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Unmet Need for Family Planning in Nepal

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Unmet family planning needs is one of the key global health issues that needs to be addressed in order to avert unwanted pregnancy, unsafe abortion and prevent sexually transmitted infections (WHO, 2011). World Health Organization defines unmet need as the gap between a woman's desire to prevent or delay pregnancy and the actual use of contraceptives (WHO, 2012). It is a woman's want or urge to postpone or avoid childbearing but not using any contraceptive methods to do so (Casterline and Steven, 2000). Determination of unmet needs for family planning has been found to be one of the best tools to measure and predict contraceptive needs of population (Sedgh et al., 2007; Igwegbe et al., 2009).

Burden and Trend of Unmet Family Planning Needs:

Globally 200 million couples are facing the problem of unmet needs for family planning with an estimated 21.6 million unsafe abortion per year (WHO, 2008). The statistics of unmet needs have been declining, but still it is very high in the African region (22%), where a decrease of only 2% in the unmet needs occurred during a period of 10 years (WHO, 2011). As compared to other regions, Asia is seen to have relatively low unmet needs of 9% (WHO, 2011). Data suggests that one in every four women have unmet family planning needs in Nepal and only half of the Married Women of Reproductive Age (MWRA) in the country have used any modern contraceptive methods i.e. hormonal methods (pills), barrier methods (condom) and permanent methods (sterilization) (DoHS, 2011).

The total estimated population of Nepal was 28,584,975 in 2011 consisting of 24% women of reproductive age group (CBS, 2003). With a quarter of the population consisting of women in child bearing age, the population of Nepal is expected to increase at a high rate if the unmet family planning needs are not addressed. The current contraceptive prevalence rate (CPR) of Nepal is only 48%, which is way behind targets of 65% CPR of Millennium Development Goal (MDG) by 2015 (DoHS, 2011). These poor reproductive health indicators are one of the reasons for high rates of unwanted pregnancies and about 90,000 induced abortions in the country in one year (DoHS, 2011).

Multifaceted problem:

Family planning not only has impact in the size of the population but has a collective significance in peoples' lives. The level of utilization of the family planning methods in a society has huge implication on health, environment and economic status of people (Cleland, 2009). Less utilization of family planning contributes to increasing birth rate and population growth, eventually leading to poverty, hunger and environmental degradation (Bongaarts et al., 1990). Family planning also has a close link with all eight MDGs and will help to reach them, thus without addressing issues related to family planning, achieving the MDGs is impossible (Cates, 2010; Potts and Fotso, 2007).

Factors Affecting Unmet Needs:

Factors causing unmet needs should be considered while implementing any family planning programme in the country. With the persistence of these factors causing unmet needs, there are high chances of a woman to experience unwanted pregnancy leading to unsafe abortion causing health hazard to the mother or even death (Aryal et al., 2008). Due to the lack of data on unsafe abortion, it is difficult to estimate the actual relationship of unmet needs and abortion (Grimes et al., 2006). It is also one of the neglected health care problems in developing countries, hence making it difficult to estimate morbidity and mortality due to unsafe abortion (WHO, 2012).

Unmet need of family planning is also seen to be higher among those couples who do not live together as compared to those who live together (NFHP, 2010). A contradictory data projected by Nepal Demographic and Health Survey (NDHS), 2006 showed an increase in unmet needs of women of urban areas between 2001 and 2006 from 16% to 20% respectively (MoHP, 2007). This was assumed to be more among migrated couple who might have been unaware about the existing family planning services in the urban areas. As for the residence difference, unmet need was higher among the rural women as compared to their urban counterparts (CREHPA, 2010). This can be explained by more accessible and available health services in the urban areas as compared to that of the rural areas because of the poor geographical location, lack of manpower and resources, low level of education, etc in the rural areas (Aryal et al., 2008; Chaudhury, 2001; Chacko, 2001).

A comparative analysis of the unmet needs from DHS of 1996, 2001 and 2006 done by Aryal et al. showed that unmet needs was seen to be higher among the younger women (Aryal et al., 2008). A study done by Chacko, among women in rural India, showed similar association of age and contraceptive use, where women of younger age were found to use less contraception than their older counterparts, because the younger women had restrictions in making decision about family planning (Chacko, 2001).

However, the effect of education on unmet needs was seen to be rather different and did not follow any patterns similar as place of residence or age. Women with no education seemed to have very low unmet need because they were less likely to express need of family planning than the educated women. On the other hand, as the level of education increased up to primary level there was also an increase in the unmet needs, again with a gradual decrease in the unmet needs as the education level increased more (Aryal et al., 2008). This is due to the fact that women with lower level of education were likely to have knowledge of family planning methods but had less access to those methods whereas, those women with higher level of education were likely to access the family planning services (Aryal et al., 2008; Chaudhury, 2001).

Global Guidance:

The importance of unmet need was addressed by International Conference on Population and Development (ICPD), which states that “Government goals for family planning should be defined in terms of unmet needs for information and services and all countries should, over the next several years, assess the extent of national unmet need for good-quality family planning services” (UN, 1994).

WHO states the reasons behind less utilization of family planning methods by women as follows (WHO, 2011):

• Limitation



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