**Background:** Fertility and family planning decision-making in Nepal is heavily shaped by social norms, particularly for newly married women who face pressure to prove fertility early in marriage. Approximately half of newly married women in Nepal become pregnant within one year of marriage, and 34–59% of pregnancies are unintended. Despite legal abortion since 2002, awareness remains low. Household decision-making is often shared across generations, yet few interventions engage intact household groups. The Sumadhur intervention was developed to address these gaps by engaging newly married women, their husbands, and mothers-in-law together.
**Methods:** Sumadhur was piloted from January through May 2021 in six villages across one rural (Palhinandan) and one urban (Sunwal) municipality in Nawalparasi District, Nepal. The study enrolled 30 household triads (90 participants total: 30 newly married women, 30 husbands, 30 mothers-in-law). Two husbands emigrated during the intervention, leaving 28 at endline. The intervention consisted of weekly group sessions over four months covering nutrition, anemia, prenatal health, gender norms, fertility planning, contraception, and household dynamics. Pre/post surveys were administered to all participants. Paired sample non-parametric tests (Wilcoxon Signed-Rank) were used to analyze quantitative changes. In-depth qualitative interviews were conducted with a subset of 45 participants (all three members from 15 randomly selected households) approximately three months post-intervention due to COVID-19 restrictions. Interviews were conducted in Awadhi by trained female Nepali researchers, transcribed, translated to English, and analyzed thematically using Dedoose.
**Key Results:** Significant changes were observed across multiple domains. For norms on fertility: agreement that it is wrong to use contraception before the first birth decreased from 70% to 57% overall, with significant shifts among women (p=0.015) and husbands (p=0.017). However, 20% more husbands strongly agreed with this statement at endline, indicating a counter-directional shift. Norms on pregnancy spacing improved significantly across all groups: women (p=0.009), husbands (p<0.001), and mothers-in-law (p=0.031). The proportion agreeing it is wrong to use contraception to space pregnancies dropped from 29% to 6% overall. Norms on sex preference shifted significantly among mothers-in-law (p=0.016), with qualitative data indicating reduced son preference. Norms on family size did not change significantly. For decision-making norms, only one measure showed statistical significance: newly married women's perception that husbands should decide the total number of children (p=0.048), though the direction was mixed. Individual intentions to use contraception increased from baseline: 93% of women reported intent at endline (p=0.008), and 90% of husbands (p=0.125). Knowledge outcomes improved substantially: identification of at least one benefit of birth spacing increased by 20% among women (p=0.031), 60% among husbands (p<0.001), and 17% among mothers-in-law (p=0.125). Correct identification of permanent contraceptive methods increased by 33% among women (p=0.001), 50% among husbands (p=0.002), and 20% among mothers-in-law (p=0.031). Knowledge that abortion is legal in Nepal increased dramatically: +70% among women (p<0.001), +40% among husbands (p<0.001), and +68% among mothers-in-law (p<0.001). Ever use of contraception increased by 13% among women and 17% among husbands, though neither was statistically significant. During the 4-month intervention, 37% of newly married women reported becoming pregnant. Qualitative findings revealed persistent tension between personal beliefs favoring delayed childbearing and perceived societal pressure for early pregnancy. Participants described improved family dynamics, increased couple communication, and reduced son preference. Mothers-in-law reported shifting from pressuring for early pregnancy to supporting delayed childbearing for education or employment.
**Clinical Implications:** The Sumadhur intervention demonstrates that engaging household triads can shift entrenched social norms around fertility and family planning in a relatively short period (4 months). The dramatic improvements in knowledge about abortion legality are particularly significant given that only 41% of Nepali women aged 15–49 were aware of this in national surveys. The findings support scaling up household-level interventions that address both individual beliefs and perceived community norms. However, the persistence of gender norms around male decision-making suggests that longer-term or complementary strategies may be needed. The intervention's success in reducing son preference and improving pregnancy spacing knowledge has direct implications for maternal and child health outcomes. The authors recommend that Nepal's Ministry of Health incorporate pre-pregnancy interventions with gender norms components into national women's health strategies.