DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2017 No. 133

Ramesh Babu Kafle 

Komal Prasad Dulal

Krishna Prasad Pandey

July 2017

This document was produced for review by the United States Agency for 

International Development.

Continuum of Maternal Health Care and the 

Use of Postpartum Family Planning in Nepal

Continuum of Maternal Health Care and the 

Use of Postpartum Family Planning in Nepal 

Ramesh B. Kafle1

Komal P. Dulal1

 Krishna P. Pandey1

ICF 

Rockville, Maryland, USA 

July 2017 

1

Centre for Population and Development (CPAD), Purbanchal University, Biratnagar, Nepal 

Corresponding author: Ramesh B. Kafle, Centre for Population and Development (CPAD), Purbanchal 

University, Biratnagar, Nepal; email: rbkafle@gmail.com 
Acknowledgments 

We appreciate the suggestions and comments provided by our two facilitators, Wenjuan Wang and 

Shireen Assaf, during the preparation of this paper since the first workshop held in Bangkok. Their 

suggestions obviously deepened our understanding of the issues and prompted us to make the 

analysis more precise and comprehensive. We also thank two other co-facilitators, Bwalya Bupe 

Bwalya and Mulenga C. Mulenga, for their kind cooperation during the workshop. We 

acknowledge Sarah Staveteig for comments and suggestions on this paper. We also thank all the 

participants of the 2017 DHS Fellows Workshop for their suggestions during the presentations in 

Bangkok and Bali. We are thankful to USAID for providing us modest financial support and ICF 

for providing technical assistance in preparation of this paper. 

We did not encounter any conflict of interest while preparing this paper. 

Editor: Bryant Robey 

Document Production: Joan Wardell 

The DHS Working Papers series is a prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried 

out with support provided by the United States Agency for International Development (USAID) 

through The DHS Program (#AID-OAA-C-13-00095). The views expressed are those of the 

authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and 

evaluate population, health, and nutrition programs. For additional information about The DHS 

Program, contact DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. 

Phone: +1 301-407-6500; Fax: +1 301-407-6501; Email: reports@dhsprogram.com; Internet: 

www.dhsprogram.com. 

Recommended citation: 

Kafle, Ramesh B., Komal P. Dulal, and Krishna P. Pandey. 2017. Continuum of Maternal Health 

Care and the Use of Postpartum Family Planning in Nepal. DHS Working Paper No. 133. 

Rockville, Maryland, USA: ICF.
iii 

Abstract 

Continuum of maternal health care is crucial for women’s reproductive health. Initiation of family 

planning use during the postpartum period also is crucial for both maternal and child health. Nepal 

has emphasized the continuity of maternal health care as well as the use of modern contraception 

postpartum. In this context, the paper examines the role of the continuum of maternal care on 

subsequent use of postpartum family planning. For the analysis, the study uses information 

obtained in the 2011 Nepal Demographic and Health Survey (NDHS) from women of reproductive 

age who reported at least one birth in the 5 years before the survey. 

Results show that within 12 months following the last birth, 37% of women started using a modern 

family planning method. Continuity in the use of maternal health care is significantly associated 

with contraceptive use postpartum after controlling for other socioeconomic and demographic 

factors. The results imply that providing a continuum of maternal health care—antenatal, delivery, 

and postnatal—and ensuring that all women receive this care can increase the use of postpartum 

contraception. It is time to consider the importance of the continuum of maternal health care and 

to establish responsible institutions to implement and monitor the integrated maternal child health 

and family planning program during the process of state restructuring and power devolution in the 

new federal structure in Nepal. 

Key words: continuum of maternal health care, postpartum family planning, husband’s 

absence, Nepal 

1 

1. Introduction and Rationale 

The government of Nepal introduced the National Family Planning Program as an integral part of 

the Maternal and Child Health Program from its third 5-year plan period 1965-1970 (NPC 1965). 

From the beginning, the main objective of the National Family Planning Program of Nepal has 

been to improve the health status of mothers and children and the overall quality of life for the 

whole family by increasing access to and use of good-quality family planning services. Therefore, 

the Family Planning Program has become one of the government’s most prioritized programs 

under the Nepal Health Sector Program II (2010-2015). Effective integration of family planning 

services with other health services and along with other programs has been implemented at the 

grass-roots level under the regular program through the Department of Health Services and its 

institutions (DOHS 2014). 

The government of Nepal also emphasizes postpartum family planning (PPFP) counseling for 

women who use postnatal care (MOHP, New Era, and ICF International 2012; DOHS 2014). A 

woman who comes for any component of maternal health care services routinely gets an 

opportunity to interact not only with the maternal health personnel but also with many other people 

who might have come for family planning services. This context generates two pathways. First, a 

woman who receives maternal health care learns to take care of her own health and growing fetus 

until she gives birth to the child, and is better able to overcome the existing barriers to use of health 

services. Second, after a long exposure to health services and interaction with service providers 

and others gathered for health seeking, a woman gains knowledge of the time to start using a family 

planning method after delivery. These are the main pathways through which women can get 

information to better plan their next births. Therefore, use of maternal health care before and during 

delivery can play a vital role in improving the use of contraception within a year after delivery. 

The program related to PPFP is focused on starting family planning soon after delivery so as to 

maintain appropriate birth spacing for health benefits to both mother and child. In spite of some 

improvements in fertility planning in Nepal since 2001, the 2011 Nepal Demographic Health 

Survey (NDHS) revealed that, 12% of the total births in the 5 years preceding the survey were 

mistimed and 13% of the total births were unwanted (MOHP, New Era, and ICF International 

2012; MOHP, New Era, and Macro International Inc. 2007; MOH, New Era, and ORC Macro 

2002). Moreover, half of women (50%) maintained birth spacing of less than 36 months, and about 

a fifth (20%) spaced births less than 24 months apart (MOHP, New Era, and ICF International 

2012). Birth spacing of at least 2 years is considered essential for maintenance of good health of 

women and their children during and after childbirth or breastfeeding. Ensuring that births are 

adequately spaced is linked to early use of an effective family planning method. Therefore, use of 

modern contraception postpartum appears to be one of the most important components of the 

family planning program. 
2 

Despite commitments made during each plan period, maternal health care service utilization in 

Nepal before 1990 was limited, mainly due to the lack of health facilities in rural areas. The 2011 

NDHS revealed a substantial improvement in the use of maternal health care services since 2001. 

