Attitude towards family planning in Dharan, east Nepal: implications for the family planning programme

612 TRANSACTIONS OF THE ROYAL

SOCIETY OF TROPICAL MEDICINE

Attitude towards family planning family planning programme Mary J. Glennon* and David J. Fegan

AND HYGIENE (1993) 87, 612-614

in Dharan, east Nepal: implications

for the

Eastern Regional Hospital, Dharan, Nepal

Abstract A survey of the knowledge, attitude and practice of family planning was conducted in Dharan, Nepal. The town offers a full range of family planning services free of charge. There was a strong desire to limit family size; 52.5% of couples were currently using some modern method of family planning. Of the current users, 62.3% had been sterilized, including 92.3% of those in the lowest socioeconomic group. Health risks and incompleteness of the family were the most common reasons for non-use of contraception, the latter reason reflectmg ignorance of the temporary nature of some methods. There was a strong preference for male children and couples rarely used contraception until at least one son had been born. Even in this prosperous town where couples were highly motivated towards family planning and all methods were readily available, there was heavy reliance on sterilization. This is typical of Nepal and has largely been responsible for the failure of the family planning programme-as most couples choosing sterilization are in the older age group and have completed a relatively large family. If Nepal is to succeed in meeting its target of reducing the total fertility rate (i.e., births per woman) from the current 5.8 to 4 by the year 2000 it will need not only to expand services but actively to promote temporary methods of contraception, particularly the more reliable longer acting reversible methods such as Depo-Provera *, Norplant@ and intrauterine contraceptive devices. Introduction Nepal has a population of approximately 19 million. The average annual growth rate over the last 2 decades 1986). A vertical family planning was >2.5% (NEPAL, programme was first introduced in Nepal in 1966. The total fertility rate (TFR), i.e. births per woman, at that time was 6.2. The main emphasis of the programme was on sterilization provided free through sterilization camps. The number of sterilizations reached a peak of 60 000 per annum in the mid 1980s. However, this policy had little impact on the TFR as most couples accepting sterilization were in the older age group and had completed a relatively large family. In 1987 the family planning programme was integrated into the Ministry of Health (MOH). More emphasis was placed on temporary methods of contraception which were to be provided through the public health outlets and through non-governmental organizations (NGOs) and the number of sterilizations fell to approximately 20 000 per annum. A target was set to reduce TFR to 2.5 by the year 2000. However, integration of the family planning programme into the general MOH services was beset with organizational problems and has not been widely effective. By 1990 the TFR was 5.8 (NEPAL, 1992a). Study area Dharan is a town in the south-eastern part of Nepal with a nonulation of 68 173 (NEPAL. 1991). It is the site of the largest British Army‘ Gurkha recrbitment camp which was operational from the early 1950s until 1990. Many currently serving and retired Gurkhas have made their homes in Dharan and so, unlike most towns of comparable size in Nepal, Dharan has a large middle class community and is one of the most prosperous towns in the country. Methods A household survey of the knowledge, attitude and practice of family planning was conducted in Dharan over 4 weeks in February 1992. As there were no adequate data available to establish a representative sample of the Dharan population, the sampling frame for the survey was designed to collect data from couples who represented the socioeconomic distribution of the population. Dharan is divided into 19 wards of approximately equal population. One or 2 clusters of households, which were considered to be repre*Overseas Development Administration Family Planning Consultant. Address for correspondence: Dr M. J. Glennon, c/o Dr D. Fegan, FCO (Kathmandu), King Charles’s Street, London, SWlA 2AH, UK.

sentative of the socioeconomic range of the ward by 2 personnel familiar with the area, were selected from each ward. Households were randomly selected from each cluster, 10 from each of 18 wards and 5 households from ward 6 which has a much smaller population than the others. The survey was conducted by a female who had previous experience in data collection accompanied by a male representative from Dharan town council. Only one couple aged 15-49 years from each household was eligible for inclusion in the survey. The questionnaire was a combination of fixed format and open ended questions; it was translated into Nepali and pretested. Results From the 185 households there were 23 non-respondents, including 2 refusals, 8 too elderly for inclusion, and 13 not at home, a response rate of 87%. In the remaining 162 households 161 wives and 40 husbands were interviewed. The difference in formal education received by husbands and wives was striking; 83 wives had received no formal education compared to 30 husbands (Table 1). Table 1. Level of education of husbands and wives participating survey in Dharan, Nepal

