“We decided to plan from the beginning. So the doctor checked my menstrual cycle and advised on the right time for me to conceive,” says Parveen, who is now a happy mother of a nine-month-old toddler.
Dr Usha Shrestha, obstetrician and gynecologist at Paropkar Maternity and Women’s Hospital, Thapathali, says that there are very few cases of couples visiting her to plan their pregnancy from the beginning. “Couples usually come for supervision after they have discovered that they are expecting the baby. This trend is mostly common in women who are pregnant for the first time,” she says.
However, according to the doctor’s experience, couples are eager for pregnancy planning if they have had complications during the first time or they have problems conceiving for the second time even though the first one was carried out without any special attention. There are also cases of women visiting her after recurrent miscarriages or if they are planning for a child after one or more abortions.
“Very few couples seek advice and supervision on their first pregnancy,” says Dr Shrestha.
The trend of planning for pregnancy hasn’t yet developed in Nepal. Though doctors have experienced that people in urban areas are more aware of their choices to bear children and are relatively more prepared financially and psychologically, there are many cases of unintended pregnancies.
To minimize unwanted pregnancies, the government has been emphasizing on family planning contraceptives. The Family Planning Association of Nepal (FPAN), a leading non-governmental organization working towards sexuality and reproductive health information and services, has also been working to control unwanted pregnancies through promotion of usage of contraceptives.
“Family planning has been the primary objective for planned parenthood as it helps couples to bear children when they are ready. Bearing children comes with great responsibilities and so every pregnancy should be wanted, not accidental,” says Dr Shailendra Uprety, Director of Family Health Division at Department of Health Services.
He adds that planning for pregnancy reduces the risks of negligence during pregnancy which has its adverse effects on mother’s and child’s health. And even though couples and families are careful during unintended pregnancies, it puts a lot of pressure on the mother which can affect her mental health and consequently the health of the unborn baby as well.
Legalization of abortion for fetus up to 12 weeks in 2002 has also prompted many women to terminate their unplanned pregnancies. “Sometimes, couples have conflicting priorities and ask for abortion. There are times when women are least prepared mentally, and though all the conditions are favorable, we need to go according to their choice,” says Dr Shrestha.
Unintended pregnancies also take place when family planning contraception fails. And most women in such cases decide to abort the fetus. But Dr Barun Rai, Medical Officer at Paropakar Maternity and Women Hospital, says that he has experienced many cases of unwanted pregnancies due to lack of family contraceptive usage during his work outside the capital.
“I have also handled cases of pregnant adolescent girls of less than 17 years. In such cases, the mother and unborn child had to go through many complications, and surgery is the only option for delivery,” he says.
Nepal had the highest maternal mortality rates (MMR) in the world with 850 per 100,000 live births in 1990. The number has been, however, steadily declining from 281 in 2006, 229 in 2008-2009 and the last recorded data of 170 in 2010. This has been possible through various programs such as Family Planning, National Safe Motherhood Program and Aama Surakshya Program (Mother Safety Program).
Dr Uprety claims that knowledge of family planning contraceptive is widespread in Nepal. But many refrain from using them due to fear of side effects or due to unavailability of desired family contraceptive devices in some rural areas.
“The cultural factor and traditional attitude in Nepal also creates difficulties, especially for adolescents, to use family contraceptive devices,” he says. Even when girls are married young, they are expected to bear a child to prove their fertility to the family and relatives. “In such cases, it’s very hard for couples to plan to have a baby after a few years of marriage,” says Dr Uprety.
He adds that pregnant adolescent girls make up 17-18% of the total pregnant women in Nepal. “So the government launched National Safe Motherhood Program in 1997 with its long term plan till 2017, which is mainly focused to spread awareness against early marriages,” he says.
When girls are married early, they lack sufficient knowledge to take care of themselves during pregnancy, let alone take care of the child. Many times, due to negligence during pregnancy period, pregnant women develop hypertension and depression.
“There are also cases of pressure from their families to bear a male child on some women. In such cases, women develop anxiety regarding the childbirth and are depressed when the delivery turns against their wish,” says Dr Rai.
Even though couples look forward to usage of family planning contraceptives, families interfere on these matters, influencing couple’s decision. As family relations are close-knit in Nepal, their say on childbirth also puts women in pressure.
