Knowledge and utilization of family planning and safe abortion services among married women of reproductive age in the Raute community of Nepal: a census-based cross-sectional study

This census-based study of Nepal's marginalized Raute community reveals that while over half of married women utilize family planning, primarily through injectables, there is a critical lack of awareness regarding safe abortion policies and negligible access to these services, highlighting an urgent need for culturally tailored, mobile outreach and legal literacy programs to improve reproductive health equity.

The Gist

Imagine a small, wandering tribe in the mountains of Nepal called the Raute. They are one of the last groups in the world who still live as nomadic hunter-gatherers, moving through the forests rather than settling in one village. Because they move so much and live on the edge of society, they have been like a "ghost town" in health statistics—nobody really knew what their health needs were.

This paper is the first time researchers have tried to take a complete "headcount" (a census) of all the married women in this tribe to understand how they handle family planning (preventing pregnancy) and safe abortion (ending a pregnancy safely if needed).

Here is the story of what they found, explained simply:

1. The Family Planning Picture: A One-Way Street

Think of family planning like a toolbox. In most places, a toolbox has many different tools: pills, condoms, injections, implants, and permanent solutions.

• The Good News: More than half of the Raute women (53.6%) are currently using some form of family planning. This is actually a pretty good number for such a hard-to-reach group.
• The Problem: The toolbox is missing almost all the tools. It's like having a toolbox that only contains a hammer and a screwdriver, but no wrench or pliers.
  • Almost all the women are using injections (shots), sterilization (permanent surgery), or implants.
  • Condoms? Almost nobody uses them (only 1%). This means the "job" of preventing pregnancy is entirely on the women's shoulders, with the men largely uninvolved.
• Why aren't more using it? For the women who aren't using family planning, nearly everyone (97.7%) said, "I just don't have an interest in it." The researchers suggest this isn't just a simple choice; it's likely a mix of fear of side effects, cultural pressure, or not having the right information to make a different choice.

2. The Safe Abortion Picture: Knowing the Map but Not Taking the Trip

Imagine you have a map that shows a life-saving exit door (safe abortion services), but you've never actually walked through it.

• The Knowledge: About 6 out of 10 women know that safe abortion services exist and that they can go to government hospitals for them.
• The Reality: Only about 8 out of 100 women have ever actually used these services.
• The Legal Gap: Nepal has had a law allowing safe abortion since 2002. However, only about 1 in 10 Raute women even knows this law exists. It's as if a library opened its doors 20 years ago, but this specific community still thinks the building is locked.

3. The Big Connection: The "Either/Or" Relationship

The most interesting finding is like a seesaw. The study found a strong link between the two topics:

• Women who do not use family planning are much more likely to have used abortion services in the past.
• Women who do use family planning are less likely to need abortion.

Think of it this way: If you have a good umbrella (contraception), you don't need to run for cover when it rains (abortion). If you don't have an umbrella, you might eventually have to run for cover. The study suggests that for this community, using contraception and using abortion are two different ways of managing the same problem: unwanted pregnancy.

4. Who is Getting Help?

• Age and Location: Younger women and those living in slightly more "urban" (town-like) areas were more likely to use abortion services in the initial checks, but because so few women used these services overall, the data wasn't strong enough to say this is a definite rule.
• The "Why" Factor: Surprisingly, things like how much money a family makes, how many children they have, or whether the woman can read and write didn't change the results much. The biggest factor was simply whether they had ever used abortion services before.

The Bottom Line

The researchers found that while the Raute women have made progress in using birth control, the methods are limited, and men are largely absent from the conversation. Furthermore, there is a massive gap between knowing abortion is legal and actually knowing how to access it or feeling safe doing so.

What the paper suggests needs to happen:

• Mobile Clinics: Since the Raute move around like nomads, health workers need to go to them, not wait for them to come to a hospital.
• Talk to the Men: Family planning needs to become a team effort between husbands and wives, not just a job for the women.
• Clearer Signs: The government needs to explain the abortion laws in the local language and through stories or pictures, since many women cannot read.

This study is the first time we have a clear, complete picture of this specific community's reproductive health, and it highlights that while progress has been made, there is still a long road to go to ensure these women have the same rights and options as everyone else.

