Association of Socio-demographic and Decision Making Factors with the unmet need of family planning among Married Women in Madi Municipality, Chitwan, Nepal

doi:10.21203/rs.3.rs-4997097/v1

Background

Sustainable Development Goal of Nepal targets universal access to family planning (FP) services and increasing the contraceptive prevalence rate to 75% by 2030. Despite continuous efforts from the government of Nepal in the FP sector, the prevalence of unmet need for FP is high. This study aimed to identify sociodemographic and decision-making factors associated with the unmet need for FP among married women of reproductive age.

Methods

This is a community-based cross-sectional study conducted in Madi municipality, Chitwan, Nepal. Face-to-face interviews were conducted with 218 married women of reproductive age using a semi-structured questionnaire. Descriptive statistics, chi-square tests and multivariable logistic regression were used to analyse the data.

Results

Nearly half (47%) were age group 25–34, 58% lived in nuclear families, 76% belonged to advantaged ethnic groups, majority of respondents (67%) and their husbands (75%) had at least secondary education. Most women (59%) were involved in agriculture, while most husbands (44%) were in foreign employment. Participants (91.3%) have heard about Depo-Provera. The overall unmet need for FP was 38%. Respondents whose husbands were involved in foreign employment were more likely [aOR: 4.408; CI: 2.068–9.399] to have an unmet need for FP than those employed within the country. The likelihood of the unmet need was higher [aOR: 3.212; CI: 1.368–8.135] among couples who did not discuss using FP methods compared to those who discussed three or more times. Women with up to two children [aOR: 5.212; CI: 1.163–23.363] and three or more children [aOR: 8.758; CI: 1.691–45.355] were more likely to have a higher unmet need for FP than women without a child.

Conclusion

A significant proportion of women had an unmet need for FP. Intervention should focus on addressing the FP needs of migrants and their spouses, promoting spousal discussion on FP and counselling on the treatment as well as side effects of contraceptives. Furthermore, empowering women would enable them in the decision-making process and in accessing FP services.

Contraception

Cross-sectional

Factors associated

Foreign employment

Nepal

Spousal communication

Unmet need

Sustainable Development Goal (SDG) of Nepal has focused on ensuring healthy lives and promoting well-being for all age groups. One of the targets of the SDGs of Nepal is ensuring universal access to sexual and reproductive health care services, including family planning (FP). It aims to increase the contraceptive prevalence rate (CPR) to 75% by 2030(1). Globally, the CPR is 76%, and the prevalence of unmet need is 10%(2), while in Nepal, a larger unmet need of 21% exists when CPR is 53%(3). Nepal aims to achieve 74% of women aged 15–49 years having their family planning needs met by modern methods by 2022, with this target increasing to 80% by 2030. This aligns with Sustainable Development Goal (SDG) target 3.7.1(4). Women with an unmet need for FP are those who are not currently using any contraceptive method but want to postpone childbirth for at least two years(5). In Nepal, the unmet need declined by only 7% in a decade, from 28% in 2011 to 21% in 2022(6)(4). Unwanted pregnancy is associated with higher unsafe abortion(7).

There are various ongoing efforts to address the unmet need of family planning. Both, government and private sector is working to make family planning accessible(8). The government of Nepal is providing short-acting reversible contraceptive methods (male condoms, oral pills, and injectable) through primary health care centres (PHCCs), health posts and primary health care outreach clinics. Long-acting reversible contraceptive methods such as Intra Uterine Contraceptive Device (IUCD) and Implant are available in hospitals, PHCCs, and health posts through trained and skilled providers. Similarly, male and female sterilization are usually performed in mobile camps and hospitals. Clinics/centres, private hospitals/clinics, and pharmacies run by nongovernmental organizations are also providing quality FP services. Female community health volunteers (FCHVs) are responsible for raising awareness in the community regarding FP as well as distributing male condoms and oral contraceptive pills(9). Despite the availability of FP services, the CPR for the modern FP method has remained stagnant (43%) since 2006, and a significant proportion of unmet needs exists(3).

