Knowledge and practices of modern contraceptives among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

Dipendra Singh Thakuri; Yamuna K C Singh; Rajendra Karkee; Resham B Khatri

doi:10.1371/journal.pone.0278899

. 2022 Dec 12;17(12):e0278899. doi: 10.1371/journal.pone.0278899

Knowledge and practices of modern contraceptives among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

Dipendra Singh Thakuri ^1,^*, Yamuna K C Singh ², Rajendra Karkee ³, Resham B Khatri ^4,⁵

Editor: Ai Theng Cheong⁶

PMCID: PMC9744303 PMID: 36508399

Abstract

Background

Uptake of family planning (FP) services could prevent many unwanted pregnancies, and unsafe abortions and avert maternal deaths. However, women, especially from ethnic and religious minorities, have a low practice of contraceptives in Nepal. This study examined the knowledge and practices of modern contraceptive methods among Muslim women in Nepal.

Methods

A cross-sectional study was conducted among 400 Muslim women in the Khajura Rural Municipality of Banke district. Data were collected using face to face structured interviews. Two outcome variables included i) knowledge of and ii) practices of contraceptives. Knowledge and practice scores were estimated using the list of questions. Using median as a cut-off point, scores were categorised into two categories for each outcome variable (e.g., good knowledge and poor knowledge). Independent variables were several sociodemographic factors. The study employed logistic regression analysis, and odds ratios (OR) were reported with 95% confidence intervals (CIs) at a significance level of p<0.05 (two-tailed).

Results

Almost two-thirds (69.2%) of respondents had good knowledge of modern contraceptive methods, but only 47.3% practised these methods. Women of nuclear family (adjusted odds ratio (aOR) = 0.60; 95% CI: 0.38,0.95), and who work in agricultural sector (aOR = 0.38; 95% CI: 0.22, 0.64) were less likely to have good knowledge on modern contraceptives. Women with primary (aOR = 2.59; 95% CI: 1.43, 4.72), secondary and above education (aOR = 4.41; 95% CI:2.02,9.63), women with good knowledge of modern contraceptives (aOR = 2.73; 95% CI: 1.66, 4.51), who ever visited a health facility for FP counselling (aOR = 4.40; 95% CI: 2.58, 7.50) had higher odds of modern contraceptives practices.

Conclusion

Muslim women had low use of modern contraceptive methods despite having satisfactory knowledge about them. There is a need for more equitable and focused high-quality FP practices. Targeted interventions are needed to increase the knowledge and practices of contraceptives in the Muslim community. The study highlights the need to target FP interventions among socially disadvantaged women, those living in a nuclear family, and those with poor knowledge of modern contraceptives.

Introduction

Family planning (FP) is one of the high-impact interventions that prevent unintended pregnancies, unsafe abortions, reduce high-risk births, avert maternal and neonatal deaths, and protect women’s and children’s health [1–4]. Despite multiple benefits, many women needing FP methods cannot access the FP services. This unmet need for FP results in approximately 539,000 annual unintended pregnancies in Nepal [5, 6]. These unintended pregnancies can pose serious health risks to mothers and their newborns, including deaths [7]. Maternal morbidity and mortality risks are also high among poor, rural women facing many barriers to accessing FP services in Nepal [5, 8, 9]. One in 200 women dies from pregnancy-or delivery-related causes in their lifetime in Nepal [10].

Nepal made considerable progress in health services access and improved maternal and child health services coverage over the last three decades [11, 12]. However, the FP program has poor performance and has low and stagnant progress in the contraceptive prevalence rate (CPR) [13]. The Nepal Demographic Health Survey (NDHS) 2016 [12] revealed that CPR for modern contraceptive methods in Nepal was 43%, with 24% unmet needs. In addition, women from the poorest households, living in remote areas, disadvantaged ethnicities, religious minorities, and those without education had poor knowledge and the lowest practice of contraceptive methods [14].

Nepali Muslims are recognised as one of the most marginalised and disadvantaged communities [15], consisting of 4.4% of the total population [16]. Most of them live in the Terai districts. Muslims are economically, socially, educationally, and politically backward and deprived of various facilities, including health services [15]. In 2011, the poverty incidence for the Muslim population was 20.2%, and the adult literacy rate was 43.5%, compared with 25.2% and 40.43% for the general population, respectively [16]. Muslims ranked at the bottom of the Human Development Index (HDI) (HDI score: 0.41) [17]. In Nepal, Muslims have low access to and practice of family planning with a high unmet need for FP services, including other health services [16, 18]. Muslim women have low CPR (25.4%), high unmet need (37%) for modern contraceptive methods, high fertility and large family size in Nepal [16, 19]. In Nepal, the total fertility rate has increased from 4.6 (2006) to 4.9 (2011) in Muslim populations [16]. Muslim groups had high unintended pregnancies leading to the highest maternal mortality ratio (318 per 100000 live births) in Nepal [20], which suggests the need for quality FP services delivery and utilisation among Muslims. Better use of family planning could reduce many of these mistimed and unplanned pregnancies. At the same time, it could reduce the number of unsafe abortions and the mortality related to childbirth [21].

Several factors have contributed to poor progress in practices of contraceptive methods, including poor access to contraceptive methods, lack of contraceptive methods in health facilities [22], poor uptake due to perceived side effects, poor knowledge of contraceptive methods, opposition from family members, psychological factors, lack of proper counselling services on contraceptive methods and religious and cultural beliefs and value system [18, 23]. In addition, behavioural norms prevailing in Muslim society may affect Muslim women’s access to and utilisation of family planning services [24]. For example, a common concern in Muslim communities is that FP is deemed a Western ideology and a conspiracy to reduce the Muslim population [19]. Previous studies reported that some Muslims believe that using family planning services will result in divine retribution or that the number of children they should have is ‘God’s business,’ and that parents should not try to change God’s will [16, 25].

Evidence showed that knowledge and attitude contributed to modern contraceptive methods [26]. In addition, other socioeconomic and demographic factors were also identified as determinants of contraceptive methods, such as women’s age, education, number and sex of children, occupation, and access to a health facility [3, 18]. However, limited evidence is available on the status of knowledge and practices of modern contraceptive methods and their associated determinants among Muslim women in Nepal.

Therefore, we aimed to assess the existing family planning knowledge and practice among Muslim women and identify the factors influencing access to and uptake of modern family planning services in Mid-western Nepal. The findings of this study could inform policymakers and program managers to design contextual policies and programmatic strategies for universal coverage of contraceptive methods among the Muslim population.

Policy and services delivery context of family planning program in Nepal

The FP program is Nepal’s oldest public health program [19], and services are available at the community level through Female Community Health Volunteers (FCHVs). Nepal’s health policy 2019 and strategies also emphasised the family planning program and ensuring quality family planning services. Current periodic strategies and plans, such as Nepal Health Sector Strategy (NHSS) 2015–2020 [27], and the Population Perspective Plan (2010–2031) [28], have highlighted family planning as the major component of the Safe Motherhood Initiative in Nepal [29]. The family planning Costed Implementation Plan 2015–2021 has also highlighted the cost and implementation strategies [30]. However, these policies and program approaches are implemented one-size-fits-all [19]. There have not been focused and context-specific implementation strategies to recognise religious and cultural considerations for addressing FP needs of marginalised populations.

