Impact of Sumadhur intervention on fertility and family planning decision-making norms: a mixed methods study

Participants included 90 individuals within triads across 30 households, evenly split between the Palinandan and Sunwal Municipalities of Nepal (Table 1). Among participants, newly married women had a mean age of 20.48 (SD: 1.83), husbands a mean age of 24.30 (SD: 3.92), and mothers-in-law a mean age of 50.10 (SD: 8.69). Approximately 75% of marriages between women and their husbands were described to be arranged, while the remaining were reported as “love” marriages. While most of the women (73.33%) and husbands (80.00%) reported achieving a high-school education or above, majority of mothers-in-law (86.67%) reported no formal education. Over 80% of all participants were Hindu.

Table 1 Participant demographic summariesImpact on norms on fertilityNorms about timing of first pregnancy

Baseline and endline surveys revealed statistically significant changes to ideas about the timing of first pregnancy (Table 2).

Table 2 Sumadhur intervention impact on norms on fertility and on decision-making by participant typeImpact on Norms on Fertility

At baseline, 70% of participants agreed or strongly agreed that “it is wrong to use contraceptives or other means to avoid or delay pregnancy before having had at least one birth”, and this decreased to 57% at endline. The change was most significant among newly married women (p = 0.015). Interestingly, shifts were reported in opposing directions by gender. While 23% fewer newly married women and 17% fewer mothers-in-law strongly agreed that “it is wrong to use contraceptives or other means to avoid or delay pregnancy before having had at least one birth” at endline, 20% more husbands strongly agreed compared to baseline.

In general, qualitative findings underscored the strength of societal pressures to prove fertility early in marriage. When asked about the consequences of delaying the first pregnancy and birth, most participants acknowledged deeply ingrained societal expectations of birth within the first year of marriage though often personally disagreed with this pressure. The separation of personal and societal beliefs was common across participants, many of whom noted the historical norms of early childbirth but did not prescribe to this view themselves. Even within interviews, participants wrestled with the perceived harms and benefits of obliging with social fertility norms to conceive early in marriage. While delaying birth was seen to lead to safer outcomes for young women and increased stability for the infant, early conception squelched community gossip and stigma and increased community belonging. For example, one mother-in-law explained that, for her, educational and employment goals in addition to young maternal age were reasonable justifications to delay first birth. However, she went on to acknowledge the sometimes-unbearable weight of societal stigma, compounded by the positive reinforcement and community embrace that occurs following a first birth.

Families also frequently described navigating long-held beliefs that using contraception to delay a first pregnancy could lead to infertility. Even though these beliefs were considered “old thoughts” and “an outcome of illiteracy,” it was clear that they continued to influence fertility decision-making among the younger generations. For several couples, this limited the types of contraception they were willing to use—often relying only on male condoms. Early first pregnancy norms were further affirmed by pregnancy findings among newly married women and over the course of the four-month intervention, 37% of newly married women reported becoming pregnant.

Despite persistent norms to prove fertility early, several families spoke affirmatively towards delaying the first birth following their participation in Sumadhur. Some families noted that the intervention evoked familial and community conversations conveying both recognition of the norms shaping the older generation alongside a willingness to support the changing priorities of the younger generation. One mother-in-law summarized that while “Everyone uses the family planning measures only after having a first child”, she knows and supports that her “daughter-in-law doesn't have any desire to be a mother this soon as she wants to have a baby after completing her studies” (58-year-old Mother-in-Law in family triad #9, Palhinandan). The daughter-in-law in this triad recognized this shift in her mother-in-law’s opinion and described her surprise on this:

“My mother-in-law had a very old way of thinking. She used to tell me to plan for childbirth right after marriage. But after participating in the program, she now tells me to have a baby only after completing my studies and getting a good job. I’m very happy to see my mother-in-law change completely. She even helps me in the household work, and talks to me very nicely giving her suggestions.” (21-year-old Newly Married Woman in family triad #9, Palhinandan).

This sentiment was shared by other families as well. When asked what surprised her about the intervention, one mother-in-law admitted: “Me and my son used to say to my daughter-in-law that we need a baby soon, but now the things have changed. My son and daughter-in-law are not in hurry. I have also realized that I shouldn’t pressure them. They are still young… I am happy with their decision to delay first childbirth.” (41-year-old Mother-in-Law in family triad #3, Palhinandan).