The underlying reasons for the non-use of contraception among women with an unmet need for FP are a lack of awareness regarding the details of specific methods of contraception and the concept of fertility control, fear of side effects or health risks and the inconvenience of using contraceptives(10).

The unmet need for FP among married women is influenced by several factors, such as their age, caste/ethnicity, place of residence, education, occupation, education and occupation of husband, number of living children, number of living sons, approval of husband and spousal communication (11–14).

Unlike previous studies on the unmet need for FP in Nepal(11–14), this study was conducted in a semi urban setting of a newly formed municipality. There are a limited number of unmet need studies conducted in Nepal(5, 11–15). This study aimed to identify the socio-demographic and decision-making-related factors influencing the unmet need for FP among married women of reproductive age (MWRA).

Study area

This study was conducted in the Madi Municipality of Chitwan District. In Chitwan, in addition to two pre-existing municipalities, village development committees were merged, and five new municipalities were gradually formed, including Madi. Madi was declared a municipality with 9 wards in 2014. It has nine public health facilities, including one hospital, three health posts, one community health care unit, and four urban health care centers. FP service is available at all the health facilities as well as from an FCHV of the respective ward. According to the record of household survey conducted by the municipality in 2017 [Local Level Publication 2017], Madi Municipality has a total population of 43,402, of which 12,577 are females of reproductive age (15-49). It comprises a total of 8,649 households inhabiting 37 types of caste/ethnicity groups. The major caste/ethnicity are Brahmin, Chhetri, Chaudhary, Chepang, Damai, Gurung, Tamang, Bote, Magar, Kami and Sarki[13 (16).

Study design and study participants

This was a cross-sectional study conducted among MWRA (15-49 years) who were residents of Kalyanpur of Madi Municipality. Among the 12,577 female of reproductive age group we interviewed married women aged 15 to 49 years residing in the municipality(16), willing to participate in the study and provided informed consent.

Sampling and sample size

A multistage sampling technique was used in the study. Among the newly formed municipalities in Chitwan, Madi was selected purposively, being farthest in distance from Bharatpur – the district headquarters – that takes a two-hour drive. A ward was selected randomly using the lottery method. Then, a systematic sampling technique was used to select households for data collection. The selected ward (ward number 7) had a total of 978 households and 1,373 females in the reproductive age group [14]. The sample size for the study was calculated as follows:

\(\:n=\frac{{Z}^{2}p\left(1-p\right)}{d²}\) = (1.96)² x 0.24 x 0.76/0.06² = 195

where n is the sample size, Z is the z score (set to 1.96 at the 95% confidence level), p is the prevalence of unmet need (24%) and d is the margin of error (6%).

By considering a nonresponse rate of 10 percent, the final sample size (n)= 215

Then, the sampling interval was calculated as follows:

Sampling Interval = total households/sample size = 978/215 = 4.54

Every fifth house was selected after random selection of a first house. A total of 218 MWRAs were included in the study to cover all the remaining houses in the ward.

Study variables

Dependent variable: The dependent variable was ‘Unmet need for FP’.

Independent variables

Independent variables include the age of the respondent, religion, caste/ethnicity, wealth index, educational status of the respondent, occupation of the respondent, educational status of the husband, occupation of the husband, number of living children, decision-maker, frequency of discussion, and approval of husband.

Operational Definition

Unmet need for FP

Fecund women who desired to postpone birth for two or more years or stop childbearing altogether but were not currently using a contraceptive method, as well as pregnant women whose current pregnancy was unwanted/mistimed, were considered to have an unmet need for FP. The unmet need was categorized as ‘Yes’ (coded 1) and ‘No’ (coded 0)(17)(4).

(1) Age of respondent: Completed years of life of respondent. It was classified into three categories: ‘≤24 years’, ‘25-34 years’ and ‘35 years & above’(18).

(2) Religion: Religion followed by the respondents. It was classified into two categories: ‘Hindu’ and ‘Non-Hindu’ (Buddhist, Christian, and Muslim) (19)(20).