In Nepal, modern contraceptive services provided from different outlets ranging from community to tertiary level (Fig 1). Services outlets include community clinics, health posts, static health clinics, and mobile health camps from public, private, and private non-profit sector health institutions. In addition, several short-term modern contraceptives are available at peripheral facilities. In contrast, long-term modern contraceptives are being provided in health posts (HP), primary health care centers (PHCC) and hospitals [31].

Methods

Study design and setting

A community-based cross-sectional study was carried out between June and September 2019 in Khajura Rural Municipality of Banke district. The study population was married Muslim women with reproductive ages of 15 to 49 years. We selected Khajura Rural Municipality purposively. More than one in four (26.7%) people in this municipality belong to Muslim backgrounds [32]. Khajura Rural Municipality has 50,961 residents from 10,288 households (Female: 27,457 and 19,397 aged 15 to 49 years) [32]. Four wards (of eight wards) of the municipality were selected randomly for the household survey. A Ward is the lowest administrative unit in Nepal. An estimated 1,750 Muslim married women of reproductive age (MWRA) were living in those selected wards [33].

Sampling and participants selection

This study’s sampling frame was married Muslim women aged 15–49 years. The sampling frame of Muslim MWRA was obtained from the selected ward office. Sample size was calculated using formula N = Z²pq/d² where [Z = 1.96, p = 0.44 q = 0.56, d = 0.05] and 44% prevalence rate [34]. We determined 379 as the minimal sample size. Considering a non-response rate of 5% [35], a sample of 400 Muslim women were interviewed among 1,750 Muslim MWRA. We selected participants through a systematic random sampling method. The first women were selected randomly, and then every fourth (having a gap of three) women were selected for the interview. If there was more than one MWRA in the family, the youngest women were included in the study. Likewise, the adjoining households were recruited if the participants were unavailable in the selected households.

Study variables

Based on previous studies in Nepal and elsewhere [19, 36, 37], explanatory variables were basic socioeconomic and demographic variables. Demographic variables were respondent’s age (≤18 years,19–29 years and ≥30 years), parity (0 to 2 and ≥3), respondent’s family type (nuclear and joint family) [38]. Socioeconomic variables were respondent’s education (illiterate, primary education, and secondary and above) [39], respondent’s occupation (agriculture, daily wage workers and housewives). Similarly, family monthly income (≤20000 NRs and >20000 NRs (130 Nepalese Rupees = 1 USD, 2022)). Additionally, access to family planning service variable included: ever visited a health facility for family planning counselling (yes/no). Knowledge of modern contraceptive methods was also included as the independent variable for practices of modern contraceptive methods.

Outcome variables

Two outcome variables were included: knowledge on modern contraceptive methods (good and poor knowledge), and practices of modern contraceptive methods (yes or no). Knowledge of modern contraceptive methods was created using ten questions about modern contraceptives. Each question’s response was coded as “1” for “yes” and “0” for “no”. The possible knowledge score ranges between a minimum 0 and maximum 10. Next, the median score of the knowledge was calculated. Using the median as a cut-off-point, we categorised knowledge level into “Good” (> = median score) and “Poor” (<median score) [7, 40].

Women were asked if they had used modern contraceptive methods in the last six months before this survey and coded their responses as ‘yes’ or ‘no’ to assess the practice of modern contraceptive methods.

Data collection tools and techniques

A questionnaire on knowledge and practice of modern contraceptive methods was adopted from the previous studies [19, 34, 41] and a survey [12]. The structured questionnaire was first developed in English, and then translated into Nepali and the local language (Awadhi). The second author YKCS translated the English version of the tool into Nepali and the local language (Awadhi) with the support of a professional translator. It was pretested among 20 women aged 15–49 years in an adjoining ward to refine it. Necessary adjustments were made, including in the flow of question patterns and language style. The local language was used in data collection. A face-to-face interview was conducted in the participant’s households. The interview was carried out in a separate area of the participants’ households to ensure confidentiality. Participation was voluntary, and none approached respondents who refused to be interviewed. Data were collected by local enumerators consisting of three females. The enumerators were the local Muslim community. They were recruited based on their educational background, local language knowledge, and prior data collection experience. The two days of training were provided to the enumerators about the study purpose, methodologies, tools, and techniques before preceding the actual data collection. All the data collection-related field activities were closely supervised and monitored by the second author (YKCS).

Data analysis

Data analysis was performed using SPSS version 25.0 (SPSS Inc., Chicago, IL). The collected data were entered, coded, and cross-checked to ensure consistency. Descriptive analyses were employed and reported as frequencies and proportions. The Chi-square test was conducted to assess the association between independent and outcome variables. Binomial logistic regression was examined to identify the determinants of knowledge and practices of modern contraceptive methods. Odds ratio with 95% confidence interval (CIs) were reported. The significance level was set at p < 0.05 (two-tailed).

Ethical approval

Ethical approval was obtained from this study’s ethical review board of Nepal Health Research Council and the educational and administrative ethical committee, faculty of Nursing and Medical College of Xi’an Jiaotong University, China. Before collecting data, written permission was obtained from the local administrative authority Khajura Rural Municipality of Banke district. Before the interview, enumerators and the second author (YKCS) met Muslim religious leaders, shared the study’s objective, and obtained permission to meet and collect data from their community. Verbal informed consent was obtained from participants before conducting the interview. The respondent’s participation was voluntary, and the respondents had the right to refuse the interview process.

Results

Table 1 shows the distribution of respondents accordingly to sociodemographic characteristics, the prevalence of knowledge and the use of modern contraceptive methods. Nearly half (46%) of the respondents were between 19 and 29 years. The mean age of respondents was 29 (±8.74 SD) years. Over three-quarters of respondents (78.5%) had up to 2 living children, and almost half (48%) of respondents had primary level education. Approximately half (49.5%) of respondents were housewives, while 37% of respondent’s husbands were involved in agriculture. Over 6 in 10 respondents had >20000 NRs family monthly income. Almost two-thirds (69.2%) of respondents had good knowledge of modern contraceptive methods, and 47.3% used modern contraceptive methods. Overall, the mean knowledge score of FP was 6.9 (±1.18), with minimum knowledge scores of 3 and maximum scores of 10, and the median knowledge score was 7. Injectable (43.4%) was the most used modern contraceptive, and an implant (3.7%) was the least used. Additionally, over 7 in 10 (71%) visited a health facility for family planning counselling (Table 1).

Table 1. Background characteristics and modern contraceptive methods, knowledge, and practices of Muslim women (N = 400) in Nepal.

