 months 80.0 100.0 83.6 7-9 months 2.2 - 1.8 12 months 17.8 - 14.5 Total % 100.0 100.0 100.0 Total n 45 10 55 Palungtar municipality 1-6 months 13.0 21.4 14.6 7-9 months 8.9 3.6 7.9 10-11 months 3.3 3.6 3.3 12 months 74.8 71.4 74.2 Total % 100.0 100.0 100.0 Total n 123 28 151 Siranchok rural 1-6 months 12.5 9.1 11.7 municipality 7-9 months 6.9 9.1 7.4 10-11 months 4.2 - 3.2 12 months 76.4 81.8 77.7 Total % 100.0 100.0 100.0 Total n 72 22 94 All 1-6 months 25.4 30.0 26.3 7-9 months 7.1 5.0 6.7 10-11 months 2.9 1.7 2.7 12 months 64.6 63.3 64.3 Total % 100.0 100.0 100.0 Total n 240 60 300

Among the survey respondents literacy was high as only 4 per cent were illiterate and among the males no one was found illiterate while among their female counterparts illiteracy was 5 per cent (Table 4.6). In rural municipalities, illiteracy is high – 10 per cent in Siranchok and 4 per cent in Ajirkot.

Table 4.6 Per cent distribution of respondents by sex, according to municipality and literacy, Gorkha, Nepal 2018 Literacy Sex Municipality Illiterate Literate Total Female Ajirkot rural municipality 4.4 95.6 100.0 Palungtar municipality 2.4 97.6 100.0 Siranchok rural municipality 9.7 90.3 100.0 Total % 5.0 95.0 100.0 Total n 12 228 240 Male Ajirkot rural municipality 0.0 100.0 100.0 Palungtar municipality 0.0 100.0 100.0 Siranchok rural municipality 0.0 100.0 100.0 Total % 0.0 100.0 100.0 Total n 0 60 60 Both sexes Ajirkot rural municipality 3.6 96.4 100.0 Palungtar municipality 2.0 98.0 100.0 Siranchok rural municipality 7.4 92.6 100.0 Total % 4.0 96.0 100.0 Total n 12 288 300

Among the survey respondents, nearly 95 per cent ever attended school and slightly more (97%) males ever attended school than female respondents (94%, Table 4.7). In Ajirkot rural municipality all male and female respondents ever attended school while in Siranchok rural municipality and Palungtar municipality this was not the case.

Table 4.7 Per cent distribution of respondents by sex, according to school attendance and municipality, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Ever attended school? municipality municipality municipality Total Female Yes 100.0 90.8 96.9 94.3 No 0.0 9.2 3.1 5.7 Total % 100.0 100.0 100.0 100.0 Total n 43 120 65 228 Male Yes 100.0 92.9 100.0 96.7 No 0.0 7.1 0.0 3.3 Total % 100.0 100.0 100.0 100.0 Total n 10 28 22 60 Both exes Yes 100.0 91.2 97.7 94.8 No 0.0 8.8 2.3 5.2 Total % 100.0 100.0 100.0 100.0 Total n 53 148 87 288

Among the respondents who ever attended school, the average years of schooling completed was 8.3 years and respondents from Shiranchok rural municipality completed mores years of schooling (8.8 years) than their counterparts from other two areas (8.1 years, Table 4.8). Males completed more years of schooling (8.5 years) than females (8.3 years).

Table 4.8 Per cent distribution of respondents by sex, according to years of schooling completed and municipality, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Years of schooling municipality municipality municipality Total Female 2-5 Years 27.9 21.1 15.9 20.9 6-8 Years 20.9 32.1 30.2 29.3 9-10 Years 30.2 37.6 31.7 34.4 11-12 Years 18.6 8.3 15.9 12.6 13 Years and above 2.3 0.9 6.3 2.8 Total % 100.0 100.0 100.0 100.0 Total n 43 109 63 215 Mean years of schooling 8.1 7.9 8.9 8.3 Male 2-5 Years 20.0 26.9 27.3 25.9 6-8 Years 20.0 11.5 9.1 12.1 9-10 Years 60.0 42.3 50.0 48.3 11-12 Years 0.0 15.4 9.1 10.3 13 Years and above 0.0 3.8 4.5 3.4 Total % 100.0 100.0 100.0 100.0 Total n 10 26 22 58 Mean years of schooling 8.2 8.6 8.4 8.5 Both sexes 2-5 Years 26.4 22.2 18.8 22.0 6-8 Years 20.8 28.1 24.7 25.6 9-10 Years 35.8 38.5 36.5 37.4 11-12 Years 15.1 9.6 14.1 12.1 13 Years and above 1.9 1.5 5.9 2.9 Total % 100.0 100.0 100.0 100.0 Total n 53 135 85 273 Mean years of schooling 8.1 8.1 8.8 8.3

Of the total survey respondents, 22 per cent were unmarried and 78 per cent were married and by sex more (80%) female respondents were married than male respondents (68%, Table 4.9). Similar pattern was found for females from Ajirkot and Palungtar while in Siranchok slightly more females (81%) were married.

Table 4.9 Per cent distribution of respondents by municipality, according to marital status and sex, Gorkha, Nepal 2018 Municipality Marital status Sex Unmarried Married Total % Total n Ajirkot rural municipality Female 20.0 80.0 100.0 45 Male 50.0 50.0 100.0 10 Both sexes 25.5 74.5 100.0 55 Palungtar municipality Female 20.3 79.7 100.0 123 Male 32.1 67.9 100.0 28 Both sexes 22.5 77.5 100.0 151 Siranchok rural municipality Female 19.4 80.6 100.0 72 Male 22.7 77.3 100.0 22 Both sexes 20.2 79.8 100.0 94 All Female 20.0 80.0 100.0 240 Male 31.7 68.3 100.0 60 Both sexes 22.3 77.7 100.0 300

Chapter Five: Women’s empowerment

In the survey respondents were asked who makes important decision in the family and in response only 16 per cent of females said they make the decisions themselves while among the males nearly half (43%) of the respondents said they make decisions (Table 5.1).

Table 5.1 Per cent distribution of respondents by sex, according to caste/ethnicity status and person making decision, Gorkha, Nepal 2018 Caste/ethnicity Sex Person making decision Chhetri Bahun Janajati Newar Dalit Total Female Respondent (self) 22.5 7.7 15.1 9.1 21.1 16.3 Husband 32.5 48.7 36.6 45.5 40.4 39.2 Father/ Father-in-law 35.0 30.8 34.4 36.4 31.6 33.3 Mother/ Mother-in-law 7.5 12.8 12.9 9.1 7.0 10.4 Male family members 0.0 0.0 1.1 0.0 0.0 0.4 Grand father 2.5 0.0 0.0 0.0 0.0 0.4 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 40 39 93 11 57 240 Male Respondent (self) 45.5 66.7 40.0 100.0 31.6 43.3 Wife 0.0 0.0 5.0 0.0 0.0 1.7 Father/ Father-in-law 36.4 33.3 25.0 0.0 52.6 36.7 Mother/ Mother-in-law 18.2 0.0 30.0 0.0 15.8 18.3 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 11 9 20 1 19 60 Both Respondent (self) 27.5 18.8 19.5 16.7 23.7 21.7 sexes Husband/ Wife 25.5 39.6 31.0 41.7 30.3 31.7 Father/ Father-in-law 35.3 31.3 32.7 33.3 36.8 34.0 Mother/ Mother-in-law 9.8 10.4 15.9 8.3 9.2 12.0 Male family members 0.0 0.0 0.9 0.0 0.0 0.3 Grand father 2.0 0.0 0.0 0.0 0.0 0.3 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 51 48 113 12 76 300

Self decision making is relatively high among Chhetri(23%) and Dalit women (21%) while among the women from other caste/ ethnic groups they are low (Table 5.1). Female respondents said that decisions are made mostly (nearly 75%) by male members of the family such as husband, father/father-in-law, grandfather or any male member of the family. About 10 per cent female respondents said decisions are made by mother or mother-in-law. Apparently senior members of the family particularly male members make important decisions in the family as it is evident that among the male respondents too, high proportion (37%) mentioned father/father-in-law making decisions.

Nearly half (48%) of the female respondents said that they are consulted when making decisions in the family (Table 5.2). Proportionately more (57%) male respondents said they are consulted than their female counterparts (48%, Table 5.2). Consultation on decision making is higher among Bahun and Chhetri castes than with Janajati, Newar and Dalit.

Table 5.2 Per cent distribution of respondents by sex, according to whether respondent consulted when making decision and caste/ethnicity, Gorkha, Nepal 2018 How often are your consulted when making important decisions? Sex Caste/ethnicity Always Mostly Sometimes Never Total % Total n Female Chhetri 52.5 22.5 22.5 2.5 100.0 40 Bahun 53.8 25.6 15.4 5.1 100.0 39 Janajati 47.3 32.3 18.3 2.2 100.0 93 Newar 36.4 54.5 9.1 0.0 100.0 11 Dalit 42.1 31.6 24.6 1.8 100.0 57 Total 47.5 30.4 19.6 2.5 100.0 240 Male Chhetri 63.6 18.2 18.2 0.0 100.0 11 Bahun 77.8 22.2 0.0 0.0 100.0 9 Janajati 50.0 40.0 10.0 0.0 100.0 20 Newar 100.0 0.0 0.0 0.0 100.0 1 Dalit 47.4 26.3 26.3 0.0 100.0 19 Total 56.7 28.3 15.0 0.0 100.0 60 Both Chhetri 54.9 21.6 21.6 2.0 100.0 51 sexes Bahun 58.3 25.0 12.5 4.2 100.0 48 Janajati 47.8 33.6 16.8 1.8 100.0 113 Newar 41.7 50.0 8.3 0.0 100.0 12 Dalit 43.4 30.3 25.0 1.3 100.0 76 Total 49.3 30.0 18.7 2.0 100.0 300

The married respondents were asked who decided about their marriage and only about one in three (34%) female respondents said they decided themselves while this proportion is much higher for male respondents (59%, Table 5.3). Most (58%) marriages are decided by fathers in the case of female respondents whereas only about 29 per cent male marriages were decided by fathers.

Table 5.3 Per cent distribution of respondents by sex, according to caste/ethnicity andperson deciding on respondent's marriage, Gorkha, Nepal 2018 Person deciding on Caste/ethnicity Sex respondent's marriage Chhetri Bahun Janajati Newar Dalit Total Female Respondent (Self) 30.3 17.6 44.6 40.0 30.2 34.0 Father 60.6 76.5 50.0 60.0 53.5 57.7 Mother 3.0 0.0 5.4 0.0 7.0 4.1 Male member 3.0 2.9 0.0 0.0 0.0 1.0 Sister 3.0 2.9 0.0 0.0 4.7 2.1 Mother’s brother 0.0 0.0 0.0 0.0 4.7 1.0 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 33 34 74 10 43 194 Male Respondent (Self) 25.0 66.7 71.4 0.0 66.7 58.5 Father 50.0 22.2 21.4 0.0 33.3 29.3 Mother 25.0 11.1 7.1 100.0 0.0 12.2 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 8 9 14 1 9 41 Both Respondent (Self) 29.3 27.9 48.9 36.4 36.5 38.3 sexes Father 58.5 65.1 45.5 54.5 50.0 52.8 Mother 7.3 2.3 5.7 9.1 5.8 5.5 Male member 2.4 2.3 0.0 0.0 0.0 0.9 Sister 2.4 2.3 0.0 0.0 3.8 1.7 Mother’s brother 0.0 0.0 0.0 0.0 3.8 0.9 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 41 43 88 11 52 235

Nearly three in four (71%) female respondents said that they have to ask someone in the family to spend the money they earned and this proportion is much lower for male respondents (31%, Figure 5.1). Highest proportion (92%) of Chhetri women said they have to ask someone in the family before they can spend the money they earned. Over 70 per cent of women respondents said that they do not spend the money they earned without asking someone in the family.

Figure 5.1 Percentage of respndents mentioning the need to ask someone in family to spend one's earnings by sex and caste/ethnicity, Gorkha, 2018

Per cent Female

100.0 91.7 Male 80.0

90.0 80.0 Both sexes

76.5 76.5 75.0

80.0 71.4

67.4 61.3 70.0 61.0

60.0 41.7

50.0 40.0

37.5 33.3

40.0 31.3 25.0

30.0 14.3 20.0

10.0 0 0.0 Chhetri Bahun Janajati Newar Dalit Total Caste/ethnicity

Among the female respondents who said they have to ask someone in the family before they can spend their earnings, nearly nine in ten (88%) ask their husband and this proportion is highest (100%) among Bahun, followed by Dalit and Janajati (89%) and Chhetri (82%, Table 5.4).

Table 5.4 Per cent distribution of respondents by sex, according to caste/ethnicity and person to ask to spend the money earned, Gorkha, Nepal 2018 Person to ask to spend the Caste/ethnicity Sex money earned Chhetri Bahun Janajati Newar Dalit Total Female Husband 81.8 100.0 88.5 75.0 88.9 87.7 Mother-in-law 9.1 0.0 3.8 0.0 5.6 4.6 Father-in-law 9.1 0.0 3.8 25.0 0.0 4.6 Mother 0.0 0.0 0.0 0.0 5.6 1.5 Father 0.0 0.0 3.8 0.0 0.0 1.5 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 11 6 26 4 18 65 Male Wife 100.0 100.0 60.0 0.0 100.0 80.0 Mother 0.0 0.0 20.0 0.0 0.0 10.0 Father 0.0 0.0 20.0 0.0 0.0 10.0 Total % 100.0 100.0 100.0 0.0 100.0 100.0 Total n 2 2 5 0 1 10 Both Husband/ Wife 84.6 100.0 83.9 75.0 89.5 86.7 sexes Mother-in-law 7.7 0.0 3.2 0.0 5.3 4.0 Father-in-law 7.7 0.0 3.2 25.0 0.0 4.0 Mother 0.0 0.0 3.2 0.0 5.3 2.7 Father 0.0 0.0 6.5 0.0 0.0 2.7 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 13 8 31 4 19 75

Chapter Six: Knowledge, attitude and behaviour on SRH, safe abortion and family planning

6.1 Understanding of reproductive health (RH)

In response to the question ‘What do you understand by Reproductive Health’, over 6 in 10 (66%) female respondents aged 13-49 years responded child bearing. Over half (55%) of females said that reproductive health is the development of reproductive organs. About one in three (33%) females said becoming mentally matured is reproductive health. Good health of mother and child was mentioned by a quarter of female respondents. Use of FP methods for birth spacing was mentioned by 21 percent females being reproductive health (Table 6.1).

