Background: Family planning (FP) enables people to attain their desired number of children and determine the spacing of pregnancies, but many barriers prevent the use of family planning and result in unplanned pregnancies. This study investigates the trend of intention not to use contraceptives among married women in Nepal.

Methods: The data for this study was obtained from three sequential Nepal Demographic and Health Surveys [NDHS] of 2006, 2011, and 2016. We used data from 4297, 4833, and 4677 women who were currently not using any FP methods on NDHS 2006, NDHS 2011, and NDHS 2016, respectively. Univariate, Bivariate and Multivariate analyses were made.

Results: Minor fluctuation can be seen in the proportion of women who did not intend to use FP methods for ten years. Above a fourth (26%) women who were currently not using any FP methods had no intention to use FP in 2006, which decreased to 19% in 2011 and slightly increased to 23% in 2016. Overall, the significant socio-demographic predictors of intention to not use FP methods were the age of women, age at marriage, and education of women, religion, residence, and wealth index. Education was a significant predictor of intention not to use FP. Uneducated women and women with only primary education were 83 percent (aOR=1.84, CI=1.52-2.22) and 17 percent (aOR=1.17, CI=0.97-1.43), respectively, more likely not to intend to use FP than women with secondary or above education, and the relation was significant among uneducated women. Similarly, Muslim women were three times (aOR=3.28, CI=2.66-4.02) more likely to intend not to use contraceptives than Hindu women. Likewise, women residing in rural areas and belonging to richer wealth index were significantly more likely to intend not to use FP methods than their counterparts.

Conclusion: Although expenditure for enabling environment has increased, nonuse intentions of FP have increased in 2016 than in the survey year 2011, highlighting the necessity of different program modality. This study elucidates the necessity of focusing the FP interventions among uneducated women, rural women, and those belonging to the Muslim religion to increase the intention to use FP in the future. 

This study investigates the trend of intention not to use contraceptives among married women in Nepal. The data for this study was obtained from three sequential Nepal Demographic and Health Surveys [NDHS] of 2006, 2011, and 2016. We used data from 4297, 4833, and 4677 women who were currently not using any FP methods on NDHS 2006, NDHS 2011, and NDHS 2016, respectively. Data were analyzed using Univariate, Bivariate (Chi-square test), and Multivariate analysis (binary logistic regression).

Minor fluctuation can be seen in the proportion of women who did not have the intention to use FP methods for ten years. Almost a fifth of women had no intention to use FP (23%) in 2016. Overall, the significant socio-demographic predictors of intention to not use FP methods were the age of women, age at marriage, education of women, religion, place of residence, and wealth index. Uneducated women and women with only basic education were more likely not to intend to use FP than women with secondary or above education. Similarly, Muslim women were three times more likely to have the intention to not use contraceptives than Hindu women. Likewise, women residing in a rural area and belonging to a richer wealth index were significantly more likely to have the intention to not use FP methods than their counterparts. This study elucidates the necessity of focusing on the FP interventions among uneducated women, rural women, and those belonging to the Muslim religion to increase the intention to use FP in the future. 

Background:

The unrestrained increase in population is a burden on the resources of many developing countries. A high fertility rate, high maternal and infant mortality rate, and low life expectancy is a feature of  75% of the world population live in developing countries (Pegu et al., 2014). The use of contraceptives has been identified as an important factor in reducing the fertility rate for all women in reproductive age groups in developing countries (Lakkawar et al., 2014). Family planning enables people to attain their desired number of children and determine the spacing of pregnancies. It is essential to promote family planning and ensure access to FP methods to ascertain the well-being of women (WHO, 2018). Family planning services are necessary to save maternal health and reduce maternal mortality rates. Provision of adequate antenatal care, ensuring skilled attendance at birth, backed by emergency obstetric care when needed, is essentials to reduce maternal and neonatal mortality in addition to voluntary access to voluntary family planning to space births. (Abdel-Tawab, 2010). It has also been reported that nearly 90% of unintended pregnancies in low- and middle-income countries can be prevented using modern contraceptive methods (Bellizzi et al., 2015).

The non-use of contraceptive methods by people who need contraception has been associated with potential implications at the individual, familial, community, and global levels (Moreira et al., 2019). Although there is evidence of progressive increases in the use of contraceptive methods (Alkemaetal, 2013), many women still face various barriers to contraceptive use (UNDP et al., 2017). Many barriers prevent the use of family planning and result in unplanned pregnancies. These barriers are numerous factors like lack of education and exposure to mass media that results in poor knowledge about family planning methods and services (Campbell, Sahin- Hodoglugil & Potts,2006) and concerns and experience of side effects (Campbell, Campbell, Sahin-Hodoglugil& Potts,2006) and health system-related factors like poor coverage of health facilities (Hamid& Stephenson2006).

