1. Padmashree School of Public Health Bangalore, Karnataka, India.
2. Padmashree School of Public Health Bangalore, Karnataka, India.
3. Professor, Padmashree School of Public Health Bangalore, Karnataka, India.
4. Faculty Coordinator, Padmashree School of Public Health Bangalore, India.

* Correspondence:  Prakash.bhattamph2018@gmail.com

Keywords: Demographic, contraceptive, India

1. INTRODUCTION

Family planning is defined as birth spacing, preventing unwanted pregnancies or secure wanted pregnancy [1]. Family planning (FP) is adopted voluntarily through the practice of contraception or other methods of birth control on the basis of knowledge [2], attitude and responsible decision by individuals and couples, in order to promote the health welfare of the family and contribute to the social and economic development of the country [3]. Family planning (FP) has been identified by World Health Organization as one of the six essential health interventions needed to achieve safe motherhood [4]. A women ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy [5]. Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next children [6]. The concept of unmet need points to the gap between women’s reproductive intensions and their contraceptive behaviors. The primary aim of FP enables women and men to plan their families and space their children through the use of modern contraceptives. However, FP also embraces activities such as infertility and genetic counseling, contraception, abortion and sterilization [7]. At the beginning of Christian era nearly 2000 year ago, World population was estimated to be around 250 million [8]. Human civilization and development took place in rapid speed along with that world population also increased rapidly and as of March 1st, 2020 world population has reached 7.80 billion (world meter).It takes a whole human civilization to reach population to 1 billion and only 200 years to reach from 1 billion to 7 billion population [9]. Unmet need is especially high among groups such as adolescents, migrants, urban slums dwellers, refugees and women in the post-partum period and in Nepal unmet need in Hilly region is high and then in Terrain region [10]. Unmet need for family planning is defined as the percentage of fecund women who do not currently use a contraceptive method even though they do not want any more children or they want to wait at least two years before having another child [11]. Family planning method use during the postpartum period is essential for the health of the mother and children. However, knowledge about the contraceptive use and the determining factor in Nepal is observed negligible among the women during this period [12].Family planning use has major value in prevention of unplanned pregnancy and abortion, it also plays vital role in reduction of maternal and child mortality [13]. Family planning and contraceptive use among women is importance in spacing pregnancies and limiting the birth [14]. It endorse the maternal and child health by providing appropriate interval between the pregnancies as well as evade health cost, financial broaden, psychological and physical strain to the mother and family [15]. This study assessed the knowledge on family planning, pregnancy spacing, family planning use and barriers for not using the family planning methods among married women in Nepal.  Studies have also found couple communication and joint decision making also plays a vital role for the acceptance and use of family planning services. Effective communication and decision making empowers people to seek what is best for their own health and to exercise their right to good quality health care. However, decisions about family planning are discussed without sufficient communication between couples. Efforts to improve couples communication can help lead to decisions about family planning that reflect the needs of both women and men. Similarly, many factors plays as a barriers in the utilization of the family planning services, such as poor knowledge of family planning, poor perception of pregnancy risk, accessibility and affordability of services, geographical difficulties. Furthermore lower status of women, fear of side effect, family pressure, social and cultural norms, poor method choice, financial status and service providers bias play important role as barrier for not using family planning method. Meeting the need of family planning is one of the most cost effective investments to alleviate poverty and improve maternal and child health. Dhangadhi Sub-metropolitan City is the district headquarter of Kailali district in Sudurpaschim Province of Nepal. It is divided into 19 wards. It has a population of about 101,970 within 21,030 households, among them half is female population (50,531) [16]. In Dhangadhi Sub-metropolitan city, health services are provided through regional, community, municipal and private hospitals and health centers. 125 Female community health workers are providing door to door health services including family planning services. Still the Contraceptive use rate is only 48.4%, which is below the national average i.e. 53%. Also Total Fertility rate (TFR) is 4.3 birth which is almost double then the National data (2.25 birth). Similarly unmet need for family planning is 24% including 8% for spacing and 16% for limiting the birth. Although presence of multiple level of health institutions the data depict that there is less use of family planning and increasing unmet need, which shows that there must be some hurdles, which need to be find out from the research of that particular municipality. Thus this research is planned to be conducted in this area, which can support the implementer to effectively design and plan the activities that can address the particular issue.