Variables	Category	Frequency	Percentage
Age of women	≤18 Years	34	8.5
	19–29 Years	184	46.0
	≥30 Years	182	45.5
Parity	0 to 2	314	78.5
Parity	3 or above	86	21.5
Family types	Nuclear	145	36.3
Family types	Joint	255	63.7
Women’s education	Illiterate	108	27.0
	Primary	192	48.0
	Secondary & above	100	25.0
Women’s occupation	Agriculture	158	39.5
	Daily wages worker	44	11.0
	Housewives	198	49.5
Husband’s occupation	Agriculture	148	37.0
	Business and service	50	12.5
	Daily wages worker	82	20.5
	Foreign migrant worker	120	30.0
Family income (NRs)	≤20000	158	39.5
Family income (NRs)	>20000	242	60.5
Knowledge of modern contraceptive methods	Poor knowledge	123	30.8
Knowledge of modern contraceptive methods	Good knowledge	277	69.2
Practices of modern contraceptive methods	Yes	189	47.3
Practices of modern contraceptive methods	No	211	52.7
Contraceptive practices (n = 189)	Condom	33	17.5
	Oral contraceptive	49	25.9
	Injectable	82	43.4
	Implant	7	3.7
	Intrauterine contraceptive Device (IUCD)	10	5.3
	Female sterilisation	8	4.2
Ever visited a HF for FP counselling	Yes	284	71.0
Ever visited a HF for FP counselling	No	116	29.0

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Table 2 shows the descriptive findings of knowledge regarding modern contraceptive methods. The majority of respondents (89%) heard about family planning. However, almost half (47.3%) of respondents didn’t know that using both a condom and oral contraceptives is effective. Over 7 in 10 (71%) respondents knew that women who use injectables must get an injection every three months. Almost seven in ten (69%) women knew that using contraceptives prevents unwanted pregnancies. However, over four in ten (44%) women didn’t know about contraceptive pills’ common side effects, as shown in Table 2.

Table 2. Descriptive findings of knowledge related to modern contraceptives among Muslim Women, Banke, Nepal, 2019 (N = 400).

Variables	Yes	No
	Number (%)	Number (%)
	n (%)	n (%)
1. Have you ever heard about FP?	356 (89%)	44 (11.0%)
2. Does female sterilisation avoid pregnancy?	288 (72%)	112 (28.0%)
3. Do oral contraceptive pills guarantee 100% protection?	269 (67.2%)	131(32.8%)
4. Are women using the birth control injectables to get an injection every three months?	284 (71.0%)	116 (29.0%)
5. Do the use of both a condom and oral contraceptives considered to be very effective contraceptives?	211(52.8%)	189 (47.2%)
6. Does use of contraceptives prevent unwanted pregnancies?	276 (69.0%)	124 (31.0%)
7. Are contraceptive methods appropriate to space childbirth?	268 (67.0%)	132 (33.0%)
8. Does condom provide dual protection (Prevents STI/HIV and unplanned pregnancies)	286 (71.5%)	114 (28.5%)
9. Do common side effects of contraceptive pills include mood swings and weight gain?	224 (56%)	174 (44%)
10. Does health education important for women who want to use contraceptives?	266 (66.5%)	134 (33.5%)

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Table 3 depicts the different sociodemographic variables, knowledge, and practice of modern contraceptive methods. Nearly three fourth (72.5%) of respondents from a joint family had good knowledge of modern contraceptive methods. Over half (56.6%) of respondents belonging to the nuclear family practised modern contraceptive methods. Respondents with secondary and above education reported greater (56.0%) use of modern contraceptive methods. More than half (51.6%) of women who had good knowledge of modern contraceptive methods used modern contraceptives. Six in ten (60.3%) respondents who visited a health facility for FP counselling have used modern contraceptive methods (Table 3).

Table 3. Factors associated with knowledge and practices of modern contraceptive methods among Muslim women (N = 400) in Nepal.

Variables	Frequency (%)	Knowledge modern contraceptive		P value	Practice modern contraceptive		P value
Variables	Frequency (%)	Poor (<median) (%)	Good (> = median) (%)		No (%)	Yes (%)
Women’s age
≤18 years	34 (8.5)	12 (35.3)	22 (64.7)	0.805	15 (44.1)	19 (55.9)	0.580
19–29 years	184 (46.0)	57 (31.0)	127 (69.0)		99 (53.8)	85 (46.2)
≥30 years	182 (45.5)	54 (29.7)	128 (70.3)		96 (52.7)	86 (47.3)
Family type
Joint	255 (63.8)	70 (27.5)	185 (72.5)	0.058	147(57.6)	108(42.4)	0.006
Nuclear	145 (36.3)	53 (36.6)	92 (63.4)	0.058	63(43.4)	82(56.6)	0.006
Parity
0–2	314 (78.5)	97 (30.9)	217 (69.1)	0.907	164(52.2)	150(47.8)	0.836
≥3	86 (21.5)	26 (30.2)	60 (69.8)	0.907	46(53.5)	40(46.5)	0.836
Women’s education
Illiterate	108 (27.0)	35 (32.4)	73 (67.6)	0.772	68(63.0)	40(37.0)	0.020
Primary	192 (48.0)	60 (31.3)	132 (68.8)		98(51.0)	94(49.0)
Secondary and above	100 (25.0)	28 (28.0)	72 (72.0)		44(44.0)	56(56.0)
Women’s occupation
Housewives	198 (49.5)	48 (24.2)	150 (75.8)	<0.001	103(52.0)	95(48.0)	0.444
Agriculture	158 (39.5)	68 (43.0)	90 (57.0)		80(50.6)	78(49.4)
Daily wages worker	44 (11.0)	7 (15.9)	37 (84.1)		27(61.4)	17(38.6)
Husband’s occupation
Agriculture	148 (37.0)	53 (35.8)	95 (64.2)	0.078	79(53.4)	69(46.6)	0.123
Business and service	82 (20.5)	16 (19.5)	66 (80.5)		20(40.0)	30(60.0)
Daily wages workers	50 (12.5)	15 (30.0)	35 (70.0)		40(48.8)	42(51.2)
Foreign migrant worker	120 (30.0)	39 (32.5)	81 (67.5)		71(59.2)	49(40.8)
Income (monthly) NRs
≤20000	158 (39.5)	53 (33.5)	105 (66.5)	0.328	78(49.4)	80(50.6)	0.311
>20000	242 (60.5)	70 (28.9)	172 (71.1)	0.328	132(54.5)	110(45.5)	0.311
Knowledge of modern contraceptive methods
Poor knowledge					76(61.8)	47(38.2)	0.013
Good knowledge					134(48.4)	143(51.6)	0.013
Ever visited a HF for FP counselling
No					85 (73.3)	31(26.7)	<0.001
Yes					125(39.7)	190(60.3)	<0.001

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Table 4 illustrates the determinants of knowledge on contraceptive methods. Women who belonged to the nuclear family (aOR = 0.598; 95% CI: 0.38,0.95) had lower odds of knowing modern contraceptive methods than those in the joint family. Women who involve in agricultural sector (aOR = 0.379; 95% CI: 0.22, 0.64) were less likely to be aware of modern contraceptive methods than housewives (Table 4).

