Thursday 31 May 2012



Unmet need for family planning and persisting unintended fertility: Evidence from India

Dr. Devendra Kothari

Population and Development Analyst
Forum for Population Action

Today, around 50% of currently married women (ages 15-49) in India use or whose sexual partners use any form of modern contraception. In 1980, that figure was less than 25%.  Despite this dramatic increase, about one in eight married women still has an “unmet  need” for family planning: that is, she  wants to postpone her next pregnancy or stop having children altogether but, for whatever reason, is not using contraception. As a consequence, 6 million women in India still experience unintended pregnancies each year; and around 4 million resorts to unsafe abortions as per the World Health Organization. It is estimated that currently there are around 450 million people in India out of 1200 million who are product of unintended/unplanned pregnancies, and most of them are from the lower economic strata. The consequences of such an unwanted fertility are serious, slowing down the process of socio-economic development[1]. India’s policy makers have not recognized important linkages between large unwanted fertility and sustainable development.  The post uses   data from three consecutive rounds of the National Family Health Surveys (NFHSs)[2] to argue its point.  The post argues that high level of unmet need is a major cause of unintended/unwanted fertility, which is mainly responsible for chaotic governance and policy paralysis.

The concept of unmet need was developed more than 35 years ago[3]  and has been refined several times over the years. The concept was highlighted first time in India in a study conducted by the author in Rajasthan in 1988 on behalf of Ministry of Health and Family Welfare, Government of India[4]The National Family Health Survey  defines unmet need for family planning as the proportion of currently married women who are not using any method of family planning but do not want any more children (unmet for limiting) or prefer to space births for at least two years (unmet need for spacing). The sum of the two is the total unmet need for family planning.  An analysis of NFHS data reveals that the unmet need of family planning has declined from 15.8% in 1998-99 to 12.8% in 2005-06, but it is very high.

The results of NFHS-3 show that most of the unmet need women (or eligible couples) were enumerated in the Four Large North Indian (FLNI) States of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh and overwhelming wanted to limit their fertility, as shown in Table 1. Around 70% of India’s unmet need was recorded in these States. In fact, Bihar recoded the highest unmet need for family planning (23%), followed closely by Uttar Pradesh (21%) among the major States of India.

Table 1: Unmet need for modern contraceptives in India, 2005-06
Category
Total number of Currently married women
(In million)
Currently married women using any modern methods
(In million)
Total currently married women having unmet need for modern methods
(In million)
Per cent
FLNI States
69
25
8.6
69.9
Rest of India
119
66
3.7
10.1
Total
188
91
12.3
100.0
Source: Devendra Kothari and Sudha Tewari. 2009. Slowing Population Growth in India : Challenges, Opportunities and the Way Forward, MUPD Policy Brief No. 2, Management Institute of Population and Development, a unit of Parivar Seva  Sanstha, New Delhi.

Table 2 indicates that unmet need decreases sharply with age. Younger women (15-19) have a greatest unmet need; especially for spacing methods.  For the older women (35 -49), the   reverse pattern is evident. Unmet need for family planning varies by women’s education, but only within a narrow range, however, unmet need for limiting decreases significantly with education. The unmet need for limiting is highest for women with no education.  Rural women have a higher unmet need than urban women for spacing as well limiting. Total unmet need for family planning is substantially greater among Muslim women as compared to their Hindu counterparts. Further, unmet need especially for limiting methods decreases significantly with an increase in economic status.  These background findings indicate that the family planning program’s strong emphasis on limiting methods results in failure to meet the spacing needs of younger couples who are still in the process of forming their families.