Wife Husband

Number

None

162 162

51.5 18.5

Education’ Primary Secondary 13.6 23.5

22.8 33.3

in the

Tertiarv 12.3 24.7

“Percentages receiving education at the stated level

One hundred and forty-five couples (89.5%) had some knowledge of modern methods of family planning. Accurate use of any of the methods was much lower (Table 2); 135 (83.3%) couples knew where to obtain family planning services with 123 (75.9%) naming the Family Planning Association Nepal (FPAN) clinic in Dharan. The survey showed that there is a strong desire to limit family size and that preferred family size, defined as ‘if you could start again, how many children would you like to have?’ was 2 for 95 wives (58.6%) and 25 (62.5%) husbands and 3 for 48 wives (29.6%) and 13 husbands (32.5%). There was definite gender preference for male children among both husbands and wives: 41 women (85%) who thought 3 children was the ideal number preferred 2 boys and 1 girl, as did 12 of the 13 husbands who thought 3 children ideal. The mean number of living children per couple was 2.76. Sixty-five couples (40%) had more children than they ideally desired; 110 wives (68%) and 32 husbands (80%) wanted no more

613 Table 2. Knowledge and use of specific methods traception of 162 couples in Dharan, Nepal

Method Pill Depo-Provera@ Condoms T”u”r,“d”“‘” a

of con-

Knowledge of Used at Unprompted accu;Ft;-use any time naming (%‘1 00 f%) 16.0 64.8 19.8 45.0 13.6 12 35.8 15.4 ;:; 20.9 37.7 3.7 3.1 I.

I

~

~

I

I

2:.: 2:: 9.3 25.9 0.6 Tubal ligation Vaginal foams 12.9 12.3 Vasectomy 48.0 ‘Sterilization operation’ ;2 1.9 ‘Natural’b “Intrauterine contraceptive device. bEither coitus interruptus or modified Billings method.

children. 97 (60%) couples had at sometime used a modern method of family planning and 85 (53%) were still using some form. Of the 54 couples (33%) who had been sterilized, 33 had opted for tubal ligation and 21 for vasectomy. Sterilized couples had a mean familv size of 3.7 children. Thirty-one couples (19%) were* ‘currently using’ temporary methods, of which pills were used most frequently followed by condoms (Table 2). Twelve couples had stopped using contraception; 6 of these wished to have another child and the remaining 6 cited side effects. Reasonsfor never using family plating were multiple in many cases,but came under 3 broad headings: family incomplete (33; 20%), health reasons (26; 16%), and ignorance (18; 11%). Religious reasonswere cited by only 1 Hindu couple (Table 3). Among the 28 couples who Table 3. Reasons for never using contraception couples among 162 surveyed in Dharan, Nepal

stated by

Number Family incomplete No children yet Want more children Not before children complete Want another son Waiting until children are older Health reasons Fear of side effects Contraindications cited by family planning provider Waiting for return of menstruation Secondary infertility Ignorance Don’t know about family planning Don’t know where to get family planning Don’t know why Others Husband working away from home No time Against religion Waiting for mother-in&w’s approval

::

4 :

15 5 t 11 6 1 3

had received no formal education, 25 (90%) were able to name some modern

method

of fat&y

planning,

22

(78.5%) knew where services were available, 16 (57.1%) had at some time used someform of family planning and 13 of these were still usine familv olannine. Again sterilization was the preferred hethod by 12 orthe- current users (92O/,).The mean family size was larger in this uneducated group, at 3.5. Those who had been sterilized had a mean family size of 4.25. Discussion

Superficial knowledge of family planning in Dharan is high, as is knowledge of where to obtain services. The ‘currently using’ family planning figure of 52% in our survey is relatively high compared to the national contra-