Table 6.1 Per cent distribution of respondents by sex, according to caste/ethnicity and perceived meaning of RH, Gorkha, Nepal 2018 Caste/ethnicity Sex Meaning of RH Chhetri Bahun Janajati Newar Dalit Total Female Child rearing 57.5 76.9 62.4 81.8 68.4 66.3 Child care 40.0 43.6 39.8 45.5 43.9 41.7 Development of reproductive organs 57.5 61.5 57.0 36.4 50.9 55.4 Becoming mentally mature 30.0 30.8 36.6 27.3 29.8 32.5 Learn to adjust in society 5.0 0.0 8.6 0.0 3.5 5.0 Birth spacing by using FP methods 17.5 15.4 24.7 9.1 22.8 20.8 Good health of mother & child 30.0 15.4 28.0 27.3 22.8 25.0 Health care 0.0 0.0 2.2 0.0 0.0 0.8 Reproductive hygiene 2.5 0.0 0.0 0.0 1.8 0.8 Personal hygiene 2.5 0.0 1.1 0.0 0.0 0.8 Female diseases 0.0 0.0 0.0 0.0 1.8 0.4 Don't know 10.0 7.7 4.3 9.1 8.8 7.1 Total n 40 39 93 11 57 240 Male Child rearing 72.7 66.7 55.0 0.0 63.2 61.7 Child care 45.5 44.4 30.0 0.0 47.4 40.0 Development of reproductive organs 54.5 44.4 65.0 100.0 42.1 53.3 Becoming mentally mature 27.3 55.6 35.0 0.0 31.6 35.0 Learn to adjust in society 0.0 0.0 5.0 0.0 15.8 6.7 Birth spacing by using FP methods 9.1 22.2 20.0 0.0 5.3 13.3 Good health of mother & child 27.3 33.3 20.0 100.0 31.6 28.3 Pregnancy at an appropriate age 0.0 11.1 0.0 0.0 0.0 1.7 Health care 0.0 0.0 0.0 0.0 5.3 1.7 Sexual relation 0.0 0.0 5.0 0.0 0.0 1.7 Reproductive hygiene 0.0 0.0 5.0 0.0 0.0 1.7 Don't know 0.0 33.3 10.0 0.0 21.1 15.0 Total n 11 9 20 1 19 60

Among the caste/ethnic groups, highest proportion (82%) of Newar women said RH was about rearing children followed by Bahun (77%), Dalit (68%), Janajati (62%) and Chhetri women (58%, Table 6.1). Reproductive health being development of reproductive organs was mentioned by 58 per cent of Chhetri women, 62 per cent of Bahun women, 57 per cent of Janajati women and only 36 per cent of Newar women. Child care, becoming mentally mature, learning to adjust in society, birth spacing by using FP methods, good health of mother and child, health care, reproductive hygiene, personal hygiene and female diseases were mentioned as manifestations of reproductive health (Table 6.1).

Male respondents participating in the survey mentioned similar views on the meaning of reproductive health. They emphasized mainly childrearing, development of reproductive organs,

21 child care, good health of mother and child, becoming mentally mature, birth spacing by using FP methods, health care, reproductive hygiene, personal hygiene and female diseases were mentioned by male respondents implying the meaning of RH.

Almost half (43%) of female respondents faced reproductive health problem during adolescence while the comparative figure for males was only 10 per cent (Figure 6.1). Among the caste/ethnic groups, 51 per cent of Dalit women faced reproductive health problem during adolescence and the least proportion of Newar women did so (18%).

Figure 6.1 Per cent of female and male respondents facing RH problems during adolescence, Gorkha, 2018

60.0 50.9 50.0 46.2 43.0 43.3 37.5 40.0

30.0 Female Per cent Per Male 18.2 20.0 15.0 11.1 9.1 10.0 10.0 5.3 0.0

0.0 Chhetri Bahun Janajati Newar Dalit Total Caste/ethnicity

Few male respondents reported experiencing SRH problems during adolescence and they experienced social stigma, insufficient information or lack of knowledge and emotional, mental problem (Table 6.2).

Table 6.2 Per cent distribution of respondents by sex, according to caste/ethnicity and problems faced during adolescence, Gorkha, Nepal 2018 Types of problems faced during Caste/ethnicity Sex adolescence Chhetri Bahun Janajati Newar Dalit Total Female Social stigma 18.8 11.1 0.0 50.0 3.6 6.7 Insufficient information 0.0 16.7 0.0 0.0 10.7 5.8 Lack of knowledge 0.0 5.6 0.0 50.0 0.0 1.9 Emotional, mental problem 18.8 0.0 12.5 50.0 17.9 13.5 Pain in the stomach and back while menstruating 87.5 83.3 85.0 50.0 75.0 81.7 Heavy bleeding 31.3 55.6 62.5 50.0 42.9 51.0 Irregular menses 31.3 38.9 42.5 0.0 35.7 37.5 Feel shame to go to school when menstruating 0.0 27.8 2.5 50.0 14.3 10.6 Embarrassed to see organs growing 6.3 0.0 7.5 0.0 7.1 5.8 Total 16 18 40 2 28 104 Male Social stigma 100.0 0.0 33.3 0.0 100.0 50.0 Insufficient information 100.0 0.0 66.7 0.0 0.0 50.0 Lack of knowledge 0.0 0.0 33.3 0.0 0.0 16.7 Emotional, mental problem 0.0 100.0 66.7 0.0 0.0 50.0 Total 1 1 3 0 1 6

Female respondents were asked about their perception on age at menarche. Overall, the perceived age at menarche was reported as 12.7 years which was slightly higher (13.1 years) for Bahun women and lowest for Newar women (11.9 year, Table 6.3).

Table 6.3 Per cent distribution of female respondents, according to caste/ethnicity and perceived age at menarche, Gorkha, Nepal 2018 Perceived age at Caste/ethnicity menarche Chhetri Bahun Janajati Newar Dalit Total 9 0.0 0.0 0.0 0.0 1.8 0.4 10 2.5 7.7 4.3 0.0 1.8 3.8 11 5.0 5.1 7.5 45.5 17.5 10.8 12 47.5 15.4 38.7 27.3 26.3 32.9 13 22.5 28.2 29.0 18.2 31.6 27.9 14 20.0 30.8 14.0 9.1 10.5 16.7 15 2.5 12.8 5.4 0.0 8.8 6.7 16 0.0 0.0 1.1 0.0 0.0 0.4 18 0.0 0.0 0.0 0.0 1.8 0.4 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 40 39 93 11 57 240 Mean 12.6 13.1 12.6 11.9 12.6 12.7

The actual average age (13.9 years, Table 6.4) at menarche of the female respondents was higher than the perceived age at menarche (12.7 years, Table 6.3). Chhetri, Bahun and Dalit women had their menarche at age 13.9 years while the corresponding figure for Janjati was 14 years and for Newar 14.6 years.

Table 6.4 Per cent distribution of female respondents, according to caste/ethnicity and actual age at menarche, Gorkha, Nepal 2018 Caste/ethnicity Age at menarche Chhetri Bahun Janajati Newar Dalit Total 10 0.0 0.0 1.1 0.0 0.0 0.4 11 5.0 0.0 4.3 0.0 1.8 2.9 12 2.5 12.8 7.5 18.2 7.0 7.9 13 35.0 25.6 31.2 9.1 33.3 30.4 14 32.5 33.3 28.0 36.4 35.1 31.7 15 15.0 23.1 14.0 9.1 14.0 15.4 16 5.0 2.6 4.3 9.1 3.5 4.2 17 2.5 2.6 3.2 0.0 3.5 2.9 18 2.5 0.0 4.3 9.1 1.8 2.9 19 0.0 0.0 2.2 9.1 0.0 1.3 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 40 39 93 11 57 240 Mean 13.9 13.9 14.0 14.6 13.9 13.9

More (45%) female respondents said that women menstruate every 30 days and 44 per cent said every 28 days (Table 6.5). The corresponding figures reported by males were 43 per cent and 40 per cent.

Table 6.5 Per cent distribution of respondents by sex, according to caste/ethnicity and perceived frequency of menstruation (days), Gorkha, Nepal 2018 Perceived frequency of Caste/ethnicity Sex menstruation (days) Chhetri Bahun Janajati Newar Dalit Total Female 20 0.0 0.0 1.1 0.0 0.0 0.4 21 0.0 0.0 2.2 0.0 0.0 0.8 22 0.0 2.6 3.2 0.0 0.0 1.7 24 2.5 0.0 0.0 0.0 0.0 0.4 25 2.5 2.6 0.0 0.0 1.8 1.3 26 2.5 0.0 0.0 0.0 1.8 0.8 27 2.5 2.6 3.2 9.1 5.3 3.8 28 57.5 48.7 36.6 36.4 43.9 43.8 29 0.0 2.6 2.2 0.0 0.0 1.3 30 32.5 41.0 49.5 54.5 47.4 45.0 35 0.0 0.0 2.2 0.0 0.0 0.8 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 40 39 93 11 57 240 Male 10 0.0 11.1 0.0 0.0 0.0 1.7 24 0.0 0.0 10.0 0.0 0.0 3.3 25 9.1 0.0 0.0 0.0 0.0 1.7 26 0.0 0.0 5.0 0.0 10.5 5.0 27 0.0 0.0 5.0 0.0 0.0 1.7 28 45.5 55.6 30.0 100.0 36.8 40.0 30 45.5 33.3 50.0 0.0 42.1 43.3 35 0.0 0.0 0.0 0.0 5.3 1.7 DK 0.0 0.0 0.0 0.0 5.3 1.7 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 11 9 20 1 19 60

In the last six months before the survey, overall more female respondents (20%) visited health facility for RH service than their male counterparts (7%, Table 6.6). By municipalities, it is seen that

24 the largest proportion (36%) of Ajirkot women visited health facilities for RH services than their counterparts from Palungtar municipality (20%) and Siranchok rural municipality (8%, Table 6.6).

Table 6.6 Per cent distribution of respondents by sex, according to municipality and whether visited health facility for RH service in last 6 months, Gorkha, Nepal 2018 Whether visited health Name of municipality facility for RH service in Ajirkot rural Palungtar Siranchok rural Sex last 6 months municipality municipality municipality Total Female Yes 35.6 20.3 8.3 19.6 No 64.4 79.7 91.7 80.4 Total % 100.0 100.0 100.0 100.0 Total n 45 123 72 240 Male Yes 10.0 10.7 0.0 6.7 No 90.0 89.3 100.0 93.3 Total % 100.0 100.0 100.0 100.0 Total n 10 28 22 60 Both Yes 30.9 18.5 6.4 17.0 sexes No 69.1 81.5 93.6 83.0 Total Total % 100.0 100.0 100.0 100.0 Total n 55 151 94 300

Among the female respondents who visited health facility in the last 6 months, 26 per cent each visited for RH education and because of irregular menstruation while 19 per cent went to obtain FP methods and 15 per cent went for HIV&AIDS counselling/ blood test (Table 6.7). Some 13 per cent women from Ajirkot rural municipality also went for abortion service which was not reported in other two municipalities. Few males visited health facilities for RH education and FP methods.

Table 6.7 Per cent distribution of respondents by sex, according to municipality and problem for which respondent went to health facility in last 6 months, Gorkha, Nepal 2018 Municipality Problem for which respondent went Ajirkot rural Palungtar Siranchok rural Sex to health facility municipality municipality municipality Total Female To learn about RH 43.8 12.0 33.3 25.5 Abortion service 12.5 0.0 0.0 4.3 HIV&AIDS counselling/ Blood test 0.0 28.0 0.0 14.9 To get FP method 12.5 20.0 33.3 19.1 Psycho-social counselling& support 0.0 4.0 0.0 2.1 Irregular menstruation 25.0 28.0 16.7 25.5 Video x-ray 0.0 4.0 0.0 2.1 Painful urination 0.0 4.0 0.0 2.1 Delivery 0.0 0.0 16.7 2.1 Stomach ache 6.3 0.0 0.0 2.1 Total % 100.0 100.0 100.0 100.0 Total n 16 25 6 47 Male To learn about RH 0.0 100.0 0.0 75.0 To get FP method 100.0 0.0 0.0 25.0 Total % 100.0 100.0 0.0 100.0 Total n 1 3 0.0 4

Most (53%) female respondents went to HPs for RH service in the last 6 months, 34 per cent went to hospital, 6 per cent went to private clinics, 4 per cent went to pharmacies and 2 per cent went to PHC (Table 6.8). Most women (92%) said their problems were cured after visiting the health facility and all males had their problems solved (Table not shown).

Table 6.8 Per cent distribution of respondents by sex, according to municipality and service centre visited in last 6 months, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Service centre visited municipality municipality municipality Total Female Hospital 12.5 40.0 66.7 34.0 PHC 0.0 4.0 0.0 2.1 HP 87.5 40.0 16.7 53.2 Private clinic 0.0 12.0 0.0 6.4 Pharmacy 0.0 4.0 16.7 4.3 Total % 100.0 100.0 100.0 100.0 Total n 16 25 6 47 Male Hospital 0.0 66.7 0.0 50.0 HP 100.0 33.3 0.0 50.0 Total % 100.0 100.0 0.0 100.0 Total n 1 3 0 4 Both Hospital 11.8 42.9 66.7 35.3 sexes PHC 0.0 3.6 0.0 2.0 HP 88.2 39.3 16.7 52.9 Private clinic 0.0 10.7 0.0 5.9 Pharmacy 0.0 3.6 16.7 3.9 Total % 100.0 100.0 100.0 100.0 Total n 17 28 6 51

For 61 per cent of female respondents the nearest health facility is a Health Post and this proportion is highest (91%) for Ajirkot women followed by Palungtar municipality (55%) and Siranchaok rural municipality women (53%), in that order (Table 6.9). Primary Health Care Centre is nearest for about 17 per cent of women. About equal proportion (17%) women also have private facilities like pharmacies and private clinics nearest to them.

Table 6.9 Per cent distribution of respondents by sex, according to municipality and nearest health facility, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Sex Nearest health facility municipality municipality municipality Total Female Hospital 0.0 7.3 1.4 4.2 PHCC 2.2 26.8 9.7 17.1 HP 91.1 55.3 52.8 61.3 Private clinic 6.7 7.3 9.7 7.9 Pharmacy 0.0 2.4 25.0 8.8 Outreach clinic 0.0 0.0 1.4 0.4 Community hospital 0.0 0.8 0.0 0.4 Total % 100.0 100.0 100.0 100.0 Total n 45 123 72 240 Male Hospital 0.0 10.7 0.0 5.0 PHCC 0.0 25.0 13.6 16.7 HP 80.0 57.1 40.9 55.0 Private clinic 10.0 7.1 18.2 11.7 Pharmacy 10.0 0.0 22.7 10.0 Outreach clinic 0.0 0.0 4.5 1.7 Total % 100.0 100.0 100.0 100.0 Total n 10 28 22 60

In the nearby health facilities all have general treatment services and FP services are available in over two in three (68%) facilities while abortion facility is available in 24 per cent centres (Table 6.10). Responses from male respondents are similar.