(3) Caste/ethnicity: This was categorized as ‘Advantaged caste/ethnicity’ and ‘Disadvantaged caste/ethnicity’. So-called upper caste group, i.e., Brahmin & Chhetri and relatively advantaged Janajati were classified as ‘Advantaged caste/ethnicity’, whereas Dalits and Disadvantaged Janajati were classified as ‘Disadvantaged caste/ethnicity’[13, 17].

(4) Wealth index: A wealth index was created using a principal component analysis of a number of household assets. It was classified into ‘Poor’ and ‘Rich’. Household assets were considered for calculation of wealth index as adopted by Shah R, et al(21).

(5) Educational status refers to completed years of schooling of the respondents and their husbands. It was measured in three categories – ‘no schooling’, ‘primary education’, ‘secondary education’ and ‘postsecondary or higher education’. Respondents who had completed any grades from 1 to 5 were classified as having ‘primary education’, respondents who had completed 9^th grade up to 12th grade were classified as having ‘secondary education’, and respondents with any completed education higher than 12th grade were classified as having ‘postsecondary or higher education’(6).

(6) Occupation of respondent: Occupation of the respondent at the time of data collection was classified into three categories: ‘Housewife’, ‘Agriculture’ and ‘Employed within country’ (service/labor/business)’(22)(23).

(7) Occupation of husband: Occupation of the respondent’s husband at the time of data collection. It was classified into three categories: ‘Agriculture’, ‘Foreign employment’, and ‘Employed within country’ (Service/Business/Labor) (22)(23).

(8) Number of living children: The number of living children of the respondents. It was classified as ‘No child’, ‘Up to 2 children’, or ‘3 or more children’(24).

(9) Decision maker: The individual who makes decisions regarding the use of the FP method. It was categorized as ‘By woman herself’ and ‘Husband and wife jointly’(25)(26).

(10) Frequency of discussion: This variable assessed the number of discussions on FP that a couple had regarding family planning. It was measured as ‘Never’, ‘Once or twice’ and ‘Three or more times’(27)

(11) Approval of husband: The variable assessed perceived approval of husband for using contraceptives. The response was categorized as ‘Approves’ and ‘Disapproves’.

Data collection procedure

Data were collected from June 30 to July 20, 2019. Data were collected using a structured questionnaire that was developed from relevant literature (3)(18)(27)(28) in the local Nepali language. The English version of questionnaire is available at [Supplementary file- S1]. The questionnaire was pretested in a similar setting of another municipality (Kalika municipality) in Chitwan. The questionnaire was then customized based on the findings of the pretesting, which included the addition of a ‘skip’ label, deletion of vague words, and ‘reordering’ the questions to make it friendly to both the data collector and respondents. The final questionnaire consisted of variables related to socio-demographic characteristics, knowledge and practice of FP, and decision-making.

Data were collected through face-to-face interviews by visiting women at their homes. A brief overview of the objectives of the present study was provided prior to the data collection among the women. The first house was selected by taking the community school as a landmark (29). A direction was randomly chosen by tossing a pen and following the direction of the point of the pen(30). Then, every fifth house was chosen until the required sample size was met. Additionally, two more eligible women were included from the remaining houses following the same procedure. Any fifth house where there was no eligible woman or was not available, the house just next to that was chosen as a sample, and then the next fifth house was selected. If there was more than one eligible woman in a house, one was randomly selected using the lottery method for interviews. Data were collected by the first (RG- BPH Student) and third author (YR- BPH Student) themselves.

Data processing and analysis

The data were entered and analysed using SPSS version 20 software. The frequency and percentage of data were calculated in descriptive analysis. Pearson’s chi-square test was used to assess the statistically significant association of the independent and dependent variables. Multicollinearity between independent variables was checked using variation inflation factor (VIF), taking the highest VIF value >3 into account (REF 1). The VIF value for any of the independent variables was not found >3. The variables that were significant at P value ≤0.1 were entered in multivariable analysis to ensure that potential predictors are included in the multivariable analysis(31). A P value <0.05 was considered to indicate statistical significance in multivariable analysis.