In July 2017, Nepal invigorated its commitment to maintaining and sustaining the efforts already initiated by implementing its initial 2015 commitment to FP2020. The Government of Nepal restated to continue to increase the government budget in family planning by 7

Background characteristics 
Approximately two-fifths of women who were not using any FP methods were aged less than 25 years in all the surveys (41%, 39%, and 36% in 2006, 2011, and 2016, respectively). Regarding age at marriage, more than three-fourth (76%) and above two-fifths (45%) women were married at age 21 and above in 2006 and 2011, respectively. Similarly, more than two-fifths (44%) of women not using any FP methods were married at 15-17 years in the year 2016. Nearly half (45%) of the women who were not using any FP methods were uneducated in 2011, while the same proportion of women had secondary or above education in 2016. Over four-fifths of women followed the Hindu religion in all three surveys. The majority of women who were not using any FP methods resided in a rural area in 2006 (89%) and 2011 (90%), but most of them resided in the urban area in 2016 (58%). Most women not using any FP methods were currently working in all surveys (70%, 56%, and 53% in 2006, 2011, and 2016, respectively). Likewise, most of the women who were not using any FP methods belonged to the poor wealth index in 2006 (46%) and 2011(41%), but in 2016 greater proportion of them belonged to the rich family (40%). Nearly two-fifths (43%) of women not using any FP methods had no autonomy in 2006, while the same proportion of women had high autonomy in 2011 (41%) and 2016 (37%). Almost three fourth women who were not using any FP methods had no exposure to the newspaper in all surveys (76%, 73%, and 77% respectively in 2006, 2011, and 2016 respectively). Similarly, nearly half of the women not using any FP methods had no exposure to the radio (47%) but high exposure to television (45%) in 2016.

Bivariate analysis:

Minor fluctuation can be seen in the proportion of women who did not intend to use FP methods for ten years.  Above a fourth (26%) women who were currently not using any FP methods had no intention to use FP in 2006, which decreased to 19% in 2011 and then slightly increased to 23% in 2016. Bivariate analysis was done to find the association between different socio-demographic variables and intention to use FP. The age group had a significant association with intention to use FP in which a higher proportion of women aged 35 years or above had no intention to use FP in the future than their counterparts (68%, 59%, and 62% in 2006, 2011, and 2016 respectively). Similarly, a significantly higher proportion of women married at age less than 15 had no intention to use FP in all surveys. The proportion was 39%, 29%, and 31%, respectively, in 2006, 2011, and 2016. The intention of not using FP methods decreased with the increase in education of women as a higher proportion of uneducated women were not intending to use FP in the future than their counterparts (36%, 32%, and 37% respectively in 2006, 2011, and 2016) and the association was statistically significant as well (p<0>0.001).

Significantly higher proportions of working women than non-working women did not intend to use FP in the future in all three surveys (28%, 22%, and 25% in 2006, 2011, and 2016, respectively). Wealth also had a significant association with intention to use FP, but the relationship varied in different surveys. A higher proportion of poor women did not intend to use FP than their counterparts in 2011 (21%), while the proportion was higher among rich women in 2016 (25%). Likewise, a significantly higher proportion of women with high autonomy had no intention to use FP than their counterparts in all surveys (36%, 27%, and 27% in 2006, 2011, and 2016, respectively). Similarly, a higher proportion of women with no or low exposure to radio and no exposure to television did not intend to use FP in the future in all surveys, and the association was statistically significant.

Multivariate Analysis:

Multivariate analysis was done to find the predictors of intention to not use any FP methods in the future among women who were currently not using any FP. First of all, the unadjusted effect of time of the survey was calculated on intention not to use FP. In this regard, women were 31 percent (OR=0.69, CI=0.692-0.764) and 17 percent (OR=0.83, CI=0.757-0.919) less likely to intend not to use FP in the future in the survey of 2011 and 2016 respectively than in the survey of 2006. After adjusting all other variables, the time of the survey remained a significant predictor of intention not to use FP as women in 2011 and 2016 were 45 percent and 37 percent respectively less likely to intend for not using FP. Hence, the likelihood of intending not to use FP increased after controlling the other socio-demographic variables.

Overall, the significant socio-demographic predictors of intention to not use FP methods were the age of women, age at marriage, education of women, religion, residence, and wealth index. Women aged 25-34 years and 35 or above years were 2 and 32 times respectively more likely not to intend to use FP in the future than women aged less than 25 years. Regarding age at marriage, women married at an age less than 15 years (aOR=1.65, CI=1.34-2.04) and 15-17 years (aOR=1.37, CI=1.19-1.58) were significantly more likely to have the intention to not use FP in the future than women married at age 21 or above. Education was also a significant predictor of intention to not use FP. Uneducated women and women with only primary education were 83 percent (aOR=1.84, CI=1.52-2.22) and 17 percent (aOR=1.17, CI=0.97-1.43) respectively more likely not to intend to use FP than women with secondary or above education, and the relation was significant among uneducated women.