In the 2011 NDHS, about 85% of pregnant women made at least one visit for antenatal care (ANC), 

which was an increase from 74% in 2001 (MOH, New Era, and Macro International 2002; MOHP, 

New Era, and ICF International 2012). Similarly, in 2011 about 39% of women had given birth in 

a health facility, representing an increase of 29 percentage points from 2001. In addition, about 

45% of women went for a postnatal care (PNC) check-up within 6 weeks of delivery, which is 

considered to be the most crucial time for both mother and child to get information on maternal 

and child health. The PNC check-up is very important for a country like Nepal, where 45% of 

births still take place with the assistance of relatives/friends, which is considered medically unsafe. 

Policies and programs on maternal health care in Nepal are consistently updated in line with 

international recommendations. The Nepal safe motherhood policy of 1998 stresses use of ANC, 

facility delivery supported by skilled birth attendants, and use of PNC, with a view to save women 

from maternal complications and deaths. The transportation allowances program, which was 

initiated in 2005 to support pregnant women delivering at a health institution (DOHS 2005), and 

maternity health care services, which have been provided at no cost to users since 2009 (DOHS 

2009), are the major elements of the safe motherhood program in Nepal. The revised Safe 

Motherhood and Neonatal Health Long Term Plan (SMNHLTP 2006-2017) includes skilled 

attendants, safe abortion, and equity and access efforts under the umbrella of safe motherhood 

(DOHS 2014). 

The government’s effort to provide maternity services to all pregnant women in Nepal and to 

improve access to health facilities in the last decade may have further encouraged women to seek 

care at a health facility. Uptake of services—ANC, delivery at a health facility, and PNC—could 

play a role in influencing women to start using a family planning method soon after childbirth. 

Many earlier studies have focused on the connection between use of maternal health care services 

and subsequent use of family planning. The literature shows that women’s interaction with an 

organized health service system during the postconception and postpartum stages of reproduction 

offers an opportunity to provide information and counseling on family planning services. The use 

of modern methods increases substantially when more women use antenatal and postnatal care 

(Akinlo, Bisiriyu, and Esimai 2013). Ahmed and Mosley (2002) showed a direct and significant 

association between contraceptive use and use of maternal health care in a study of six countries 

with data from DHS surveys. The authors argued that the joint demand for better quality health 

and limited family size was translated into action through the use of maternal and child health 

services and fertility regulation. 

A study by Zerai and Tsui (2001) showed that, after controlling for effects of living in high health 

service contact areas and for various demographic and background factors, prior use of prenatal 
3 

care had a strong influence on subsequent use of modern contraception in Bolivia, Egypt, and 

Thailand. A study in Morocco found that if women used MCH services more intensely, they were 

more likely to use modern contraceptive services subsequently (Hotchkiss et al. 1999). Similarly, 

a positive association between intensity of MCH service use and subsequent contraceptive use was 

found in a study of Bolivia, Guatemala, Indonesia, Morocco, and Tanzania (Hotchkiss et al. 2005). 

Significant associations between the service intensity of ANC and PNC combined, as well as ANC 

only, and postpartum modern contraceptive use were also found in Kenya and Zambia, indicating 

that use of such services would be an opportunity to promote modern contraceptives use (Do and 

Hotchkiss 2011). 

Aside from maternal health services, other factors influence the use of family planning postpartum. 

For example, a study in Nigeria found that social and cultural factors often prevented women from 

obtaining reproductive health care, including family planning, indicating a need for programs to 

help overcome the problem in order to provide safe motherhood to all women (Yahaya 2002). 

Region, education, household wealth, and exposure to family planning messages are significant 

predictors of modern contraceptive use in the postpartum period in Nigeria (Akinlo, Bisiriyu, and 

Esimai 2013). 

Likewise, a multi-country study based on 43 DHS surveys showed a strong correlation between 

use of maternal health care and use of postpartum family planning, particularly by women’s urban 

location, household wealth, education, achievement of desired family size, and current fertility 

desires (Winfrey and Rakesh 2014). Their result also showed that in most of the countries 

postpartum contraceptive use was not strongly related to women’s age, parity, and whether the last 

birth was wanted. Wamala, Kabagenyi, and Kasasa (2017), using data from the 2011 Uganda DHS 

survey, analyzed time-to-contraceptive use after resumption of sexual intercourse after last 

childbirth among Uganda’s married women, and found that women with no formal education, 

women who gave birth at home or with traditional attendants, and women in the lowest wealth 

quintile took a significantly longer time after childbirth to begin use of modern contraceptives. 

Male migration to foreign countries for earning has become more common in Nepal. About onethird of currently married women of reproductive age in Nepal reported their husbands staying 

away from home at the time of the 2011 NDHS (MOHP, New Era, and ICF International 2012). 

Spousal separation due to a husband’s migration in Nepal has influenced contraceptive use (Khanal 

et al. 2013; Kafle 2016). Husband’s presence or absence in the specified postpartum period could 

have a direct influence on use of a modern family planning method. 

Behavioral scientists argue that the adoption of a new behavior is a process that involves passage 

through a sequence of behavioral changes that begins with awareness, extends through 

accumulation of knowledge, and ends in behavioral consolidation. Emphasizing hierarchical 

behavioral models, McGuire (1981) urged that the consolidation of one behavior may facilitate 

more rapid adoption of a similar behavior. Therefore, a woman going for maternal health care 
4 

services may be more likely to learn about and adopt family planning. Such a behavioral model 

helps to analyze the connection between adoption of maternal health care services and timely 

adoption of family planning services. 