Ethical considerations

Ethical approval for the study was obtained from the Institutional Review Committee (IRC) of Shree Medical & Technical College (SMTC), Bharatpur, Chitwan (SMTC-IRC-2020720-2). Written informed consent was obtained from the respondents before initiating the interview using an informed consent form. Voluntary participation of the respondents was ensured throughout the study. The information collected was kept confidential and was used for research purposes only.

In this study, we found that most women who were in fecund reported their status themselves. Among the seven pregnant women found during the survey, two had unwanted pregnancies. We interviewed 218 eligible women and overall unmet need for family planning is found to be 38%. All the women who we met provided consent for the data collection.

Socio-demographic characteristics and relationship with unmet need of family planning of the respondents

Nearly half of the respondents (47%) were aged 25-34 years, and 58% of the respondents were living in nuclear families. Approximately three-quarters (76%) of the respondents belonged to advantaged ethnic groups, and approximately 9 out of 10 were Hindus. The majority of the respondents (67%) and their husbands (75%) were educated at least to secondary and higher levels. The majority of women (59%) and their husbands (44%) were involved in agriculture and foreign employment, respectively. Two-thirds of the respondents had up to two children (Table 1). Among socio-demographic variables, husband’s occupation (p<0.001) showed a strong association in Pearson’s Chi-square test with unmet need for FP. Furthermore, spousal discussion on FP (p=0.025) and approval of husband (p=0.034) were also significantly associated.

Table 1 Socio-demographic characteristics and association with unmet need for FP (n=218)

Characteristics	Total *	Unmet need		P value**
Characteristics	Frequency (%)	No Frequency(%)	Yes Frequency(%)	P value**
Age of respondent (Years)
£ 24	51 (23.4)	30 (58.8)	21 (41.2)	0.517
25-34	102 (46.8)	61 (59.8)	41 40.2)
35 & above	65 (29.8)	44 (67.7)	21 (32.3)
Religion
Hindu	195 (89.4)	121 (62.1)	74 (37.9)	0.921
Non-Hindu	23 (10.6)	14 (60.9)	9 (39.1)	0.921
Caste
Advantaged	166 (76.1)	101 (60.8)	74 (37.9)	0.556
Disadvantaged	52 (41.7)	34 (65.4)	18 (34.6)	0.556
Education of respondent
No schooling	39 (17.9)	28 (71.8)	11 (28.2)	0.338
Primary	32 (14.7)	18 (56.2)	14 (43.8)
Secondary /higher	147 (67.4)	89 (60.5)	58 (39.5)
Education of husband
No schooling	13 (6.0)	7 (53.8)	6 (46.2)	0.807
Primary	14 (18.8)	25 (61)	16 (39)
Secondary/higher	164 (75.2)	103 (62.8)	61 (37.2)
Occupation of respondent
Housewife	59 (27.1)	36 (61.0)	23 (39.0)	0.531
Agriculture	128 (58.7)	77 (60.2)	51 (39.8)
Employed within country	31 (14.2)	22 (71.0)	9 (29.0)
Occupation of husband
Agriculture	59 (27.1)	47 (79.7)	12 (20.3)
Foreign employment	95 (43.6)	38 (40.0)	57 (60.0)	<0.001
Employed within country	64 (29.4)	50 (78.1)	14 (21.9)
Number of living children
No child	19 (8.7)	16 (84.2)	3 (15.8)
Up to 2 children	143 (65.5)	84 (54.7)	59 (41.3)	0.099
3 & more children	56 (25.7)	35 (62.5)	21 (37.5)
Wealth Index
Poorer	109 (50.0%)	74 (67.9)	35 (32.1)	0.07
Better	109 (50.0%)	61 (56.6)	48 (44.0)
Decision maker on FP
By women herself	29 (13.3)	16 (55.2)	13 (44.8)	0.421
Husband and wife jointly	189 (86.7)	119 (63.0)	70 (37.0)
Spousal discussion on FP
Never	36 (16.5)	16 (44.4)	20 (55.6)
Once or twice	52 (23.9)	30 (57.7)	22 (42.3)	0.025
More often	130 (59.6)	89 (68.5)	41 (31.5)
Approval of husband
Approves	198 (90.8)	127 (64.1)	71 (35.9)	0.034
Disapproves	20 (9.2)	8 (40.0)	12 (60.0)