Similarly, Muslim women were three times (aOR=3.28, CI=2.66-4.02) more likely to intend not to use contraceptives than Hindu women. Likewise, women residing in rural areas were significantly more likely (aOR=1.15, CI=1.02-1.34) to not intend to use FP than urban women. Similarly, working women were less likely to intend not to use FP than non-working women. Wealth is also a significant predictor for intention to not use FP in which richer women were 41 percent (aOR=1.4, CI=1.2-1.65) more likely to have the intention not to use the FP method than poorer women. Likewise, women with no autonomy and moderate autonomy were more likely not to use any FP methods than women with high autonomy. Similarly, although not significant, women with no exposure to mass media like newspapers, radio, and television were more likely to intend not to use FP than women having high exposure to these mass media.

This study investigated the trend of intention not to use contraceptives among married women in Nepal.  The finding showed that more than a fourth (26%) women who were currently not using any FP methods had no intention to use FP in 2006, which decreased to 19% in 2011 and slightly increased to 23% in 2016. The bivariate analysis showed that variables such as survey year, age group of women, age at first marriage, number of children ever born, education of women, religion, place of residence, currently working status, wealth status, women's autonomy in the household decision, and exposure to mass media (Newspaper, radio, and TV) are important determinants of intention to nonuse of contraception in future. The multivariate analysis supported many of the findings of bivariate analysis. In the multivariate analysis, survey year, age group, age at marriage, education, religion, place of residence, and wealth status were statistically significant influences on intention to nonuse contraception. 

Our study showed that the age group of women was also associated with using contraception. The increase in non-intention to use among older women may be related to the fact that they had reduced their coital frequency, and some were near menopause (Tiruneh et al., 2015). This finding was consistent with studies conducted in Malawi (Palamuleni 2013) and Ethiopia (Tiruneh et al., 2015). The lower intention to use contraception among women who married early may be due to a lack of access to information and related services (Raj et al., 2009). 

Similarly, age at first marriage/cohabitation was a significant predictor for non-intention to use contraception.  Marriage in early ages/child marriages frequently occurs in Nepal (Adhikari, 2018). Previous studies suggested that women's decisions to have children and use contraceptive services mainly depend on their husbands (Adhikari et al., 2019, Alemu 2008). 

The education of women was one of the critical factors associated with to use of contraceptives. Education usually improves the knowledge of women regarding contraceptive use; thus, it was positively associated with contraceptive intention. Illiteracy was negatively associated with contraception intention. This result was consistently reported in previous studies (Alriyami et al., 2004; Tiruneh et al., 2015, Meskele & Mekonnen (2014)). In contrast to our study in the USA (Esber 2014) study in which age and education had no significant association with the intention of women to use FP in the future.

Similarly, in regards to religion, like our findings, the study was conducted in Ethiopia (Tiruneh 2015), in which Muslim women were less likely to intend to use FP methods than their counterparts. It could be due to the norms and principles of the Muslim religion, which encourages large families (Manjeera 2013; Najafi-Sharjabad et al. 2013).

Likewise, our study showed that rural women were more likely not to intend to use contraception. The finding is similar to the study in Ethiopia that rural women were less likely to have the intention to use contraception. Similarly, our study found that richer women were more likely not to intend to use contraception in the future. This finding is the opposite of the findings of the study conducted in Ethiopia (Tiruneh 2015).   

There was a slight fluctuation in the trend of nonuse intention of contraceptives among women currently not using any FP methods from 2006 to 2016. Time of the survey, age of women, age at marriage, women's education, religion, place of residence, and wealth index were significant predictors of intention not to use FP methods.

Although small, there was an increment in the proportion of women not intending to use FP in 2016 than in 2011. So, this finding highlights the necessity of different program modalities for family planning interventions in the country. Similarly, this study also depicts that FP interventions should emphasize mainly the uneducated women residing in the rural area and belonging to the Muslim religion to increase contraceptive use. 

Ethics approval and consent to participate:

This study used secondary data. The survey protocol was reviewed and approved by the Nepal Health Research Council (NHRC) and the ICF Institutional Review Board.

Consent for publication:

Not applicable.

Availability of data and materials:

The datasets generated and/or analyzed during the current study are available in the [DHS PROGRAM] repository, [https://dhsprogram.com/data/Using-DataSets-for-Analysis.cfm]

Competing interests:

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors’ contributions 

RA and AW analyzed, interpreted the data, and drafted the manuscript. Both authors read and approved the final version of the manuscript.

Acknowledgments 

The authors thank MEASURE DHS + for providing access to the data.