Many of the past studies mentioned above have taken the 3components of maternal health service 

in isolation instead of as a single set. Considering these 3 sequential components of maternal health 

together as a continuum of care envisions the length of women’s exposure to health providers 

during their service uptake. A continuous service uptake in all the stages of maternity means that 

women have a longer exposure to health care, which might be associated with an easier and quicker 

behavioral change in terms of subsequent family planning use. Therefore, this study considers that 

a continuous use of maternal health service can play a crucial role in using family planning 

postpartum within a year of childbirth. A detailed study of this kind is expected to fill the literature 

gap in the Nepalese context. Therefore, a study on determining the role of maternal health care 

service uptake in postpartum family planning use is considered imperative for developing 

countries like Nepal. 

The study was guided by a conceptual framework, presented in Figure 1, which represents the 

relationship among the study variables. The main outcome variable is use of postpartum family 

planning, and the main explanatory factor is use of a continuum of maternal health services. 

Socioeconomic, demographic, and regional factors may influence the extent to which women 

receive messages in the media related to family planning. These variables, selected on the basis of 

empirical research, also play critical roles in continuous delivery of maternal health care services. 

We hypothesize that the continuous uptake of maternal care plays an important role in a woman’s 

adoption of family planning within a year after her child’s birth. The direct influence of continuous 

uptake of maternal health service use, after controlling for socioeconomic, demographic, and other 

regional factors, cannot be ignored in postpartum family planning use.
5 

Figure 1. Conceptual framework for the study 

Postpartum family 

planning 

Demographic and 

regional factors 

• Geographic region 

• Husband’s 

residential status 

• Age at child’s birth 

• Parity 

• Number of sons 

• Need of next child

Maternal 

health care 

• ANC 

• Delivery 

at health 

facility 

• PNC

Socioeconomic factors 

• Education 

• Occupation 

• Household 

economic condition 

• Type of place of 

residence 

Program-related 

factors 

• Exposure to FP 

messages in media 

7 

2. Research Objectives and Questions 

2.1 Objectives 

The objectives of this study were to: 

1. Determine the proportion of women initiating use of modern contraception within 12 

months after childbirth; 

2. Analyze the differentials in the use of modern contraception within 12 months of childbirth 

by selected socioeconomic and demographic factors; 

3. Examine the role of receiving maternal health care services in initiating the use of modern 

contraception within 12 months after childbirth. 

2.2 Research Question 

In short, this research tried to answer the following question:

Is women’s initiation of modern contraceptive use within 12 months of childbirth associated 

with their use of maternal health care services even after controlling for other factors? 

9 

3. Data and Methods 

3.1 Data and sample 

The study used data from the 2011 Nepal Demographic and Health Survey (NDHS). The 2011 

NDHS was a nationally representative survey conducted for the fourth round in Nepal as part of 

The DHS Program. It was carried out under the aegis of the Ministry of Health and Population 

under the technical assistance of ICF and funded by the United States Agency for International 

Development (USAID). 

The 2011 NDHS used a 2-stage sampling design and interviewed 12,674 women age 15-49 and 

4,121 men age 15-49 from 10,826 sampled households. This analysis used only the information 

from Woman’s questionnaire. 

The dataset contained calendar information on the use of family planning methods for the 5 years 

before the survey month. Information on uptake of maternal health care services (ANC, delivery 

at a health facility, and PNC) was also collected for the most recent child born to a woman in the 

5 years before the survey. This analysis was restricted to women who had at least one live birth 

during the 5 years before the survey. The analysis pertained to the most recent birth in this 

reference period. Applying these selection criteria, the final study sample was 4,148 women age 

15-49. 

3.2 Key variables and measurements 

The outcome variable for the present study was the use of postpartum family planning (PPFP). 

This was defined as the use of any modern method—pill, IUD, injection, implant, condom (male 

or female), diaphragm, foam/jelly, and sterilization (male or female)—in the first 12 months 

following the most recent childbirth1

. Women with their last child under age 12 months were also 

included in analysis. PPFP was measured as a dichotomous variable, coded “1” for use of any 

modern method of family planning within 12 months following the childbirth, and “0” otherwise. 

The outcome variable was constructed from the calendar data collected in the survey. The DHS 

calendar records month-by-month information about each woman’s experiences with childbearing 

and contraceptive use for a period of 5-6 years preceding the date of interview. Based on 

information provided by the woman about the date of her most recent birth and start date of using 

a modern method, duration in months was obtained from the last birth to the initiation of modern 

contraceptive method use. This duration was modeled in the survival analysis. 

 

1

Lactational amenorrhea method (LAM) was not included in the modern methods studied because this 

method is advised only for use during the 6 months following childbirth. Actually, no women reported use 

of LAM during the period of interest. 
10 

The explanatory variable of interest was women’s use of maternal health care services. Information 

on ANC, place of delivery, and PNC for the most recent birth was used to construct a variable 

representing the continuum of maternal health care. First, the number of ANC visits was 

dichotomized as “0” for less than 4 visits, and “1” for at least four visits. Similarly, place of 

delivery was coded as “1” for institutional delivery, and “0” otherwise, and PNC was coded “1” if 

the woman had received PNC services within 6 weeks following childbirth, and “0” otherwise. 

The three variables were then used to generate the following eight categories of women using 

various combinations of the three services: none of the services; ANC only; facility delivery only; 

PNC only; ANC and facility delivery only; ANC and PNC only; facility delivery and PNC only, 

and all three services. Women who used all three components of maternal health care were 

categorized as “continuous service received.” Each woman in this category sequentially used all 

three kinds of maternal health services, as recommended and provided by the government. All 

women who used any one or two of the three components of maternal health services, but not all 

three, were treated as a separate category in the analysis. These were the women who encountered 

some kind of discontinuation somewhere in the process of obtaining all three maternal care 

services. This category therefore was termed “discontinuous service received.” All remaining 

women were categorized as “no service received.” 