*Yields column % equals to 100 **P value from Pearson chi-square test, Family Planning- FP

Knowledge and practice of FP

Depo-Provera was the most commonly (91%) heard FP method. Most of the respondents had knowledge about FP methods from health posts (60%) and FCHV (34%). Approximately half of the respondents (51%) used the FP method. Among the current users, 84% were using modern methods, while the remaining (16%) were following traditional methods of FP. Nearly 37% of the users had permanent FP, including vasectomy (31.3%) and Minilap (5.4%). Among nonusers, approximately 62% of the respondents reported husbands being abroad as a major reason for not using any FP methods (Table 2).

Table 2 Knowledge and practice of FP (n=218)

Characteristics	Frequency	Percent
Heard method of FP*
Depo-Provera	199	91.3
Pills	190	87.2
Condom	162	74.3
Implant	128	58.7
Vasectomy	111	50.9
Minilap	111	50.9
IUCD	109	50.0
Withdrawal	21	9.6
Calendar method	17	7.8
Source of knowledge on FP*
Health post	131	60.1
Neighbors/Friends	81	37.2
FCHVs	73	33.5
Newspaper	36	16.5
Radio	22	10.1
Teachers	16	7.3
Television	15	6.9
Internet	8	3.7
Family member	3	1.4
Training	3	1.4
Current status of FP use
Yes	112	51.4
No	106	48.6
Currently used FP method
Vasectomy	35	31.3
Pills	23	20.5
Withdrawal	16	14.3
Depo-Provera	14	12.5
Condom	10	8.9
Mini lap	6	5.4
Implant	4	3.6
IUCD	2	1.8
Calendar method	2	1.8
*Reasons for not using FP method(#=106)**
Husband away	66	61.7
Breast feeding	16	15.0
Desire of child	11	10.3
Rare sex	10	9.3
Fear of side-effects	9	8.4
Poor health	3	2.8

*Multiple response, Female community health volunteers- FCHVs, Intrauterine contraceptive device- IUCD

Results of multivariable logistic regression analysis

Of the five variables included in multivariable logistic regression analysis, only three variables had a statistically significant association with unmet need for FP. The respondents whose husbands were involved in foreign employment were 4 times [aOR: 4.408; CI: 2.068-9.399] more likely to have unmet needs than those employed within the country. The couples who had no discussion on FP were 3 times [aOR: 3.212; CI: 1.368-8.135] more likely to have unmet needs than those who discussed three or more times. Similarly, women who had 3 or more children [aOR: 8.758; CI: 1.691-45.355] or up to 2 children [aOR: 5.212; CI: 1.163-23.363] were more likely to have unmet needs than women with no children (Table 3).

Table 3 Multivariable logistic regression analysis (n=218)

Characteristics	Unadjusted OR (95% CI)		P value (Crude)	Adjusted OR (95% CI)	P- value (adjusted)
Occupation of husband
Employed within country		1		1
Foreign employment	5.357 (2.605-11.01)		<0.001	4.408 (2.068-9.399)	<0.001
Agriculture	0.912 (0.383-2.172)		0.835	0.640 (0.248-1.650)	0.355
Spousal discussion on FP
Three or more times	1			1
Never	2.713 (1.276-5.769)		0.009	3.212 (1.368-8.135)	0.014
Once or twice	1.592 (0.820-3.089)		0.169	1.840 (0.855-3.959)	0.119
Number of living children
No child	1			1
Up to 2 children	0.313 (0.81-1.201)		0.090	5.212 (1.163-23.363)	0.031
3 & more children	1.17 (0.620-2.21)		0.627	8.758 (1.691-45.355)	0.010
Wealth Index
Better	1			1
Poorer	0.601 (0.346-1.044)		0.71	0.610 (0.318-1.171)	0.138
Approval of husband
Approves	1			1
Disapproves	2.683 (1.048-6.873)		0.040	2.257 (0.732-6.964)	0.157

