Background <p>Fertility intentions or desires for future childbearing are necessary variables in understanding reproductive behavior, particularly in transitioning societies like Nepal. Despite a national decline in fertility rates, regional disparities persist, notably in Madhesh Province, where socio-economic and cultural barriers remain entrenched. This study explores the socio-economic and demographic factors influencing fertility intentions among women of reproductive-age in Madhesh Province.</p> Methods <p>A cross-sectional analysis of secondary data from Nepal Demographic Health Survey (NDHS) 2022 was conducted. This study concentrated on women aged 15–49&#xa0;years and residing in Madhesh, selected through a multistage stratified sampling approach. A weighted sub-sample of 1,643 women was analyzed using descriptive statistics and binary logistic regression to explore the determinants of fertility intentions.</p> Results <p>Age emerged as the strongest predictor: younger women (15–24&#xa0;years) exhibited significantly higher fertility intentions than older cohorts. Parity showed a significant negative association with fertility intentions, with higher parity linked to lower desire for more children. Rural women had 33% lower odds of desiring more children compared to urban women. Initial associations with wealth, education, and caste/ethnicity were not significant after adjustment, while media exposure (especially newspapers) inversely correlated with fertility desires. Occupation, religion, and partner's education showed negligible effects.</p> Conclusion <p>Fertility intentions in Madhesh Province are predominantly shaped by age, parity, rural–urban disparities, and media exposure. Interventions should prioritize the dissemination of reproductive health information through print media and the development of youth-friendly, rural-sensitive family planning programs.</p>