Table 4. Determinants of good knowledge on modern contraceptive methods among Nepali Muslim women (N = 400).

Variables	Knowledge on modern contraceptive
Variables	COR 95% CI	p	AOR 95% CI	p
Women’s age
≥30 years	1.00		1.00
≤18 years	0.77 (0.36,1.67)	0.514	0.61 (0.25,1.48)	0.276
19–29 years	0.94 (0.60,1.47)	0.786	0.84 (0.49,1.44)	0.533
Family type
Joint	1.00		1.00
Nuclear	0.66 (0.42, 1.02)	0.059	0.60 (0.38,0.95)	0.030
Parity
0–2	1.00		1.00
≥3	1.03 (0.61,1.73)	0.907	1.11(0.61,2.01)	0.728
Women’s education
Illiterate	1.00		1.00
Primary	1.05 (0.64, 1.75)	0.836	0.86 (0.49,1.54)	0.620
Secondary and above	1.23 (0.68,2.23)	0.490	0.77 (0.36, 1.64)	0.495
Women’s occupation
Housewives	1.00		1.00
Agriculture	0.42 (0.27,0.67)	<0.001	0.38 (0.22, 0.64)	<0.001
Daily wages worker	1.69 (0.71,4.04)	0.237	1.61 (0.62,4.19)	0.327
Husband’s occupation
Agriculture	1.00		1.00
Business and service	2.30 (1.21,4.37)	0.011	1.56 (0.68,3.59)	0.295
Daily wages workers	1.30 (0.652,2.60)	0.455	0.91 (0.42,1.94)	0.802
Foreign migrant worker	1.16(0.70,1.93)	0.570	0.81 (0.40,1.62)	0.554
Income (monthly) in NRs
≤20000	1.00		1.00
>20000	1.24 (0.81,1.91)	0.328	1.02 (0.56, 1.83)	0.958

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Bold Significant at p< 0.05.

Table 5 demonstrates the determinants of practice of modern contraceptive methods. Women with primary (aOR = 2.59; 95% CI: 1.43, 4.72), secondary and above education (aOR = 4.41; 95% CI:2.02,9.63) had significantly higher odds of practices of modern contraceptive methods compared to illiterate women. Women living in a nuclear family (aOR = 2.24; 95% CI:1.40,3.59) had more than two-fold higher odds of modern contraceptive practices than their counterparts. Additionally, the practices of modern contraceptives were significantly higher among women in the business and service sector (aOR = 2.55; 95% CI:1.17,5.56) compared to agriculture. Women having good knowledge of modern contraceptive methods (aOR = 2.73; 95% CI: 1.66, 4.51) and women who ever visited a health facility for FP counselling (aOR = 4.40; 95% CI: 2.58, 7.50) were more likely to practice modern contraceptive methods compared to those who had poor knowledge and those who have not visited a health facility for FP counselling respectively (Table 5).

Table 5. Determinants of good practices of modern contraceptive methods among Nepali Muslim women (N = 400).

Variables	Practice of modern contraceptive
Variables	COR 95% CI	p	AOR 95% CI	p
Women’s age
≥30 years	1.00		1.00
≤18 years	1.41 (0.68, 2.95)	0.357	1.22 (0.50,3.01)	0.664
19–29 years	0.96 (0.64,1.45)	0.839	0.99 (0.58,1.69)	0.968
Family type
Joint	1.00		1.00
Nuclear	1.77 (1.17, 2.67)	0.006	2.24 (1.40,3.59)	0.001
Parity
0–2	1.00		1.00
≥3	0.95 (0.59,1.53)	0.836	1.22 (0.67,2.24)	0.511
Women’s education
Illiterate	1.00		1.00
Primary	1.63 (1.01, 2.64)	0.047	2.59 (1.43, 4.72)	0.002
Secondary and above	2.16 (1.24, 3.77)	0.006	4.41(2.02,9.63)	<0.001
Women’s occupation
Housewives	1.00		1.00
Agriculture	1.06 (0.70,1.61)	0.795	1.46 (0.84,2.52)	0.179
Daily wages worker	0.68 (0.35,1.33)	0.263	0.57 (0.25,1.29)	0.175
Husband’s occupation
Agriculture	1.00		1.00
Business and service	1.72 (0.90, 3.30)	0.104	2.55 (1.17,5.56)	0.019
Daily wages workers	1.20(0.70,2.06)	0.504	1.29 (0.58,2.85)	0.532
Foreign migrant worker	0.79 (0.49,1.29)	0.343	1.00 (0.49,2.02)	0.989
Income (monthly) in NRs
≤20000	1.00		1.00
>20000	0.81 (0.54,1.21)	0.311	0.67(0.36,1.21)	0.177
Knowledge of modern contraceptive methods
Poor knowledge	1.00		1.00
Good knowledge	1.73 (1.12, 2.66)	0.014	2.73 (1.66, 4.51)	<0.001
Ever visited a HF for FP counselling
No	1.00		1.00
Yes	3.49(2.17,5.60)	<0.001	4.40 (2.58,7.50)	<0.001

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Bold Significant at p< 0.05.

Discussion

The current study assessed the knowledge and practice of modern contraceptives among Muslim women. Most Muslim women had relatively good knowledge and poor practice of modern contraceptives. Knowledge of modern contraceptive methods was low among the women working in agriculture and living in nuclear families. The practice of modern contraceptives was poor among women with no education, husbands working in the agriculture sector, women having poor knowledge on modern contraceptive methods, and who have not visited a health facility for family planning counselling.

This study revealed that 69% of women had good knowledge of modern contraceptive methods. Past studies reported mixed results on knowledge of modern contraceptive methods in Nepal. For example, a previous study (2016) reported low (44%) knowledge on modern contraceptive methods among Muslim women in Nepal [34]. Another study showed relatively higher (94.5%) knowledge on modern contraceptive methods in Nepal [35]. About 87% of women knew contraceptive methods in India [42]. Exposure to FP information through mass media message dissemination, community HWs and Female Community Health Volunteers (FCHVs) in the study area might have helped acquire good knowledge of modern contraceptive methods.

Despite a high proportion of good knowledge on modern contraceptive methods, Muslim women have low practices of modern contraceptive methods in Nepal. Religious beliefs, societal pressure and fear of going against religious values could be a potential driving force of lower practices of modern contraceptive methods [43]. Our study’s finding is consistent with past studies conducted in Bangladesh [44], and India [45]. Injectable was the most practised modern contraceptive method, followed by oral contraceptive pills. Similar to our findings, previous research conducted in the eastern district of Nepal also reported injectables as the most used contraceptives (53.1%), followed by oral contraceptives (24%) [34]. Likewise, another study conducted in the Kapilvastu district in Nepal reported that injectable (51.3%) was the most commonly used contraceptive method, followed by oral contraceptives (25.6%) [19]. Injectables are the most preferred modern contraceptive methods among Muslim women in Nepal. Their popularity could be due to their simplicity, effectiveness for three months and accessibility even in private pharmacies at a low cost [46].