ceptive prevalence rate (CPR) figure for urban areas of 31.9% (NEPAL, 1987) and compares favourably with that of the capital Kathmandu where the most recently determined CPR is 50.7% (NEPAL, 1992b). Bv contrast, the most recently estimated CPR. for the whole of S&sari district, in which Dharan is situated. is onlv 14.8% (NEPAL, 1992b). Reasonsfor the high figures in’ Dharan include (i) the urban setting with easy access to a full range of family planning services provided free through FPAN and, to a lesser extent, by MOH facilities and (ii) its unique demographic compo&ion, i.e. the high d&L sity of British Army Gurkha families. Although ‘currently using’ figures are relatively high in Dharan, the pattern of use is similar to that found in other surveys in Nepal; i.e., heavy reliance on sterilization particularly among the lower socioeconomic groups, suspicion of temporary methods, and strong preference for male children. The concept of contraception for child spacing has not been accepted; 2 1 of 53 couples in our survey who had at least one child and had never used any method of contraception cited incompleteness of the family as the reason. This suggesteda lack of awarenessthat births can be delayed or spaced by temporary methods. Most couples prefer to complete their family and then choose sterilization; 62% of current users in our survey were sterilized and this figure rose to 92% in the lowest socio-economic group compared to 86% of current users nationally (NEPAL, 1987). This reflects both the promotion of sterilization by the family planning programme and suspicion of temporary methods. Health risks have been found to be the most important reason given for non-use of contraception by those with an unmet need for contraception in other surveys in Nepal (SHRESTHAet al., 1988). There still remains a strong preference for male children. Couples rarely use contraception until at least one child, preferably a son, has been born (KARKI, 1988). Reasonsfor this are religious (only a son can perform the rituals intended to ensure that the parent will be admitted to heaven after death) and also economic. There has recently been a review of population and family planning policy in Nepal (NEPAL, 1992a). New targets have been set to reduce the TFR to 4 by the year 2000. This implies increasing the CPR from its current finure of 19.4% (NEPAL, 1992b) to 40%. with a more equitable mix of’ permanent &d tempoiary methods. The main strategies of the revised family planning programme are (i) expansion of services through further integration of family planning activities into hospital and health post services in the more populous areas, (ii) confining mobile sterilization camps to the more remote areas(these camps previously provided the acceptor with a small financial compensation and the provider with a financial incentive per client), (iii) training of health personnel in clinical techniques with particular emphasis on clinically reversible, longer acting contraceptive methods such as Depo-Provera@,NorplanP and intrauterine contraceptive devices (IUCDs). To meet these new targets, expansion of services will need to be matched with increased promotion. Indeed, lack of facilities has rarely been cited as a reason for non-use of contraception and many of the family planning facilities are under-utilized (SHRESTHAet al., 1988). Dharan has better family planning facilities than most towns in Nepal and offers a full range of family planning services free of charge but still has not managed to achieve an equitable mix of permanent and temporary methods. To overcome this problem the flagging information, education and communication (IEC) programme will have to be revitalized. Both the IEC programme and service providers will need to address the problems of ignorance and fear of temporary methods which are so widely prevalent and which have proved major constraints to increasing the uptake of temporary methods. Family planning course curricula need to be developed to encourage health workers to adopt a

614

methods must not only be made widely available but also widely promoted if Nepal is to achieve its family planning targets by the year 2000.

more ‘cafeteria’ approach to promotion of all contraceptive methods. Greater emphasis needs to be placed on follow-up activities and reasonsfor high ‘drop-out’ numbers with temnorarv methods. Pills and condoms are still . the most popular
References Karki, Y. B. (1988). Sex reference and the value of sons and daughters in Nepal. Stu lftes tn Family Planning, 19, 169. Nepal (1986). Population Projection of Nepal, Medium Variant, 1980-2000. Kathmandu: National Planning Commission, Central Bureau of Statistics. Nepal (1987). Nepal Fertility Survey: First Report. Kathmandu: Ministry of Health. Nepal (1991). Four-monthly Statistical Bulletin 2048-2049 (19911992), Year 13, issue 1. Kathmandu: Central Bureau of Statistics Department. Nepal (1992a). His Majesty’s Government of Nepal Population and Policy ProgrammeReport. Kathmandu: National Planning Commission and Secretariat Population Division. Nepal (1992b). Family Planning Perfmance Report, February 1992. Kathmandu: Ministry of Health. Shreshtha, A., Stoeckel, J. 8i Tuladhar, J. M. (1988). Factors

Conclusion

Dharan is a prosperous town and, in the context of Nepal, has very good family planning facilities. The population in general is well motivated towards limiting family size. Even in these circumstances there is high dependence on sterilization for family planning and a very low uptake of the longer acting reversible contraceptives. Over-promotion of sterilization has failed the family plannmg campaign rather like ‘shutting the gate after the horse has bolted’. Therefore the long acting reversible

related to non-use of contraception among couples with an unmet needfor family planning in Nepal. Final Report, Demographic

and Health Surveys Project, IRD, Westinghouse.

Received 10 November 1992; revised 22 February accepted for publication 23 February 1993

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