Technical Summary

Technical Summary: Knowledge and Utilization of Family Planning and Safe Abortion Services Among Married Raute Women in Nepal

Problem Statement
Indigenous and nomadic communities globally face disproportionate barriers to reproductive health services, yet quantitative data on these populations are frequently absent from national surveys. The Raute community of Nepal, one of the country's last nomadic hunter-gatherer groups, represents a uniquely marginalized population with no prior population-level quantitative data regarding family planning (FP) and safe abortion services. This evidence gap hinders the design of culturally appropriate interventions for a community characterized by high fertility rates, early marriage, reliance on traditional healers, and near-absent antenatal care. While Nepal has maintained a progressive legal framework for safe abortion since 2002 and established family planning targets, the extent to which these services reach the Raute remains unknown.

Methodology
This study employed a census-based, cross-sectional design to enroll all 192 eligible married women of reproductive age (15–49 years) within the Raute community residing in Parshuram Municipality, Dadeldhura district, as of the study period (September–November 2022).

• Data Collection: Structured, pre-tested, face-to-face interviews were conducted in the local language by trained researchers. The instrument covered socio-demographics, FP knowledge/methods, and safe abortion knowledge/policy awareness.
• Analysis: Data were analyzed using IBM SPSS version 16. Descriptive statistics summarized prevalence and patterns. Chi-square tests examined bivariate associations, and binary logistic regression identified independent predictors of service utilization.
• Ethics: The study received approval from the Institutional Review Committee of Manmohan Memorial Institute of Health Sciences. Written informed consent was obtained, and anonymity was maintained.

Key Results

• Family Planning Utilization: The current FP prevalence was 53.6%. The method mix was heavily skewed toward long-acting and permanent female-dependent methods: injectables (42.7%), female sterilization (33.0%), and implants (24.3%). Condom use was negligible (1.0%). Among non-users (46.4%), 97.7% cited "lack of interest" as the primary reason.
• Safe Abortion Knowledge and Utilization: While 61.5% of women knew of safe abortion services and 96.6% of those knew government facilities provided them, only 8.3% had ever utilized these services. Awareness of the specific national safe abortion policy was critically low at 10.4%.
• Predictors of Utilization:
  • Family Planning: No socio-demographic or socioeconomic variables (age, residence, income, literacy) were significantly associated with FP use. The sole significant independent predictor was non-utilization of safe abortion services (Adjusted Odds Ratio [AOR] = 4.275; 95% CI: 1.145–15.954), suggesting an inverse relationship where contraceptive use and abortion use function as alternative reproductive management strategies.
  • Safe Abortion: In bivariate analysis, younger age (≤30 years) and urban residence were significantly associated with higher utilization. However, these associations were attenuated to non-significance in the adjusted model, a result the authors attribute to limited statistical power due to the small number of outcome events (n=16).

Key Contributions and Significance
This paper provides the first population-level quantitative evidence on reproductive health service utilization among the Raute community. Its primary contributions include:

1. Filling an Evidence Gap: It establishes baseline data for a nomadic indigenous group previously excluded from national reproductive health metrics.
2. Identifying Critical Disparities: The study highlights a severe "knowledge-to-practice" gap in safe abortion services (61.5% knowledge vs. 8.3% utilization) and a critical deficit in legal literacy (10.4% policy awareness), which is significantly lower than national averages.
3. Methodological Insight: It documents a near-total absence of male-controlled contraception (condoms), indicating that reproductive responsibility remains exclusively female in this community.
4. Policy Implications: The findings suggest that strengthening family planning access is the most efficient strategy to reduce unintended pregnancies and reliance on abortion services in this specific context. The authors argue that interventions must be tailored to nomadic movement patterns (mobile outreach), include targeted legal literacy in the local language, and incorporate structured male engagement strategies to address the gendered nature of contraceptive decision-making.

The authors conclude that while FP coverage has achieved meaningful penetration, the lack of method diversity, low safe abortion utilization, and poor policy literacy represent critical barriers to reproductive health equity for this vulnerable indigenous population.