The 1996 Nepal Family Health Survey (NFHS) is a nationally representative survey of 8,429 ever- married women age 15-49. The survey is the fifth in a series of demographic and health surveys conducted in Nepal since 1976. The main purpose of the NFHS was to provide detailed information on fertility, family planning, infant and child mortality, and matemal and child health and nutrition. In addition, the NFHS included a series of questions on knowledge of AIDS.
The primary objective of the Nepal Family Health Survey (NFHS) is to provide national level estimates of fertility and child mortality. The survey also provides information on nuptiality, contraceptive knowledge and behaviour, the potential demand for contraception, other proximate determinants of fertility, family size preferences, utilization of antenatal services, breastfeeding and food supplementation practices, child nutrition and health, immunizations, and knowledge about Acquired Immune Deficiency Syndrome (AIDS). This information will assist policy-makers, administrators and researchers to assess and evaluate population and health programmes and strategies. The NFHS is comparable to Demographic and Health Surveys (DHS) conducted in other developing countries.
Survey results indicate that fertility in Nepal has declined steadily from over 6 births per woman in the mid-1970s to 4.6 births per woman during the period of 1994-1996. Differentials in fertility by place of residence are marked, with the total fertility rate (TFR) for urban Nepal (2.9 births per woman) about two children less than for rural Nepal (4.8 births per woman). The TFR in the Mountains (5.6 births per woman) is about one child higher than the TFR in the Hills and Terai (4.5 and 4.6 births per woman, respectively). By development region, the highest TFR is observed in the Mid-western region (5.5 births per woman) and the lowest TFR in the Eastern region (4.1 births per woman).
Fertility decline in Nepal has been influenced in part by a steady increase in age at marriage over the past 25 years. The median age at first marriage has risen from 15.5 years among women age 45-49 to 17.1 years among women age 20-24. This trend towards later marriage is supported by the fact that the proportion of women married by age 15 has declined from 41 percent among women age 45-49 to 14 percent among women age 15-19. There is a strong relationship between female education and age at marriage. The median age at first marriage for women with no formal education is 16 years, compared with 19.8 years for women with some secondary education.
Despite the trend towards later age at marriage, childbearing begins early for many Nepalese women. One in four women age 15-19 is already a mother or pregnant with her first child, with teenage childbearing more common among rural women (24 percent) than urban women (20 percent). Nearly one in three adolescent women residing in the Terai has begun childbearing, compared with one in five living in the Mountains and 17 percent living in the Hills. Regionally, the highest level of adolescent childbearing is observed in the Central development region while the lowest is found in the Western region.
Short birth intervals are also common in Nepal, with one in four births occurring within 24 months of a previous birth. This is partly due to the relatively short period of insusceptibility, which averages 14 months, during which women are not exposed to the risk of pregnancy either because they are amenorrhoeic or abstaining. By 12-13 months after a birth, mothers of the majority of births (57 percent) are susceptible to the risk of pregnancy. Early childbearing and short birth intervals remain a challenge to policy-makers. NFHS data show that children born to young mothers and those born after short birth intervals suffer higher rates of morbidity and mortality.
Despite the decline in fertility, Nepalese women continue to have more children than they consider ideal. At current fertility levels, the average woman in Nepal is having almost 60 percent more births than she wants--the total wanted fertility rate is 2.9 births per woman, compared with the actual total fertility rate of 4.6 births per woman. Unplanned and unwanted births are often associated with increased mortality risks. More than half(56 percent) of all births in the five-year period before the survey had an increased risk of dying because
the mother was too young (under 18 years) or too old (more than 34 years), or the birth was of order 3 or higher, or the birth occurred within 24 months of a previous birth.
Nevertheless, the percentage of women who want to stop childbearing in Nepal has increased substantially, from 40 percent in 1981 to 52 percent in 1991 and to 59 percent in 1996. According to the NFHS, 41 percent of currently married women age 15-49 say they do not want any more children, and an additional 18 percent have been sterilized. Furthermore, 21 percent of married women want to wait at least two years for their next child and only 13 percent want to have a child soon, that is, within two years.
Knowledge of family planning is virtually universal in Nepal, with 98 percent of currently married women having heard of at least one method of family planning. This is a five-fold increase over the last two decades (1976-1996). Much of this knowledge comes from media exposure. Fifty-three percent of ever-married women had been exposed to family planning messages on the radio and/or the television and 23 percent have been exposed to messages through the print media. In addition, about one in four women has heard at least one of three specific family planning programmes on the radio.
There has been a steady increase in the level of ever use of modern contraceptive method over the past 20 years, from 4 percent of currently married women in 1976, to 27 percent in 1991 and 35 percent in 1996. Among ever-users, female sterilization and male sterilization are the most popular methods (37 percent), indicating that contraceptive methods have been used more for limiting than for spacing births.
The contraceptive prevalence rate among currently married women is 29 percent, with the majority of women using modern methods (26 percent). Again, the most widely used method is sterilization (18 percent, male and female combined), followed by injectables (5 percent). Although current use of modern contraceptive methods has risen steadily over the last two decades, the pace of change has been slowest in the most recent years (1991-1996). Current use among currently married non-pregnant women increased from 3 percent in 1976 to 15 percent in 1986 to 24 percent in 1991 and to 29 percent in 1996. While female sterilization increased by only 3 percent from 45 percent of modern methods in 1986 to 46 percent in 1996, male sterilization declined by almost 50 percent from 41 percent to 21 percent over the same period.