Participants’ perception of Sumadhur’s success also led to reflections about the benefit this knowledge could have prior to marriage. Couples in particular explained that effective prevention of early pregnancy would require intervention before a couple is married given societal pressure for immediate pregnancy. When asked whether others would benefit from this intervention, one newly married woman summarized:

“It will be good if you can keep other newlywed couples like us. But it will be better if you bring the unmarried ones to participate; if they get knowledge on these things before getting married, they will know what to do after marriage. We would have known more if we had got a chance to participate in this program before marriage, we would have known when to plan for a baby and what should be the right year gap for another child. I didn’t know anything, so I am pregnant already.” (said laughingly) (23-year-old Newly Married Woman in family triad #16, Sunwal)

Similarly, another newly married woman shared that the only thing she could not implement from the training was her desire to use contraception to delay pregnancy in order to pursue higher education, because she became pregnant immediately after marriage and prior to participation in the intervention. She went on to share that the information she had gained about child spacing would allow her to complete education between births, however, she also recommended engagement earlier among women in her community:

“These programs should be implemented before we get pregnant. In our area, women get pregnant immediately after marriage and such trainings if provided at the preconception period might help ambitious people like us and cooperative households like ours. Apart from that, such education should be given in school. Also, people should know about this before they get married.” (21-year-old Newly Married Woman in family triad #13, Palhinandan).

Husbands agreed with this, acknowledging competing desires to pursue personal advancement via employment or education and appeasing familial or community expectations. One husband shared that while he did not regret that his wife was already pregnant, he wished they could have used a contraceptive method to delay pregnancy. When asked specifically if it would be acceptable to use contraception prior to a first birth, he advocated: “Yes, they should use the method. This is because if they use it, they can prevent pregnancy. If they want to work, they can continue working. They can use it for certain time and stop it if they want a baby.” (30-year-old Husband in family triad #23, Sunwal). He went on to explain that while relatives and community members are allowed to provide advice to couples, their opinions shouldn’t be binding, explaining “I don’t think they should force anyone to give birth. It is completely husband and wife's decision. We shouldn’t be under someone's influence about giving birth… But I am okay if they give advice or suggestions.”

Norms about the spacing of pregnancies

Across all participant types, significant changes were observed related to norms about the spacing of pregnancies. All participants trended significantly toward strongly disagreeing or disagreeing that it is wrong to use contraceptives or other means to avoid or delay pregnancy—29% agreed it was wrong to use contraception to space pregnancies at baseline, which decreased to 6% at endline (Table 2). The most dramatic shift (p < 0.001) was seen among husbands as 53% agreed it was wrong pre-intervention which decreased to 7% at endline. Qualitatively, all participants supported contraceptive use as a means of pregnancy prevention following the first birth. Several couples described both increased knowledge and increased communication between husband and wife because of participation in the intervention, strongly illustrated by one newly married woman’s response to changes in views following the intervention:

“There has been changes in many of my views. Nowadays I give due respect to my husband and mother-in-law. And they reciprocate the same feeling by loving me and respecting me. I did not know anything about the use of family planning methods earlier, but now I feel I’m fully aware about the topic. Well, my current pregnancy happened because of my lack of awareness. But I will bear another child three to four years after of birth of my first child…Actually, me and my husband have discussed about using this. Earlier, there used to be no discussion between me and my husband regarding the number of children to bear as a couple and use of family planning methods; but now we discuss about these topics in detail.” (21-year-old Newly Married Woman in family triad #8, Palhinandan)

All participant types reflected positively about family planning knowledge, naming its relevance between pregnancies. These findings correlated with significant increases in knowledge related to birth spacing benefits across all participants. At endline, an additional 12% of newly married women, 60% of husbands, and 17% of mothers-in-law identified at least one benefit of birth spacing (Table 2). The most reported benefits at endline included better health for mothers and children as well as better control of socioeconomic status and personal expenses.

Impact on norms on family size

Significant changes were not observed for all participant types related to norms about family size. Across types, participants generally tended to report wanting one or more additional children at endline compared to baseline (Table 2). While qualitative reflections on this topic were limited, there was little indication of strong societal pressure or influence to have a certain number of children. Generally, participants saw this as a decision for couples to make. One mother-in-law explained, “And regarding the number of children, it is better that they are decided as per the wish of the husband and wife instead of other people’s sayings.” (61-year-old Mother-in-law in family triad #14, Palhinandan). Additionally, while couples frequently suggested their family size was unpredictable, they also reported specific desires. In response to how many children she wanted to have, one newly married woman explained “Whatever happens, but I will bear two babies in total (she said this with a smile).” (23-year-old Newly Married Woman in family triad #29, Sunwal). At endline, most of all participants desired two children or grandchildren.

