Fertility differentials
Chapter 6 Fertility regulation
2 There has been reorganization of the Ministry o f Health with all vertical programs including FP/MCH being integrated within the Ministry o f Health At the district level, they will be
6.3 Levels and trends in knowledge and practice of contraception in Nepal
W estern bureaucracies but actually functions on the basis o f familial, patron-client, caste, regional and ethnic loyalties' (Justice, 1986: 41). Thus, while the rhetoric of the population sector in general and the family planning program in particular remains strong, there is little support mechanism to achieve this target. The strategy is also salient on infant and child mortality, which remains among the highest in South Asia. It is with this weakness in mind that the stated national objective of achieving a TFR o f 2.5 (NCP, 1983: 3) by the end of this century has to be viewed.
6.3 Levels and trends in knowledge and practice of contraception in Nepal
Development o f family planning services in Nepal has gone through three different phases. The first phase (up to 1972) was primarily clinical in that family planning services were limited to those who cared to visit the clinics, typically a 'cafeteria
approach' (Tuladhar, Gubhaju and Stoeckel, 1978: 54; Pant and Acharya, 1988: 213-214).
The second phase (1972-86), was an extension period, in which program efforts were directed not only to intensifying the mass popularization campaign but also to creating an institutional infrastructure to facilitate such activities. The organization of mobile camps became a characteristic of the extension activities. During this period, the whole philosophy of family planning services seemed to have shifted from the 'cafeteria' to the sterilization approach. Target fixing and achievement of sterilization became effective tools for program evaluation. Over time the increase in sterilized persons is indicative of this fact. The number of female sterilization operations increased from 558 in 1972/73 to 41, 428 in 1983/84. The comparable figure for male sterilization was 4161 in 1972/73 which increased to 26,311 in
1983/84 (Tuladhar et al., 1978: 54; Pant and Acharya, 1988: 215).
During this period (1972-86), there was an enormous increase in the number of institutions including FP/MCH, FPAN and ICHSDP: at least one of these institutions became operative in each of the districts. This was because successive plan documents emphasized the need for expansion of the institutional base for family planning services (NPC, 1972, 1975, 1980).
The realization that the family planning movement in Nepal was not primarily geared to meet the demands of spacers is a recent one and can be considered the third phase of the movement. Prospective users of contraceptive methods may use contraception either to space or to terminate childbearing. However, the methods offered by the program and the priority accorded to sterilization indicate that an appropriate method-mix strategy is lacking in the delivery of family planning services. In a a recent review of a decade of family planning services in Nepal, Thapa (1989a) observed that 'the welfare of couples who may be in need of contraception for spacing births, but not necessarily for terminating childbearing, does not appear to be adequately addressed by the program'. In another study,
Thapa and Tsui (1990) found that to achieve a demographic target of reducing TFR to 2.5 by the turn of the century, the current use rate of contraception needs to be increased fourfold.
In a search for new directions, the Ministry of Health and FP/MCH project has been restructured. There is also a policy to adopt appropriate method-mix strategies to meet the objective of bringing down fertility to replacement level (His Majesty's Govemment/N, 1988a: 12; B. P. Acharya, personal communication, 1989). This is important because family planning services are to be provided to all women, whose motivational change to a small family size will have profound effects on fertility decline.
Until 1976, very little information was available on the levels and trends of contraceptive knowledge and practice. The Nepal Fertility Survey (NFS) was the first reliable data source on the knowledge and practice of contraception. Since then, two more national surveys have been carried out - the Contraceptive Prevalence Survey (CPS), 1981 (FP/MCH, 1983) and the Fertility and Family Planning Survey (NFFS), 1986 (FP/MCH, 1987). Therefore, the NFS data on contraceptive knowledge and practice can be treated as a benchmark for subsequent analysis.
Figure 6.1 shows trends in knowledge of family planning methods during the 1976- 86 period (also see Appendix Table 6.1). During the period, knowledge of contraceptive methods increased from 22 per cent in 1976 to 56 per cent in 1986.The largest increase in contraceptive knowledge occurred to women aged 15- 19 followed by women aged 30-34. Women in the prime reproductive age
60 - 50 - 40 30 20 - 10 - ;
%
i
/!!
' I 1 p-%
'8
ip ' I:1
t f ^ '■u
15-19 20-24 25-29 30-34 35-39 40-44 Age group □ 1976 M 1981 □ 1986 45 +Source: Appendix Table 6.1.
Figure 6.2: Contraceptive prevalence rate in Nepal, 1976-86.
15-29 30-39 40 +
□ 1976 El 1981 B 1986
Age group Source: Appendix Table 6.2.
group (25-29) registered the lowest increase in knowledge. The figure also clearly shows that the increase in contraceptive knowledge was not as great in the period 1981-86 as it was during 1976-81. The percentage increase in knowledge and use of contraception is impressive; even so, in 1986, almost 44 per cent of women of reproductive age did not know of any modem methods of contraception. A corollary to a sharp rise in the knowledge of contraceptive methods was a significant percentage increase in acceptors. The NFS, 1976, reported the ever use of modem methods of contraception by currently married women at 3.7 per cent. This increased to 8.6 per cent in 1981 and 15.8 in 1986.
As with knowledge and past use, there has been a steady increase in the current use of contraceptive methods. Current use of contraceptives, which refers to the prevalence of contraception at a particular point of time, is more meaningful in relation to its effect on fertility. The current use of modem contraceptive methods of 2.9 per cent in 1976 increased to 6.8 per cent in 1981 and 15.1 per cent in 1986 (Figure 6.2 and Appendix Table 6.2).