Table 6.10 Per cent distribution of respondents by sex, according to municipality and types of services available at nearest health facility, Gorkha, Nepal 2018 Municipality Types of services available (Multiple Ajirkot rural Palungtar Siranchok rural Sex responses) municipality municipality municipality Total Female General treatment 97.8 95.1 100.0 97.1 Psycho-social services 0.0 8.9 0.0 4.6 HIV & various sexually transmitted infections 2.2 15.4 2.8 9.2 FP services 91.1 61.8 63.9 67.9 Abortion service 68.9 8.9 22.2 24.2 Special services for youth and adolescents 4.4 16.3 15.3 13.8 Birthing service 0.0 0.8 0.0 0.4 Maternity services 0.0 0.0 13.9 4.2 Total n 45 123 72 240 Male General treatment 100.0 100.0 100.0 100.0 Psycho-social services 0.0 10.7 0.0 5.0 HIV & various sexually transmitted infections 0.0 7.1 4.5 5.0 FP services 80.0 46.4 72.7 61.7 Abortion service 40.0 3.6 13.6 13.3 Special services for youth and adolescents 0.0 17.9 13.6 13.3 Maternity services 0.0 0.0 13.6 5.0 Total n 10 28 22 60

Over 9 in 10 female respondents said that practicing family planning methods can prevent getting pregnant; a little over 1 in 4 women also said avoiding sex and nearly 1 in 3 mentioned use of herbs or medicines (Table 6.11). Responses from males were similar.

Table 6.11 Per cent distribution of respondents by sex, according to municipality and knowledge on ways to prevent pregnancy, Gorkha, Nepal 2018 Municipality Ways to prevent pregnancy Ajirkot rural Palungtar Siranchok rural Sex (Multiple responses) municipality municipality municipality Total Female Avoid sex 62.2 21.1 15.3 27.1 Practice FP methods 62.2 98.4 98.6 91.7 Use herbs or medicines 75.6 33.3 2.8 32.1 Use withdrawal method 0.0 0.8 2.8 1.3 DK 0.0 0.8 0.0 0.4 Total n 45 123 72 240 Male Avoid sex 60.0 21.4 4.5 21.7 Practice FP methods 90.0 92.9 100.0 95.0 Use herbs or medicines 50.0 28.6 4.5 23.3 Practice safer sex 0.0 0.0 9.1 3.3 Use withdrawal method 0.0 3.6 0.0 1.7 DK 0.0 3.6 0.0 1.7 Total n 10 28 22 60

Knowledge of family planning method is universal in the project operational areas with all women and men knowing at least one method of contraception. The most well-known method among women is pill (97.1%), followed by injectables (95%), condom (94.2%), Implant/ Norplant (84.6%), Male sterilization (83.8%), Female sterilization (83.3%), IUCD (82.5%) and Emergency contraception pill (55.8%); among men, the most commonly known method is the condom (95%), followed by injectables and pill (93.3% each), male sterilization (88.3%), female sterilization (86.7%), implant/ Norplant (83.3%), IUCD (78.3), withdrawal (68.3) and Emergency contraception pill (65%, Table 6.12). Among women, knowledge of withdrawal, Lactational amenorrhea method (LAM) and calendar method is poor with only 45 per cent 42.5 per cent and 20 per cent of women respectively have ever heard of these methods. Among men, knowledge of Lactational amenorrhea method (LAM) and calendar method is poor with only 35 per cent each having ever heard of these two methods.

Table 6.12 Per cent distribution of respondents by municipality and sex having knowledge of specific contraceptive method, Gorkha, Nepal 2018 Municipality Ajirkot rural Palungtar Siranchok rural Method Sex municipality municipality municipality Total Female sterilization Female 40.0 93.5 93.1 83.3 Male 70.0 89.3 90.9 86.7 Male sterilization Female 42.2 93.5 93.1 83.8 Male 70.0 92.9 90.9 88.3 IUCD Female 64.4 88.6 83.3 82.5 Male 60.0 78.6 86.4 78.3 Injectatbles Female 88.9 94.3 100.0 95.0 Male 80.0 92.9 100.0 93.3 Implant/ Norplant Female 73.3 87.0 87.5 84.6 Male 70.0 85.7 86.4 83.3 Pill Female 95.6 99.2 94.4 97.1 Male 90.0 92.9 95.5 93.3 Condom Female 91.1 93.5 97.2 94.2 Male 90.0 92.9 100.0 95.0 Emergency contraception pill Female 44.4 57.7 59.7 55.8 Male 70.0 50.0 81.8 65.0 Lactational amenorrhea method (LAM) Female 51.1 49.6 25.0 42.5 Male 20.0 50.0 22.7 35.0 Calendar method Female 13.3 14.6 33.3 20.0 Male 10.0 42.9 36.4 35.0 Withdrawal Female 2.2 52.0 59.7 45.0 Male 60.0 60.7 81.8 68.3

The main sources of FP methods in Ajirkot rural municipality are Health Posts (87%), hospitals (73%) and FCHVs (62%) for both male and female respondents and this pattern is similar in other two areas (Table 6.13). Private clinics and pharmacies are also reported in all three areas but their share is less than the government sources such as hospitals, health posts and FCHVs. As part of their voluntary work, FCHVs carry pills and condoms when they meet with local women in their communities.

Table 6.13 Per cent distribution of respondents by municipality according to sex and source of family planning methods (multiple responses), Gorkha, Nepal 2018 Sex Municipality Source of FP methods Female Male Total Ajirkot rural municipality Hospital 75.6 60.0 72.7 PHC 8.9 10.0 9.1 HP 84.4 100.0 87.3 Private clinic 13.3 0.0 10.9 Pharmacy 31.1 50.0 34.5 FCHV 62.2 60.0 61.8 Total n 45 10 55 Palungtar municipality Hospital 52.8 50.0 52.3 PHC 24.4 17.9 23.2 HP 79.7 78.6 79.5 Private clinic 30.9 28.6 30.5 Pharmacy 38.2 32.1 37.1 FCHV 16.3 17.9 16.6 Total n 123 28 151 Siranchok rural municipality Hospital 56.9 63.6 58.5 PHC 11.1 13.6 11.7 HP 95.8 90.9 94.7 Private clinic 22.2 22.7 22.3 Pharmacy 63.9 72.7 66.0 FCHV 26.4 31.8 27.7 Total n 72 22 94

The contraceptive prevalence rate (CPR) among currently married women age 15-49 is 44.5 per cent with 44 per cent using modern methods (Table 6.14). This rate is higher than the CPR of 37 per cent reported for Gandaki Province (MOH, New Era and ICF. 2017). Among married women, injectables popularly known as Depo is the most commonly used method (17.3%), followed by the pill (5.8%), Male Sterilization and Implant/ Norplant (5.2% each), IUCD and condom (3.7% each ) and Female Sterilization (3.1%, Table 6.14).

The contraceptive prevalence rate varies with age, from 33 per cent among married women age 15- 19 to a high of 52 per cent among women age 35-39. Modern contraceptive method peaks at 50 per cent among married women age 30-34 and also for women age 40-44. Among adolescent married women CPR is 33 per cent which is higher than the national rate of 15 per cent (MOH, New Era and ICF. 2017).

Table 6.14 Per cent distribution of all and currently married women age 15-49 by family planning methods currently used, according to age, Gorkha, Nepal 2018 All women Female Male Any Number Steriliz Steriliz Inject Implant/ Con Withdr Any modern of Age ation ation IUCD ables Norplant Pills dom awal method method women 15-19 0.0 0.0 1.4 4.3 1.4 2.9 0.0 0.0 10.1 10.1 69 20-24 0.0 1.4 2.8 11.1 6.9 4.2 4.2 0.0 30.6 30.6 72 25-29 2.7 2.7 2.7 24.3 5.4 5.4 0.0 0.0 43.2 43.2 37 30-34 3.7 0.0 7.4 11.1 0.0 7.4 7.4 0.0 37.0 37.0 27 35-39 6.9 3.4 3.4 17.2 3.4 3.4 3.4 3.4 44.8 41.4 29 40-44 0.0 8.3 0.0 16.7 4.2 4.2 4.2 0.0 37.5 37.5 24 45-49 7.1 17.9 0.0 3.6 0.0 0.0 0.0 0.0 28.6 28.6 28 Total 2.1 3.5 2.4 11.5 3.5 3.8 2.4 0.3 29.7 29.4 286 Currently married women Female Male Any Number Steriliz Steriliz Inject Implant/ Con Withdr Any modern of Age ation ation IUCD ables Norplant Pills dom awal method method women 15-19 0.0 0.0 4.8 14.3 4.8 9.5 0.0 0.0 33.3 33.3 21 20-24 0.0 1.8 3.6 14.3 8.9 5.4 5.4 0.0 39.3 39.3 56 25-29 3.0 3.0 3.0 27.3 6.1 6.1 0.0 0.0 48.5 48.5 33 10. 30-34 5.0 0.0 10.0 15.0 0.0 0 10.0 0.0 50.0 50.0 20 35-39 8.0 4.0 4.0 20.0 4.0 4.0 4.0 4.0 52.0 48.0 25 40-44 0.0 11.1 0.0 22.2 5.6 5.6 5.6 0.0 50.0 50.0 18 45-49 11.1 27.8 0.0 5.6 0.0 0.0 0.0 0.0 44.4 44.4 18 Total 3.1 5.2 3.7 17.3 5.2 5.8 3.7 0.5 44.5 44.0 191

Chapter Seven: Safe abortion and SRH problems and access to services

Survey respondents were asked about the types of sexual and reproductive health and abortion related problems found in their community and the results show that in Ajirkot rural municipality the most common problem is the lack of sex education (95%), followed by lack of FP services (80%), adolescent pregnancy (42%), child/early marriage (20%), rape (9%) and sexual violence (2%, Table 7.1). Similar problems are reported in other two municipalities. In Siranchok rural municipality a few respondents also mentioned uterine problem, stomach ache during menses and lack of RH knowledge.

Table 7.1 Per cent distribution of respondents by sex, according to municipality and SRH problems in community (multiple responses), Gorkha, Nepal 2018 Sex Municipality SRH problems in community Female Male Total Ajirkot rural Lack of Sex Education 93.3 100.0 94.5 municipality Lack of FP services 80.0 80.0 80.0 Adolescence pregnancy 42.2 40.0 41.8 Child/ Early marriage 17.8 30.0 20.0 Rape 11.1 0.0 9.1 Sexual Violence 2.2 0.0 1.8 Total n 45 10 55 Palungtar Lack of Sex Education 61.8 60.7 61.6 municipality Child/ Early marriage 61.0 50.0 58.9 Lack of FP services 42.3 32.1 40.4 No problem 22.8 28.6 23.8 Adolescence pregnancy 15.4 21.4 16.6 Rape 11.4 17.9 12.6 Sexual Violence 5.7 14.3 7.3 Don't know 4.1 0.0 3.3 Total n 123 28 151 Siranchok Child/ Early marriage 72.2 59.1 69.1 rural Adolescence pregnancy 47.2 27.3 42.6 municipality Lack of Sex Education 31.9 36.4 33.0 Lack of FP services 20.8 18.2 20.2 No problem 6.9 18.2 9.6 Sexual Violence 4.2 9.1 5.3 Uterine problems 4.2 0.0 3.2 Rape 1.4 4.5 2.1 Stomachache during menses 0.0 4.5 1.1 Lack of RH knowledge 1.4 0.0 1.1 Don't know 6.9 4.5 6.4 Total n 72 22 94

A number of barriers are reported in accessing SRH and safe abortion services by the survey respondents. Highest proportion (98%) of Ajirkot respondents said that abortion is unsafe there and this proportion is lower in Palungtar (48%) and Siranchok municipalities (34%, Table 7.2). Lack of sex education is another important barrier in Ajirkot as 93 per cent respondents mentioned it and in Palungtar 58 per cent mentioned it while in Siranchok this proportion is lowest at 30 per cent (Table 7.2).Lack of FP service, adolescent pregnancy, child/ early marriage and sexual violence are also reported as barriers to accessing SRH and safe abortion services.

Table 7.2 Per cent distribution of respondents by sex, according to municipality and barriers in accessing SRH and abortion services (multiple responses), Gorkha, Nepal 2018 Barriers in accessing SRH and abortion Sex Municipality services Female Male Total Ajirkot rural Unsafe Abortion 100.0 90.0 98.2 municipality Lack of Sex Education 93.3 90.0 92.7 Lack of FP services 68.9 70.0 69.1 Adolescence pregnancy 15.6 30.0 18.2 Child/ Early marriage 2.2 20.0 5.5 Sexual Violence 0.0 10.0 1.8 Total n 45 10 55 Palungtar Lack of Sex Education 57.7 57.1 57.6 municipality Child/ Early marriage 52.0 42.9 50.3 Unsafe Abortion 48.8 42.9 47.7 Lack of FP services 28.5 25.0 27.8 No problem 23.6 28.6 24.5 Rape 17.9 25.0 19.2 Adolescence pregnancy 13.8 14.3 13.9 Sexual Violence 4.1 10.7 5.3 Sex discrimination 1.6 0.0 1.3 Don't know 4.9 0.0 4.0 Total n 123 28 151 Siranchok rural Child/ Early marriage 54.2 40.9 51.1 municipality Unsafe Abortion 34.7 31.8 34.0 Adolescence pregnancy 34.7 18.2 30.9 Lack of Sex Education 27.8 36.4 29.8 Lack of FP services 23.6 22.7 23.4 No problem 11.1 18.2 12.8 Sexual Violence 1.4 4.5 2.1 Rape 1.4 4.5 2.1 Lack of awareness 1.4 4.5 2.1 Services are not good 1.4 0.0 1.1 Long distance to seek care 1.4 0.0 1.1 Hiding one's problem 1.4 0.0 1.1 Sex discrimination 0.0 4.5 1.1 Don't know 9.7 18.2 11.7 Total n 72 22 94

Ajirkot rural municipality respondents in the survey said that main problems related to the use and access of SRH services faced by WRA and adolescents are lack of proper physical facility at health facility (90.9%), untrained HWs (76.4%), very low knowledge about Sexual Health (69%), irregular supply of drugs, HP building being unfriendly (Table 7.3).

This pattern is similar in Palungtar municipality while in Siranchok low knowledge about Sexual Health tops the list (70%) followed by untrained HWs (62%, Table 7.3).

Table 7.3 Per cent distribution of respondents by sex, according to municipality and problems of accessing SRH services (multiple responses), Gorkha, Nepal 2018 Sex Municipality Problems in accessing SRH services Female Male Total Ajirkot rural Physical facility at health facility not good 93.3 80.0 90.9 municipality Untrained HWs 75.6 80.0 76.4 Very low knowledge about Sexual Health 73.3 50.0 69.1 Irregular supply of drugs 55.6 60.0 56.4 HP building is unfriendly 13.3 10.0 12.7 No proper equipment 8.9 30.0 12.7 Behaviour of HWs 4.4 10.0 5.5 Hesitation to discuss problem with male HWs 0.0 10.0 1.8 Total n 45 10 55 Palungtar Physical facility at health facility not good 71.5 64.3 70.2 municipality Very low knowledge about Sexual Health 63.4 53.6 61.6 Untrained HWs 39.8 39.3 39.7 Irregular supply of drugs 26.0 21.4 25.2 Hesitation to discuss problem with male HWs 23.6 10.7 21.2 No proper equipment 12.2 21.4 13.9 HP building is unfriendly 11.4 3.6 9.9 Behaviour of HWs 7.3 0.0 6.0 Don't know 6.5 14.3 7.9 Total n 123 28 151 Siranchok rural Very low knowledge about Sexual Health 68.1 81.8 71.3 municipality Untrained HWs 38.9 59.1 43.6 Physical facility at health facility not good 27.8 22.7 26.6 Irregular supply of drugs 20.8 22.7 21.3 No proper equipment 18.1 27.3 20.2 Hesitation to discuss problem with male HWs 20.8 9.1 18.1 Behaviour of HWs 4.2 0.0 3.2 Feeling shy to express one's problem 2.8 4.5 3.2 HP building is unfriendly 1.4 4.5 2.1 Early pregnancy and childbirth 1.4 0.0 1.1 Uterine problems 1.4 0.0 1.1 Don't know 12.5 9.1 11.7 Total n 72 22 94

Ajirkot rural municipality respondents in the survey said that main problems related to the use and access of safe abortion services faced by WRA and adolescents are lack of equipment at health facility (76%), iirregular supply of drugs (71%), untrained health workers (66%), etc and this pattern is similar in other two municipalities but very low knowledge about Sexual Health tops the list in these municipalities (Table 7.4).

