Original research articleDo mobile family planning clinics facilitate vasectomy use in Nepal?
Introduction
Over the last 15 years, Nepal has achieved a substantial reduction in fertility rates from 4.6 births to 2.6 births per woman [1], [2], [3]. Yet, the desired fertility stands at the replacement level of 2.1 births per woman, which implies that women have about one additional unwanted birth in their reproductive life [4]. The desire to stop having more children suggests high demand for family planning (FP) among Nepalese couples, particularly permanent methods.
Although contraceptive use is generally skewed toward females, Nepal is one of the countries in South Asia, apart from Bhutan, to have the highest prevalence of male sterilization [5]. According to the 2011 Nepal Demographic and Health Survey (NDHS), permanent methods constitute more than one-half of modern contraceptive use and about a third of all sterilized couples use vasectomy [4]. Yet, unmet contraceptive need for limiting fertility represents over two-third of total unmet need which vary considerably across population subgroups and ecological zones [4], [6], [7].
One of the strategic goals of the National Family Planning Program in Nepal has been to improve access to modern contraception through mobile FP camps targeting the poorest-poor and socially excluded communities residing in geographically isolated and economically deprived areas [8], [9]. FP services are generally delivered through a wide network of facilities at different levels, such as hospitals, primary health care (PHC) centers, health (sub)posts, private clinic/pharmacies, mobile camps and nongovernment organizations (NGOs) such as the Family Planning Association of Nepal (FPAN), Marie Stopes and Red Cross [9], [10], [11]. FP services in public sectors and some NGOs are available generally free of charge [12].
Sterilization services are usually offered through a network of static (fixed location), seasonal (fixed period of time) and mobile (community-based) sites. Mobile sterilization camps in Nepal have a long history spanning over three decades, and they operate mostly at the village level under the district administration [9], [10], [11]. The camps are often the major source for sterilization in remote areas with poor road network and in areas with health/subhealth units not adequately equipped to provide clinical services [12], [13]. Most women who seek sterilization services in a clinic/camp in remote areas generally have little or no prior contraceptive use history [13]. Also, women in poor households discourage their husbands against vasectomy, instead choose sterilization on their own, due to fear of losing economic support from their sterilized husbands if they become ill or experience side effects [14].
Nepal has a distinct topography divided into three ecological zones: harsh terrain mountain zone, densely populated hill zone and terai (plain) zone where about one-half of the population resides with better access to transportation facilities [4]. The hill and mountain zones have generally poor access to health services [11], [12], [13]. These zones have relatively high fertility rates and high unmet need for limiting methods [4], [6], and often mobile camps are the only convenient source for FP services [13]. In these remote areas, gynecological surgeons usually travel a long distance with the mobile unit, mostly during dry season, and offer long-term methods including vasectomy, mini-laparoscopy and laparoscopic sterilization [15]. Community health volunteers and female health workers provide information about mobile camps ahead of the schedule on a door-to-door basis [12].
A gender-oriented question arises in this context: do mobile clinics influence the type of sterilization outcome (male/female)? Although women generally exchange reproductive health experiences and interact with health workers/peers more frequently [16], [17], men tend to participate in community FP camps and seek contraception either voluntarily or jointly with their spouses or through peer influence [18]. Such decisions are also determined by individual and program/supply factors, for example, education and autonomy [19], [20], service standards, cash incentives [11] and other psychosocial and cultural influences including strong son preference [14], [21], [22], [23], [24]. There is also a perception that vasectomies would render men frail and potentially impair their ability to provide economic support for the family [14].
This paper investigates the influence of mobile FP clinics on vasectomy use in Nepal. We hypothesize that men use mobile FP clinics over other facilities for permanent methods than women.
Section snippets
Data
Data for this study are drawn from the 2011 NDHS, which collected nationally representative data from 12,674 women aged 15–49 years [2]. Current FP users were asked specific questions about the method type and the source where the method was obtained. The reported source include the following: government hospital/clinic, PHCs, mobile clinic, NGO (FPAN, Marie Stopes, Adventist Development and Relief Agency, Nepal Red Cross and United Mission to Nepal), private clinics, pharmacy and other
Descriptive
Of those who had a female sterilization, about 59% had the procedure in a government hospital, 19% in a mobile clinic and 22% in a private hospital (Table 1). In contrast, about 51% of all vasectomy users had the procedure in a government hospital, 33% in a mobile clinic and 17% in a private hospital.
About 36% of those who had vasectomy in rural areas had the procedure in a mobile clinic, and the corresponding figure in urban areas was about 11%. About 59% of those who had vasectomy in mountain
Discussion
Improving access to modern contraception and encouraging method mix require multiple intervention strategies [27]. This paper demonstrates evidence that mobile clinics significantly contribute to facilitating vasectomy use in Nepal, particularly in mountain and hill region, with considerable heterogeneity at the community and district levels. Policy makers and program managers involved in designing and implementing targeted FP interventions could consider mobile clinic as an effective strategy
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