Abstract:
Faced with stagnant contraceptive prevalence,
the Government of Nepal has
recently ramped up efforts to reduce barriers
to family planning, to increase methods and
services available, and to satisfy the demand
for modern contraception. This study, which
took place in Eastern Nepal, was a follow-up
to the 2016 Nepal Demographic and Health
Survey (NDHS). The
follow-up study reinterviewed a sample of
married female NDHS respondents age 15-39 in
17 clusters of Province 1, typically within a
week following their NDHS interview (90%
response rate, n=194). It included a range of
in-depth questions about family planning use,
fertility preferences, and perceived barriers
to family planning. In line with an earlier
study in Ghana, the study found an
underreporting of traditional method use in
the NDHS. Husbands had an important role in
family planning, with about half
of all users reporting that their husband had
specifically suggested the current method.
This was disproportionately the case for
women who reported using condoms, withdrawal,
and periodic abstinence. Nepal is a major
labor exporting country. Unsurprisingly,
their husband’s absence
was the main reason women cited for not using
contraception. Respondents tended to be
poorly prepared for using contraception when
their husbands returned home, often intending
to start a hormonal method only
after he arrived. Most respondents were in
regular contact with nonresident husbands,
but many reported not feeling comfortable
broaching the issue of contraceptive
preparedness before their husband’s
return. Nearly all study respondents knew
about family planning methods and where to
obtain contraceptives. Women’s main concern
was finding a suitable method, typically
described as one that did not cause
undesirable side effects. Fear of health
hazards and side effects of commodity-based
contraception was a theme in about a third of
the interviews. Among women who used
traditional methods or did not use any
method, the major source for their concerns
about health hazards and side effects of
modern methods appeared to be the views of
their husbands. Lack of access to
contraceptives was rarely reported as a
reason for nonuse, but discussions revealed a
number of access-related barriers to
commodity-based methods, including geographic
inaccessibility, limited or inconsistent
provider operating hours, and a small number
of method types locally available.
Female community health volunteers helped
bridge this gap in some rural communities,
but could only dispense condoms and re-supply
pills. A more subtle barrier to access was
that condoms, pills, and injectables were
sometimes perceived as the entire universe of
available commodity-based
contraceptives, indicating a lack of method
diversity in several communities. However,
despite these challenges, women and couples
who
were motivated to use commodity-based methods
of contraception were nearly always
successful in their efforts, for example, by
paying for contraceptives at local pharmacies
rather than traveling long distances to
obtain them for free at government health
posts, or opting for their second-choice
method. Unfortunately, upon receiving their
method from
pharmacies, they were not usually counseled
about possible side effects or the time
needed for the method to provide protective
effects. Overall, the findings suggest that
improved family planning messaging, broader
availability of long-term methods, expanded
and reliable operating hours,
consistent supplies, and more counseling
would improve contraceptive uptake and
continuation in Eastern Nepal. The study also
provides
lessons learned for future follow-up studies
as well as implications for large-scale
survey measurement of family planning
worldwide.
Barriers to Family Planning Use in Eastern Nepal: Results from a Mixed Methods Study (PDF, 1817K)