Table 7.4 Per cent distribution of respondents by sex, according to municipality and problems of accessing safe abortion services (multiple responses), Gorkha, Nepal 2018 Sex Municipality Problems in using and accessing safe abortion services Female Male Total Ajirkot rural No proper equipment 82.2 50.0 76.4 municipality Irregular supply of drugs 75.6 50.0 70.9 Untrained HWs 64.4 70.0 65.5 Physical facility at health facility not good 22.2 60.0 29.1 Very low knowledge about Sexual Health 17.8 50.0 23.6 Hesitation to discuss problem with male HWs 22.2 10.0 20.0 HP building is unfriendly 13.3 20.0 14.5 Behaviour of HWs 6.7 0.0 5.5 Total n 45 10 55 Palungtar Physical facility at health facility not good 67.5 71.4 68.2 municipality Very low knowledge about Sexual Health 58.5 57.1 58.3 Untrained HWs 30.9 32.1 31.1 No proper equipment 26.8 25.0 26.5 Hesitation to discuss problem with male HWs 26.8 17.9 25.2 HP building is unfriendly 22.0 17.9 21.2 Irregular supply of drugs 17.9 28.6 19.9 Behaviour of HWs 3.3 0.0 2.6 Uterine problems 0.8 0.0 0.7 Don't know 6.5 3.6 6.0 Total n 123 28 151 Siranchok Very low knowledge about Sexual Health 59.7 68.2 61.7 rural Untrained HWs 40.3 50.0 42.6 municipality Physical facility at health facility not good 30.6 22.7 28.7 Irregular supply of drugs 16.7 13.6 16.0 No proper equipment 18.1 9.1 16.0 Hesitation to discuss problem with male HWs 18.1 9.1 16.0 HP building is unfriendly 11.1 18.2 12.8 Early pregnancy and childbirth 2.8 0.0 2.1 Behaviour of HWs 1.4 0.0 1.1 Feeling shy to express one's problem 0.0 4.5 1.1 Don't know 12.5 13.6 12.8 Total n 72 22 94

Ajirkot rural municipality respondents in the survey said that main problems related to the use of SRH services faced by WRA and adolescents are lack of resource (33%), service centre too far (31%), untrained health workers (29%), etc and this pattern is similar in other two municipalities (Table 7.5). Fairly large number of problems was mentioned by the respondents such as lack of awareness/ illiterate, lack of regular medical/ medicines supply, lack of appropriate equipments, lack of transport and media, hesitate to share one's problem to male HW, lack of RH education/ education, lack of sex education, lack of FP services, behaviour of HWs and poor physical facilities.

Table 7.5 Per cent distribution of respondents by sex, according to municipality and problems of using SRH services (multiple responses), Gorkha, Nepal 2018 Sex Total Municipality Problems of using SRH services Female Male Ajirkot rural Lack of resources 31.1 40.0 32.7 municipality Seeking care too far 31.1 30.0 30.9 Lack of trained /experienced health workers 26.7 40.0 29.1 Lack of awareness/ illiterate 26.7 20.0 25.5 Lack of regular medical/ medicines supply 22.2 30.0 23.6 Lack of appropriate equipments 26.7 0.0 21.8 Lack of transport and media 20.0 20.0 20.0 Hesitate to share one's problem to male HW 4.4 0.0 3.6 Lack of RH education/ education 4.4 0.0 3.6 Lack of sex education 2.2 0.0 1.8 Lack of FP services 2.2 0.0 1.8 Behaviour of HWs 2.2 0.0 1.8 Poor physical facilities 0.0 10.0 1.8 Total n 45 10 55 Palungtar Lack of awareness/ illiterate 32.5 39.3 33.8 municipality Seeking care too far 11.4 17.9 12.6 Lack of sex education 12.2 7.1 11.3 Early pregnancy 10.6 10.7 10.6 Lack of regular medical/ medicines supply 8.1 7.1 7.9 Hesitate to share one's problem to male HW 6.5 7.1 6.6 Early/ Child marriage 4.9 10.7 6.0 Lack of trained /experienced health workers 4.1 3.6 4.0 Lack of RH education/ education 1.6 3.6 2.0 Lack of appropriate equipments 1.6 0.0 1.3 Poor physical facilities 1.6 0.0 1.3 Behaviour of HWs 0.8 0.0 0.7 Lack of confidentiality 0.8 0.0 0.7 Lack of counselling services 0.8 0.0 0.7 Lack of skills 0.8 0.0 0.7 Sexual abuse 0.8 0.0 0.7 Don't know 25.2 21.4 24.5 Total n 123 28 151 Siranchok Lack of awareness/ illiterate 73.6 68.2 72.3 rural Lack of trained /experienced health workers 11.1 18.2 12.8 municipality Seeking care too far 6.9 13.6 8.5 Hesitate to share one's problem to male HW 8.3 0.0 6.4 Early/ Child marriage 4.2 9.1 5.3 Lack of resources 2.8 9.1 4.3 Lack of appropriate equipments 4.2 0.0 3.2 Lack of RH education/ education 2.8 4.5 3.2 Stomachache during menses 2.8 0.0 2.1 Unsafe sexual activities 1.4 4.5 2.1 Lack of sex education 0.0 4.5 1.1 Lack of confidentiality 1.4 0.0 1.1 Irregular menses 1.4 0.0 1.1 Don't know 1.4 4.5 2.1 Total n 72 22 94

Ajirkot rural municipality respondents in the survey said that main problems related to the use of abortion services faced by WRA and adolescents are lack of trained health workers (67%), service

35 centre too far (44%), untrained health workers (29%), lack of appropriate equipments (29%), etc and this pattern is similar in other two municipalities (Table 7.6).

Table 7.6 Per cent distribution of respondents by sex, according to municipality and problems of using abortion services (multiple responses), Gorkha, Nepal 2018 Sex Total Municipality Problems in using abortion services Female Male Ajirkot rural Lack of trained /experienced health workers 68.9 60.0 67.3 municipality Seeking care too far 46.7 30.0 43.6 Lack of appropriate equipments 26.7 40.0 29.1 Lack of transport and media 13.3 40.0 18.2 Lack of regular medical/ medicines supply 17.8 0.0 14.5 Lack of awareness/ illiterate 11.1 20.0 12.7 Lack of resources 8.9 0.0 7.3 Hiding one's problems 0.0 10.0 1.8 Poor physical facilities 2.2 0.0 1.8 Lack of access to health services 2.2 0.0 1.8 Total n 45 10 55 Palungtar Seeking care too far 26.0 35.7 27.8 municipality Lack of confidentiality 23.6 14.3 21.9 Lack of awareness/ illiterate 23.6 7.1 20.5 Lack of appropriate equipments 8.1 7.1 7.9 Lack of trained /experienced health workers 7.3 3.6 6.6 Poor physical facilities 4.1 3.6 4.0 Lack of sex education 2.4 3.6 2.6 Hesitate to share one's problem to male HW 2.4 3.6 2.6 Lack of RH education/ education 1.6 7.1 2.6 Lack of FP services 2.4 0.0 2.0 Early/ Child marriage 0.8 3.6 1.3 Lack of safe abortion facility 0.0 7.1 1.3 Lack of regular medical/ medicines supply 0.8 0.0 0.7 Lack of resources 0.0 3.6 0.7 Hiding one's problems 0.8 0.0 0.7 Social stigma 0.8 0.0 0.7 Women go for unsafe abortion 0.8 0.0 0.7 Seeking abortion service from pharmacy 0.0 3.6 0.7 Don't know 26.0 28.6 26.5 Total n 123 28 151 Siranchok Lack of awareness/ illiterate 56.9 63.6 58.5 rural Lack of appropriate equipments 12.5 22.7 14.9 municipality Seeking care too far 9.7 4.5 8.5 Lack of trained /experienced health workers 8.3 4.5 7.4 Poor physical facilities 2.8 9.1 4.3 Lack of resources 1.4 9.1 3.2 Lack of transport 4.2 0.0 3.2 Lack of safe abortion facility 2.8 0.0 2.1 Lack of knowledge about safe abortion 2.8 0.0 2.1 Abortion risky 2.8 0.0 2.1 Hiding one's problems 0.0 4.5 1.1 Lack of confidentiality 1.4 0.0 1.1 Son preference 0.0 4.5 1.1 Don't know 13.9 13.6 13.8 Total n 72 22 94

Fairly large number of problems was mentioned by the respondents such as lack of awareness/ illiterate, lack of regular medical/ medicines supply, lack of transport and media, hesitate to share one's problem to male HW, lack of RH education/ education, lack of sex education, lack of FP services, behaviour of HWs and poor physical facilities.

Almost every (95%) adolescent and youth and other women and men of reproductive age go to HP for RH services in Siranchok rural municipality and this is highest in Ajirkot (86%) as well as Palungtar municipality (63%, Table 7.7). The second most important source of service is FCHV in Ajirkot (80%) and Palungtar (52%) while in Siranchok Government hospital (49%) is the second most important source of service.

Table 7.7 Per cent distribution of respondents by sex, according to municipality and place where people go for SRH services (multiple responses), Gorkha, Nepal 2018 Sex Municipality Place where people go for SRH services Female Male Total Ajirkot rural Traditional healers 2.2 0.0 1.8 municipality FCHV 77.8 90.0 80.0 Government hospitals 15.6 20.0 16.4 PHC 11.1 20.0 12.7 HP 88.9 70.0 85.5 Pharmacy 26.7 30.0 27.3 Total n 45 10 55 Palungtar Traditional healers 10.6 14.3 11.3 municipality FCHV 51.2 57.1 52.3 Government hospitals 43.9 32.1 41.7 PHC 30.1 28.6 29.8 HP 60.2 75.0 62.9 Pharmacy 23.6 14.3 21.9 Private hospitals 2.4 0.0 2.0 Community hospitals 1.6 0.0 1.3 Don't know 1.6 0.0 1.3 Total n 123 28 151 Siranchok Traditional healers 2.8 4.5 3.2 rural FCHV 25.0 13.6 22.3 municipality Government hospitals 45.8 59.1 48.9 PHC 13.9 13.6 13.8 HP 94.4 95.5 94.7 Pharmacy 68.1 81.8 71.3 School 0.0 4.5 1.1 Total n 72 22 94

Most (96%) adolescent and youth and other women and men of reproductive age go to government facilities such as hospital and HP forabortion counselling and service in Ajirkot and this is highest (88% visiting HP) in Siranchok rural municipality while in Palungtar the proportion of people going to government hospital is highest (62%, Table 7.8).High proportion (62%) of people from Siranchok rural municipality also visit pharmacy for abortion counselling and service.

Table 7.8 Per cent distribution of respondents by sex, according to municipality and place where people go for abortion counselling and service (multiple responses), Gorkha, Nepal 2018 Sex Municipality Place where people go for abortion counselling and service Female Male Total Ajirkot rural Traditional healers 2.2 0.0 1.8 municipality FCHV 6.7 20.0 9.1 Government hospitals 97.8 90.0 96.4 PHC 11.1 10.0 10.9 HP 97.8 90.0 96.4 Pharmacy 2.2 10.0 3.6 Total n 45 10 55 Palungtar Traditional healers 15.4 14.3 15.2 municipality FCHV 53.7 50.0 53.0 Government hospitals 63.4 57.1 62.3 PHC 28.5 25.0 27.8 HP 34.1 42.9 35.8 Pharmacy 30.1 17.9 27.8 Private hospitals/ clinics 4.1 7.1 4.6 Community hospitals 1.6 0.0 1.3 Total n 123 28 151 Siranchok rural Traditional healers 1.4 9.1 3.2 municipality FCHV 22.2 13.6 20.2 Government hospitals 51.4 59.1 53.2 PHC 13.9 13.6 13.8 HP 91.7 77.3 88.3 Pharmacy 56.9 77.3 61.7 MarieStopes 1.4 0.0 1.1 Private hospitals/ clinics 1.4 0.0 1.1 Total n 72 22 94

The respondents were asked about the types of services available at the service centres they visit for RH and other services and most (over 95%) respondents from Ajirkot said FP services are available and about one quarter (24%) respondents said abortion service is also available (Table 7.9).

Table 7.9 Per cent distribution of respondents by sex, according to municipality and types of services available (multiple responses), Gorkha, Nepal 2018 Sex Municipality Types of services available Female Male Total Ajirkot rural Counselling 11.1 20.0 12.7 municipality HIV&AIDS/ STI 2.2 0.0 1.8 FP services 93.3 100.0 94.5 Abortion services 24.4 20.0 23.6 Special care of adolescents 33.3 30.0 32.7 Total n 45 10 55 Palungtar Counselling 86.2 75.0 84.1 municipality Psychosocial counselling 9.8 7.1 9.3 HIV&AIDS/ STI 29.3 28.6 29.1 FP services 65.0 57.1 63.6 Abortion services 56.1 46.4 54.3 Special care of adolescents 17.9 21.4 18.5 Total n 123 28 151 Siranchok rural Counselling 88.9 95.5 90.4 municipality HIV&AIDS/ STI 8.3 0.0 6.4 FP services 77.8 77.3 77.7 Abortion services 31.9 40.9 34.0 Special care of adolescents 22.2 27.3 23.4 General treatment 19.4 18.2 19.1 Emergency service 1.4 0.0 1.1 Total n 72 22 94

In Siranchik rural municipality and Palungtar municipality counselling service is reported by highest proportions (90% and 84% respectively) of respondents but second highest proportion f respondents mentioned about the availability of FP services (Table 7.9). Of the three municipalities, highest proportion (54%) of respondents from Palungtar reported the availability of abortion service and second highest (34%) proportion of respondents reported about the availability of abortion service in Siranchok.

Overall, in three municipalities combined, the quality of FP and abortion services was rated as being of good quality by about 20 per cent respondents (Table 7.10). Quality of service was rated good by about 1 in 3 respondents (35%) in Palungtar. Only 36 per cent respondents rated the services as satisfactory.