2. MATERIALS & METHODS

The descriptive cross-sectional study design was used to carry out the present study. Data regarding number of Health facility, available health workers was collected from District Public Health Office (DPHO) of Kailali district. Demographic information, household and population and number of age group population were received from Dhangadhi Sub-Metropolitan office and Ward office of respective municipality. Similarly information were received from Family planning (Health Management Information System) register of respective Study was conducted in randomly selected 5 wards out of 19 wards of Dhangadhi, Sub Metropolitan city, Kailali district, Sudurpaschim Province, Nepal. Five wards out of 19 wards was selected randomly using the random number table. N=210 samples was collected from the selected five wards of the Sub-metropolitan city. Interview was conduct with the help of enumerator among married women of reproductive age (15-45 years) of Dhangadhi Sub-metropolitan city. Quantitative data was collected base on the semi-structure pre-tested questionnaire. Similarly interview was conducted using pre-structured questionnaire to collect Health facility information from health worker available in the health facility (usually from Family planning service provider or In-charge of the health facility. The frequency table and percentage analysis was used to describe the demographic, socio economic and family planning data of the study. Necessary cross tabulation and Chi square test was applied to find out the association between independent and dependent variables. Data was analyzed by using the SPSS statistical software (version 20.0) MS Excel.

3. RESULTS & DISCUSSION

3.1 Demographic Characteristics

Demographic characteristics provides information about age structure, family size and type of family and socio-economic characteristic provides information regarding education, ethnic group, occupation etc.

Table 01: Distribution of respondents according to age

Age group(Years) of respondents	N=206	%
15- 19	14	6.8
20-24	55	26.7
25-29	67	32.5
30-34	34	16.5
35-39	36	17.5
Total	206	100.0

Age is the most important variable for any study, the respondents were categorized into class interval as shown in the above table. The table shows that higher percent (32.5 %) of respondent where in age group of 25 to 29 years, whereas low percent were in less than 19 age group (6.8 %). Nearly 60% of the respondent fall under the age group 20-29 years. The table also shows that 93.2 % were above or equals to 20 years of age. The mean age of respondents was 27.29 years (S.D. =5.724).

Table 02: Distribution of respondents and their spouse by education

Educational level pass	Respondent	Husband
	N=206	%	N=206	%
Illiterate	2	1.0	0	0
Can read and Write	30	14.6	3	1.5
1-5 standard	8	3.9	18	8.7
6-10 standard	105	51.0	50	24.3
Intermediate (12th standard)	47	22.8	91	44.2
Degree/Diploma and Above	14	6.8	44	21.4
Total	206	100.0	206	100.0

Among total respondents, 1% had never attended school, 14.6 % of the respondents can read and write. Half of them have attended education up to lower secondary level (6-10 standard), whereas 6.8 % of the respondent have attended degree and above level of education. On the other hand, 1.5 % of the total respondents’ husbands can read and write, 8.7 % attended primary level education, 24.3 % completed lower secondary level education and 65.6 % had attained intermediate or higher level of education.

Table 03: Distribution of respondents and their spouse by occupation

Occupation	Respondent		Husband
	N	%	N	%
Housework	96	46.6	16	7.8
Agriculture	45	21.8	80	38.8
Business/shop	26	12.6	22	10.7
Job/service*	39	18.9	23	11.2
Labour migrant**	0	0	65	31.6
Total	206	100.0	206	100.0

*Job/service refers to government/Private organization/Industries/NGO employee

**Labour Migrant refers to a person who moves to another country or area in order to find employment, in particular seasonal or temporary work (UN). Majority (46.6%) of the respondents were engaged in housework followed by agriculture (21.8%). Similarly 12.6% of the respondents were doing business and 18.9% were engaged in job or service.  On the other hand 38.8% husbands of respondent were engaged in agriculture and 31.6% were Labour migrant. 11.2% were engaged in job service and 10.7% were doing business.