The level of current use is nearly twice as high in the urban areas (50 percent) as in rural areas (27 percent). Only 18 percent of currently married women residing in the Mountains are currently using contraception, compared with 30 percent and 29 percent living in the Hills and Terai regions, respectively. There is a notable difference in current contraceptive use between the Far-western region (21 percent) and all the other regions, especially the Central and Eastern regions (31 percent each). Educational differences in current use are large, with 26 percent of women with no education currently using contraception, compared with 52 percent of women who have completed their School Leaving Certificate (SLC). In general, as women's level of education rises, they are more likely to use modem spacing methods.
The public sector figures prominently as a source of modem contraceptives. Seventy-nine percent of modem method users obtained their methods from a public source, especially hospitals and district clinics (32 percent) and mobile camps (28 percent). The public sector is the predominant source of sterilizations, 1UDs, injectables, and Norplant, and both the public and private sectors are equally important sources of the pill and condoms. Nevertheless, the public sector's share of the market has fallen over the last five years from 93 percent of current users in 1991 to 79 percent in 1996.
There is considerable potential for increased family planning use in Nepal. Overall, one in three women has an unmet need for family planning--14 percent for spacing and 17 percent for limiting. The total demand for family planning, including those women who are currently using contraception, is 60 percent. Currently, the family planning needs of only one in two women is being met. While the increase in unmet need between 1991 (28 percent) and 1996 (31 percent) was small, there was a 14 percent increase in the percentage of women using any method of family planning and, over the same period, a corresponding increase of 18 percent in the demand for family planning.
MATERNAL AND CHILD HEALTH
At current mortality levels, one of every 8 children born in Nepal will die before the fifth birthday, with two of three deaths occurring during the first year of life. Nevertheless, NFHS data show that mortality levels have been declining rapidly in Nepal since the eighties. Under-five mortality in the period 0-4 years before the survey is 40 percent lower than it was 10-14 years before the survey, with child mortality declining faster (45 percent) than infant mortality (38 percent).
Mortality is consistently lower in urban than in rural areas, with children in the Mountains faring much worse than children living in the Hills and Terai. Mortality is also far worse in the Far-western and Mid-western development regions than in the other regions. Maternal education is strongly related to mortality, and children of highly educated mothers are least likely to die young. For example, infant mortality is nearly twice as high among children of mothers with no education as among children of mothers with some secondary education.
Neonatal mortality is expectedly higher among males than females. However, child mortality is 24 percent higher among females than males. First births, higher order births and births spaced less than 24 months apart also experience higher mortality.
Perinatal mortality in Nepal has declined by 17 percent over the last 15 years from 63 deaths per 1,000 stillbirths and live births in the period 10-14 years before the survey to 52 deaths in the period 0-4 years before the survey. First pregnancies, high order pregnancies, pregnancies to women residing in rural areas, in the Terai, and in the Eastern region, are all at an increased risk of loss.
One possible reason for the declining mortality is improvements in childhood vaccination coverage. The NFHS results show that about 76 percent of children age 12-23 months have been vaccinated against tuberculosis, DPT and polio. However, coverage declines after the first dose for DPT and polio, with one-third of children who start the series not completing it. Fifty-seven percent of children age 12-23 months were vaccinated against measles. Overall, two of five children had all the recommended vaccinations, and 36 percent were fully vaccinated before their first birthday.
Diarrhoeal and respiratory illnesses are common causes of child deaths in Nepal. In the two weeks before the survey, 28 percent of children suffered from diarrhoea and 34 percent were ill with acute respiratory infections (AR1). However, use of health facilities is low in Nepal: only 14 percent of children with diarrhoea and 18 percent of children with ARI were taken to a health facility. Solution prepared from oral rehydration salts (ORS) was given to 26 percent of children with diarrhoea, and 4 percent received recommended home fluids (RHF). In addition, 35 percent of children with diarrhoea were given more to drink than before the diarrhoea. Over one-third of children with diarrhoea received no treatment at all.
The care that a woman receives daring pregnancy and childbirth reduces the risk of illness and death for both mother and child. The NFHS data show that mothers received antenatal care from a doctor for only 13 percent of births in the three years preceding the survey, and from a nurse/midwife for I 1 percent of births. One of two women who received some antenatal care had fewer than 3 visits. For the majority of births (56 percent), mothers did not receive any antenatal care.
An important component of antenatal care is protection against tetanus. Two or more doses of tetanus toxoid vaccines were received by mothers for about one-third of births, while 13 percent received one dose. For well over half of births, mothers did not receive a single dose.
The majority of Nepalese children are born at home without assistance from trained medical personnel. Overall, only 8 percent of births are delivered in a health facility and 9 percent are delivered under the supervision of a doctor or nurse/midwife.
Breastfeeding is nearly universal in Nepal and the average length of time that children are breastfed is relatively long (28 months). However, a significant minority of children (40 percent) are not breastfed within one day of birth. Bottle feeding is relatively rare in Nepal and less than 3 percent of children under three years of age were fed with a bottle using a nipple. Even though exclusive breastfeeding is recommended until 4-6 months of age, one-third of children age 4-5 months receive complementary foods.
There is considerable malnutrition among children in Nepal. Forty-eight percent of children under age three are stunted, 11 percent are wasted, and 47 percent are underweight. Variation by place of residence is marked, with rural children, children living in the Mountains and in the Far-western regions of Nepal more likely to be malnourished than other children.
Maternal nutritional status was also assessed from the NFHS data. Fit~een percent of Nepalese mothers of children born during the three years before the survey were less than 145 centimetres tall, the height below which a woman is considered to be at nutritional risk. Furthermore, more than one of four women fell below the cutoff of 18.5 for body mass index, which measures thinness, indicating that the level of chronic energy deficiency in Nepal is relatively high. Maternal deaths are high relative to developed countries. According to the NFHS data, maternal deaths accounted for 27 percent of all deaths to women age 15-49, with a maternal mortality ratio of 5 deaths per 1,000 live births.