Table 7.10 Per cent distribution of respondents by sex, according to municipality and quality of SRH and abortion services in the community, Gorkha, Nepal 2018 Quality of SRH services in your Quality of safe abortion services in community your community Municipality Sex Sex Ajirkot rural municipality Female Male Total Female Male Total Good quality 4.4 30.0 9.1 0.0 10.0 1.8 Poor quality 35.6 30.0 34.5 55.6 60.0 56.4 Satisfactory 46.7 40.0 45.5 33.3 30.0 32.7 Don't know 13.3 0.0 10.9 11.1 0.0 9.1 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 45 10 55 45 10 55 Palungtar municipality Good quality 34.1 35.7 34.4 34.1 39.3 35.1 Poor quality 35.8 32.1 35.1 35.0 32.1 34.4 Satisfactory 22.0 25.0 22.5 20.3 21.4 20.5 Don't know 8.1 7.1 7.9 10.6 7.1 9.9 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 123 28 151 123 28 151 Siranchok rural municipality Poor quality 12.5 13.6 12.8 22.2 3.0 19.0 Satisfactory 75.0 77.3 75.5 62.5 15.0 60.0 Don't know 12.5 9.1 11.7 15.3 4.0 15.0 Total % 100.0 100.0 100.0 100.0 22.0 94.0 Total n 72 22 94 72 22 94 All three Good quality 18.3 21.7 19.0 17.5 20.0 18.0 Poor quality 28.8 25.0 28.0 35.0 30.0 34.0 Satisfactory 42.5 46.7 43.3 35.4 40.0 36.3 Don't know 10.4 6.7 9.7 12.1 10.0 11.7 Total % 100.0 100.0 100.0 100.0 100.0 100.0 Total n 240 60 300 240 60 300

In Siranchok rural municipality, in respect of RH services, about 4 in 5 (81%) respondents said that the quality services and supply of drugs need to be improved and this was mentioned by about half of respondents in the other two areas (53 % in Ajirkot and 54 % in Palungtar, Table 7.11). Higher proportion of respondents (55% in Ajirkot, 57% in Palungtar and 72% in Siranchok) suggested for the improvements of quality services and supply of drugs on safe abortion services in all three areas.

Respondents from Ajirkot (87%) and Palungtar (62%) suggested for the improvement of physical infrastructure while this was not much pronounced by Siranchok respondents (Table 7.11). Training

39 of health workers was suggested by 69 per cent of respondents in Ajirkot while the corresponding figures for Siranchok and Palungtar were 62 per cent and 58 per cent respectively.

Table 7.11 Per cent distribution of respondents by sex, according to municipality and Suggestions for improvement of SRH and abortion services (Multiple responses), Gorkha, Nepal 2018 Suggestions for improvement of Suggestions to improve abortion Municipality SRH services service Sex Sex Ajirkot rural municipality Female Male Total Female Male Total Good physical infrastructure 88.9 80.0 87.3 22.2 50.0 27.3 Training of health workers 46.7 60.0 49.1 71.1 60.0 69.1 Quality services and drugs 51.1 60.0 52.7 51.1 70.0 54.5 Good FP education 37.8 20.0 34.5 62.2 50.0 60.0 Total n 45 10 55 45 10 55 Palungtar municipality Good physical infrastructure 61.8 64.3 62.3 62.6 67.9 63.6 Training of health workers 57.7 50.0 56.3 58.5 57.1 58.3 Quality services and drugs 52.0 60.7 53.6 57.7 53.6 57.0 Good FP education 32.5 25.0 31.1 29.3 17.9 27.2 Awareness generation programs 2.4 0.0 2.0 1.6 0.0 1.3 Ensure confidentiality 0.0 0.0 0.0 0.8 0.0 0.7 Don't know 4.1 0.0 3.3 2.4 3.6 2.6 Total n 123 28 151 123 28 151 Siranchok rural municipality Good physical infrastructure 12.5 18.2 13.8 33.3 18.2 29.8 Training of health workers 63.9 72.7 66.0 61.1 63.6 61.7 Quality services and drugs 84.7 68.2 80.9 77.8 54.5 72.3 Good FP education 22.2 22.7 22.3 19.4 18.2 19.1 Awareness generation programs 5.6 13.6 7.4 2.8 9.1 4.3 No X-ray to determine sex 0.0 0.0 0.0 0.0 4.5 1.1 Regular supervision 2.8 0.0 2.1 0.0 0.0 0.0 Don't know 1.4 0.0 1.1 1.4 0.0 1.1 Total n 72 22 94 72 22 94

Chapter Eight: Marriage, fertility, abortion and sexuality education Of the total 300 respondents, 78 per cent were married and by sex more (80.4%) females were married than males (68.3%). Among the married women of all three municipalities, the median age at marriage was 17 years and for males it was 21 years (Table 8.1).

Table 8.1 Per cent distribution of respondents by sex, according to municipality and age at marriage, Gorkha, Nepal 2018 Sex Municipality Age at marriage Female Male Total Ajirkot rural 12-14 2.8 0.0 2.4 municipality 15-19 55.6 20.0 51.2 20-24 33.3 60.0 36.6 25-29 8.3 20.0 9.8 Total % 100.0 100.0 100.0 Total n 36 5 41 Median 19 22 19 Palungtar 12-14 11.2 0.0 9.4 municipality 15-19 61.2 31.6 56.4 20-24 27.6 47.4 30.8 25-29 0.0 10.5 1.7

30-34 0.0 10.5 1.7 Total % 100.0 100.0 100.0 Total n 98 19 117 Median 17 21 18

Siranchok rural 12-14 6.8 0.0 5.3 municipality 15-19 72.9 29.4 63.2 20-24 15.3 47.1 22.4 25-29 3.4 11.8 5.3 30-34 0.0 11.8 2.6

35 1.7 0.0 1.3 Total % 100.0 100.0 100.0 Total n 59 17 76 Median 17 21 18 All three 12-14 8.3 0.0 6.8 15-19 63.7 29.3 57.7 20-24 24.9 48.8 29.1 25-29 2.6 12.2 4.3 30-34 0.0 9.8 1.7 35 0.5 0.0 0.4 Total % 100.0 100.0 100.0 Total n 193 41 234 Median 17 21 18

Over 6 in 10 women get married between age 15-19 where as among males nearly half (48.8%) get married between age 20-24 implying in terms of age some 5 years’ gap between husbands and wives (Table 8.1). Most females (73%) got married between age 15-19 in Siranchok than in other two municipalities (61% in Palungtar and 56% in Ajirkot). Despite being an urban area, females’ mean age at marriage is the lowest (17.5 years) in Palunbgtar than in other two areas (18 years in Siranchok and 18.9 years in Ajirkot, Table 8.1).

Table 8.2 shows age at marriage of respondents by caste/ethnicity, age and sex. The mean age at marriage of females is the lowest (17.1 years) among Dalit community and highest among the Bahun caste (18.4 years, Table 8.2).

Table 8.2 Per cent distribution of respondents by sex, according to caste/ethnicity and age at marriage, Gorkha, Nepal 2018 Sex Caste/ethnicity Age at marriage Female Male Total Chhetri 12-14 12.1 0.0 9.8 15-19 57.6 37.5 53.7 20-24 30.3 50.0 34.1 30-34 0.0 12.5 2.4 Total % 100.0 100.0 100.0 Total n 33 8 41 Mean 18.1 20.9 18.6 Bahun 12-14 2.9 0.0 2.3 15-19 64.7 11.1 53.5 20-24 26.5 55.6 32.6 25-29 5.9 33.3 11.6 Total % 100.0 100.0 100.0 Total n 34 9 43 Mean 18.4 23.4 19.4 Janajati 12-14 9.6 0.0 8.0 15-19 60.3 7.1 51.7 20-24 24.7 57.1 29.9 25-29 4.1 14.3 5.7 30-34 0.0 21.4 3.4 35 1.4 0.0 1.1 Total % 100.0 100.0 100.0 Total n 73 14 87 Mean 18.2 24.2 19.2 Newar 15-19 80.0 0.0 72.7 20-24 20.0 100.0 27.3 Total % 100.0 100.0 100.0 Total n 10 1 11 Mean 17.4 20.0 17.6 Dalit 12-14 9.3 0.0 7.7 15-19 69.8 77.8 71.2 20-24 20.9 22.2 21.2 Total % 100.0 100.0 100.0 Total n 43 9 52 Mean 17.1 18.6 17.3

The average age at first birth among females was 20 years for all three municipalities combined and it was highest (20.5 years) in Siranchok, followed by Ajirkot (21 years) and Palungtar (19.3 years, Table 8.3). Interestingly, despite being an urban area some women had birth even before age 15.

Table 8.3 Per cent distribution of respondents by sex, according to municipality and age at first birth, Gorkha, Nepal 2018 Municipality Sex Total Ajirkot rural Age at first child Female Male municipality 15-19 34.4 0.0 29.7 20-24 53.1 60.0 54.1 25-29 12.5 40.0 16.2 Total % 100.0 100.0 100.0 Total n 32 5 37 Mean 21.0 24.2 21.5 Palungtar <15 2.4 0.0 2.1 municipality 15-19 56.1 0.0 48.4 20-24 40.2 38.5 40.0 25-29 1.2 46.2 7.4 30-34 0.0 7.7 1.1 35-36 0.0 7.7 1.1 Total % 100.0 100.0 100.0 Total n 82 13 95 Mean 19.3 25.9 20.2 Siranchok 15-19 40.0 21.4 36.2 rural 20-24 49.1 28.6 44.9 municipality 25-29 9.1 28.6 13.0 30-34 0.0 21.4 4.3 35-36 1.8 0.0 1.4 Total % 100.0 100.0 100.0 Total n 55 14 69 Mean 20.5 24.9 21.4 All three <15 1.2 0.0 1.0 15-19 46.7 9.4 40.8 20-24 45.6 37.5 44.3 25-29 5.9 37.5 10.9 30-34 0.0 12.5 2.0 35-36 0.6 3.1 1.0 Total % 100.0 100.0 100.0 Total n 169 32 201 Mean 20.0 25.2 20.8

Among the different caste/ethnic groups, Dalit had their first child the earliest (19 years), followed by Chhetri (19.8 years), Janajati (20.5 years) and Bahun (22.7 years, Table 8.4). Some Janajati women had their first child even before age 15.

Table 8.4 Per cent distribution of respondents by sex, according to caste/ethnicity and age at first birth, Gorkha, Nepal 2018 Sex Caste/ethnicity Age at first child Female Male Total Chhetri 15-19 39.3 25.0 36.1 20-24 57.1 50.0 55.6 25-29 3.6 12.5 5.6 35-36 0.0 12.5 2.8 Total % 100.0 100.0 100.0 Total n 28 8 36 Mean 19.8 23.4 20.6 Bahun 15-19 34.4 0.0 27.5 20-24 56.3 12.5 47.5 25-29 9.4 87.5 25.0 Total % 100.0 100.0 100.0 Total n 32 8 40 Mean 20.7 26.5 21.9 Janajati <15 3.2 0.0 2.8 15-19 44.4 0.0 38.9 20-24 41.3 33.3 40.3 25-29 9.5 22.2 11.1 30-34 0.0 44.4 5.6 35-36 1.6 0.0 1.4 Total % 100.0 100.0 100.0 Total n 63 9 72 Mean 20.5 27.3 21.3 Newar 15-19 62.5 0.0 55.6 20-24 37.5 0.0 33.3 25-29 0.0 100.0 11.1 Total % 100.0 100.0 100.0 Total n 8 1 9 Mean 19.0 26.0 19.8 Dalit 15-19 63.2 16.7 56.8 20-24 36.8 66.7 40.9 25-29 0.0 16.7 2.3 Total % 100.0 100.0 100.0 Total n 38 6 44 Mean 19.0 22.3 19.5

Using data from births in the last 12 months from the female respondent’s age specific fertility rate and total fertility rate have been estimated for the three municipalities of Gorkha.

Table 8.5 Age specific fertility rate per 1000 women Age Age specific fertility rate per 1000 women 15-19 65.4 20-24 114.9 25-29 244.4 30-34 76.9 35-39 80.0 40-44 18.5 Total fertility rate (TFR) 3.0

The TFR thus estimated is 3 per woman (Table 8.5) which is higher than the national rate of 2.3 (MOHP, New ERA and ICF. 2017) estimated in 2016 but compares with the rate of the Mountain region which was 3 per woman.

Age specific fertility rate shows that the fertility rate peaks at age 25-29 and thereafter declines steadily (Figure 8.1). Fertility peaking is later in sample areas than the national rate which showed fertility peaking at age 20-24 ((MOHP, New ERA and ICF. 2017). In addition, no births were reported for women age 45-49.

Figure 8.1 Age specific fertility rate per 1,000 women, Gorkha sample, 2018 Per 1000 women 300.0

244.4 250.0

200.0

150.0 114.9

100.0 80.0 65.4 76.9

50.0 18.5

0.0 15-19 20-24 25-29 30-34 35-39 40-44 Age of women

Of the total female respondents the appropriate age for marriage was 20.9 years while males reported 22.6 years and this varied very little by municipality (Table 8.6). When the figures are rounded the appropriate age for marriage turned out to be 21 years in all three areas. The majority of respondents said that the appropriate age for marriage would be 20 years.

Table 8.6 Per cent distribution of respondents by municipality, according to sex and appropriate age for marriage, Gorkha, Nepal 2018 Municipality Appropriate age for Sex (palika) marriage Female Male Total Ajirkot rural 18 2.2 0.0 1.8 municipality 20 71.1 60.0 69.1 21-24 22.2 40.0 25.5 25+ 4.4 0.0 3.6 Total % 100.0 100.0 100.0 Total n 45.0 10.0 55.0 Mean age 20.6 20.9 20.7 Palungtar 18 1.6 0.0 1.3 municipality 20 73.2 25.0 64.2 21-24 19.5 42.9 23.8 25+ 5.7 32.1 10.6 Total % 100.0 100.0 100.0 Total n 123.0 28.0 151.0 Mean age 20.7 22.6 21.1 Siranchok 18 2.8 0.0 2.1 rural 20 56.9 31.8 51.1 municipality 21-24 22.2 22.7 22.3 25+ 18.1 45.5 24.5 Total % 100.0 100.0 100.0 Total n 72.0 22.0 94.0 Mean age 21.4 23.3 21.9 All three 18 2.1 0.0 1.7 20 67.9 33.3 61.0 21-24 20.8 35.0 23.7 25+ 9.2 31.7 13.7 Total % 100.0 100.0 100.0 Total n 240.0 60.0 300.0 Mean age 20.9 22.6 21.2

In defence of the appropriate age for marriage, the respondents gave a number of reasons (Table 8.7). For respondents from Ajirkot rural municipality and Palungtar municipality the reason “education would be complete” topped the list while in Siranchok rural municipality person becomes “matured” topped the list. Other important reasons that surfaced include “body fully grown”, “reproductive organs fully grown”, “mentally full grown”, “healthy age”, “health of mother and child good” and so on (Table 8.7).

