Rural Communities in Nepal Lack Family Planning Options, Awareness


Article Highlights

DHADING, NEPAL – Hem Kumari Chepang, 42, has given birth to more than 20 children during the last 30 years.

“Have as many children as you can,” she says her husband, Hari Chepang, 50, told her. “I will feed you [and the children], and [if you die in the process] I will take care of your cremation.”

The Chepangs are residents of Dhading, a district just 75 kilometers west of Kathmandu, the capital. In Kathmandu, thousands of people acquire family planning and maternal and child health care services every day. But Chepang says she has never been to the city, let alone obtained any of the family planning services there.

Orphaned as a child, Chepang married her husband 30 years ago at age 12. She says she was working as a housemaid and he, 20 at the time and also working as house help, promised to take care of her.

Within a year of their marriage, Chepang gave birth to her first child, which survived for only four months. She says she believed at the time that giving birth to one child after another – with some surviving and some not – was a natural phenomenon after marriage. In all, Chepang conceived 26 times.

“Some died in the womb, some within a few days of their birth and some after six months,” she says.

Only two of the babies Chepang has given birth to are alive today – a son and a daughter, who is deaf.

In addition to the multiple births, Chepang says that she often had no help during labor.

“One of my sons was positioned ectopically in the womb,” she says. “His hands came out first, and I tugged him out myself. The placenta followed, and I almost died with the pain.”

After her 23rd child, she suffered from uterine prolapse, a condition when the uterus slips down from its normal position. She began to bleed regularly and suffer from dizziness and pain. But she continued to give birth. Her condition worsened, and her movement was limited to dragging herself to the toilet when necessary.

Chepang’s physical condition also kept her from helping her husband with the housework. She says her husband had to single-handedly take care of the cattle, the fields and the housework while Chepang watched helplessly.

Although Chepang’s case is not the norm in Nepal, the average number of children born by a single mother is still high in rural areas.

A lack of awareness of family planning options in rural communities often leads to more births than women say their bodies can withstand. The government and nongovernmental organizations, NGOs, here have started to disseminate family planning information to rural communities. But many women say that even with this knowledge, their families and cultural beliefs stand in the way of taking advantage of available options.

The total fertility rate, or births per woman, in Nepal fell from 6.3 in 1976 to 3.1 in 2006 because of campaigning and promotion of family planning, according to a 2009 report by the Family Planning Association of Nepal, FPAN, a national NGO. The contraceptive prevalence rate, the percentage of women or their partners using contraception, increased from 26 percent in 1996 to 44 percent in 2006, according to the latest Nepal Demographic and Health Survey, NDHS.  

But the FPAN report also notes that although the fertility rate in urban areas of Nepal has declined to two children for each set of parents, it is still high in rural areas. The contraceptive prevalence rate is also lower in rural areas than in urban areas.

Aswini Rana, an FPAN counselor, says that family planning is a challenge in rural areas.

“It is still a big challenge to effectively spread awareness of family planning in the rural, remote and socially backward societies of Nepal,” Rana says. “There is a dearth of family planning services, methods and devices at the health posts situated in the rural areas.” 

Chepang says that her husband once had to carry her for more than an hour to reach a health post. But she says the health post staff hesitated to touch her. Rana attributes this reluctance to the lack of necessary knowledge, skills and resources needed to handle such maternity health complications at rural health posts.

Chepang’s village is less than a three-hour drive from Kathmandu, with its myriad of hospitals and health facilities that promote family planning and provide care for pregnant women. Yet the lack of health services and awareness of family planning in Chepang’s community, the Chepangs, one of the most socially excluded and “backward” indigenous communities of Nepal, seems worlds away.

Although there has been a decline in unmet needs when it comes to family planning in Nepal, there is still a geographical disparity, according to the NDHS. Three-fourths of women in urban areas of Nepal said their needs were met, compared with less than two-thirds of women in rural areas.

But Dr. Kiran Regmi, director of the Family Health Division under the Department of Health Services, says Chepang’s case is an exception and that she is optimistic about the increasing awareness of family planning in Nepal.

“We have started to promote appropriate methods of family planning targeted towards those who do not understand and are hence averse to surgical measures of family planning,” Regmi says.   

Family planning services used to only be available in the Kathmandu Valley, according to the NDHS. But thanks to FPAN, the Nepal Family Planning and Maternal Child Health Project was established at government level in 1968 and has gradually expanded to cover all of Nepal’s districts since then.

Temporary methods, such as male condoms and contraceptive pills, are now available at national, regional, zonal and district hospitals; health care centers; and health posts and sub-health posts; according to the NDHS. But more long-term services, such as Norplant implants, IUD insertions and sterilization, are only available in certain districts.

Sagar Dahal, the Family Health Division’s senior public health administrator, says that the governmental department has started to work on guidelines for how to make family planning services more available in rural areas, especially among indigenous groups. But he says this will take time.

“This will take about six to seven months, and the government plans to take the rural family planning program ahead on the basis of those guidelines,” he says.

But women say that even when they do become aware of family planning options, many times cultural beliefs and family members stand in the way.

One mother, Sumitra Pulami Magar, 33, of Balajor, a village in southeastern Nepal, says that she has been using a temporary contraceptive, an injection that she must receive every three months, for the past four years. But her husband, Balkrishna Pulami Magar, says they can’t tell his mother, who objects to family planning.

“After the first two children, I had said we must take permanent measures of family planning, but my mother was not happy with the decision,” he says. “After that, we had two more children and the responsibilities also increased, and my wife and I decided to start on the contraceptive measures without informing my mother.”

The radio is the most popular outlet for family planning messages in rural areas, with televisions, billboards, and newspapers and magazines much less common than in urban areas, according to the NDHS. But still, family members and communities disapprove.

Sarita Tamang, 27, from the same district as Chepang, says her body is tired after giving birth to three daughters and that she learned from radio announcements that contraceptives could prevent her from having more children. But she says that women in her village, who usually deliver their babies at home, are too shy and embarrassed to go to the local health post to obtain contraceptives. Plus, she says her husband still yearns for a male heir.

“What can I do?” she asks. “My husband has said that he needs a son anyhow.”

Chepang says that she also learned about an operation that can stop future pregnancies on the radio. But she says that when she asked her husband to take her to the city to get the operation, he told her that showing her private parts to others was shameful.

Chepang resigned herself to immobility until a stranger got involved after he heard Chepang’s story on the radio, thanks to a youth from her village. The listener, Kiran Gautam, assistant inspector general of the police, contacted the radio station and said he wanted to pay for Chepang to have the operation.

“When I heard about her condition, I felt very sorry for her,” Gautam says. “I immediately called up the radio station and made arrangements for her treatment.”

He says her story made him realize that women in Nepal deserve more respect.

“Seeing a woman, who is barely 50, in such a state and knowing how she was compelled to lead this life of pain, I realized that the status of women in Nepal is still very lamentable,” he says.

Thanks to Gautam's support, Chepang’s uterus was surgically removed in a hospital in a neighboring district last year. She now leads a healthy life and is able to go about her daily activities.

”I had given myself up for dead and never believed that I could lead a normal life ever again,” Chepang says, smiling. “I feel like I have been given a new lease to life by God himself.”

Chepang now does her part to promote family planning by advising younger women in her village to not bear too many children.

“Sasu-aama [mother-in-law] has advised me not to have more than two children,” Chepang’s daughter-in-law, Sharmila, says shyly.