No conceivable reason for unwanted pregnancies

Kewara Koli, 34, is already mother to seven daughters and one son. Her eldest daughter, Laxmi, is in Grade 10 at a local school in Baitadi. Laxmi advised her mother to get an implant from a nearby health post. “My mother was giving birth every two years, and she became weaker after every baby,” says Laxmi (standing at back).

Lack of access to and awareness of family planning, the prevalence of unhealthy superstitions and taboos, and the desire to produce a son together explain why Nepal’s average fertility rate has stalled after a steep drop in the last decades. 

Many families in the far western hills and the central Tarai still believe that contraceptive use is against god’s wishes. These areas also tend to be steeped in patriarchy, with low female literacy rates and a high incidence of child marriage.

It is a vicious cycle: women are anemic, malnourished, uneducated, disempowered, physically weak because of annual pregnancies, and poor. And they do not use family planning methods even when they are available at rural health posts.

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Kokila BK (sitting at right, with her sixth child on her lap) from Achham was married at 14. Now 30, she is the mother of seven children. Her oldest child is a son of 16, and her youngest a five-month-old baby. “It has not been easy. Every time I felt like I would die,” says Kokila of her pregnancies. “I really want to stop it now.” Her husband Ujire BK (first from left, above) is a shaman and does not believe in birth control. The family is gathering the corn harvest, and grows enough food to last only five months of the year. Kokila’s son is away in India working as a porter, and his 15-year-old sister Bishna (standing with baby sister) cannot wait to get married herself so she can escape the family’s grinding poverty. The woman standing at the door is Jamuna BK, Kokila’s mother-in-law.

In these villages in the mountains of Bajura, Achham and Baitadi there are many families where a mother and her daughter are giving birth simultaneously. The region’s medical services are also basic, which means a low incidence of institutional delivery and a maternal mortality rate that remains more than twice the national average.

The government offers five types of contraception for free in health posts: condoms, pills, injectables, implants and intrauterine contraceptive devices (IUCDs). However, belief that contraceptives affect health or the unavailability of the desired device means many do not opt for family planning.

Jamuna Nepali is seven months pregnant with her fourth child in her village in Bajura. At 22, she wanted a gap between her third and fourth babies because the family could not afford to feed another mouth. She went to a health post in Bajura and was given some pills. But despite taking these, she became pregnant again. Her husband is working in India to feed the family.

“Every day an average of five women come to our health post to ask about long-acting contraceptives like IUCDs or implants, but we either do not have the devices or the trained health workers to insert them,” shrugs Sabina Thapa, a nurse at a Bajura health post. “Even women on pills miss the timeline and get pregnant.”

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Currently, 43% of all married women of reproductive age in Nepal use modern contraceptives, and another 10 % use traditional family planning methods. A 2016 survey showed that there is a 44% unmet need for family planning measures in Nepal.

At 42, Bhana Jaisi (breast-feeding her baby, above) from Achham has ten daughters. She gave birth to her last child last year when her eldest daughter was already 25, and had four children of her own. “My life will not be complete if I don’t give birth to a son,” Jaisi says tearfully. Her husband Raghe says: “We believe we will not go to heaven if we do not have a son.”

A recent report by the Guttmacher Institute showed that Nepali women have 1.2 million pregnancies each year, of which 539,000 are unintended. Nearly a quarter of these result in unplanned births and two-thirds are aborted.

“Actually, we have achieved a lot with the little money we have invested,” explains Bhim Singh Tinkari of the Family Welfare Division in Kathmandu. “But the money is mainly to buy contraception and family planning products. There is a huge gap in contraceptive supply, public awareness and trained health workers.”

“If all unmet need for modern contraception were met, unintended pregnancies would be reduced by 87%, or 469,000 annually, and unplanned births, abortions and miscarriages would decline by the same proportion. Fully meeting women’s need for contraception would reduce maternal deaths,” The Guttmacher Institute report concludes.

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Sunita Gurung is 21, but is already mother to four children aged five, three, two, and four months (above). She thinks contraception is bad for health because her friend using an IUCD is bleeding, and another who uses pills is putting on weight. “I do not want more children, but I am scared to use contraception,” she says.

To address the unmet need would cost only $30million according to a survey, but this is five times more than the government’s current family-planning budget. Without this funding Nepal is unlikely to meet the Sustainable Development Goals (SDG) target of 75% contraceptive prevalence.

“The situation has become more complicated than before with the new federal system. Local health needs are now the responsibility of provincial and municipality governments, but work has not started yet,” says Tinkari. “We need the money and we need to act soon if we are to meet the 2030 target.”

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