A number of socioeconomic and demographic variables were controlled for in the multivariate 

analysis examining the association between the key explanatory factor (use of maternal health 

services) and outcome variable (postpartum modern contraceptive use). Women’s education, 

occupation, household economic condition, type of place of residence, geographical region of 

residence, and exposure to family planning messages in the mass media were socioeconomic 

factors considered for analysis. Choice of these variables was made based on the existing empirical 

literature, as discussed earlier. 

A variable representing husband’s presence or absence during the reference period was considered 

for analysis. The data file for women contained a variable on husband’s absence at the time of 

survey. This variable was not sufficient to capture husband’s presence or absence during the 

specified postpartum period. Therefore, a variable on husband’s absence during the 12 months 

after birth was computed based on the age of last child and the duration of husband’s absence at 

the time of the interview. 

Women’s age at the time of the index child’s birth, their parity, and fertility preferences were also 

considered as demographic factors for analysis. Higher preference for sons versus daughters is a 

cultural phenomenon in Nepal that has some influence on family planning use (Leone, Matthews, 

and Zuanna 2003). Therefore, women’s number of living sons was also considered in the analysis. 

Table 1 provides the details of the study variables. 

 
11 

Table 1. List of variables included in the analysis with their categories 

Variables Categories and coding 

Postpartum family planning use (PPFP) Used a modern method in 12 months after the most recent birth (1); 

otherwise (0) 

Time to start PPFP use Number of months after last childbirth 

Maternal health care services No service received; discontinuous service received (received only 1 

or 2 services); continuous service received (received all 3 services) 

Place of residence Urban; rural 

Geographical region Mountain; Hill; Tarai 

Women’s education No education; up to primary (up to grade 8); secondary and above 

(higher than grade 8) 

Women’s occupation Not working; agriculture; non-agriculture 

Household wealth quintile Lowest; second; middle; fourth; highest 

Exposure to family planning messages in 

mass media (radio, television and 

newspaper in recent months) 

Not exposed (exposed to no type of media); exposed (exposed to at 

least one of the media) 

Husband’s presence during the reference 

period 

Present; absent 

Maternal age at the last childbirth Under age 20; 20-34; 35 and above 

Parity 1; 2; 3+ 

Number of sons No son (0); at least one son (1+) 

Fertility preference Want next child soon; want later; want no more 

3.3 Analytical methods 

Data analysis was performed with STATA 14 software. Individual women’s sample weight was 

applied to take into account the differences in probability of selection and nonresponse. The effect 

of complex survey design that was followed in Nepal DHS was accounted for by applying the svy

command. We described women’s use of maternal health services and distribution of the study 

sample for the selected study variables. The cumulative proportion of women starting a modern 

family planning method over time was also obtained. 

The main outcome of interest was whether a woman started using a modern family planning 

method within 12 months following childbirth and after how many months she started to do so. 

Therefore, survival analysis was considered appropriate. For this, the “event” (failure) was use of 

postpartum family planning and the “duration” was the number of months after childbirth at which 

the woman started using contraception. The duration variable was measured up to 12 months 

(follow-up period), and all women who did not start using contraception within 12 months were 

considered to be survivors and were not followed up, so it is not known if they used any modern 

method subsequently. Those women who had their last child less than 12 months earlier and had 

not started using a modern family planning method by the time of the survey were considered to 

be censored cases. Survival probabilities were presented as Kaplan-Meier (K-M) survival function; 

K-M curves for different categories of maternal health care service utilization and other selected 

variables were computed. The differences in the survival curves for different categories of each 

study variable were examined by applying the Log-Rank test. Finally, Cox regression was used to 

examine the unadjusted effect of each of the variables and the adjusted effect of use of maternal 

health care services on postpartum modern contraceptive use after controlling for selected 
12 

socioeconomic and demographic factors. Because the aim of this paper was to examine the 

association between maternal health care service uptake and postpartum modern contraceptive use 

after controlling for selected socioeconomic and demographic factors, all the variables selected for 

study were included in the regression rather than a specific model fitting to establish a significant 

association. However, a pair-wise correlation matrix was examined to detect possible 

multicollinearity; none of the pairs showed correlation greater than 0.6. 

3.4 Data limitations 

General limitations that are applicable for cross-sectional survey data, especially the issues of 

recall lapses in retrospective data collection and inability to establish a cause-and-effect 

relationship, are also applicable to this study. The possibility of recall bias in the retrospectively 

collected calendar data cannot be ruled out. Methodological analysis has shown that the DHS 

calendar does not completely capture episodes of contraceptive use, and calendar data appear to 

underestimate episodes of contraceptive use (Bradley, Winfrey, and Croft 2015). However, use of 

calendar methods to collect data on contraceptive use in large-scale retrospective surveys has 

become standard practice (Callahan and Becker 2012), and reporting of contraceptive histories in 

calendar form has been found superior to other standard forms (Goldman, Moreno, and Westoff 

1989). 

Moreover, some of the variables used in analysis pertain to the status of respondents at the time of 

the survey rather than to the reference period of study. For instance, education of women 

corresponds to the survey date. It was found that less than 6% of the women had the index birth 

before age 18. Therefore, it would be reasonably safe to assume that the current educational 

distribution of women was almost similar to that at the time their last children were born, at least 

for women with no education or only a primary education. Some changes in the educational level 

of women who had attained a higher level of education at the time of survey could be possible, but 

such detailed information was not gathered in the dataset. Because there was no information on 

the exposure of women to family planning messages through mass media (radio, television, and 

newspaper) during the reference period of study, the same information for the survey date with a 

reference period of a few months before the survey was used as a proxy. Rather than using common 

variables of media exposure, it was considered better to use exposure to family planning messages 

in the media. 
13 

4. Results 

4.1 Background characteristics of respondents 

Table 2 presents the percent distribution of the sample according to selected socioeconomic and 

demographic characteristics. The women under study were predominantly from rural areas (90%), 

and about half lived in the Tarai region (52%). Nearly half (45%) of the women were uneducated, 

and 58% worked in an agricultural occupation. The distribution of women by household wealth 

quintile shows that the highest proportion (24%) were in the lowest wealth quintile, and the lowest 

proportion (16%) were in the highest wealth quintile. About 60% of women were recently exposed 

to family planning messages in the mass media. Among the survey respondents, 14% stated that 

their husbands were absent from home during the first 12 months following the last childbirth. 

