When family planning services were first introduced in Nepal more than 30 years ago, the Americans who were then supporting population control strongly pushed contraceptive pills for women.

But the Pill never really took off in Nepal, and it was later superseded by the condom, injectible contraceptives, sterilisation and intra-uterine devices. Today, only two percent of Nepali women using contraceptives take the Pill.

Shyam Thapa, a demography expert with Family Health International (FHI), attributes this to social factors. "All over Asia it is found that people have greater faith in injectibles and liquid medications than in tablets. This also affects their choice of contraceptives."

In the early 1970s, reports of serious side effects of the Pill had not yet reached Nepal. Even so, Nepalis women found it cumbersome to keep track of the tablets, and preferred sterilisations or injectibles-actually it was the men who decided and they preferred their wives sterilised.

In a country with serious gender disparities, the ease of the Pill could theoretically have given Nepali women greater freedom and choice over reproduction. However, research showed that it was actually the men in many cases who made the decision about the kind of contraceptive that their wives could use, and the men preferred to have their wives strerilised.

In the 1980s, the injectible depo-provera gained popularity as the birth spacing method of choice. In the 1990s, injections and implants became the mainstay of Nepal\'s family planning programme after sterilisation.

When family planning was introduced in the late 1960s, Nepal\'s population of 10 million was growing at 2.7 percent a year. But these early efforts took 20 years to begin slowing down growth and lowering the fertility rate.

Statistics show that in just five years between 1981 and 1986, the percentage of contraceptive users among married couples in Nepal almost doubled from 8 to 15 percent. Presently, almost 35 percent couples belonging to the reproductive age-group practise one or the other kind of contraceptive method. Nepal\'s population is now 23 million and is growing at 2.3 percent a year.

Nepal\'s uniqueness lies in the popularity of modern contraceptive methods for limiting the number of children rather than spacing birth, and since the Pill is more suitable for the latter this could also be why it has not proved popular here.
"The contraceptive career of Nepali couples is short. For the majority of them it begins and ends with sterilisation," says Thapa.

Studies show that early marriage, and the subsequent social pressure on newly-weds, leave them with little choice but to produce a baby as soon as possible.

FHI surveys show that 88 percent of the married women in Nepal have a child by the age of 21, with an average interval between marriage and the first baby of only 27 months. Hence, by the age of 30 to 35, a woman would have given birth to four to five children.

Sterilisation was then a logical choice for couples who did not want any more children. Eighty percent of Nepali couples who practise family planning go for sterilisation. Interestingly, in the hills 75 percent sterilisations are male while in the tarai 75 percent are female.

The real factor retarding Pill-use was the effectiveness of mobile sterilisation camps first introduced in the 1970s. As laparoscopy became easier and safer, its popularity grew among Nepali women.

The mobile camps emphasised sterilisation rather than temporary spacing methods.

The use of pills increased after private sector and non-government organisations were allowed to deliver family planning services. The availability of the Pill in urban areas improved vastly and new users easily identified it as an easy alternative. But because of the cost involved, the Pill could still not make major inroads in rural areas.

Increase in availability alone is unlikely to increase the use of the Pill in Nepal. Nepali couples have displayed a loyalty to their contraceptive of choice. Surveys show that 86 percent of current users have stuck to the same method they accepted for the first time. Moreover, the most common switching is from the Pill to other methods.

"Many women find the routine of using the Pill impractical," says Laxmi Raj Pathak, the director of the government\'s Family Health Division. The theoretical effectiveness of pills in preventing pregnancy is estimated at 99 percent, but in Nepal reliability is only 80 percent, mainly because women do not follow instructions properly. Figures for Egypt and Thailand are 85 percent.

Pathak says that in some cases men are found to have forced their wives to accept family planning decisions. He says, "Men have great faith in sterilisation. They think the pill is less reliable. Also, if the wife is taking pills it is the man who will have to go to the store and buy it. Whereas if his wife has a laparoscopy he doesn\'t have to worry about it anymore."