The knowledge of modern contraceptive methods was influenced by several socioeconomic factors such as family type and occupation of women. The current study revealed that women who lived in the nuclear family and were involved in agriculture had poor knowledge of modern contraceptive methods. The women belonging to a nuclear family may have limited exposure to other family members, resulting in less opportunity to obtain information about contraceptive methods. In addition, women involved in agriculture might lack access to information on contraception. The finding of this study is consistent with the study conducted in India [47]. However, previous studies in Nepal have reported no association between the type of family and knowledge of modern contraceptive methods [34, 35].

Several determinants such as education, nuclear family, good knowledge of contraceptive methods and access to counselling services were positively associated with the practices of modern contraceptive methods. Studies from Nepal [18, 34] and other Asian countries [48] have reported increased practices of modern contraceptive methods with increased education [18, 48]. The findings of the current study are consistent with the previous studies conducted in Nepal [34], Bangladesh [44], and India [45]. Illiterate women may have limited access to contraceptives, leading to a lack of awareness about the benefits of contraceptive use. Furthermore, those women may not openly discuss contraceptives with their spouses due to lower autonomy in marital relationships [26, 49]. Previous evidence showed that illiterate Muslim women became unaware of their reproductive rights and were reluctant to visit health facilities for FP services [16].

Similarly, this study identified women living in the nuclear family have good practices of modern contraceptive methods despite having poor knowledge. The women in the nuclear family may be less likely to be influenced by in-laws and other family members for FP decision-making and more freedom to uptake FP services. Likewise, In the nuclear family, a supportive environment for women may have encouraged them to use family planning services despite their lack of knowledge. Future research can explore the contributing factors of low knowledge but good practices among Muslim women from the nuclear family in Nepal.

Past evidence documented that having good knowledge of contraceptive methods may increase the practice of these contraceptives [26]. Our study also showed that women’s knowledge of modern contraceptive methods was related to their practice. Women with good knowledge were more likely to practice modern contraceptive methods than those with poor knowledge. This might be because women with good knowledge may know better about the benefits of contraceptive use. Therefore, it would increase the women’s decision making power for the practice of contraceptives [50].

Moreover, access to FP counselling was another factor affecting contraceptive practices in our study. Women who had ever visited a health facility for FP counselling were more likely to practice modern contraceptive methods than those who had not visited. Women who have ever visited a health facility for FP counselling might be aware of the benefits of contraceptive use. Therefore, they have favourable behaviour toward the practices of contraceptive methods. A similar study conducted from abroad reported consistent findings [51].

Programmatic implications

This study has highlighted some implications for policy and programs. First, the current study revealed a satisfactory level of good knowledge and poor practices of modern contraceptive methods. These women groups require accessible quality contraceptive choices. Some targeted interventions can be adopted and implemented to improve the knowledge and practice of modern contraceptives. Such interventions include Social Behaviour Change Communication (SBCC) initiatives to raise contraceptive awareness, embedding the Muslim values and culture and mobilising health workers (HWs) from their community.

Similarly, raising awareness and developing educational materials in Urdu for Muslim women and working to extend support for smaller family norms, providing counselling and advice about the contraceptive practice from the community and religious leaders. Moreover, this study suggests that the Ministry of Health and Population (MOHP) should design targeted program strategies for Muslim women based on a deeper understanding of needs, including religious and cultural recognition.

Strengths and limitations of the study

This study has some strengths. We have used pretested and well-designed questions and trained interviewers from the local community. The study has also explored the factors influencing the practice of modern contraceptive methods among most unreached groups. However, this study has some limitations: First, it was a survey design that did not provide us with inferences regarding causality. Second, some important covariates, such as distance to a health facility where FP service is available and cost that previous studies found important predictors of contraceptive practices, were not included in this study [52, 53]. Third, this study cannot be generalised to all populations as this study was conducted among Muslim women. Finally, though this study provided a cross-sectional analysis of knowledge and practices, a qualitative study can explore the underlying drivers of gaps in high knowledge and low practices of modern contraceptive methods among Muslim communities in Nepal.

Conclusions

The practice of modern contraceptive methods is relatively low despite having satisfactory knowledge among Muslim women. The poor knowledge and practice of modern contraceptive methods are seen especially among socially disadvantaged groups. Therefore, improving FP practices among Nepali Muslims needs integrated and focused health interventions. Such program interventions include health education and information dissemination, SBCC interventions, and mobilisation of health workers from the Muslim community. In addition, Focusing on SBCC interventions among socially disadvantaged groups and improving access to modern contraceptive methods could improve the practices of FP services among Muslims in Nepal. Moreover, the study suggests that future studies should look into the contributing factors of low knowledge but good practices of modern contraceptive methods among Muslim women from the nuclear family in Nepal.

Supporting information

S1 Data

(SAV)

Click here for additional data file.^{(41.1KB, sav)}

Acknowledgments

The authors would like to acknowledge the Khajura Rural Municipality and all the participants who participated in this study.

Disclaimer: Views presented in this article are solely those of the authors, and do not represent views, interest, or funded work of the organisations where authors affiliated.

Abbreviations

FP: Family Planning
FPAN: Family Planning Association of Nepal
NFCC: Nepal Fertility Care Center
IUCD: Intrauterine Contraceptive Device
SBCC: Social Behavior Change Communication
HW: Health Workers
FCHV: Female Community Health Volunteer
NHSS: Nepal Health Sector Strategy
MOHP: Ministry of Health and Population
PHCC: Primary Health Care Center

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0278899.r001

Decision Letter 0

Ai Theng Cheong

26 Apr 2022

PONE-D-22-08164Knowledge and practices of modern contraceptive among religious minority (Muslim) women: A cross-sectional study from Southern NepalPLOS ONE

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Results:

Was the knowledge score normally distributed? What was the cut off score for the good and poor knowledge? Please provide the results of knowledge score in mean, median and the minimum and maximum score.
Table 2 Kindly change the No and yes for knowledge contraceptive methods to poor (score <xx) and good (score >= xxx).
Table 3 Title: kindly specify determinants of good or poor knowledge

Pragmatic implications and conclusion

The suggestion in implication need to base on the results. This study did not show any results of male engagement, thus might not appropriate to introduce this in the pragmatic implications and conclusion.

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Reviewer #1: 1. Abstract: Data were collected using face-to-face semi-structured interviews. Semi-structured is for qualitative. Remove semi.

2. In Nepal, modern contraceptive services are provided from different outlets ranging from community to tertiary level (Figure 1). If this is, what is the real gap in your study?