Dr Shrestha has experienced that in urban areas, though women have started to marry late and consequently bear children after their thirties, the pressure to bear a child is still intact. “The ideal age to conceive a child is 25-32 for women. The ratio of complications during pregnancy before or after the age-range is relatively higher,” she says.
Therefore, Dr Shrestha counsels women to keep their age in mind while planning to conceive. Sometimes, even though pregnancies are planned and women have taken good care during their pregnancies, there can be some complications during childbirth. “In cases of premature delivery or any other complications, women who are either very young or older than the ideal age don’t respond well to the situation,” she says. According to her experience, there is a pressure for older women as the situation may get worse as they age.
In case of women from rural areas, though they are of the ideal age, lack of skilled human resources in their neighborhood puts them into grave risks during pregnancy and childbirth. Rural pregnant women require more planning as they need to get to health centers before their labor, which may take them a few days to reach.
Apart from the incentive by the government to remunerate transportation and institutional costs to the mothers who come to the Paropkar Maternity and Women Hospital, Dr. Uprety says that they also have projects to aware women and their families of the advantages of proper planning for pregnancy.
“The Information, Education and Communication (IEC) program under family planning works towards education of women about the healthy timing for pregnancy and appropriate spacing between two children,” he says.
The IEC program is carried out through female community health volunteers as they instruct women about regular health checkups, dietary requirement during pregnancy, preparations for delivery, among others.
To encourage women and their families to opt for safer delivery, the government has initiated Aama program in 2009 which not only waives transportation and institutional costs but also provides Rs 400 extra to pregnant women who have completed four ante-natal and three post-natal checkups.
Though government incentives may encourage people to have safe delivery, planning for pregnancy and parenthood is in the hands of would-be parents and their families. Planning for pregnancy under expert supervision provides health benefits for mothers and newborn and helps women to prepare themselves for any complications during or after pregnancy. It not only helps to curb any physical or mental stress but also provides enough time to create a proper environment for the child to grow up in stable financial conditions.
Family planning: Prevention better than termination
Expecting a baby is a very exciting and happy time for women and their families. But when a woman conceives a child unplanned, there are various factors that can lead to disappointment. As every child should be by choice and not by chance, it’s necessary that couples seriously weigh their options of contraception.
There are various contraceptive methods and devices which help to curb pregnancy on a temporarily or permanent basis. The usage of family planning devices is the first step in planned parenthood.
“When a couple visits our centers, we advise them on the most suitable family contraceptive device according to their future plan,” says Pramij Thapa, Project Coordinator of Family Planning Association of Nepal (FPAN).
If a couple decides not to have any more kids, they are advised to go for permanent sterilization. However, if a couple is planning not to have children temporarily or is planning to space births, contraceptive implants, injections or pills are recommended.
Thapa adds that there are increasing cases of couples visiting their centers for the termination of unwanted pregnancy. “It’s family planning devices that we emphasize on, but after the child is already conceived and the parents aren’t ready for it, abortion is the only option,” he says.
However, he adds that abortion shouldn’t be considered as a part of parenthood planning but only opted as a last resort. Apart from abortion by choice which is legal only for fetus of maximum 12 weeks, abortion in case of pregnancies due to rape or incest can be carried out till 18 weeks. And in case of the pregnancy being dangerous to the mother or unborn child’s health, the process of termination can be carried out any time with the expert’s permission.
To provide services for family planning and abortion, the government has listed more than 500 service centers in 75 districts of Nepal with more than 1,500 service providers. FPAN has also operated various service centers that work to provide information on family planning methods according to individual needs.
“The government also reinforces the idea of usage of family planning methods rather than abortion. But since it’s women who need to go through all the complications, it’s, of course, their right to vote for or against the termination,” says Dr Shailendra Uprety, Director of Family Health Division at Department of Health Services.
Unwanted pregnancies occur when people are ignorant of family planning methods or when family planning devices fail. According to Dr Uprety, government study shows that the number of married women opting for abortion is more than unmarried women, which indicates that unwanted pregnancies occur due to couples’ failure in supervision of the contraceptive methods.
Therefore, better regulation of family planning methods or devices not only saves one from unplanned pregnancy but also helps to minimize child’s risk of future adult health. Better planning is also necessary to have less health issues after giving birth and for pleasant post-partum experience
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