This cross section study conducted in a newly formed municipality in the Chitwan district, Bagmati province, Nepal, interviewed 218 married women of reproductive age group. It explored various influencing factors for unmet need of family planning, including socio-demographic and decision making factors previously underrepresented in national studies. Unmet need for family planning was found to be 38 percent in this study, exceeding the national average of 21 percent in 2022 Nepal Demographic and Health Survey (4). This survey also indicated provincial disparities ranging from 16 to 28 percent (4), likely attributed to geographic, socio-cultural, socio-economic background throughout the Nepal. Population density, sampling strategies, ethnic group and other reasons could be the factors. Despite of the lower geographical coverage and heterogensou populations with a smaller sample size, we identified husband’s absence due to foreign employment, spousal discussion and number of living child significantly affected the unmet need of family planning.

Despite a smaller sample size, we have been able to differentiate various similarities with other study from Nepal and other countries. Three primary factors- foreign employment, lack of spousal discussion, an number of children- emerged as significant influences on unmet need of family planning. As Nepal being labour force exporter for foreign employment(32), major migrate to India and other countries(33), seasonally migrated for works, higher among the Dalit(34). Thus, couples living separately need to use contraceptives whenever husbands visit home(33). Furthermore, couples living together has lower unmet that than those being separated as stated by national level studies from Nepal (35, 36). Less time to prepare about family planning on husband’s arrival and communication gap is the factor for unused of it (37). Furthermore, conceptive use during the absences of husband was considered as challenges(37). In this study we could not explore the sexual activity of women due to privacy reason. In present study, we reported discussion about FP is important about the couples. Studies from Nepal showed that communication is important for better use of family planning in rural areas(38), joint decision making for contraceptives(23). Consistent findings were reported from studies conducted in Botswana(28), Cameroon(30) and Ethiopia(39), mini literature review by Fatemeh Najafi-Sharjabad et. Al.(40), Tanzania qualitative study(41). As we reported, male are the major decision makers for family planning(40)(41). All these collectively emphasize about the importance of discussion between couples.

Number of the children among the couple was one of the factors in our study which was found consistent with studies from Nepal(12),(15), Ethiopia(42), Burundi(43). Unmet need of FP is greater among the women with higher number of children(44), (12), (45). Women do not use FP as they find their family size complete(45). Due to the fear factors, women consider abortion as an alternative than contraception(45)(46). Consistently, in sub-Saharan Africa, women chose abortion as a method of limiting family size rather than use of contraception(47). Fear of side effects and health concerns among women is the major reason for not using contraceptive in Nepal and around the globe(11)(13)(30)(44)(46). Most of the non-user reporting fear of side effects have already used contraception and discontinued them(48).

While our findings align with several aspects of previous research, our study]s focus on newly formed municipality near Bharatpur metropolitan city offers a unique perspectives. Moreover, our findings contrast with those of previous studies in several key areas. As reported by secondary analysis of Nepal Demographic and health survey 2022, the total unmet need is 20.8%(49) but we reported quite high. Similarly, the same study reported higher difference in urban 67.6 (66.1, 69.0)% Vs rural 32.4 (31.0, 33.9)% areas for unmet need of family planning(49). We are here unable to differentiate between rural urban difference, however we claim the areas is semi-urban in nature. We also reported the difference between advantaged castes versus disadvantage caste is low in our study however the same secondary data analysis(49) shows that difference is high. The main reason for this is the geographical coverage, population composition and socio-economic context, access to the major cities of our study. Adhering to the similar facts, we also observed difference in unmet among the multipara in NDHS(49) is higher than our study. Furthermore, our study identified several discrepancies compared to previous research. A critical review of multiple rounds of Nepal's health survey reports(6)(50)(49) reveals substantial changes in unmet needs and associated factors over time. These similarities and differences may be partly attributed to socio-economic factors.