3. Your method part is shallow; try to address the study period, data analysis...

4. Page- 5: Method part, 1st paragraph “Muslims in Nepal”. This is unclear. What is its importance? This sensitive issue (religious-based). Better if it’s addressed in the statement of the problem as a gap by linking with your objectives.

5. Page 5: Your sample size is 417, i.e. p-0.44 + 10% non-response rate= 417. How you said 400?

6. Page 6: Conceptual framework of the study. What is the importance? i.e. its repetition you have already in the discussion part. If it has justifiable importance, take it at the end of the introduction rather than in the method part.

7. Page 6: “Study variables”. Minimize it- put the main list of the variables.

8. Page 6: Outcome variables. Similarly, minimize it- as good/poor knowledge of modern contraceptive methods is assessed from 10 items and then we considered a score of mean and above ‘Good Knowledge’ and a score of below mean ‘poor knowledge [7, 36]. Do not list everything.

9. Adopted–adaptation

10. Result part: add the descriptive finding of 10 sets of questions related to knowledge about modern contraceptives

11. It needs an English edition

Reviewer #2: This article has potential for highlighting social, religion and cultural issue in family planning among the minority ethnic group of women.

Introduction: The objectives are not clear. Investigating the status of knowledge and practice need clarification. The justification and problem gaps were not clearly laid down. Why still study the practice status when there have been studies that demonstrated the low CPR among Nepal minority group?

Methods:

Information regarding the venue not clear- work office? Was it done from the hospital base or the central office of MWRA community?

Sample size calculation needs to demonstrate a recalculation that is based on the two dependant variables (not only practice base). I would also advise to use the two proportion sample size formula.

Discussion/ conclusion: Since this study was done among a minority Muslim women; unfortunately there is very little said regarding the role of religion and culture in the family planning practice. Why would there be a low practice despite an acceptable percentage of women with good knowledge. The author earlier mentioned about the inaccessible family planning services and also being the minority ethnic group how does this influence the status of familkyplanning knowledge and practice but nothing was discussed on thesis.

This article still need English editing

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Alemu Guta

Reviewer #2: No

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PLoS One. 2022 Dec 12;17(12):e0278899. doi: 10.1371/journal.pone.0278899.r002

Author response to Decision Letter 0

22 Jun 2022

June 5, 2022

Dear Editors-in-Chief

PLOS ONE

Thank you very much for your email with the decision dated April 26, 2022. We found that reviewers' and editor feedbacks were insightful. We have addressed both reviewers’ and editors' comments point by point. We have uploaded the revised manuscript showing track changes so that you can see all revisions and modifications we have made. We believe that our revisions will satisfy you and both reviewers. We have included a clean copy and track change copy of the revised manuscript.

Thank you for considering this manuscript for publication.

Sincerely,

Dipendra Singh Thakuri

On behalf of Yamuna KC Singh, Rajendra Karkee, Resham Bahadur Khatri

Editor

1. Was the knowledge score normally distributed? What was the cut off score for the good and poor knowledge? Please provide the results of knowledge score in mean, median and the minimum and maximum score.

Authors response: Thank you so much for your insightful comments. The knowledge score was not normally distributed; therefore, we employed to run logistic regression to identify the factors associated with the outcome variables of this study. We dichotomised the knowledge and practices scores based on previous studies using mean cut-off point. Below the mean score, we consider as poor knowledge and mean and above as good knowledge. Additionally, we have added results of knowledge scores in mean, median and the maximum and minimum scores in the page no. 9 of revised manuscript.

2. Table 2 Kindly change the No and yes for knowledge contraceptive methods to poor (score <xx) and good (score >= xxx).

Authors response: Thank you so much for your comments. We have changed it in the revised manuscript as suggested.

3. Table 3 Title: kindly specify determinants of good or poor knowledge

Authors response: Thank you so much for your comments. We have revised it as suggested in the revised manuscript. “The good and poor knowledge was determined by using mean cut-off point. We considered below the mean score as poor knowledge and mean and above as good knowledge.”

4. The suggestion in implication need to base on the results. This study did not show any results of male engagement, thus might not appropriate to introduce this in the pragmatic implications and conclusion.

Authors response: Thank you so much for your important feedback. We agree with you, and we have removed it?

Reviewer #1

1. Abstract: Data were collected using face-to-face semi-structured interviews. Semi-structured is for qualitative. Remove semi.

Authors response: Thank you for your suggestion. It was a typo error. We have corrected it.

2. In Nepal, modern contraceptive services are provided from different outlets ranging from community to tertiary level (Figure 1). If this is, what is the real gap in your study?

Authors response: Thank you so much for your comment. Despite the availability of FP services, our study population does not go or is very reluctant to take services from local health posts and health centres.

3. Your method part is shallow; try to address the study period, data analysis...

Authors response: Thank you so much for your comments. Our study period was between June and September 2019, described under the study design and setting section on page no. 6. Similarly, we have mentioned details about data analysis under the separate data analysis section on page no.8.

Authors response: Thank you so much for your important feedback. We have reviewed and moved the information to the Introduction part.

5. Page 5: Your sample size is 417, i.e., p-0.44 + 10% non-response rate= 417. How have you said 400?

Authors response: Thank you so much for your important comment. Non-response rate has been reported to be very low by various studies in Nepal, so we take a 5% non-response rate. Considering a 5% non-response rate, we calculated a sample size of 398, So we collected 400 as our final sample size. We have taken the reference of past studies to consider the non-response rate of 5%.

https://www.jnhrc.com.np/index.php/jnhrc/article/view/2244/939

Authors response: Thank you so much for your valuable comment. We have removed it as you suggested.

7. Page 6: “Study variables”. Minimize it- put the main list of the variables.

Authors response: Thank you so much for your suggestions. We have revised it as suggested.

Authors response: Thank you so much for your important feedback. We have revised it as suggested. Please see it in the page no. 7 of revised manuscript.

9. Adopted–adaptation

10. Result part: add the descriptive finding of 10 sets of questions related to knowledge about modern contraceptives.

Authors response: Thank you so much for your important comments. We have added descriptive findings of 10 sets of questions in the revised manuscript, see table 2 of the revised manuscript.

11. It needs an English edition

Authors response: Thank you so much for your comment. We have reviewed and edited the English language in the revised manuscript.

Reviewer #2:

This article has potential for highlighting social, religion and cultural issue in family planning among the minority ethnic group of women.

Authors response: Thank you so much for your comment. We have revised objectives and added information about problem gaps and justification in the introduction section.

Methods:

Information regarding the venue not clear- work office? Was it done from the hospital base or the central office of MWRA community?

Authors response: Thank you so much for your comment. It was a community based study, and data were collected at a community level. A face to face interview was carried out in the respondent’s household. We have described it in the methodology part on page no.8 of the revised manuscript.

Sample size calculation needs to demonstrate a recalculation that is based on the two dependent variables (not only practice base). I would also advise to use the two proportion sample size formula.