Table 2: India- Need for family planning among currently married women by background characteristics
Background characteristics
% of married women having unmet need for family planning
NFHS-1 (1992-93)
NFHS- 2 (1998-99)
NFHS-3 (2005-06)
Total
Spacing
Limiting
Total
Spacing
Limiting
Total
Spacing
Limiting
Age Group:
·         15-19
·         35-39

30
14

28
02


02
12

28
10

26
01

02
09

27
08

25
01

02
07
Education:
·         Illiterate
·         High school +

20
18

11
11

09
07

16
15

08
09

08
06

14
12

06
07

08
05
Residence:
·         Urban
·         Rural

17
20

07
12

08
08

14
17

07
09


07
08

10
14

05
07

05
07
Religion:
·         Hindu
·         Muslim


19
26

11
13

08
13

15
22

08
11

07
11

12
19

06
09

06
10
Economic Status:
·         Lowest
·         Highest


NA
NA

NA
NA

NA
NA

18
13

09
07

09
06

18
08

08
04

10
04
Total
20
11
09
16
08
08
13
06
07
National Family Health Survey - 1, 2, and 3, IIPS, Mumbai.

Available data indicate that there is limited progress towards converting unmet need into demand in India. There are many reasons why women do not use modern methods of contraceptives. Major barriers to reducing unmet need for contraception persist for various reasons:

·         Inadequate knowledge of contraceptive methods and incomplete or erroneous information about where to obtain methods and how to use them.
·         A woman does not believe she is at risk of getting pregnant, or she is concerned about health risks and side effects.
·         Contraception is not readily available or too inconvenient to use or the range of available methods is limited. For example, Injectable Contraceptives (ICs) are available in more than 106 countries and they are popular especially among the Muslim women and working women belonging to low economic strata; however they are not the part of the public sector family planning program in India even after nearly two decades of discussions and scientific trials[5].
·         The woman, her partner, or other close family members are opposed to family planning methods or religious strictures against family planning.

It is interesting to note that more and more women today choose not to use available public sector modern contraception because they are concerned about the health risks and side effects of various methods, or they find available contraception too inconvenient to use. Around 21% of married women in 1995 cited one of these method-related reasons, but 29% of women recently said the same in the study conducted by author in Rajasthan[6]. This suggests that, although programs have been successful in educating women about their family planning options, a number of both perceived and real risks associated with some forms of contraception continue to prevent use.  

The right to decide freely and responsibly the number and spacing of children and to have the information, education and means to do so is well recognized as an important component of reproductive rights. Contraceptives enable men and women to exercise these rights. Modern technology has provided us with a range of contraceptive choices. The distribution pattern of usage of various methods to prevent pregnancies is called method mix. India is unique in that female sterilization is the predominant method, since it is aggressively promoted by the program. Sterilization accounts for roughly 80% of all modern contraceptive methods used. Less than 20% of currently married women use the officially sponsored spacing methods (pills, IUD and condoms).  Further, there is no significant change in the so called “method mix” since the introduction of contraceptive pills in the program in the eighties. It appears that India’s family planning program has largely failed to encourage the use of reversible methods, particularly among young women (age 15-25) who are in the most fertile years of their reproductive period. And there is urgent need to promote convenient and effective spacing methods like ICs.

While India’s population continues to grow by 16-17 million people annually, 13 million women, mostly belonging to the “bottom of the pyramid” seek to postpone childbearing, space births, or stop having children, but are not using a modern method of contraception. Often, these women travel far from their communities to reach a health facility, only to return home “empty handed” due to shortages, stock outs, and/or non availability of doctors and paramedical staff. When women are thus turned away, they are unable to protect themselves from unwanted/unplanned pregnancies and sexually transmitted infections, including HIV/AIDSs. Further, most women and men do not have access to a wide choice of contraceptives, particularly those who are dependent on the public sector. And this type of incomplete control over the reproductive process leads to relatively high levels of unwanted childbearing.