Table 8.7 Per cent distribution of respondents by municipality, according to sex and reasons for appropriate age at marriage, Gorkha, Nepal 2018 Reasons for appropriate age at marriage Sex Municipality (Multiple responses) Female Male Total Ajirkot rural Education would be complete 88.9 90.0 89.1 municipality Body full grown 57.8 70.0 60.0 Reproductive organs fully grown 57.8 50.0 56.4 Mentally full grown 35.6 30.0 34.5 Matured 33.3 20.0 30.9 Healthy age 22.2 30.0 23.6 Health of mother and child good 11.1 10.0 10.9 Mother can take good care of child 8.9 0.0 7.3 Becomes capable 4.4 10.0 5.5 Total n 45 10 55 Palungtar Education would be complete 83.7 88.9 84.7 municipality Healthy age 48.8 48.1 48.7 Reproductive organs fully grown 43.9 44.4 44.0 Body full grown 39.8 44.4 40.7 Matured 43.1 29.6 40.7 Becomes capable 37.4 55.6 40.7 Health of mother and child good 41.5 25.9 38.7 Mother can take good care of child 33.3 29.6 32.7 Mentally full grown 28.5 18.5 26.7 Can earn to support 16.3 33.3 19.3 For timely child bearing 0.8 0.0 0.7 Total n 123 27 150 Siranchok rural Matured 70.8 81.8 73.4 municipality Reproductive organs fully grown 70.8 59.1 68.1 Becomes capable 50.0 63.6 53.2 Healthy age 51.4 36.4 47.9 Can earn to support 33.3 72.7 42.6 Education would be complete 36.1 40.9 37.2 Health of mother and child good 31.9 22.7 29.8 Mentally full grown 16.7 22.7 18.1 Body full grown 18.1 0.0 13.8 Mother can take good care of child 12.5 13.6 12.8 Have good knowledge about health 2.8 0.0 2.1 For timely child bearing 1.4 0.0 1.1 Total n 72 22 94

Of all women respondents, nearly 10 per cent had an abortion and this was highest (15.3%) in Siranchok rural municipality followed by Palungtar municipality (8.1%) while in Ajirkot rural municipality this proportion was only 4.4 per cent (Table 8.8). Mostly older women above 20 years of age reported having had an abortion but in Palungtar even younger women aged 15-19 reported having had an abortion.

Table 8.8 Per cent distribution of female respondents by municipality, according to age and whether had an abortion, Gorkha, Nepal 2018 Ever had an abortion? Total Municipality Age Yes No % n Ajirkot rural municipality 13-14 0.0 100.0 100.0 1 15-19 0.0 100.0 100.0 7 20-24 0.0 100.0 100.0 14 25-29 0.0 100.0 100.0 5 30-34 50.0 50.0 100.0 2 35-39 0.0 100.0 100.0 4 40-44 25.0 75.0 100.0 4 45-49 0.0 100.0 100.0 8 Total 4.4 95.6 100.0 45 Palungtar municipality 13-14 0.0 100.0 100.0 11 15-19 10.0 90.0 100.0 30 20-24 3.7 96.3 100.0 27 25-29 15.8 84.2 100.0 19 30-34 30.0 70.0 100.0 10 35-39 0.0 100.0 100.0 9 40-44 0.0 100.0 100.0 8 45-49 0.0 100.0 100.0 9 Total 8.1 91.9 100.0 123 Siranchok rural municipality 13-14 0.0 100.0 100.0 1 15-19 0.0 100.0 100.0 14 20-24 9.5 90.5 100.0 21 25-29 0.0 100.0 100.0 9 30-34 25.0 75.0 100.0 8 35-39 33.3 66.7 100.0 12 40-44 50.0 50.0 100.0 6 45-49 0.0 100.0 100.0 1 Total 15.3 84.7 100.0 72 All three 13-14 0.0 100.0 100.0 13 15-19 5.9 94.1 100.0 51 20-24 4.8 95.2 100.0 62 25-29 9.1 90.9 100.0 33 30-34 30.0 70.0 100.0 20 35-39 16.0 84.0 100.0 25 40-44 22.2 77.8 100.0 18 45-49 0.0 100.0 100.0 18 Total 9.6 90.4 100.0 240

Table 8.9 shows even adolescent women having had an abortion and abortion practice increasing over age. Older women apparently have more abortions.

Table 8.9 Distribution of female respondents reporting number of abortions age, Gorkha, Nepal 2018 Number of abortion Age One Two Total 15-19 3 0 3 20-24 3 0 3 25-29 3 0 3 30-34 4 2 6 35-39 4 0 4 40-44 3 1 4 Total 20 3 23

Most important reason for abortion (70%) mentioned was that women “did not want any more children” and second most important reason was “wanted to delay child bearing” or “wanted to space child birth” (Table 8.10).

Table 8.10 Percentage distribution of female respondents reporting reasons for abortion by municipality, Gorkha, Nepal 2018 Municipality (palika) Reasons for abortion (Multiple Ajirkot rural Palungtar Siranchok rural responses) municipality municipality municipality Total Health of mother 0.0 0.0 9.1 4.3 No money to bring up baby 50.0 0.0 18.2 13.0 Wanted to delay child bearing 0.0 50.0 0.0 21.7 Did not want any more children 100.0 60.0 72.7 69.6 Wanted to space child birth 0.0 40.0 18.2 26.1 Husband/ partner did not want child 0.0 0.0 9.1 4.3 Miscarriage 0.0 30.0 0.0 13.0 Total n 2 10 11 23

Of the 23 abortions reported, 13 per cent were miscarriages and of the remaining abortions most (52%) were performed using MVA method, 30 per cent were medical abortions and 4 per cent were D&E/ D&C (Table 8.11). Only 17 out of 23 women who had an abortion reported that they were counseled about family planning after abortion and 11 of them adopted FP method and only 10 women visited health facility after abortion.

Table 8.11 Percentage distribution of female respondents by municipality and method used for abortion, Gorkha, Nepal 2018 Method used for abortion Total Medical Municipality (palika) Abortion MVA D&E/ D&C Miscarriage % n Ajirkot rural municipality 50.0 0.0 50.0 0.0 100.0 2 Palungtar municipality 20.0 50.0 0.0 30.0 100.0 10 Siranchok rural municipality 36.4 63.6 0.0 0.0 100.0 11 Total 30.4 52.2 4.3 13.0 100.0 23

Knowledge that abortion is legal in Nepal is known to 43.3 per cent of the survey respondents and by sex more (53.3%) males know about it than their female counterparts (40.8%, Table 8.12). The proportion of women having knowledge that abortion is legal in Nepal is lowest among women less than 15 years of age (7.7%) and highest (51.6%) among women 20-24 years of age. Slightly more than half of women aged 25-34 know that abortion is legal in Nepal.

Table 8.12 Per cent distribution of respondents by sex, according to age and knowledge about legality of abortion, Gorkha, Nepal 2018 Is abortion legal in Nepal? Total Sex Age Yes No Don't know % n Female 13-14 7.7 53.8 38.5 100.0 13 15-19 35.3 41.2 23.5 100.0 51 20-24 51.6 33.9 14.5 100.0 62 25-29 51.5 45.5 3.0 100.0 33 30-34 50.0 30.0 20.0 100.0 20 35-39 32.0 32.0 36.0 100.0 25 40-44 27.8 33.3 38.9 100.0 18 45-49 38.9 50.0 11.1 100.0 18 Total 40.8 38.8 20.4 100.0 240 Male 13-14 0.0 100.0 0.0 100.0 1 15-19 38.9 44.4 16.7 100.0 18 20-24 60.0 40.0 0.0 100.0 10 25-29 50.0 50.0 0.0 100.0 4 30-34 42.9 42.9 14.3 100.0 7 35-39 75.0 0.0 25.0 100.0 4 40-44 66.7 33.3 0.0 100.0 6 45-49 70.0 20.0 10.0 100.0 10 Total 53.3 36.7 10.0 100.0 60 Both 13-14 7.1 57.1 35.7 100.0 14 sexes 15-19 36.2 42.0 21.7 100.0 69 20-24 52.8 34.7 12.5 100.0 72 25-29 51.4 45.9 2.7 100.0 37 30-34 48.1 33.3 18.5 100.0 27 35-39 37.9 27.6 34.5 100.0 29 40-44 37.5 33.3 29.2 100.0 24 45-49 50.0 39.3 10.7 100.0 28 Total 43.3 38.3 18.3 100.0 300

Among the females, knowledge that abortion is legal in Nepal is highest (48.9%) in Ajirkot rural municipality followed by Siranchok rural municipality (40.3%) and lowest Palungtar municipality (38.2%, Table 3.13).

Table 8.13 Per cent distribution of respondents by sex, according to municipality and knowledge about legality of abortion, Gorkha, Nepal 2018 Is abortion legal in Nepal? Total Sex Municipality (palika) Yes No Don't know % n Female Ajirkot rural municipality 48.9 51.1 0.0 100.0 45 Palungtar municipality 38.2 40.7 21.1 100.0 123 Siranchok rural municipality 40.3 27.8 31.9 100.0 72 Total 40.8 38.8 20.4 100.0 240 Male Ajirkot rural municipality 40.0 60.0 0.0 100.0 10 Palungtar municipality 50.0 35.7 14.3 100.0 28 Siranchok rural municipality 63.6 27.3 9.1 100.0 22 Total 53.3 36.7 10.0 100.0 60 Both Ajirkot rural municipality 47.3 52.7 0.0 100.0 55 sexes Palungtar municipality 40.4 39.7 19.9 100.0 151 Siranchok rural municipality 45.7 27.7 26.6 100.0 94 Total 43.3 38.3 18.3 100.0 300

Of the females, knowledge that abortion is legal in Nepal is highest (46.2%) among the Bahun women and lowest (35.1%) among Dalit women (Table 8.14).

Table 8.14 Per cent distribution of respondents by sex, according to caste/ethnicity and knowledge about legality of abortion, Gorkha, Nepal 2018 Is abortion legal in Nepal? Total Sex Caste/ethnicity Yes No Don't know % n Female Chhetri 42.5 27.5 30.0 100.0 40 Bahun 46.2 38.5 15.4 100.0 39 Janajati 40.9 39.8 19.4 100.0 93 Newar 45.5 18.2 36.4 100.0 11 Dalit 35.1 49.1 15.8 100.0 57 Total 40.8 38.8 20.4 100.0 240 Male Chhetri 72.7 27.3 0.0 100.0 11 Bahun 66.7 22.2 11.1 100.0 9 Janajati 55.0 40.0 5.0 100.0 20 Newar 100.0 0.0 0.0 100.0 1 Dalit 31.6 47.4 21.1 100.0 19 Total 53.3 36.7 10.0 100.0 60

Respondents who reported having knowledge that abortion is legal in Nepal were further asked about the circumstances allowing legal abortion. Fifty per cent female respondents said that abortion is allowed for pregnancy of any duration if life of mother is at risk and the corresponding figure for male respondents was 55 per cent. Fifty two per cent females said if mother's physical or mental health is at risk abortion would be allowed. Thirty nine per cent females said abortion would be allowed for pregnancy of 18 weeks if it is a result of rape or incest and about one in three females said abortion would be allowed if foetus is deformed. About half (51%) of all female respondents said that abortion would be allowed if pregnancy is of 9 weeks’ gestation (Table 8.15).

Table 8.15 Per cent distribution of respondents by sex, according to circumstances under which abortion is allowed and municipality, Gorkha, Nepal 2018 Municipality (palika) Sex Ajirkot rural Palungtar Siranchok rural Conditions when abortion is allowed municipality municipality municipality Total Female Pregnancy of 9 weeks of gestation 18.2 72.3 41.4 51.0

Pregnancy of 12 weeks of gestation 0.0 68.1 27.6 40.8 Pregnancy of 18 weeks if it is a result of rape or incest 27.3 40.4 44.8 38.8 Pregnancy of any duration if life of mother is at risk 77.3 46.8 34.5 50.0 Pregnancy of any duration if mother's physical or mental health is at risk 81.8 63.8 10.3 52.0 Foetus is deformed 81.8 10.6 17.2 28.6 In case of child/ early pregnancy 0.0 2.1 0.0 1.0 Total (n) 22 47 29 98 Male Pregnancy of 9 weeks of gestation 25.0 71.4 23.1 45.2

Pregnancy of 12 weeks of gestation 0.0 57.1 23.1 35.5 Pregnancy of 18 weeks if it is a result of rape or incest 75.0 35.7 53.8 48.4 Pregnancy of any duration if life of mother is at risk 50.0 57.1 53.8 54.8 Pregnancy of any duration if mother's physical or mental health is at risk 75.0 78.6 7.7 48.4 Foetus is deformed 75.0 0.0 15.4 16.1 Don’t want another child 0.0 0.0 7.7 3.2 Unwanted pregnancy 0.0 0.0 7.7 3.2 Don’t know 0.0 7.1 0.0 3.2 Total (n) 4 14 13 31

The survey respondents were asked whether they knew of a place where safe abortion service is available and in response 47 per cent women and 37 per cent men mentioned that they had knowledge of it (Table 8.16). Highest proportion (64%) of females from Siranchok rural municipality has knowledge of a place of safe abortion compared to women from Ajirkot (58%) and Palungtar (33%) municipality.

Table 8.16 Per cent distribution of respondents by municipality, according to knowledge of safe abortion place and sex, Gorkha, Nepal 2018 Do you know a place where a woman Sex Municipality (palika) can go to get safe abortion? Female Male Total Ajirkot rural municipality Yes 57.8 10.0 49.1 No 42.2 90.0 50.9 Total % 100.0 100.0 100.0 Total n 45 10 55 Palungtar municipality Yes 33.3 28.6 32.5 No 66.7 71.4 67.5 Total % 100.0 100.0 100.0 Total n 123 28 151 Siranchok rural Yes 63.9 59.1 62.8 municipality No 36.1 40.9 37.2 Total % 100.0 100.0 100.0 Total n 72 22 94 All three Yes 47.1 36.7 45.0 No 52.9 63.3 55.0 Total % 100.0 100.0 100.0 Total n 240 60 300

Most respondents said that safe abortion place is Gorkha bazaar, i.e., District Hospital or clinics there (Table 8.17). Table 8.17 indicates that including Gorkha bazaar the number of places women got for safe abortion is 11 and some of them are outside the district such as Bharatpur (in Chitwan district), Dumre (in Tanahun district), Kathmandu (capital city) and Tanahun (Tanahun district headquarters). Gorkha bazaar and Nayasanghu are outside the 20 health facilities of the project operational areas although they are within the Gorkha district.

