Kathmandu, Nepal—On a sunny day in December, two dozen Nepalese women met to discuss the nutrition and health of their families. The women in this community—in Nawalparasi District, in southern Nepal—represented several different ethnic groups, but their feelings on the number of children they would prefer were nearly unanimous. Even though these women wanted smaller families, they gave little thought to planning or spacing their pregnancies.
Most children are just two years apart, the women said. Global evidence suggests women wait at least two years before becoming pregnant again. But families prefer sons, “so much so that although couples plan to have two children, they will continue to have children until a boy is born,” said Geeta Sharma, the Jhpiego senior program officer who met with the women.
For millions of women in Nepal, the unmet need for family planning (FP) remains high. Decades of work by the government of Nepal, the U.S. Agency for International Development (USAID), Jhpiego and many other organizations has raised awareness about FP and increased access to a range of quality FP services.
Nepal has made impressive gains in reducing total fertility as well as maternal and child deaths over the past 15 years. Unfortunately, the steady increases in the contraceptive prevalence rate (CPR) have plateaued at around 43 percent (Nepal Demographic and Health Survey 2011, preliminary report) for modern methods of contraception—far short of the Millennium Development Goal of 67 percent for all methods by 2015.
One possible reason for the stalled progress on CPR is the increasing number of Nepalese men who now leave home to do seasonal work in India. A 2009 study found that CPR among couples who are together was high (55.5 percent), while it was only 22.5 percent for those separated by seasonal migration of husbands. Although migration has reduced wives’ need for FP while their husbands are away, it also puts the women at high risk for unplanned or mistimed pregnancies when husbands return.
Since the mid-1990s, Jhpiego, in collaboration with the government of Nepal, has worked to improve the quality of FP services at all levels of the health system. For example, mobile outreach clinics can now reach the most remote areas of this mountainous country, and thousands of health care providers are providing FP counseling and methods as a result of capacity-building work. National FP guidelines, protocols and training materials have been developed and revised regularly, keeping clinical evidence current. For the past 10 years, Jhpiego has worked within the Nepal Family Health Program to improve and strengthen the performance of providers, managers and facilities to deliver quality services in 20 districts. This is part of Jhpiego’s ongoing efforts to partner with countries in building the capacity of health care workers and strengthening health systems to prevent the needless deaths of women and families. The organization develops innovative, low-cost technologies to address today’s global health challenges and works with communities to increase frontline health workers’ ability to deliver lifesaving care.
Recognizing the powerful benefit of integration and the need to reach women at every contact with the health system, Jhpiego will begin two new, innovative projects in Nepal to integrate FP with other health services.
In Nepal, 41 percent of children under the age of five are “stunted,” that is, they have not grown to their expected height. For this reason, the new five-year, USAID-funded Suaahara (Good Nutrition) Project began, in 2011, to address chronic under-nutrition in women and children. Because spacing pregnancies too closely together has detrimental effects on mothers and their children’s health, Jhpiego, in collaboration with the Ministry of Health and Population, will help integrate FP with maternal, newborn and child health and nutrition services in the community and within government health facilities. Suaahara—an exciting, integrated project, led by Save the Children—will reach underserved and vulnerable households and families with a range of information and services for improved health and nutrition in 25 districts.
Jhpiego will work within the USAID-supported Saath-Saath Project over the next five years to integrate FP with HIV/AIDS services and outreach activities. The focus of Jhpiego’s work in this area will be to provide better services to the most at-risk groups through nongovernmental and government sites and activities. According to UNICEF, the number of women over age 15 who are living with HIV is estimated at 20,000. This is a unique opportunity to meet the broader reproductive health needs of people living with HIV/AIDS and to reach others with prevention, counseling, and, if needed, care and treatment services. In four districts where seasonal migration is high, Jhpiego will reach migrant couples and work with them to address their unmet need for FP.