Strengths, Policy implication and Limitations

The study has some strengths as well as limitations. It has underlined the factors associated with the unmet need for FP and the reasons behind not using FP methods. Data collection was performed by the first and third authors themselves using a pretested questionnaire prepared in the understandable Nepali language. There are lack of ground level studies in Nepal and in many low and middle income countries. Since Nepal recently transitioned to a federal structure, public health delivery has become a major responsibility of local governments. This study offers valuable policy-level insights by shedding light on the ground realities faced by local authorities. By understanding these realities, local public health leaders can design appropriate policy interventions to address unmet needs in family planning. While the study was conducted in a newly developed urban area, the observed lifestyle patterns reflect those of a semi-urban setting. Consequently, the findings provide valuable insights applicable to both newly developed urban and semi-urban areas. The specific needs of couples with husband working abroad and families with two children can be leverage from policy level perspectives.

With regard to limitations of the study, due to resource and time constraints, the study was limited to only one ward, and the findings may not be generalizable in all places of Nepal. However, the findings might reflect the situation of an unmet need for FP in other similar semi-urban settings. Being a quantitative study, the information might be limited. Being a small-scale study dealing in resource limited semi-urban setting with various socio-cultural issues, we could not explore whether the unmet need is for spacing or limiting. Similarly, we only relied on a small sample size in a ward of the municipality of semi-urban areas. Due to the relatively small sample size of 218, we were unable to employ advanced statistical modelling for exploring the relationships between predictor variables. Increasing the sample size would enhance the generalizability of family planning findings to broader populations, enabling the application of more sophisticated statistical models. Given Nepal's predominantly patriarchal society, like breastfeeding mothers, women living single or those whose sexual partner, exploring the decision-making process surrounding family planning was crucial. Furthermore, understanding who holds primary decision-making authority is vital and warrants further investigation through studies employing a gender lens. Furthermore, due to privacy reasons, we could not explore the sexual activities of migrants’ wives. Therefore, a more comprehensive study exploring more qualitative information is needed.

A high prevalence of unmet family planning (FP) needs was identified among married women in this study. Factors contributing to this included husbands working abroad, lack of communication about FP within couples, and families with three or more children. These findings inform policymakers to design targeted family planning based strategies. Interventions should focus on couples with migrant husbands by providing services during home visits and facilitating communication. Women empowerment and involvement of them in active discussion should be promoted through health education to couples. Additionally, programs should address concerns and raise awareness about additional childbearing for families with two children. Furthermore, the study emphasizes the importance of managing contraceptive side effects, promoting spousal discussions on FP, and empowering women in decision-making to address unmet needs and improve reproductive health outcomes.

aOR	Adjusted odds ratio
CPR	Contraceptive prevalence rate
FCHV	Female community health volunteer
FP	Family Planning
IRC	Institutional review committee
IUCD	Intrauterine contraceptive device
MWRA	Married women of reproductive age

Acknowledgement

We would like to thank Shree Medical and Technical College as well as Madi Municipality for their support during the study period.

Availability of data and materials

All the data associated with this study will be available freely upon request with the corresponding author.

Authors’ Contributions

RG conceptualized the design of the study, prepared tools, collected and analysed data, interpreted results, and drafted the manuscript. RS contributed to the design of the study, development of tools, analysis and interpretation of data, review of literature and drafting of the manuscript. YB contributed to the data collection, data analysis, review of literature and drafting of the manuscript. DKM contributed to data analysis, review of literature and drafting of the manuscript. All authors have read and approved the final version of the manuscript. KT finalized the final manuscript, supervision of works, review of literature, data analysis, submission of the manuscript,

Data Availability

Data will be available from the corresponding author on reasonable request.

Ethical Approval and Consent to Participate

Ethical approval was obtained from the Shree Medical and Technical College-Institutional Review Committee. Written informed consent was obtained from each respondent before data collection. Confidentiality of the information and privacy were maintained.

Consent for Publication

No individual details, images or video in form are included of the respondents.

Competing Interests

The authors declare that they have no competing interests.

Funding Statement

The study received no funding for research and publication.

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No competing interests reported.

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Association of Socio-demographic and Decision Making Factors with the unmet need of family planning among Married Women in Madi Municipality, Chitwan, Nepal

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Abstract

Background

Methods

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Background

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Discussion

Strengths, Policy implication and Limitations

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