About three-quarters of the women were age 20-34 when they gave birth to their last child within 

5 years before the survey, while 18% were under age 20. Forty-one percent of women were of 

third or higher parity, and around one-third (32%) were of first parity at the last birth. Nearly threequarters of women had at least one son at the time of their last birth. Regarding fertility preferences, 

nearly 7 in every10 women stated that they wanted no more children. Some 8% of women wanted 

another child within 2 years, whereas 24% wanted another child later. 

 
14 

Table 2. Percent distribution of women whose last birth was 

within the 5 years before the survey, by selected background 

characteristics, Nepal DHS 2011 

Background 

characteristics Percentage Number 

Place of residence 

Urban 10.1 418 

Rural 89.9 3730 

Geographical region 

Mountain 7.4 306 

Hill 40.2 1668 

Tarai 52.4 2174 

Women’s education 

No education 45.0 1869 

Up to primary 33.5 1388 

Secondary and above 21.5 891 

Women’s occupation 

Not working 27.7 1150 

Agriculture 58.2 2415 

Non-agriculture 14.1 583 

Household wealth quintile

Lowest 23.6 979 

Second 21.7 899 

Middle 21.0 873 

Fourth 18.0 748 

Highest 15.7 649 

Exposure to FP message in 

mass media 

Not exposed 42.4 1757 

Exposed 57.6 2391 

Husband’s presence*

Present 86.3 3546 

Absent 13.7 561 

Maternal age at last childbirth 

Less than 20 17.8 739 

20-34 74.4 3085 

35 and above 7.8 324 

Parity 

1 31.4 1302 

2 28.0 1162 

3+ 40.6 1684 

Number of living sons 

0 26.4 1097 

1+ 73.6 3051 

Fertility preference 

Want soon 6.9 285 

Want later 24.1 1001 

Want no more 69.0 2862 

All 100.0 4148 

* Husband’s presence was calculated only for currently married women at 

the time of survey (n=4107). 
15 

4.2 Use of Maternal Health Care Services 

Figure 2 shows use of maternal health care in terms of the number of ANC, facility delivery, and 

PNC services received. More than one-third (37%) of women received none of the three services. 

Similarly, 37% of women used only one or two of the services. About one-fourth (27%) of women 

used all three components of maternal health care at the last childbirth. With respect to the 

continuity of services, discontinuity in use of the three services substantially prevails. For example, 

16% of women had only ANC, 5% had only ANC and PNC, and 8% had only facility delivery and 

PNC. 

Figure 2. Maternal health care received for the most recent birth 

4.3 Results from survivor analysis 

Table 3 shows how women start using a modern method of family planning following childbirth. 

Declining survivor probabilities over the time indicate an upward trend in modern contraceptive 

use after childbirth. Figure 3 depicts the proportion of modern contraceptive users over time based 

on the reproductive calendar data. Seven percent of women had started using modern 

contraceptives by the end of the second month after childbirth. The proportion of users shows a 

gradual increase in the level of modern contraceptive use over the months, reaching 23% after 6 

months, 30% after 9 months, and 37% after 12 months. 

 

36.63

26.74

16.07

1.84

3.81

2.3

4.99

7.63

0

5

10

15

20

25

30

35

40

No service received Discontinuous service

received

Continuous service

received

Only FD and PNC

Only ANC and PNC

Only ANC and FD

Only PNC

Only FD

Only ANC

Continuous service

received

No service received
16 

Table 3. Survivor function of postpartum family planning use within 12 months 

from the time of childbirth for women who had given birth in the 5 years 

preceding the survey 

Beginning 

time 

(months)

Total 

number of 

exposure

Failure 

(due to 

FP use)

Lost 

(due to 

censoring)

Survivor 

function*

Standard 

error

95% confidence 

interval

1 4079 127 45 0.9689 0.0027 [0.9631, 0.9738] 

2 3907 158 82 0.9297 0.0040 [0.9214, 0.9371] 

3 3667 175 85 0.8853 0.0050 [0.8750, 0.8948] 

4 3407 175 90 0.8398 0.0058 [0.8280, 0.8509] 

5 3142 135 75 0.8038 0.0064 [0.7910, 0.8159] 

6 2932 122 78 0.7703 0.0068 [0.7567, 0.7833] 

7 2732 122 67 0.7359 0.0072 [0.7216, 0.7496] 

8 2543 69 65 0.7159 0.0074 [0.7013, 0.7301] 

9 2409 74 78 0.6940 0.0076 [0.6789, 0.7085] 

10 2257 73 62 0.6715 0.0078 [0.6561, 0.6864] 

11 2122 63 58 0.6516 0.0079 [0.6358, 0.6668] 

12 2001 75 1926 0.6272 0.0081 [0.6110, 0.6428] 

* This gives the proportion not using PPFP till the corresponding month of follow up. 

Figure 3. Cumulative proportion of women who started using any modern method of

family planning by duration from last childbirth, Nepal 2011 

Figure 4 presents salient features of the differences in the Kaplan-Meier survival curves by 

maternal health care service uptake and other selected characteristics. It is evident that the survival 

curves are substantially different for women who used none of the three maternal health services, 

used only one or two of the services, or used all three components of services continuously. 

Similarly, the Kaplan-Meier survival curves differ for various educational categories of women, 

their occupations, and their husband’s residential status during the reference period. For example, 

a vast difference between the ultimate proportions of survivors is evidenced by husband’s 

residential status, indicating a very low ultimate proportion of modern contraceptive use among 

0.03 0.07

0.11

0.16 0.20 0.23 0.26 0.28 0.31 0.33 0.35 0.37

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5 6 7 8 9 10 11 12

Cumulative proportion of users

Duration (months)
17 

women with their husbands absent compared with those living with their husbands during the 12 

months following the last childbirth. 