Table 04: Distribution of respondents according to their Type of Family among current FP user

Type of   Family	Current FP user				Total
	Yes	%	No	%	N=206	%
Nuclear	44	21.35	23	11.16	67	32.5
Joint	54	26.21	43	20.87	97	47.1
Extended	41	19.90	1	0.48	42	20.4
Total	139	67.48	67	32.52	206	100.0

About 47.1% of respondents were living in joint family whereas 32.5% belonged to nuclear family followed by 20.4% living in extended family. Among the respondents who are currently not using any family planning devices, unmet need is more observed in joint family followed by nuclear family.

Table 05: Distribution of respondents by Religion and Number of living children

Religion	No Children	1-2 children	3-4 children	More than 4 children	Total (N=206)	%
Hindu	29	131	40	1	201	97.6
Muslim	0	0	2	1	3	1.5
Buddhist	0	2	0	0	2	1.0
Total	29	133	42	2	206	100.0

97.6 % of total respondents followed Hinduism whereas 1.5% and 1% of the respondents were Muslim and Buddhist respectively. The table also describes that on percentage calculation, the ratio of the Muslim respondents have more children (more than 3child) than Hindu and Buddhist.

Table 06: Distribution of respondents by Ethnicity and Number of living children

Ethnicity	No Children	1-2 children	3-4 children	More than 4 children	Total (N=206)	%
Dalit	1	39	5	1	46	22.3
Disadvantage Janajati	12	41	27	0	80	38.8
Religious minorities	0	0	2	1	3	1.5
Relatively Advantaged Janajati	0	2	0	0	2	1.0
Upper caste	16	51	8	0	75	36.4
Total	29	133	42	2	206	100.0

The higher percent of the respondents (38.8%) were from disadvantaged, similarly 36.4% were upper caste Brahmin, Chhetri followed by dalit 22.3%. The figure describes that religious minorities and disadvantaged have higher number of off springs (more than three children) than other ethnicity whereas advantaged Janajatis and upper cast (Brahmin, Chhetri) have relatively low number of living children.

Table 07: Distribution of respondents by Age at Marriage

Age at Marriage	N=206	%
15-19	179	86.9
20-24	27	13.1
Total	206	100.0

Age at marriage and age at the first pregnancy are the key variables in the family planning discourse. Age at the first birth is vastly influenced by age at marriage. Thus it could be one of the determinants of non-use of family planning methods. The above table shows that about 86.9% of the total respondents were married by the age of 15-19 years and 13.1% women were married by the age of 20-24 years.

Table 08: Distribution of Age at the first pregnancy

Age at first pregnancy	N=206	%
15-19	120	58.3
20-24	46	22.3
25-29	11	5.3
Not pregnant yet	29	14.1
Total	206	100.0

More than half of the women (58.3%) got pregnant by the age less than 20 years. The data above describes that 86.9 % got married at age less than 20, similarly among them 58.3% get pregnant with in 15 to 19 years of age.

Table 09: Distribution of respondents by age at marriage and total number of living children

Age At Marriage (years)	Number Of  living Children					Total (N=206)
		No Children	1-2 child	3-4 child	>4 child
15-19	N	29	106	42	2	179
	%	14.07	51.45	20.38	0.97	86.90
20-24	N	0	27	0	0	27
	%	0	13.10	0	0	13.10
Total	N	29	133	42	2	206
	%	14.07	64.55	20.38	0.97	100

The above table shows that among total respondents (206), 177 (85.92%) had living number of children, among the total respondent half of the respondent have 1 or 2 children. Similarly 20.38% of the respondents had 3 or 4 children among those who are married before age 15 to 20 years, and 1% of the respondents have more than 4 children. As shown in the cross tabulation, the study revealed that those who were married at the early ages (less than 20 years) their fertility behaviour was higher (72.8%)  in comparison to the age group of more than or equals to 20 years (15.25%) and had more number of children then those who married later in life.

3.2 Knowledge and Current use of Contraceptives

Table 10:  Distribution of respondents according to Knowledge on family planning

Heard About Family Planning	N=206	%
Yes	204	99
No	2	1
Total	206	100.0

The above table illustrates that most of respondents (99 %) had heard about family planning. The 2 respondents belongs to the religious minorities women of age 32 and 35.