Authors response: Thank you so much for your insightful comments /suggestions. We appreciate your important suggestion. We considered practice as our main outcome variable, so we only considered sample size calculation using practice prevalence. We have taken the reference of past studies where a sample was calculated based on the one dependent variable (Practice). https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3643-3

http://pubs.sciepub.com/ajphr/5/1/1/

Why is the salary cut off at 20000? Why were the occupations divided as such?

Authors response: Thank you so much for your comment. We have taken reference of previously published literature for salary cut off and dividing occupations.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6510098/

http://www.aimspress.com/article/10.3934/publichealth.2019.3.291

Why doesn’t the "ever visit to hospital" not included inside the regression?

Authors response: Thank you so much for your comment. We have one variable regarding “ever visited a health facility for FP counselling” that we included inside the regression. Besides that, we didn’t have variables like ever visited hospital in this study, so we couldn’t include it.

Discussion/ conclusion: Since this study was done among a minority Muslim woman; unfortunately, there is very little said regarding the role of religion and culture in the family planning practice.

Authors response: Thank you so much for your comments. We have added details regarding the role of religion and culture in the revised manuscript (see the introduction, pages 3 and 4).

Why would there be a low practice despite an acceptable percentage of women with good knowledge. The author earlier mentioned about the inaccessible family planning services and also being the minority ethnic group how does this influence the status of family planning knowledge and practice, but nothing was discussed on thesis.

Authors response: Thank you so much for your comment. This mismatch between knowledge and practice shows knowledge always does not translate to practice because of other barriers, for example, cultural and economic reasons. We have discussed it in “Discussion”.

Any different characteristics between ref 31, 40, 41, 42 and this study?

Authors response: Thank you. These are studies from different settings, i.e., Nepal, India, Bangladesh, and other countries. Ref. 31 is a study conducted among Muslim women from eastern Nepal. Furthermore, Ref. 40-42, similar studies from abroad (India, Bangladesh, and other countries), so the context of these studies differs from this study.

This article still needs English editing

Authors response: thank you so much for your suggestion. We have reviewed and edited English.

We would like to thank editor and both the reviewers for their insightful comments and feedback. Thank you so much for inviting us to revision of this manuscript.

Dipendra Singh Thakuri, on behalf of all co-authors

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Submitted filename: Response to Reviewers.doc

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PLoS One. doi: 10.1371/journal.pone.0278899.r003

Decision Letter 1

Ai Theng Cheong

11 Aug 2022

PONE-D-22-08164R1Knowledge and practices of modern contraceptive among religious minority (Muslim) women: A cross-sectional study from Southern NepalPLOS ONE

Dear Dr. Thakuri,

==============================Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

For Lab, Study and Registered Report Protocols: These article types are not expected to include results but may include pilot data.

==============================

Please submit your revised manuscript by Sep 25 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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We look forward to receiving your revised manuscript.

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Ai Theng Cheong

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Abstract

Conclusion

Suggest remove ‘Such interventions include mobilisation of health workers (HWs) from their community, and awareness of contraceptive methods embedding with values and culture of the Muslim religion.’ This would be more appropriate in discussion section.

Methodology

You have mentioned that the knowledge score is not normally distributed, if it is so, it might be more appropriate to use the median as the cut-off point. I can see that the mean and median are close i.e 6.9 vs 7, it is likely to be normally distributed, could you please check.

Table 3:

Title: From your explanation and interpretation of the results, it looks like your interest group for your knowledge outcome is ‘good knowledge’. If it so, the title should be determinants of good knowledge….., so the aOR less than 1 is considered as having poorer knowledge. Please check your interpretation and your analysis.

For value that <0.00, please change to <0.001. Kindly check through all values

Discussion

First paragraph: Please check the interpretation and the facts for those lived in nuclear family in terms of their knowledge and practice.

It is worth to add in a paragraph to discuss about those who lived in nuclear family regarding their poor knowledge but higher practice of FP.

Pragmatic implications

Could you please focus your intervention based on your results i.e. targeted the factors that could improve your practice based on your results (which is how to increase the knowledge in Muslim women, and intervention that could address this factor ‘ever visited a HF for HP counselling’).

The following facts need to be reorganised and relate it to the factors that you have found to influence your practice.

“These women groups require accessible quality of contraceptive choices. The concept of roving midwives service providers can be adopted and implemented to offer counselling and FP services at doorsteps. Second, some targeted Social Behaviour Change Communication (SBCC) can improve the

awareness of contraceptives, and practices include mass media mobilisation programs coherent with their religious values and promote them for FP services. Third, contraceptive practices can be improved through several demand and supply-side strategies. Supply-side approaches could be the recruitment of local HWs and FCHVs from the Muslim community. The local health workforce of the Muslim community can encourage them to practice contraceptives. Fourth, demand-side approaches could raise awareness and develop education materials in Urdu for Muslim women and work to extend support for smaller family norms, providing counselling and advice about the contraceptive practice from the community and religious leaders. Other approaches such as mobile camps, satellite camps, and home visits could be essential to promote the contraceptive practice. Lastly, this study suggests that the Ministry of Health and Population (MOHP) should design targeted program strategies for Muslim women based on a deeper understanding of needs, including religious and cultural recognition”

Conclusion

The following would need to reorganise or rephrase after you have tidied up the discussion on the section of pragmatic implications : ‘To improve FP practices among Muslims in Nepal needs integrated and focused health interventions. Such program interventions include health education and information dissemination, SBCC interventions, mobilisation and home visits using local midwives, advice and supplies, and male mobilisers to reach out to Muslim men. In addition, the provision of FP services in mobile and satellite health camps could improve the practices of FP services among Muslims in Nepal.’

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

Reviewer #1: Thank you, the author, for your effort. The previously raised comments are addressed well. On the methods and all via out the manuscript.

Reviewer #2: Hi;

The Manuscript is much improved. However there are still a few sentences that have typo error and grammatically not correct. Some of the sentences are hanging. SO still need some work on English editing

2. There are 2 tables 3; need to redefine

3. Table 3 is cute crowded; suggest to separate the factors associated with knowledge and factors associated with practice. The narrative part can be improved by this separation.

4. The interpretation of table 4 regarding nuclear family predicting contraceptive use is inaccurate.

The discussion; sentence 4:

The practice of modern contraception is poor among women who lived in a nuclear family. But the OR for nuclear family in practising FP is 4.4

5.I feel that there is a lot to look at on how we can target women coming from nuclear family that can be elaborated.

6. Conclusion: some of the conclusions do not come from the data. such as the male mobiliser or cultural factors.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Alemu Guta

Reviewer #2: No

**********

PLoS One. 2022 Dec 12;17(12):e0278899. doi: 10.1371/journal.pone.0278899.r004

Author response to Decision Letter 1

14 Oct 2022

October 14, 2022

Dear Editors-in-Chief

PLOS ONE

Thank you very much for your email with the decision dated Aug 12, 2022. We found the reviewers' and editor's feedback and comments insightful. We have carefully addressed both reviewers’ and editor’s comments point by point. To facilitate your review, we have uploaded the revised manuscript in track change and clean versions so that you can see all revisions and modifications we have made. We believe that our revisions will satisfy you and both reviewers.

