Barriers to Family Planning Use in Eastern Nepal: Results from a Mixed Methods Study
DHS Qualitative Research Studies 21
May 2018 This publication was produced for review by the United States Agency for International Development (USAID). It was prepared by Sarah Staveteig, Neera Shrestha, Sunita Gurung, and Kathryn T. Kampa.
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. 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.
Staveteig, Sarah, Neera Shrestha, Sunita Gurung, and Kathryn T. Kampa. 2018. Barriers to Family Planning Use in Eastern Nepal: Results from a Mixed Methods Study. DHS Qualitative Research Studies No. 21. Rockville, Maryland, USA: ICF.