Table 11: Distribution of respondents according to Knowledge about family planning methods

Family planning methods	Responses(multiple response) N=204
	N=206		%
Oral Pills	171		19.11
Condom	204		22.79
I.U.D	28		3.13
Depo-Provera	181		20.22
Norplant	65		7.26
Calendar method	17		1.90
Vasectomy	95		10.61
Minilap	134		14.97
Tubectomy	0		0.00
Total	895	100.0

In this study, most of the respondents had knowledge about condom (22.79%), the second method to gain more frequency was Depo-Provera Injectable (20.22%) followed by oral pills (19.11%), Minilap (14.97%), Vasectomy (10.61%), Norplant (7.26%), IUD (3.13%) and Calendar Method (1.90%). Out of all the methods, calendar method and Tubectomy was the least heard by the respondent.

Table 12: Distribution of respondents on the basis of Source of Information on family planning

Source of information	Response  N=204
	N	%
Radio	11	5.39
Television	23	11.27
Poster	90	44.12
Health worker	17	8.33
FCHV	29	14.22
Friends	6	2.94
Other	28	13.73
Total	204	100.0

­

The above table shows that most of the respondents (44.12%) heard about family planning methods from posters, followed by FCHV (14.22%), Television (11.27%), Health worker (8.33%), Radio (5.39%) and Friends (2.94%). The least popular source of information regarding family planning was newspaper and internet.

Table 13: Distribution of respondents on the basis of Knowledge on Benefit of contraceptives

Benefit of Contraceptives	N=206	%
Prevent Pregnancy	95	46.1
Protection against HIV/STI	21	10.2
Spacing	76	36.9
Not known	14	6.8
Total	206	100.0

The above table illustrates that 46.1% of respondents are clear about the benefit that contraceptives ‘prevent pregnancy’ followed by ‘spacing’ as the second known benefit (36.9%). Similarly 10.2 % knows that contraceptive ‘protects against HIV/AIDS’, whereas 6.8% do not know or will to reply about the benefit of contraceptives.

Table 14: Distribution of respondents on the basis of Knowledge on after effect of modern contraceptives

After Effect of Contraceptives	N=206	%
bleeding/spotting	47	22.8
irregular menstruation	71	34.5
weight Gain	32	15.5
Mood swing	11	5.3
Don’t know	45	21.8
Total	206	100.0

The above table shows that among all method the respondent knows in general, 34.5% of respondents expressed ‘Irregular Menstruation’ is the most common after effect of contraceptives, followed ‘bleeding or spotting’ as second known after effect of contraceptives. 15.1% of respondents tell ‘weight gain’ and 5.3% tell ‘mood swing’ as the after effect of contraceptives whereas 21.8% did not give answer about after effect of contraceptives.

Table 15:  Number of living children among respondent currently using modern contractive methods

Current use of FP Methods	Number of living Children				Number	%
	No Child	1-2	3-4	>4
Oral Pills	11	12	1	0	24	17.27
Condom	2	16	3	0	21	15.11
IUD (Copper T)	0	6	1	0	7	5.04
Depo-Provera injectable	1	33	12	0	46	33.09
Norplant	0	11	4	0	15	10.79
Calendar Method	4	5	0	0	9	6.47
Minilap (Female sterilization)	0	4	8	0	12	8.63
Vasectomy (Male Sterilization)	0	1	3	1	5	3.60
Total	18	88	32	1	139	100.00

Table 15 describes that Depo-Provera was common among married women having 1 or 2 children. Similarly condom and oral pills were common among married women having less than 2 children. LARC are used by the married women who want no more children and have desired number of children. Permanent sterilization was mostly used by married women having 3 to 4 living children, whereas Minilap was preferred than Vasectomy among permanent family planning method.

Table 16: Age distributions of currently use of modern contractive methods

Current use of FP Methods	Age group					Total	%
	15-19	20-24	25-29	30-34	35-39
Oral Pills	6	6	7	2	3	24	17.27
Condom	0	7	1	10	3	21	15.11
IUD (Copper T)	0	0	2	2	3	7	5.04
Depo-Provera injectable	0	7	27	7	5	46	33.09
Norplant	0	1	2	1	11	15	10.79
Calendar Method	0	4	1	3	1	9	6.47
Minilap (Female sterilization)	0	0	2	3	7	12	8.63
Vasectomy (Male Sterilization)	0	0	1	3	1	5	3.60
Total	6	25	43	31	34	139	100.00