Figure 4. Kaplan-Meier survival curves of postpartum family planning use within 12

months from childbirth by selected characteristics of women, Nepal 2011 

(a) Kaplan-Meier survival curves by maternal health care service utilization

0.00

0.25

0.50

0.75

1.00

0 5 10 15

Duration (months)

 = No service taken = Discontinuously service taken

 = Continuously services taken
18 

(b) Kaplan-Meier survival curves by women’s education

(c) Kaplan-Meier survival curves by women’s occupation 

0.00

0.25

0.50

0.75

1.00

0 5 10 15

Duration (months)

 = No Education = Primary Level = Secondary and Above

0.00

0.25

0.50

0.75

1.00

0 5 10 15

Analysis time

 = Not Working = Agriculture = Non-agriculture
19 

(d) Kaplan-Meier survival curves by husband’s residential status 

Moreover, the Log-Rank test was performed to examine the significance of the differences among 

the survival curves for various categories of each of the background characteristics and use of the 

maternal health services. Table 4 summarizes the results. Except for parity and the number of 

living sons, survival functions for family planning use postpartum are significantly different for 

various categories of all other selected characteristics. 

Table 4. Results of Log-Rank test for equality of survivor 

functions of postpartum family planning use for selected 

background characteristics, Nepal 2011 (using nonparametric test) 

Background 

characteristics Chi square p-value 

Maternal health care service 84.3 p<0.001 

Place of residence 46.2 p<0.001 

Geographical region 23.9 p<0.001 

Women’s education 59.0 p<0.001 

Women’s occupation 87.3 p<0.001 

Household wealth quintile 123.9 p<0.001 

Exposure to FP message in mass media 48.4 P<0.001 

Husband’s presence 94.9 p<0.001 

Maternal age at last childbirth 20.4 p<0.001 

Parity 3.7 P=0.157 

Number of living sons 1.9 p=0.170 

Fertility preference 20.8 p<0.001 
20 

4.4 Results of multivariate analysis 

Table 5 presents the unadjusted and adjusted hazard ratios of postpartum family planning use. A 

significant positive association between maternal health care service uptake and postpartum family 

planning use was observed without controlling for other factors. Similarly, women’s urban 

residence, being more educated, working in the non-agricultural sector, better household economic 

condition, exposure to family planning messages in the mass media, less preference for having 

another child, lower age at last childbirth, and husband’s presence were associated with 

significantly higher relative risk of postpartum contraceptive use, when these factors were 

examined one by one. Geographical region of residence, women’s parity, and number of sons were 

not significant associated with postpartum family planning use. 

The use of maternal health care services remained a significant predictor of the risk of using family 

planning postpartum after controlling for other socioeconomic and demographic factors. 

Compared with women who used none of the three maternal health services, women who used any 

of the services had a significantly higher likelihood of postpartum contraceptive use. When women 

received all three components of maternal health care continuously, their risk of using a modern 

method of family planning significantly increased by 1.36 times (p<0.01) compared with women 

who did not use any maternal health services. Moreover, the risk of starting family planning in the 

postpartum period were significantly higher (HR= 1.27, p<0.01) for women who received any kind 

of discontinuous maternal health service. However, comparison of the unadjusted and adjusted 

hazard ratios indicated that the strength of association between maternal health care service uptake 

and postpartum contraceptive use was reduced to some extent by other explanatory variables. 

 
21 

Table 5. Unadjusted and adjusted hazard ratios for postpartum family planning use for 

selected background characteristics of women, Nepal 2011 

Background 

characteristics 

Unadjusted 

hazard ratios 95% CI 

Adjusted 

hazard ratios 95% CI 

Maternal health care services 

No service received 1 1 

Discontinuous service received 1.45*** [1.21,1.75] 1.27** [1.07,1.52] 

Continuous service received 1.77*** [1.47, 2.13] 1.36** [1.10, 1.67] 

Place of residence 

Urban 1 1 

Rural 0.64*** [0.54, 0.76] 0.87 [0.72, 1.05] 

Geographical region 

Mountain 1 1 

Hill 0.98 [0.79, 1.21] 0.87 [0.70, 1.05] 

Tarai 1.17 [0.93, 1.46] 1 [0.80, 1.23] 

Women’s education 

No education 1 1 

Up to primary 1.25** [1.06, 1.47] 1.01 [0.85, 1.20] 

Secondary and above 1.60*** [1.32, 1.95] 0.97 [0.74, 1.27] 

Women’s occupation 

Not working 1 1 

Agriculture 0.97 [0.78, 1.19] 1.28* [1.03, 1.58] 

Non-agriculture 1.79*** [1.43, 2.23] 1.57*** [1.26, 1.97] 

Household wealth quintile 

Lowest 1 1 

Second 1.23 [0.98, 1.54] 1.14 [0.90, 1.40] 

Middle 1.44** [1.14, 1.82] 1.37** [1.11, 1.70] 

Fourth 1.75*** [1.39, 2.20] 1.54** [1.17, 2.04] 

Highest 2.28*** [1.81, 2.86] 1.66** [1.18, 2.34] 

Exposure to FP message in 

mass media 

Not exposed 1 1 

Exposed 1.52*** [1.28, 1.79] 1.22* [1.02, 1.46] 

Husband’s presence1 

Present 1 1 

Absent 0.29*** [0.21, 0.40] 0.30*** [0.22, 0.42] 

Maternal age at last childbirth 

Less than 20 1 1 

20-34 1.12 [0.94, 1.34] 1 [0.81, 1.22] 

35 and above 0.57*** [0.42, 0.76] 0.54** [0.38, 0.76] 

Parity 

1 1 1 

2 1.04 [0.87, 1.25] 0.96 [0.80, 1.15] 

3+ 0.95 [0.82, 1.11] 1.1 [0.90, 1.36] 

Number of living sons 

0 1 1 

1+ 1.1 [0.93, 1.29] 1.15 [0.97, 1.35] 

Fertility preference 

Want soon 1 1 

Want later 1.3 [0.89, 1.90] 1.38 [0.94, 2.01] 