Table 8.17 Per cent distribution of respondents by municipality, according to name of place where safe abortion place is available and sex, Gorkha, Nepal 2018 Municipality (palika) Place where safe abortion service Sex Total available Female Male Ajirkot rural municipality Bhachchek 100.0 100.0 100.0 Total % 100.0 100.0 100.0 Total n 26 1 27 Palungtar municipality Aampipal 22.0 37.5 24.5 Bharatpur 0.0 12.5 2.0 Dumre 12.2 0.0 10.2 Gorkha Bazar 58.5 12.5 51.0 Kathmandu 2.4 12.5 4.1 Tanahun 4.9 25.0 8.2 Total % 100.0 100.0 100.0 Total n 41 8 49 Siranchok rural Aampipal 15.2 15.4 15.3 municipality Bhachchek 0.0 7.7 1.7 Total Bharatpur 4.3 7.7 5.1 Chhoprak 15.2 30.8 18.6 Dumre 6.5 7.7 6.8 Gorkha Bazar 41.3 23.1 37.3 Jaubari 4.3 0.0 3.4 Kerabari 4.3 0.0 3.4 Nayasanghu 8.7 7.7 8.5 Total % 100.0 100.0 100.0 Total n 46 13 59 All three Aampipal 14.2 22.7 15.6 Total Bhachchek 23.0 9.1 20.7 Bharatpur 1.8 9.1 3.0 Chhoprak 6.2 18.2 8.1 Dumre 7.1 4.5 6.7 Gorkha Bazar 38.1 18.2 34.8 Jaubari 1.8 0.0 1.5 Kathmandu 0.9 4.5 1.5 Kerabari 1.8 0.0 1.5 Nayasanghu 3.5 4.5 3.7 Tanahun 1.8 9.1 3.0 Total % 100.0 100.0 100.0 Total n 113 22 135

According to Table 8.18, for most respondents safe abortion place is Gorkha bazaar, i.e., District hospital or clinics there. Of the 11 places mentioned, Bharatpur (in Chitwan district), Dumre (in Tanahun district, by the Prithvi Highway), Kathmandu and Tanahun (Tanahun district headquarters) are located outside of Gorkha district and Gorkha Bazar and Nayasanghu are not located in the project operational areas.

Table 8.18 Per cent distribution of respondents by municipality, according to name of place where safe abortion place is available and sex, Gorkha, Nepal 2018 Municipality (palika) Place where safe abortion service Sex available Female Male Total Ajirkot rural municipality Bhachchek 100.0 100.0 100.0 Total % 100.0 100.0 100.0 Total n 26 1 27 Palungtar municipality Aampipal 22.0 37.5 24.5 Bharatpur 0.0 12.5 2.0 Dumre 12.2 0.0 10.2 Gorkha Bazar 58.5 12.5 51.0 Kathmandu 2.4 12.5 4.1 Tanahun 4.9 25.0 8.2 Total % 100.0 100.0 100.0 Total n 41 8 49 Siranchok rural Aampipal 15.2 15.4 15.3 municipality Bhachchek 0.0 7.7 1.7 Total Bharatpur 4.3 7.7 5.1 Chhoprak 15.2 30.8 18.6 Dumre 6.5 7.7 6.8 Gorkha Bazar 41.3 23.1 37.3 Jaubari 4.3 0.0 3.4 Kerabari 4.3 0.0 3.4 Nayasanghu 8.7 7.7 8.5 Total % 100.0 100.0 100.0 Total n 46 13 59 All three Aampipal 14.2 22.7 15.6 Total Bhachchek 23.0 9.1 20.7 Bharatpur 1.8 9.1 3.0 Chhoprak 6.2 18.2 8.1 Dumre 7.1 4.5 6.7 Gorkha Bazar 38.1 18.2 34.8 Jaubari 1.8 0.0 1.5 Kathmandu 0.9 4.5 1.5 Kerabari 1.8 0.0 1.5 Nayasanghu 3.5 4.5 3.7 Tanahun 1.8 9.1 3.0 Total % 100.0 100.0 100.0 Total n 113 22 135

For female respondents mass media channels FM/ Radio (69%) and TV (65%) top the list as being the sources of safe abortion information and this is true of male respondents too (FM/ Radio 67% and TV 65%, Table 8.19). The third main sources of information are friends and health workers followed by FCHV, Internet, School/ Curriculum, Newspaper, Mother's group, family members, Pharmacists, poster and so on.

Table 8.19 Per cent distribution of respondents by sex, according to sources of safe abortion information (Multiple responses) and municipality, Gorkha, Nepal 2018 Sources of safe Municipality (palika) Sex abortion information Ajirkot rural Palungtar Siranchok rural (Multiple responses) municipality municipality municipality Total Female FM/ Radio 28.9 72.4 87.5 68.8 TV 57.8 66.7 68.1 65.4 Friends 62.2 65.9 36.1 56.3 Health workers 88.9 49.6 43.1 55.0 FCHV 68.9 43.1 36.1 45.8 Internet 15.6 35.0 30.6 30.0 School/ Curriculum 2.2 22.8 41.7 24.6 Newspaper 15.6 30.1 4.2 19.6 Mother's group 2.2 25.2 12.5 17.1 Family members 15.6 18.7 6.9 14.6 Pharmacists 0.0 16.3 18.1 13.8 Poster 0.0 13.0 11.1 10.0 Pamphlet 0.0 2.4 11.1 4.6 Don't know 0.0 2.4 2.8 2.1 Total n 45 123 72 240 Male FM/ Radio 20.0 67.9 86.4 66.7 TV 80.0 57.1 68.2 65.0 Health workers 70.0 57.1 45.5 55.0 Friends 70.0 57.1 22.7 46.7 FCHV 60.0 32.1 27.3 35.0 Internet 10.0 35.7 45.5 35.0 School/ Curriculum 10.0 25.0 54.5 33.3 Newspaper 40.0 32.1 4.5 23.3 Pharmacists 0.0 17.9 4.5 10.0 Mother's group 0.0 7.1 18.2 10.0 Family members 10.0 7.1 9.1 8.3 Poster 0.0 10.7 9.1 8.3 Pamphlet 0.0 3.6 13.6 6.7 Don't know 0.0 3.6 0.0 1.7 Total n 10 28 22 60

Respondents who had completed at least 8 years of schooling were asked whether their school curriculum included SRH education and over 90 per cent said it is regardless of type of municipality or sex of respondents (Table 8.20).

Table 8.20 Per cent distribution of respondents by municipality, according to whether school curriculum includes SRH education and sex, Gorkha, Nepal 2018 Municipality (palika) Does your school curriculum Sex include SRH education? Female Male Total Ajirkot rural municipality Yes 95.7 100.0 96.8 No 4.3 0.0 3.2 Total % 100.0 100.0 100.0 Total n 23 8 31 Palungtar municipality Yes 88.7 100.0 91.1 No 11.3 0.0 8.9 Total % 100.0 100.0 100.0 Total n 62 17 79 Yes 97.6 86.7 94.7 Siranchok rural No 2.4 13.3 5.3 municipality Total % 100.0 100.0 100.0 Total n 42 15 57 All three Yes 92.9 95.0 93.4 No 7.1 5.0 6.6 Total % 100.0 100.0 100.0 Total n 127 40 167

Respondents mentioning RH curriculum in school were further asked whether the curriculum is taught by their teachers and in response most motioned positively (Table 8.21).

Table 8.21 Per cent distribution of respondents by municipality, according to whether teachers teach SRH lessons in school and sex, Gorkha, Nepal 2018 Municipality Sex (palika) Do teachers teach SRH lessons in school? Female Male Total Ajirkot rural Yes 95.5 100.0 96.7 municipality No 4.5 0.0 3.3 Total % 100.0 100.0 100.0 Total n 22 8 30 Palungtar Yes 100.0 100.0 100.0 municipality Total % 100.0 100.0 100.0 Total n 55 17 72 Siranchok rural Yes 100.0 100.0 100.0 municipality Total % 100.0 100.0 100.0 Total Total n 100.0 100.0 100.0 All three Yes 99.15 100.00 99.36 No 0.85 0.00 0.64 Total % 100.0 100.0 100.0 Total n 118 38 156

Also respondents mentioning inclusion of RH education in school teaching were further asked if the curriculum was enough for them to learn about RH and in this case too most of them responded positively (Table 8.22).

Table 8.22 Per cent distribution of respondents by municipality, according to whether present SRH contents and information in school curriculum is enough and sex, Gorkha, Nepal 2018 Municipality Present SRH contents and information in Sex (palika) school curriculum is enough Female Male Total Ajirkot rural Yes 95.5 100.0 96.7 municipality No 4.5 0.0 3.3 Total % 100.0 100.0 100.0 Total n 22 8 30 Palungtar Yes 90.9 88.2 90.3 municipality No 9.1 11.8 9.7 Total % 100.0 100.0 100.0 Total n 55 17 72 Siranchok rural Yes 75.6 46.2 68.5 municipality No 24.4 53.8 31.5 Total % 100.0 100.0 100.0 Total n 41 13 54 All three Yes 86.4 76.3 84.0 No 13.6 23.7 16.0 Total % 100.0 100.0 100.0 Total n 118 38 156

Among the survey respondents interested in improving the SRH curriculum, most of them suggested to include SRH and abortion information followed by health information/education, awareness (Table 8.23). A few male respondents explicitly mentioned that sex education should be added.

Table 8.23 Per cent distribution of respondents by sex, according to information that should be added in the present SRH contents, Gorkha, Nepal 2018 Sex What information should be added? Female Male Total Health information 25.0 0.0 16.0 SRH and abortion 37.5 33.3 36.0 Health education 18.8 11.1 16.0 More information 0.0 22.2 8.0 Awareness program 12.5 22.2 16.0 Sex education 0.0 11.1 4.0 Effective service 6.3 0.0 4.0 Total % 100.0 100.0 100.0 Total n 16 9 25

Chapter Nine: Findings of qualitative study

Qualitative findings are based on analysis of three FGDs conducted in three project operational areas, i.e., Palungtar municipality, Siranchok rural municipality and Ajirkot rural municipality and Key Informant Interviews with 27 respondents.

FGD findings: Female FGDs

Introduction Prior to conducting FGD, the group members were explained about the purpose of gathering and subjects that were to be discussed with them. Following it verbal consent was sought from each participant. The group moderator asked for short introduction of each participant. Subsequently, FGD started.

Three female FGDs were conducted, one in each municipality, namely, one in ward no. 2 of Ajirkot rural Municipality, another in ward no. 6, Siranchok rural Municipality, and the third in ward no. 1, Palungtar Municipality of Gorkha district. In Ajirkot 8 women aged between 16 to 35 years belonging to Janajati group took part in the FGD. In Siranchok, 10 females aged 22 to 28 from high castes (Chhetri) and Newar communities participated in the FGD and in Palungtar, 10 women participated, age 20 to 49, all Dalit.

The subjects of discussions included general health conditions of people in the locality, marriage and family size, sources of knowledge on SRH and safe abortion, places visited by people when they have SRH problems, legalization of abortion, conditions of SRH and abortion services, status of access to SRH and abortion services, actions taken to improve access and services for SRH and SA, knowledge of FP, recommendations/suggestions.

General health conditions of people in the locality

The FGD participants said that generally women fall sick more in comparison to men with problems like irregular menstruation, abdominal pain and uterine related problems. Health services that are available in the community are not enough and cater only towards minor diseases (like headache, fever etc). Some participants also mentioned that men suffer from HIV and non communicable diseases.

Age at marriage and family size/ composition

Most of 28 participants of 3 FGDs hold the view that there is a trend of marrying off their daughters at the age of 17 or 18 years. One participant each from Siranchok and Palungtar also mentioned that some girls get married at 14 or 15 years of age while still in school by eloping. One young FGD participant from Ajirkot remarked on the consequences of early marriage and ignorance. A 16-year old married girl said, “People have their young girls married off because they are not aware about the harmful health effects of early marriage.”

The family size most FGD participants in all three groups agreed was 2 comprising of 1 boy and one girl. Some of the participants wanted more especially sons. They believe that more sons would be needed to continue family line and for old age. A 22-year old married woman said, “2 sons are needed because, in future during old-age, if one son dies another son will take care of them.”

A 25-year old married woman said, “Sons are needed to continue family line.”

This statement was overwhelmingly supported by all the 10 participants in the FGD in Siranchok. All FGD participants in Palungtar also expressed this view. In Ajorkot all participants expressed the view that at least one son is needed.

Some participants mentioned that girls are also needed because they are more likely to help in household works than a son. Some participants said that daughters love and care for their parents more than sons.

Sources of knowledge on SRH and safe abortion

Various source of information on SRH and safe abortion mentioned by FGD participants in all three areas included health workers, women’s / mothers’ group meetings, FCHVs and radio, TV.

Places visited by people when they have SRH problems

Local government health posts in the local community, provides FP, maternal and child health and other basic services. Most participants said that they visit local facilities for these services. Abortion related services are not available in many of the communities and in the operational areas there is one hospital and one PHCC where abortion related serves are available. Only recently 7 Health Posts have been authorised to provide MA service. Ten other HPs do not have MA service available and one health facility is not yet upgraded to HP level.

For abortion service women from Ajirkot go to Bhachhek HP – the nearest one and some even go to District Hospital or Amppipal hospital (in the district) or to Kathmandu or Chitwan – long way.

The participants of FGD in Palungtar implicate that seeking abortion service is stigmatized. Therefore women go far away and get abortion. A 36-year old married Dalit woman said, “Women usually go to a far away unknown place to get abortion service so that neighbours would not know about it.”

Legalization of abortion

In Ajirkot and Siranchok only half of the 18 FGD participants knew that abortion is legal in the country while in Palungtarall women knew about it. FGD participants in Palungtar mentioned that abortion is stigmatized. A 48-year old married Dalit woman said, “Because people believe that abortion is a sin they do not like to talk about it; they do not know whether it is legal or not.”

Conditions of Abortion services

Five of 8 FGD participants in Ajorkot did not know when a woman can have abortion legally. In Palungtar, 6 out of 10 and in Siranchok 7 out of 10 FGD participants do not have any knowledge when a woman can have abortion.

The FGD participants, who mentioned conditions of abortion are incest and if a woman’s health is in risk due to pregnancy. No one mentioned about the gestation period that is eligible for abortion in case a woman wants to terminate her pregnancy.

Access to SRH and abortion services

Most FGD participants in Ajirkot expressed that women in their locality do not have access to SRH services due to mountains. The nearby health facilities have only limited facilities like medicines for fever and diarrhoea. If women want safe abortion service they have to travel long distance usually to Gorkha bazaar (district headquarters). Some women pay high price for abortion service in private pharmacies.

In Khoplang of Palungtar municipality FGD participants said that abortion service is not available nearby. All FGD participants said, “For us abortion facility is too far, we have to go to a town which is expensive. We spend money to get the service from a private pharmacy."

Actions taken to improve access to SRH services

Most of 8 FGD participants in Ajirkot agreed that no efforts have been made to improve access to SRH and abortion services in their locality. One of them also added that almost always they are told that there is no medicine when they go to their local health facility. In Khoplang of Palungtar municipality, all 10 FGD participants said that nothing has been done to improve SRH and abortion services in their local health facility.

In Siranchok, Gankhu, most FGD participants agreed that there has not been any substantial effort made to improve access to SRH services in the locality. However one of the participant mentioned that few health education programs has been conducted and another participant mentioned that, service has been made easy with female health workers.