Impact on norms on sex preference of children

Although t-tests revealed significant changes to norms on sex preference of children, quantitative findings were difficult to interpret as sex preference questions within the pre and post surveys were dependent upon answers to questions about family size preference and participants generally reported desiring more children (Table 2). Across all participants at endline, significantly fewer participants specified desiring male children or female children suggesting an overall increased openness to either sex. This trend is strongly supported by qualitative findings and appears to be a generational shift. One mother-in-law summarized: “Well, people do not give birth to more than two children. It does not matter if it’s son or daughter, two children are enough. In our time, we used to have babies until son is born. My mom too gave birth to five daughters before having a son. Today's daughters-in-law do not wait to have son. They just have two children whether both are boys or girls.” (45-year-old Mother-in-law in family triad #28, Sunwal).

Newly married women sensed this shift as well and one suggested that family members talked more openly after the intervention and expressed love toward anticipated children of all sexes: “Many family members don't show anger these days while talking. They knew about many things after the training which helped in changing their behavior… family members used to despise women if they give birth to a daughter. They don't do such these days. They love son and daughter equally.” (21-year-old Newly Married Woman in family triad #13, Palhinandan).

Impact on norms on decision-makingNorms around household dynamics and decision-making

Most participants across all types agreed that “most families they know believe men should make the decision about whether or not their wife uses birth control” at both baseline and endline (Table 2). Across all participant types, no strong changes were seen related to the belief that “most families they know believe husbands should have the final say about when to start trying to have their first child” and everyone generally agreed this was true at both baseline and endline. Similarly, a lack of significant change among newly married women and husbands was observed related to the norm that most families believe husbands should make the final decision about the total number of children they want. Statistically significant change was observed among newly married women. Interestingly, there was both a decrease in the percentage of mothers-in-law that strongly agreed with this statement and an increase in the percentage of mothers-in-laws who agreed that most families believe husbands should make the final decision about the total number of children they want. While qualitatively few participants spoke specifically about fertility decision-making roles, those that did suggest it should be something couples agree upon and decide together.

Qualitative findings suggested that in some cases, household dynamics shifted in the absence of early pregnancy in that it increased the risk of violence between couples. Unsurprisingly, the fear of negative dynamics was described to motivate some couple’s decisions to seek pregnancy early after marriage. One newly married woman explained:

“After getting married, everyone said that it will be good if I get pregnant right away. I was told that my sister-in-law couldn’t get pregnant for three years post her marriage. This caused a problem in her relationship with her husband, and he used to scold and beat her. My mother-in-law was scared that it might happen to me too, so she suggested me to get pregnant early… that’s why we did it.” (23-year-old Newly Married Woman in family triad #16, Sunwal).

Another newly married woman described additional possible consequences including infidelity and humiliation as harmful to couple dynamics:

“There can be quarrel at the home, and it is likely that the husband might start seeing another woman… not all male partners behave that way, some are very understanding. But even while the husband is understanding, the people in the community might directly tell the husband that “your wife is unable to bear a baby”, which makes husband feel bad and humiliated. Because of this, there can be heated arguments between the couple and can negatively impact their marital relationship.” (23-year-old Newly Married Woman in family triad #29, Sunwal).

Quantitative findings related to household roles and decision-making were nuanced as participants described gradual shifts toward increased gender equity related to household decision-making. Similar to societal pressures related to early first birth, many participants alluded to historically strong beliefs about gendered household roles while acknowledging the benefits of challenging these norms. One husband described the woman’s role by explaining that “The majority of women in our region are limited to kitchen. But they should be given opportunity to come outside their household. They need to be educated, aware, and should get the platform to work and earn money. Similarly, they also need to take part in household conversation as well as decision making. They can also lead if given the platform to lead.” (26-year-old Husband in family triad #9, Palhinandan). Another husband seemed to desire to express women’s autonomy though immediately recalled a limiting societal norm:

“There are three women in my family and two males. We all have our specific roles. We do not restrict women. My wife is working, and we do not restrict her. We don’t allow menstruating woman to enter the kitchen at our home and my wife complains about this as she is against this. Apart from that there are no restrictions.” (23-year-old Husband in family triad #19, Sunwal).

Following the intervention, participants consistently expressed recognition of and desires for increased women’s empowerment:

“I think women should take a part in decision making. They can also contribute to the family through many ways. Some might work outside home whereas others might do all the household chores. Everyone should be respected and treated well. We should listen to female members of the family and take their opinion in any important matter.” (23-year-old Husband in family triad #28, Sunwal)

“In earlier days, people used to say that daughter-in-law is not a core family member. She doesn’t do anything for the family and only looks after her own benefit. But nowadays, people say that son and daughter-in-law are equal. They support and respect them as well. The belief system as well as what they practice both has changed in recent times. Discrimination between daughter and daughter-in-law has decreased gradually. It feels good seeing all these changes.” (21-year-old Newly Married Woman in family triad #13, Palhinandan)

“Earlier, women were not valued, and their opinion was not asked on any matters. All the decisions were made by male household head. But these days, when decisions are to be made, they ask for the suggestions of the women of the family too. They are also involved in the household decisions. It seems to be good to involve everyone’s suggestions in the household decision making.” (54-year-old Mother-in-law in family triad #9, Palhinandan)

Qualitative interviews suggested that Sumadhur improved couple dynamics by facilitating increased and intentional conversations that allowed couples to engage in shared decision-making.