Want no more 1.66* [1.12, 2.46] 1.66* [1.12, 2.44] 

Number of cases 4148 4107 

***p<0.001; **p<0.01; *p<0.05 

1 For unadjusted model, husband presence refers to only currently married women at the time of survey 

(N=4107). 
22 

In the multivariate model, when all the factors were included in analysis and the results were 

compared with those of bivariate models, place of residence and women’s education did not remain 

significant in the risk of postpartum family planning use. However, after controlling for other 

factors, a significantly higher relative likelihood of postpartum contraceptive use was observed 

among women working in the non-agricultural sector (HR=1.57, p<0.001) compared with nonworking women, women exposed to the mass media (HR=1.22, p<0.05) compared with women 

unexposed, and women in the middle (HR=1.37, p<0.01), fourth (HR=1.54, p<0.01), or highest 

(HR=1.66, p<0.01) wealth index quintiles compared with those in the lowest quintile. 

Husband’s absence during the postpartum period was significantly associated with much lower 

relative risk of postpartum contraceptive use (HR=0.30, p<0.001 for women whose husbands were 

absent during the reference period compared with those who lived with their husbands). Its strength 

remained almost the same in bivariate and multivariate models, indicating its consistently high 

importance to explaining variation in the likelihood of using family planning postpartum. Higher 

maternal age at last childbirth was associated with reduced risk of using contraception postpartum. 

Compared with women under age 20 at the time of the last childbirth, women age 35 or older had 

a 44% lower risk of family planning use in the postpartum period. Similarly, women had a 

significantly greater hazard of postpartum contraceptive use if they did not intend to have another 

child (HR 1.66, p<0.05 for women who want no more children compared with those who want 

another child soon). 
23 

5. Discussion 

The present study was designed to examine the association between maternal health care service 

uptake and postpartum family planning use in the Nepalese context. Some studies have taken the 

three major components of maternal health care services—ANC, delivery at a health facility, and 

PNC—separately to assess the association of receiving maternal health care with using 

contraception postpartum, while others have considered only ANC and delivery services. The 

present study considered all the three services together and considered maternal health service as 

a continuum. 

The government of Nepal has a program that provides all three services at no cost to users if a 

woman takes all 3 services as a continuum of maternal care. The national planning commission of 

Nepal has targeted 203 as the date by which 90% of women should receive all three maternal 

health services (NPC 2015). 

The study results showed a significant association of postpartum family planning use with maternal 

health service uptake after controlling for various socioeconomic and demographic factors. This 

finding is in line with other studies (Akinlo, Bisiriyu, and Esimai 2013; Wamala, Kabagenyi, and 

Kasasa 2017). In a study in Uttar Pradesh, India, Yadav and Dhillon (2015) showed that use of 

ANC, institutional delivery, and postnatal care services encouraged subsequent contraceptive use. 

The study presented several important determinants of postpartum family planning use within 12 

months of the last childbirth. Women’s non-agricultural occupation, higher household wealth, 

exposure to family planning messages in the media, and preference for not having another child 

are some of the important factors associated with higher chances of using contraception within 12 

months of the last childbirth. These findings are consistent with those of other studies 

(Gebreselassie, Retstein, and Mishra 2008; Do and Hotchkiss 2011; Akinlo, Bisiriyu, and Esimai 

2013). 

In the Nepalese context, a husband’s absence during the specified postpartum period is one of the 

most important determinants of non-use of contraception postpartum and is a special phenomenon. 

It has consistent influence even after controlling for other socioeconomic and demographic factors. 

Perceived low risk of pregnancy due to infrequent sexual activity or none may be the reason for 

very low use of contraception among women with migrant husbands. This study finds that place 

of residence, women’s education, and parity do not show significant differences in adjusted 

relative risk of postpartum family planning use. This finding differs from those of Akinlo, Bisiriyu, 

and Esimai (2013) in Nigeria, where, apart from the wealth index and exposure to family planning 

messages, region of residence and women’s education are also significant predictors of the use of 

contraception in the postpartum period. 

25 

6. Conclusion and Policy Implications 

The study finds that an increase in use of a continuum of maternal health care services supports 

women in their use of modern family planning methods postpartum, within a year after childbirth. 

To maintain good reproductive health among Nepalese women, advocacy is essential to promote 

maternal health care services continuously, as soon as the pregnancy is noticed. Though these 

services are widely spread across the country, even at the grass roots level, current services should 

be convenient and ensure that all women can have access to and receive all three components of 

maternal health care service, instead of using them only when they feel the necessity. Ensuring 

that all women receive a continuum of maternal health care promotes family planning use, thus 

improving their own health and that of their children. 

Though maternal health and family planning services are available at no cost to users through the 

government program in Nepal, many opportunities are missed for counseling and services related 

to family planning. An almost stagnant level of family planning use and a high level of unmet need 

for family planning are evidence of this (MOHP, New Era, and ICF International 2012). Moreover, 

there is difficulty accessing services in rural and remote areas of the country. The prime focus of 

postnatal care in Nepal is to provide postpartum family planning counseling (DOHS 2014). 

However, only 9% women who had a live birth in the 5 years preceding the survey stated that they 

received counseling during their postnatal check-up, indicating many missed opportunities to 

impart information on family planning methods and services (MOHP, New Era, and ICF 

International 2012). 

Nepal, as a signatory to the Sustainable Development Goals (SDGs), should consider this situation 

while drafting policies and implementing programs. The findings of this study reinforce the need 

for information and counseling for continuous maternal health care service uptake from the 

beginning of pregnancy through the postpartum period. This is required for the country to help 

women remain in contact with health personnel, thus ensuring their reproductive health. 

Enhancement of this activity may support the aim of government to raise the level of use of 

maternal health care services—ANC, facility delivery, and PNC—to 90% by2030 (NPC 2015). 

Therefore, it is also vital to consider the importance of the continuum of maternal health care 

services and to establish a responsible institution for monitoring the program during the process 

of state restructuring and power devolution in the newly established federal structure in Nepal. 