Table no 16 demonstrates that out of 204 respondent who have knowledge about family planning, 139 respondent were current user of family planning methods. Among those 139 respondents 33.09% were using Depo-Provera Injectable followed by oral pills (17.29%) and condom (15.11%). Similarly 10.79% were using Norplant and 6.47% were using Calendar method of family planning. Among Permanent method, current users of Minilap female sterilization were 8.63% and Male sterilization users were 3.60%. The crosstab shows that Depo-Provera injectable was the most commonly used contraceptive and was highly acceptable among married women of 25 to 29 age group, whereas Norplant (LARC) and Minilap (female sterilization) was most accepted by married women of age more than 30 years.

Table 17: Age distribution and current use of family planning

Age	Current FP user			Total	Chi-square = 4.148 Df =1 P=0.042
		Yes	No
15-19	N	6	8	14
	%	42.85	57.14	100
20-24	N	24	31	55
	%	43.64	56.36	100
25-29	N	43	24	67
	%	64.18	35.82	100
30-34	N	31	3	34
	%	91.18	8.82	100
35-39	N	35	1	36
	%	97.22	2.78	100
Total	N	139	67	206
	%	67.48	32.52	100.00

The above table shows that Family planning use is associated with age. The figure describes that age of respondents was statistically significant (p<0.05). Respondents having more age are more likely to use family planning methods in compare to the women having age less than 20.

Table 18: Education status and the current use of family planning

Education level	Current FP user			Total	P Value
		Yes	No
Illiterate	N	0	2	2	Chi-square = 6.946 Df =1 P=0.008
	%	0	100	100
Can read and write	N	29	1	30
	%	96.67	3.33	100
1-5 standard	N	5	3	8
	%	62.5	37.5	100
6-10 standard	N	50	55	105
	%	47.6	52.3	100
Intermediate(12th standard)	N	41	6	47
	%	87.2	12.8	100
Degree/Diploma and Above	N	14	0	14
	%	100	0	100
Total	N	139	67	206
	%	67.48	32.52	100

The above table describes that Education level is associated with use of Family planning services. People with higher education are more likely to use FP services than people with less education. Thus education is one of the barrier for not using family planning services. Thus this relation is scientifically associated and statistically significant (p value <0.05).

Table 19: Occupational status and current FP use

Occupational Status	Current FP user			Total	χ2	P Value
		Yes	No
Government Job, Business and Private Job	N	50	12	62	7.009	0.008
	%	24.27	5.83	30.10
Agriculture, House work, Migrant worker	N	89	55	144
	%	43.20	26.70	69.90
Total	N	139	67	206
	%	67.48	32.52	100

The table number 19 shows that occupation of the respondent is associated with family planning use. The analysis shows that the people with higher job (Government job, Business, Private Job) are more likely to use family planning method than people with lower job (Agriculture, House work, Migrant worker). Thus this relation is scientifically associated and statistically significant (p value <0.05).

Table 20: Distribution of respondents according to Reason for not using Family Planning methods

Reasons for not Using FP Methods	N=67	%
Not having sex	4	5.97
Fear of Side effect	19	28.36
Infrequent sex	17	25.37
Currently pregnant	4	5.97
Respondent Opposed	18	26.87
Husband Opposed	2	2.99
Religious Prohibition	3	4.48
Total	67	100.00

Among total respondents 139 were current users and 67 were not using any family planning methods.  Among those 67 respondents who were not using family planning, reason of not using family planning methods was asked. The causes of non-use of family planning methods means the barriers that influence use of family planning methods. Infrequent sex (25.37%) and respondent’s opposition (26.87%) to use methods combine covers half of the reason, although ‘fear of side effect of contraceptives’ was the most common reason among all.

3.3 Unmet Need for Family Planning among Married women of Reproductive age

The study showed that among the married women of reproductive age, unmet need for FP was 32.1%. The unmet need for spacing was 11.7% and the unmet need for limiting was 20.4%.

Figure 2: Westoff model for calculating Unmet Need for Family planning

Figure 01: Unmet Need for Family Planning among Married women of age 15-45.