Despite improved availability and access to contraceptive services, a substantial proportion of pregnancies (21% of all pregnancies that result in live births) are mistimed or unplanned. Around 26 million children are born in India every year and out of this about 5.5 million births have been classified as unplanned/unintended in 2005-06. Further, based on the National Family Health Survey-3[7], it is estimated that   about 30 per cent or around 218 million people in the age group 0-35 years in India was the product of unwanted childbearing. The level of unwanted fertility in this age group has increased from 23 per cent in 1992-93 to 30 percent in 2005-06. It is mainly due to slow conversion of unmet need into acceptance, as shown in Table 3.

Table 3 India:  Level of unplanned /unwanted fertility, 1992-2006
Item
1992-92
1998-99
2005-06
Unplanned  pregnancies
Per cent of unplanned births
23.1
21.6
21.0
·         Unplanned Births (in million)
5.8
5.8
5.5
Unwanted fertility
Per cent of unwanted  fertility
22.1
25.5
29.6
·         Persons in age 0-35 resulting from  unwanted fertility (in million)
140
178
218
 Based on data obtained from National Family Health Survey 1, 2 & 3 and Sample Registration Bulletins. For details, see: Kothari, Devendra. 2010.  “Empowering women in India through better reproductive healthcare”, FPA Working Paper No 5, Jaipur: Forum for Population Action.

The consequences of unwanted fertility are serious, slowing down the process of socio-economic development. It is because unwanted childbearing results in poor physical growth, reduced school performance, diminished   concentration in daily tasks thus impacting work capacity and work output resulting in diminished earning capacity. The impact of unwanted childbearing is reflected in widespread hunger, poverty, unemployment as well as increasing scarcity of basic resources like food, water and space in several parts of India despite concerted developmental efforts since 1991. India’s large unwanted fertility, a threat to sustainable development, demands immediate attention.  In other words, India has to take steps to reduce the incidence of unwanted fertility by concentrating unmet need, otherwise the country would be down to “Hindu” rates of growth, and therefore would have to bid goodbye to any prospects of pushing the growth rate or making a serous dent on poverty.

One has to recognize that the concept of unmet need is realistic one and substantial amount of unmet need can be converted into demand and acceptance with proper management of family planning program[8]. Improving the management of the program and introducing effective strategies for capturing the unmet need for family planning services can push India towards the till now elusive goal of population stabilization.


[1] For details, see:  Devendra Kothari, “To beat the gloom, India needs to focus on real issues”, January 31, 2012 at link: kotharionindia.blogspot.com .
[2] India: National Family Health Survey- 1 (1992-93), 2 (1998-99) and 3 (2005-06), IIPS, Mumbai.
[3] For details, see: CF Westof, The unmet need for birth control in five Asian countries. Family Planning Perspectives, 1978; 10(3):173–181. Also see:  John B. Casterline and Steven W. Sinding, "Unmet Need for Family Planning in Developing Countries and Implications for Population Policy," Policy Research Division Working Paper 135 (2000).
[4] For details, see: Devendra Kothari, Family Planning Programme in Rajasthan: beyond the Existing Approach, Indian Institute of Health Management Research, Jaipur, 1989.  The study was supported by the Ministry of Health and Family Welfare, Government of India,

[5] For details, see: Devendra Kothari, “Controversy over Injectable contraceptives in India: How to resolve it? August 1, 2011. Also see: The revolutionary new birth control method for men and India’s lukewarm response, October 10, 2011 at link: kotharionindia.blogspot.com .
[6] For details, see: Kumar Vikrant, Aniraban Rudra, Anoop Khanna and Devendra Kothari, 2005, “Unmet need for family planning and its conversion into demand and acceptance: Some operational issues”. FPA Working Paper, Forum for Population Action, Jaipur

[7]India: National Family Health Survey (NFHS-3), 2005-06, IIPS, Mumbai, 2007.
[8] Devendra Kothari, Anopp Khanna &  Shameem Abbasy.  1997. “Operationalsing  the Concept of Unmet Need  for Family Planning  Services: A case Study”, Policy Brief 1, Indian Institute of Health Management Research ,Jaipur

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