27 

References 

Ahmed, S., and W. H. Mosley. 2002. “Simultaneity in the Use of Maternal Child Health Care and 

Contraceptives: Evidence from Developing Countries.” Demography 39(1): 75-93. 

Akinlo, A., A. Bisiriyu, and O. Esimai. 2013. “Influence of Use of Maternal Health Care on 

Postpartum Contraception in Nigeria.” DHS Working Paper Series No. 92. Calverton, 

Maryland, USA: ICF International. 

Bradley, S. E. K., W. Winfrey, and T. N. Croft. 2015. “Contraceptive Use and Perinatal Mortality 

in the DHS: An Assessment of the Quality and Consistency of Calendars and Histories.” 

DHS Methodological Reports No. 17. Rockville, Maryland, USA: ICF International. 

Callahan, R. L., and S. Becker. 2012. “The Reliability of Calendar Data for Reporting 

Contraceptive Use: Evidence from Rural Bangladesh.” Studies in Family Planning. 43(3): 

213–222. 

Department of Health Services [DOHS]. 2014. “Annual Report (2012/13).” Kathmandu: 

Department of Health Services, Family Health Division, Ministry of Health and 

Population. 

Department of Health Services [DOHS]. 2009. “Operational Guidelines on Safe Motherhood 

Programme 2009 [2066].” Kathmandu: Department of Health Services, Family Health 

Division, Ministry of Health and Population. 

Department of Health Services [DOHS]. 2005. “Operational Guidelines on Incentives for Safe 

Delivery Services 2005 [2062].” Kathmandu: Department of Health Services, Family 

Health Division, Ministry of Health and Population. 

Do, M., and D. Hotchkiss. 2011. “Relationships between Maternal Health Care and Postpartum 

Modern Contraceptive Use in Kenya and Zambia.” Working Paper. Chapel Hill, NC, USA: 

Carolina Population Center, University of North Carolina at Chapel Hill. 

Gebreselassie, T., S. O. Rutstein, and V. Mishra. 2008. “Contraceptive Use, Breastfeeding, 

Amenorrhea and Abstinence during the Postpartum Period: An Analysis of Four 

Countries.” DHS Analytical Studies No. 14. Calverton, MD, USA: Macro International 

Inc. 

Goldman, N., L. Moreno, and C. F. Westoff. 1989. “Collection of Survey Data on Contraception: 

An Evaluation of an Experiment in Peru.” Studies in Family Planning 20(3):147-57. 

Hotchkiss, D. R, J. J. Rous, E. E. Seiber, and A. A. Berruti. 2005. “Is Maternal and Child Health 

Services Use a Casual Gateway to Subsequent Contraceptive Use? A Multicountry Study.” 

Population Research and Policy Review 24(6):543-571. 

Hotchkiss, D. R., J. Magnani, J. J. Rous, M. Azelmat, T. A. Mroz, and J. Heikel. 1999. “The Effects 

of Maternal-Child Health Service Utilization on Subsequent Contraceptive Use in 

Morocco.” Journal of Biosocial Science 31(2): 145–165. 
28 

Khanal M. N., D. R. Shrestha, P. D. Panta, and S. Mehata. 2013. “Impact of Male Migration on 

Contraceptive Use, Unmet Need and Fertility in Nepal.” Further analysis of the 2011 Nepal 

Demographic and Health Survey. Calverton, Maryland, USA: Nepal Ministry of Health 

and Population, New ERA, and ICF International. 

Kafle, R. B. 2016. “Fertility Transition in a Low Income Country: The Case of Nepal.” Ph. D. 

Thesis, New Delhi: Jawaharlal Nehru University. 

Leone, T., Z. Matthews, and G. D. Zuanna. 2003. “Impact and Determinants of Sex Preference in 

Nepal.” International Family Planning Perspectives 29(2):69–75. 

McGuire, W. J. 1981. “The Theoretical Foundations of Campaigns in Rice.” In Public 

Communication Campaign, edited by W. and W. Paisley. pp: 41-70. Beverly Hills, CA: 

Sage Publications. 

Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. 

Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and 

Population, New ERA, and ICF International, Calverton, Maryland. 

Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc. 

2007. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Ministry of Health 

and Population, New ERA, and Macro International Inc. 

Ministry of Health [Nepal], New ERA, and ORC Macro. 2002. Nepal Demographic and Health 

Survey 2001. Calverton, Maryland, USA: Family Health Division, Ministry of Health; New 

ERA; and ORC Macro. 

National Planning Commission (NPC). 2015. “Sustainable Development Goals, 2016-2030, 

National (Preliminary) Report.” Kathmandu: National Planning Commission, Government 

of Nepal. 

National Planning Commission (NPC). 1965. “The Third Plan (1965-70).” Kathmandu, Nepal: 

National Planning Commission. 

Wamala, R., A. Kabagenyi, and S. Kasasa. 2017. “Predictors of Time-to-Contraceptive Use from 

Resumption of Sexual Intercourse after Birth among Women in Uganda.” International 

Journal of Population Studies 2017:1-12 . doi.org/10.1155/2017/3875452. 

Winfrey, W., and K. Rakesh. 2014. “Use of Family Planning in the Postpartum Period.” DHS 

Comparative Report No. 36. Rockville, Maryland, USA: ICF International. 

Yadav, D., and P. Dhillon. 2015. “Assessing the Impact of Family Planning Advice on Unmet 

Need and Contraceptive Use among Currently Married Women in Uttar Pradesh, India.” 

Plos One 10(3):e0118584. 

Yahaya, M. K. 2002. “Analysis of Women’s Reproductive Health Situation in Bida Emirate of 

Niger State, Nigeria.” African Journal of Reproductive Health 6(1): 50-64. 
29 

Zerai, A., and A. O. Tsui. 2001. “The Relationship between Prenatal and Subsequent Modern 

Contraceptive Use in Bolivia, Egypt and Thailand.” African Journal of Reproductive 

Health 5(2):68-82.