Thank you in advance for considering this manuscript for publication.

Sincerely,

Dipendra Singh Thakuri

On behalf of all co-authors

Additional Editor Comments:

Abstract

Conclusion

Authors' response: Thank you so much for your insightful suggestions. We've moved it from the conclusion section to the discussion section. (Page # 19)

Methodology

Authors response: Thank you so much for your important suggestion. We have used median as the cut-off point as advised.

Table 3:

Title: From your explanation and interpretation of the results, it looks like your interest group for your knowledge outcome is ‘good knowledge’. If it so, the title should be determinants of good knowledge…., so the aOR less than 1 is considered as having poorer knowledge. Please check your interpretation and your analysis.

For value that <0.00, please change to <0.001. Kindly check through all values

Authors response: Thank you so much for your great comments. We have reviewed and revised it as advised. For a value that <0.00, we have changed it in the revised manuscript.

Discussion

First paragraph: Please check the interpretation and the facts for those lived in nuclear family in terms of their knowledge and practice.

It is worth to add in a paragraph to discuss about those who lived in nuclear family regarding their poor knowledge but higher practice of FP.

Authors response: Many thanks for your suggestions. We have addressed this in the discussion part of the revised manuscript. (Page # 18-19)

Pragmatic implications

The following facts need to be reorganised and relate it to the factors that you have found to influence your practice.

Authors' response: Thank you so much for your valuable comments. We have reviewed and revised this section based on our study findings. (Page# 19)

Conclusion

The following would need to reorganise or rephrase after you have tidied up the discussion on the section of pragmatic implications: ‘To improve FP practices among Muslims in Nepal needs integrated and focused health interventions. Such program interventions include health education and information dissemination, SBCC interventions, mobilisation and home visits using local midwives, advice and supplies, and male mobilisers to reach out to Muslim men. In addition, the provision of FP services in mobile and satellite health camps could improve the practices of FP services among Muslims in Nepal.’

Authors response: Thank you for your comment. We have revised it based on the revision made in the discussion on the section on pragmatic implications. (Page# 20)

Reviewer #1:

Thank you, the author, for your effort. The previously raised comments are addressed well. On the methods and all via out the manuscript.

Authors response: We thank the reviewer for their great comments.

Reviewer #2:

Hi;

The Manuscript is much improved. However, there are still a few sentences that have typo error and grammatically not correct. Some of the sentences are hanging. SO still need some work on English editing

Authors response: Thank you so much for your comments. We have checked the typo error and grammar throughout the manuscript and edited English.

2. There are 2 tables 3; need to redefine

3. Table 3 is cute crowded; suggest separating the factors associated with knowledge and factors associated with practice. The narrative part can be improved by this separation.

Authors response: Thank you so much for pointing this out. We have addressed this in the revised manuscript. Also, we have separated the knowledge and practice table as suggested, and the narrative part was revised accordingly (Page# 14-16)

4. The interpretation of table 4 regarding nuclear family predicting contraceptive use is inaccurate.

Authors response: Thank you for your comment. We have rechecked the interpretation of table 4 regarding nuclear family and contraceptive use, and it seems fine.

The discussion; sentence 4:

The practice of modern contraception is poor among women who lived in a nuclear family. But the OR for nuclear family in practising FP is 4.4

Authors response: Thank you so much for your important comment. It was a typo error. The women who lived in a nuclear family had good FP practice. We have corrected it in the revised manuscript. (Page #17)

5.I feel that there is a lot to look at on how we can target women coming from nuclear family that can be elaborated.

Authors' response: We have added some recommendations regarding this in the programmatic implication section of the revised manuscript.

6. Conclusion: some of the conclusions do not come from the data. such as the male mobiliser or cultural factors.

Authors response: Thank you so much for your comments. We have revised the conclusion as advised. Page #20)

We want to thank the editor and both reviewers for their insightful comments and feedback. Thank you so much for inviting us to revise this manuscript.

Dipendra Singh Thakuri, on behalf of all co-authors

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Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(93.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0278899.r005

Decision Letter 2

Ai Theng Cheong

28 Nov 2022

Knowledge and practices of modern contraceptive among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

PONE-D-22-08164R2

Dear Dr. Thakuri,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ai Theng Cheong

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #2: Dear authors, You have addressed all my comments.

The introduction puts the issue into correct perspective.

The results are arranged systematically and coherently narrated.

Nevertheless, I have a few suggestions that may make this article more meaningful.

Strength:

Please add that this study received help from the Muslim community as the interviewers and approval from the religiousleaders. This ensure higher participation from the respondents. This also could reflect in the conclusion that what these women (especially ones from the socially and economically disadvantaged group) require to practice contraception, may not be solely about having to increase knowledge but more of the support of various parties including the Muslim community and the religious leaders.

The higher practices of contraception use among women from nuclear family and those who have had visits to the healthcare reflect the empowerment these women have regarding decision making. Hence, further research is needed how they made the decisions to use contraception. A qualitative approach would be fitting to address this.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********

PLoS One. doi: 10.1371/journal.pone.0278899.r006

Acceptance letter

Ai Theng Cheong

2 Dec 2022

PONE-D-22-08164R2

Knowledge and practices of modern contraceptives among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

Dear Dr. Thakuri:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ai Theng Cheong

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Data

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Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Knowledge and practices of modern contraceptives among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

Dipendra Singh Thakuri

Yamuna K C Singh

Rajendra Karkee

Resham B Khatri

Roles

Abstract

Background

Methods

Results

Conclusion

Introduction

Policy and services delivery context of family planning program in Nepal

Fig 1. Types and delivery outlets of modern contraceptives in Nepal.

Methods

Study design and setting

Sampling and participants selection

Study variables

Outcome variables

Data collection tools and techniques

Data analysis

Ethical approval

Results

Table 1. Background characteristics and modern contraceptive methods, knowledge, and practices of Muslim women (N = 400) in Nepal.

Table 2. Descriptive findings of knowledge related to modern contraceptives among Muslim Women, Banke, Nepal, 2019 (N = 400).

Table 3. Factors associated with knowledge and practices of modern contraceptive methods among Muslim women (N = 400) in Nepal.

Table 4. Determinants of good knowledge on modern contraceptive methods among Nepali Muslim women (N = 400).

Table 5. Determinants of good practices of modern contraceptive methods among Nepali Muslim women (N = 400).

Discussion

Programmatic implications

Strengths and limitations of the study

Conclusions

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Ai Theng Cheong

Roles

Author response to Decision Letter 0

Decision Letter 1

Ai Theng Cheong

Roles

Author response to Decision Letter 1

Decision Letter 2

Ai Theng Cheong

Roles

Acceptance letter

Ai Theng Cheong

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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