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