FP in locality

Six out of the 8 participants in Ajirkot said that women in their locality prefer to use Injectable popularly known as Depo injection. One participant said women choose pills and another said women choose implant. They mentioned that women prefer depo because one injection can work for 3 months which is easy and practical and because it suits for most women that have used it before. The participant, who said that women prefer pills, mentioned that because it does not affect their menstrual cycle. Similarly the participant, who said that women prefer implant, gave the reason that it prevents pregnancy for a long time i.e. 5 years.

Four of 10 FGD participants in Khoplang of Palungtar municipality said that women in their locality prefer to use Depo injection as it can provide protection for 3 months.

Two of 10 FGD participants in Gankhu of siranchok rural municipality said that women in this locality prefer to use depo injection as it gives effective protection for 3 months after administered once. One of them also mentioned that women prefer pills because it does not affect normal menstruation. Still another participant said that some women prefer Implant as it works for 5 years.

Suggestions to improve SRH services in the community

Women taking part in FGD in Ajirkot gave suggestions to improve SRH services and they include making services available in the nearest health facility, uninterrupted supply of medicines and female service providers at the health facility. Similarly suggestions to improve abortion services include service provision from nearest health facility, free and confidential service.

The FGD participants of Khoplang of Palungtar municipality said that SRH services should be improved, female health workers should be assigned in the facility, there should be awareness raising programme in community about SRH, health related discussion in mother’s group meeting and availability of appropriate medicines at the facility.

Similarly suggestions to improve abortion services in the community include making abortion services available in nearest health posts at free of cost, awareness raising about conditions in which abortion can be done and ensuring confidential abortion services.

In Gankhu of Siranchok rural municipality, FGD participants gave suggestions to improve SRH services in the community and the activities to include are ensuring confidentiality during service delivery, community awareness generation about abortion services and its complications and regular supply and availability of drugs in all health facilities.

KII findings:

Key Informant Interviews were conducted with local stakeholders such as Mayor/ Deputy Mayor of municipalities, ward chair persons of wards, administrative officers, health workers, health coordinators, teachers and education coordinator. In all, 27 such persons were interviewed.

Prior to conducting interview, the key informant was explained about the purpose and subjects that were to be discussed. Following it verbal consent was sought from each participant and subsequently, the interview started.

In each of three municipalities, 9 KIIs were conducted. In Ajirkot, 9 key informants included Municipality Administrative Officer, 2 HF in-charges, 2 ward chairs, 2 school teachers, Health Coordinator and Education Coordinator. In Siranchok rural municipality the 9 key informants included Municipality Administrative Officer, 2 HF in-charges, 2 ward chairs, 2 school teachers, Education Coordinator and Health Coordinator. In Palungtar, 9 key informants included Deputy Mayor, 2 HF in-charges, 2 ward chairs, 2 school teachers, Education Coordinator and Health Coordinator.

The issues discussed with key informants included overall sexual and reproductive health situation of adolescents and women of reproductive age of this locality, types of sexual and reproductive health and abortion related problems are faced by women in this locality, reproductive health and abortion related knowledge, attitude and behaviour among women in this locality, knowledge and information about sexual and reproductive health and abortion, place where adolescents and women of reproductive age go to for help and treatment of SRH and abortion related problems, condition of sexual and reproductive health and abortion services provided by the local facilities in their locality, status of access to SRH and abortion services among adolescents and WRA, actions that have been taken to improve access to SRH and abortion services, types of family planning services and methods available in their locality, any cases of death of woman during pregnancy and suggestions to improve reproductive health status of women in their locality.

Overall SRH situation of adolescents and women of reproductive age of this locality

Most of 7 elected representative and 2 administrative officer key informants were of the view that the overall situation of sexual and reproductive health of WRA and adolescents in their areas was just okay. However, early marriage, early pregnancy and child bearing are still causes of concern. Only simple health problems are treated by the health posts while for more complicated problems people have to go to Gorkha (district headquarters) or further away. They thought that people are

61 not knowledgeable of health issues and consequences which inhibit them from discussing openly about their SRH and abortion related problems.

Most of 6 health facility in-charges interviewed said that delivery at home is commonly seen in their locality. They mentioned that women and especially adolescents feel shy to discuss their problems and seek care. The situation of overall sexual and reproductive health is just okay with a general lack of appropriate SRH services in all localities. One of the health post in-charges informed that about 40% women get pregnant before 18 years of age which is due to early marriage.

All 3 health coordinators believe that the health system is providing regular health services in the community. Two of them mentioned that adolescent girls usually hesitate to seek SRH related services.

Types of SRH and abortion related problems faced by women

All the elected representatives and 2 administrative officers taking part in interviews mentioned that early marriage and early pregnancy and child birth are common in their localities. Two of 7 elected representatives mentioned that this practice is relatively more prevalent in Janajatis and Dalit communities and illiterate households. Other common problems faced by women include irregular menses, heavy bleeding during menstruation, uterine related problems and uterine prolapse. Two of the KIIs also said that some girls miss their schools during their menstrual cycle.

Other problems related to service sector mentioned included that women have to go to private clinics or pharmacies to get abortion services which is both inconvenient and expensive. Some women get abortion services secretly from private clinics because they want to keep this activity confidential. The informants think that women are not aware about where abortion services are available.

RH and abortion related KAB among women in communities

Almost all elected representatives, health coordinator and health facility in-charge key informants have the opinion that early marriage and early pregnancy is common in their communities. Health seeking behavior is not good either as girls and women do not seek care for reproductive health problems on time. The young girls are shy to go to a health facility for information and service.

Source of knowledge and information about SRH and abortion

As per elected representative key informants main sources of RH information are Radio, TV, FCHVs, health workers, Mother’s group meeting, child club and school.

According to health facility in-charges, most common sources of information about SRH and abortion include FCHVs, mother’s group meetings, posters, pamphlets, TV, radio and health workers.

Place where adolescents and WRA go for help and treatment of SRH and abortion related problems

Elected representative key informants said people in their locality get suggestions from elderly or experienced people or FCHVs. People also go to health posts, hospital or pharmacy to get service. Some people use medicinal herbs.

Only a few key informants said that women seek abortion related service from their nearby health facilities but many of them go far away to district headquarters or another district.

Health facility in-charges taking part as key informants said most people of their localities go to Ampipal hospital or nearest HP for SRH related services. For abortion, people of Ajirkot go to Bhachhek HP. One of the informant mentioned that even though abortion service is available in their facility, people prefer to go to a private providers because they want to keep it confidential. For major problems people have to go to Gorkha or Kathmandu city.

Condition of SRH and abortion services provided by the facilities in their locality

Most elected representative and 2 administrative officer key informants said that there is gap in service delivery as people do not get appropriate service or medicines when they ask for it and health workers in government facilities are not available when required. Also not all government health facilities provide abortion services.

People are compelled to travel further in order to get abortion services as such services are not available in their locality.

Since the quality of services in government health facilities are not very good and necessary medicines are not always available, people of prefer to go to private service providers. In many localities abortion services are not available.

Since such services are not available in this locality, people are compelled to seek care from private service providers which turns out to be expensive.

People of this locality go to Ampippal hospital to get such services which takes a lot of time as they have to travel all day and due to high patient flow there, they have to wait long time to see the doctor.

Status of access to SRH and abortion services among adolescents and WRA

The elected representatives think that there are both physical and financial barriers which prevent the access of adolescents and WRA to SRH and abortion services. Adolescents have even more additional difficulties due to lack of adolescent friendly services.

Health facility in-charges taking part as key informants said that there are physical barriers that hinder women’s access to SRH and abortion services as they have to travel long distance to seek such services from private clinics since it is not readily available in nearest government health facilitates. Moreover, status of access to SRH and abortion services among adolescents is very poor as they hesitate to discuss their problems especially with male health workers.

Actions that have been taken to improve access to SRH and abortion services

Elected representative key informants say in most facilities 24-hour delivery service is available. Supply of medicines has been increased and budget has been allocated by ward office to increase community awareness, train health works and ensure continuous supply of medicines. To improve quality of service delivery regular monitoring and supervision has been done.

Physical infrastructure for all health institutions has been developed as well as budget has been allocated to improve supply of necessary medicines. Efforts have been made to appoint workers to

63 fulfill the requirement. Also to ensure quality service delivery, regular monitoring and supervision has been done.

Health coordinators and health workers as key informants said that 1 day orientation about safe abortion service was conducted in some facilities.

Types of FP services and methods available in their locality

According to the elected representative key informants and 2 administrative officers FP methods that are commonly available in this locality include pills, condoms and depo injection. Male and female sterilization services are available occasionally through mobile camps. But sometimes FP devices that people want are not timely available.

Any cases of death of woman during her pregnancy

There has not been any case of death of pregnant woman in any of the study localities as reported by the elected representative, 2 administrative officer and other key informants.

Suggestions to improve RH status of women in their locality

The elected representative, 2 administrative officer and other key informants gave some suggestions to improve physical infrastructure and quality of services of health facilities, conduct SRH related awareness programme to adolescents, sex education in schools and systematic management of medicines. They also suggest to do advocacy for institutional delivery and ANC and awareness raising on adverse effects of child/ early marriage. They suggested for effective functioning of health facilities. Another important suggestion was to make health services adolescent friendly.

Teaching of reproductive health in schools

All of the 6 school teachers that were interviewed said that reproductive health subject is taught in their schools but it is taught by male teachers.

All 3 education coordinator mentioned that reproductive health subject is taught in secondary schools of their localities. Also most schools have male teachers that teach such subjects.

Opinion on sex education

Sex education means providing information about sex and reproductive health and its subject area includes changes during adolescence, reproductive health problems, safe sexual relationships, consequences of unsafe sex etc. All the school teachers interviewed had similar opinion about sex education.

The 3 education coordinators of three municipalities said that sex education entails providing information about sex and reproductive health. It helps to inform adolescents about various aspect of sexual health and to prevent different diseases and problems.

Risky behaviour among students

All 6 informants accounted that early marriage, early pregnancy and child birth are common among school going children. According to them, this is more prevalent among girls. Three teachers said that boys involve in risky behavior such as smoking and alcohol consumption. In addition, girls tend

64 to miss school days during their menstrual cycle. The three education coordinators had similar views.

Reasons for involving in risky behaviour

Most school teachers said that students get involved in risky behaviors without knowing the harmful consequences. However, one of them mentioned that reason behind involvement of students in risky behavior may be attributed to increasing use of Face book and the internet in general. Another informant also said that it might be due to the trend of imitating others.

The three education coordinators mentioned that students involve in risky behavior about which they lack information and awareness about its consequences. Also they lack necessary skills which might prevent them from showing such behavior.

Ways to prevent students from involving in risky behaviours

Students as well as parents, according to school teachers, must be given information about consequences of risky behavior through effective health education and awareness programmes. Right age at marriage should be promoted and the knowledge on adverse effects of early marriage and pregnancy should be given to students.

The three education coordinators mentioned that in order to reduce risky behaviours among students, sexual and reproductive health related awareness generation programmes must be conducted in schools. Advocacy for right age at marriage should be done through awareness programs which should include both students as well as their parents.

Knowledge about CSE and its importance

According to 6 school teacher key informants, CSE includes topics such as various changes in adolescents, attraction to opposite sex as well as all the area of sexual and reproductive health. CSE can help students to practice safer sexual behaviours and be aware of different problems that they may face. In addition it can help to de-stigmatize sexual issues and enable them to discuss their problems openly. It can also help adolescents to make good decisions by weighing out its possible future implications. The education coordinators had similar opinions.

Suggestions about CSE

Six school teacher key informants think that CSE should address all the queries of students related to their sexuality and reproductive health. To make CSE classes effective they suggested that it should include interactive ways of learning such as video presentations and street dramas. In order to address the issue of girls missing school during menstruation, school must ensure sanitary management of toilets and provision of sanitary pad distribution.

Moreover, many informants mentioned that free hot-line services should be conducted so that adolescents can freely discuss their problems and gain insightful solutions about them. Lastly, not only students, but teachers and parents should also be oriented about CSE.

The education coordinators suggest that CSE should include most common problems of the students and teach ways to appropriately handle them. Not only students but teachers and parents should also be oriented about them.

References Central Bureau of Statistics (CBS). 2012. National Population and Housing Census 2011: National Report. Government of Nepal, National Planning Commission Secretariat, Kathmandu – Nepal, November. Ministry of Health and Population (MOHP). 2017. Nepal Demography Health Survey 2016, Ministry of Health and Population, New Era and ICF, Kathmandu, Nepal. Ministry of Health. 2016. Safe Abortion Service Programme Guidelines 2016 (in Nepali). Department of Health Services. Family Health Division, Teku, Kathmandu. Ministry of Health and Population, New ERA, and ICF International Inc. 2012. Nepal Demographic Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and Macro International Inc. Ministry of Health and Population, New ERA, and Macro International Inc. 2007. Nepal Demographic Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and Macro International Inc. Ministry of Health (MOH). 2004. Annual Report 2002/03. Department of Health Services. His Majesty’s Government, Kathmandu, Nepal. Ministry of Health (MOH). 2005. Annual Report 2003/04. Department of Health Services. His Majesty’s Government, Kathmandu, Nepal. Pradhan, A, Aryal, R. H., Regmi, G., Ban , B. and Govindasamy, P. 1997. Nepal Family Health Survey 1996. Kathmandu, Ministry of Health Nepal and Calverton, Maryland. USA. World Health Organization. 2011. Preventing gender-biased sex selection: an interagency statement OHCHR, UNFPA, UNICEF, UN Women and WHO. Geneva: World Health Organization

ABBREVIATIONS AND ACRONYMS ANC Ante natal care / check-up ANM Auxiliary Nurse Midwife ASFR Age specific fertility rate CPR Contraceptive Prevalence Rate CSE Comprehensive Sexuality Education CBS Central Bureau of Statistics D & E Dilation and evacuation D & C Dilation and curettage DoHS Department of Health Services FCHV Female community Health Volunteers FP Family planning FGD Focus Group Discussion FM Frequency modulation FY Fiscal Year GBSS Gender-biased sex selection GoN Government of Nepal HF Health Facility HH Household HIV/AIDS Human Immune Deficiency Virus/ Acquired Immune Deficiency Syndrome HP Health Post HW Health Worker IEC Information, education and communication IUD Intra Uterine Device KAB Knowledge, attitude and behaviour KII Key Informant Interview LSC Local Steering Committee LAM Lactational Amenorrhoea Method MA Medical Abortion MMR Maternal mortality ratio MoH Ministry of Health MoHP Ministry of Health and Population MoWCSW Ministry of Women, children and Social Welfare MVA Manual vacuum aspiration NDHS Nepal Demographic and Health Survey NHEICC National, Health Education, Information and Communication Centre NHTC National Health Training Centre PHD Population, Health and Development (PHD) Group PHCC Primary Health Care Centre PSU Primary sampling unit RH Reproductive health SA Safe Abortion SAAF Safe Abortion Action Fund SABAS Stigmatizing Attitudes, Beliefs and Actions Scale SBA Skilled Birth Attendant SPSS Statistical Package for Social Sciences SRB Sex ration at birth SRHR Sexual and Reproductive Health and Rights SWC Social Welfare Council TFR Total Fertility Rate UN United Nations WB World Bank WHO World Health Organization WRA Women of Reproductive Age