Table 21: Distribution of respondents who motivated for using Family Planning methods

Person provided suggestion for Using FP Methods	N=139	%
Self	3	1.5
Husband	60	29.1
Relative/friends	33	16.0
Health-worker	11	5.3
parent-in-law	25	12.1
Others (Neighbour, social mobilizer)	7	3.4
Total	139	100.0

The above table shows that the most important influencer providing suggestion for utilizing family planning was ‘Husband’ (29.1%), followed by relatives and friends (16%). The other influencers were parents in law (12.1%) and Health worker (5.3%).

Table 22: Distribution of respondents according to first time use of contraceptive methods

First time use of contraceptive methods	N=139	%
After marriage and before child bearing	54	26.2
After first child	91	44.2
After second child	35	17.0
Total	139	100.0

Among the current user of FP i.e. 139 respondents, 44.2% use contraceptives after the birth of their first child, whereas 26% respondent use after marriage and before the birth of the first child.

Table 23: Distribution of respondents according to Percent distribution of Service provider

Place for seeking FP service	N=180	%
Government Hospital	40	22.22
Private Hospital	15	8.33
UHC/HP	56	31.11
FCHV	22	12.22
Pharmacy	47	26.11
Total	180	100.00

The above table describes that among the total respondents those who have ever use contraceptives were asked about the place they seek for family planning services. About one third (31.11%) received services from Urban Health Clinic or Health Post, whereas 22.22% seek FP service at Government hospital. Similarly 26.11% seek FP services through pharmacy and 8.33% through private hospitals. 12.22% of the respondents still seek FCHV for the FP related services.

Table 24: Distribution of respondents according to Health care facility and distance from their house

Health care facility near house	Distance from House in KM		Total
	<2 km	>=2 km
HP	35	104	139
%	16.99	50.49	67.48
Government Hospital	0.00	1.00	1.00
%	0.00	0.49	0.49
Private Hospital/clinic	57.00	9.00	66.00
%	27.67	4.37	32.04
Total	92.00	114.00	206.00
%	44.66	55.34	100.00

Above cross tabulation shows that 67.48% of the respondent resides near to the health post and 32.04% near to private health clinics. The cross tabulation also describes that nearly respondent half of the respondents house is more than 2 kilometer away from the health post, Whereas 27.67% of the respondent house are less than 2 KM from the private hospital or clinics.

Table 25: Distribution of respondents according to mode of travel to health care facility

Mode of travel to Health care facility	N=206	%
Walk	148	71.8
public transport/Auto/bus	27	13.1
two wheeler	31	15.0
Total	206	100.0

Table no. 25 describes that 71.8% of respondents walk for services to health care facility whereas 15% have two wheelers and 13.1% uses public transportation.

Table 26: Distribution of respondents according to accompany during health facility visit

Accompany during visit	N=206	%
Husband	114	55.3
In-laws	73	35.4
Neighbour	19	9.2
Total	206	100.0

The above table describes that most of the time respondents husband accompany during Health facility visit (55.3%) followed by In-laws (35.4%). Similarly 9.2% of the neighbor accompany during the health facility visit.

Table 27: Distribution of respondents according to percent distribution of taking permission

Permission taken from	N=206	%
Husband	101	49.0
In-laws	86	41.7
NA	19	9.2
Total	206	100.0

Among the total respondent 49% use to take permission from husband whereas 41.7% take permission from In-laws. Similarly, 9.2% didn’t take permission to visit health facility.

Table 28: Distribution of respondents according to percentage distribution of making final decision for FP service

Permission taken from	N=206	%
Self	54	26.2
Husband	38	18.4
Both	114	55.3
Total	206	100.0

Above table shows that 55% of respondent together make the final decision on family planning matter. 26% of respondent make final decision themselves and 18.4 % respondent’s husband make final decision for FP service.