Individual intentions

While one third of newly married women were unsure about whether they would use a contraceptive method to delay or avoid pregnancy at any time in the future at baseline, 93% reported they would at endline which was an increase of 27% for these participants (Table 2). Among husbands, intention to use a contraceptive method in the future increased by 10%, to 90% at endline. Throughout qualitative interviews, participants reported starting or continuing contraceptive methods as a result of the intervention. Some couples described that they were motivated to establish additional economic security prior to having children and others suggested that they were glad to have additional knowledge about how to space their planned pregnancies. For one husband, increased information about the potential side effects of female contraception seemed to influence his own decision-making. He explained, “Yes, I already knew about family planning methods, but I hadn’t used it. I came to know about different family planning methods that can be used by female. I didn’t know in detail regarding this previously. I feel that men should use condom as other methods are focused on women and have negative impacts.” (27-year-old Husband in family triad #27, Sunwal).

These findings aligned with shifts in ever use of contraception behaviors for both newly married women and husbands. Among newly married women, an additional 13% reported ever use at endline compared to baseline. Similarly, an additional 16% husbands reported of ever using contraceptives in endline compared to the baseline. However, the changes were not statistically significant, perhaps due to small sample sizes because some newly married women were already pregnant (Table 2).

In response to whether she had changed her thinking about contraceptives as a result of Sumadhur, one newly married woman reflected:

“Everyone was putting their thoughts into the discussion... I feel that I want to have a child only after three years from now. I’m just 19 years old and I am too small to be a mother. Therefore, I don’t want to have a baby now. I want to have my child after three years. And I want only one child. That’s why I’m taking pills these days.” (19-year-old Newly Married Woman in family triad #1, Palhinandan).

This woman went on to say “They never used to involve me in any household matters earlier. Now, they also ask me for my opinions in any matters and take my suggestions too.” These findings seem to support the idea that increasing women’s empowerment can increase the likelihood they have the agency to act upon their individual intentions, including those related to fertility and family planning.

Knowledge and behavior

Additional changes in knowledge related to family planning and abortion was found across participants (Table 3).

Table 3 Change in family planning knowledge and behavior by participant type

All participant types improved their ability to correctly identify both temporary and permanent family planning methods; pre-post change was marginally significant (p = 0.063) for mothers-in-law’s and husband’s knowledge of temporary methods, and statistically significant for all groups related to permanent methods (p < 0.05). Participants discussed specific myths dispelled by the intervention including the belief that condoms eliminate pleasure or that IUDs and pills often cause uterine harm. In the qualitative interviews, they also openly discussed their decision to begin a method. When asked about her changed opinions, one newly married woman summarized:

“We have been using condoms these days to plan for a baby later... Earlier, we, husband and wife never used to talk openly but it has changed now. We talk openly with each other. Love and care have increased between us. We are thinking of having a child after my husband gets a job. My in-laws also say the same.” (20-year-old Newly Married Woman in family triad #5, Palhinandan).

Several participants expressed gratitude for their changed knowledge and behavior summarized by one husband’s comments, “I think the training was fruitful. I learned many things from the training. I started using family planning method and we all eat together nowadays. So, I am very thankful for the trainers and people like you who are trying to make our lives better.” (19-year-old Husband in family triad #25, Sunwal).

Participants also acknowledged that even when knowledge had changed, additional barriers remained that may influence behavior. For example, when asked what sort of barriers couples may face to using family planning methods, one mother-in-law explained “They might fear or feel shy. They might not get the device of their choice. Some might have problem to access the device as health post might be located far away.” (48-year-old Mother-in-law in family triad #13, Palhinandan).

Dramatic improvements were also observed across participant types related to knowledge of the legality of abortion in Nepal. Compared to baseline, an additional 70% of newly married women, 40% of husbands, and 67% of mothers-in-law correctly responded yes to the question “Is abortion legal in Nepal?” (p < 0.001) (Table 3). While no participants reported a personal experience of undergoing an abortion at baseline or endline, increased awareness was supported by qualitative findings as well. One husband shared:

“I didn’t know much about abortion. After the training, I came to know that abortion can be done up to 12 weeks of pregnancy. It can be done if both husband and wife don’t have a desire for a baby. It can also be done in case of health risk of mother as well as her baby. Also, they said it is free of cost.” (24-year-old Husband in family triad #5, Palhinandan)

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