3.2 Discussion

The study examined unmet family planning needs and the factors that affect them, most respondents (86.9%) were married younger than 20 years old, while just 13.1% were married older than 20 years old. Most (58.3%) respondents became pregnant before 20. 67.8% of pregnant respondents [17]. Approximately 75.14% of respondents had ≤2 children, while 25% of those who married before 20 had ≥3 children. Respondents had increased fertility earlier in marriage [18]. Younger married respondents had greater fertility rates than those aged 20-24. Knowledge of contraceptives is essential to accessing and using them. The ability of respondents to name recognised methods measured method knowledge [19]. Contraceptives were known by 99%. Condom (22.79%), Depo-Provera Injectable (20.22%), oral pills (19.11%), Minilap (14.97%), Vasectomy (10.61%), Norplant (7.26%), IUD (3.13%), and Calendar Method (1.90%) were the most known. Calendar and tubectomy were the least heard methods [20]. Posters, pamphlets, and IEC materials effectively share family planning knowledge (44.12%), followed by FCHV (14.22%), Television (11.27%), and radio (5.39%). Family planning information from newspapers was least popular [21]. Contraceptives Prevent Pregnancy (46.1%), “spacing” (36.7%), and most significantly (10.2%) knew that contraceptives (condoms) shield against sexually transmitted diseases and HIV/AIDS [22]. 34.5% of respondents reported ‘Irregular Menstruation’ as the most prevalent contraceptive side effect, followed by ‘bleeding or spotting [23]. The most common response to the ‘after impact of contraceptives’ was ‘irregular menstruation’ (34.5%), followed by ‘bleeding or spotting’ and ‘weight gain’ (15.1%) [24]. The majority of respondents who heard of FP used FP approaches (68.14%). The survey found that Depo-Provera injectable was the most often utilised contraceptive technique (33.19%) [25]. Oral pills (17.29%) were the second most popular approach, followed by condoms (115.11%) [26]. Age significantly correlated with family planning usage. Younger women are less likely to employ FP methods than older women. There is a substantial correlation between marital age and family planning usage. Married women over 20 are more likely to employ FP methods than those under 20 [27]. Education level significantly correlated with family planning usage, compared to women with higher education, 85% of respondents with less than Primary (class 5) education adopt FP approaches [28]. A substantial correlation exists between occupational position and family planning usage. Higher-job respondents (80.65%) employ FP approaches more than lower-job respondents [29].

4. CONCLUSIONS

Family planning is a top priority in Nepal, despite a strong infrastructure and health care delivery system from government to grassroots level, Nepal’s unmet family planning requirement has remained static for 15 years. This study in Dhangadhi Sub-metropolitan city, Kailali district, Nepal found 32.52% unmet requirement among married reproductive women aged 15–45. The study indicated high awareness of modern family planning strategies. It has found a correlation between contraceptive use and educationc other socio demographic characteristics like age, occupation, and marriage age are also statistically significant and associated with contraceptive use. Married women of reproductive age were most likely to avoid contraception due to side effects (28.36%). Infrequent sex (25.37%) followed respondent hostility to usage as the second most important cause. Both causes involve husband migration-related spousal separation. On asking health service providers about “the cause of not using Family planning method by couples in the community”, the health facility assessment found the same. Family planning use is not statistically associated with distance from the health institution or ethnicity. Nearly half of respondents relied on public health facilities (health posts and urban health clinics) for contraceptives, while only 12.5% provided all five modern contraception methods (OCP, Depo, Condom, Norplant, and IUD). 38% of hospitals saw contraceptive stockouts in the past three months. Health facilities with fewer qualified and female health staff also hinder the government’s goal of making them adolescent-friendly. These demonstrate the gap between health system management and demand supply management, which may raise family planning unmet need.

5. RECOMMENDATION

Based on the finding of this study, some recommendation had been made to delivery family planning services efficiently following are the recommendation are:

1. The research only focus on the married women of reproductive age thus further research on all reproductive age women can be assessed.
2. Although Government health facilities are recognized as a key source of FP services, other non-governmental as well as private sectors should be encouraged to provide FP services in coordination with government sector.
3. IEC materials like posters, pamphlets was the main source of information regarding FP. Information provided through these media was effective among the respondents. Hence, use, availability and accessibility should be increased in strategic ways.
4. Female of each household should be more capable in making self-decision about contraceptive use.
5. Education and community based training should be strengthened to increase awareness by community effort involving husbands and In-Laws as the influencer of FP promoters.
6. Counseling should be given not only to the women but also to the family members including husband, mother-in-law.
7. Local level government should be strengthened and should be made more accountable for planning, implementation and evaluation of FP program in their community.
8. Strengthening of health facility infrastructure and departing training, mentoring skills to the health facility staff.

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