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«DEMAND FOR CONTRACEPTION IN EAG STATES OF INDIA: FAMILY PLANNING STRATEGIES TO MEET THE UNMET NEED S. C. Gulati* and Ayusmati Das** ABSTRACT The ...»

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Health and Population -

Perspectives and Issues 36 (3 & 4), 115-132, 2013

DEMAND FOR CONTRACEPTION IN EAG STATES OF INDIA:

FAMILY PLANNING STRATEGIES TO MEET THE UNMET

NEED

S. C. Gulati* and Ayusmati Das**

ABSTRACT

The study highlights factors influencing demand for contraception

for spacing as well as limiting births in Empowered Action Group (EAG) states of India. Data on socio-economic, demographic and programme factors affecting demand for contraception have been drawn from the third National Family Health Survey (NFHS-3), 2005-06. The survey covered all the 29 states in India accounting more than 99 per cent of India’s population. This study is confined to eight EAG states viz. Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Odisha, Jharkhand, Uttarakhand and Chattisgarh. The primary data pertain to 30285 currently married women aged 15-49 years in the EAG states. The Multinomial Logit Regression analysis has elicited relative significance and directions of effects of the selected socio-economic and demographic variables on the four components of demand for contraception viz. unmet and met need of contraception for spacing and limiting births.

Multiple classification analysis suggests that strengthening of IEC component on family planning needs to be prioritized, misapprehensions on side-effects and health risks of contraception, alleviation of son-preference in the society, improvement in girls’ enrolment in schools and women’s education, women’s gainful employment, mandatory implementation of legal age at marriage, reduction in infant and child mortality, involvement of village level health functionaries like ANMs, ASHAs, LHVs, etc.

would not only reduce the unmet need but also enhance demand for contraception in the demographically backward EAG states of India. Rather simultaneous efforts on the supply-side along with demand-side factors influencing contraception would facilitate faster reduction in fertility and hasten the process of demographic transition and population stabilization in the EAG states of India.

Key words: Unmet need, Met need, Contraception, Birth-spacing, Limiting births, Women empowerment, Multinomial logit regression, Multiple classification analysis.

*Senior Consultant, **Data Analyst; Policy Unit, Department of Planning and Evaluation, NIHFW, Munirka, New Delhi-110067 115 The role of contraception in fertility regulation has always been crucial to the success of historical as well contemporary fertility control. The advent of effective contraception madefertility a choice in most of the socio-economic theoretical frameworks that evolved during the Sixties and Seventies. However, most empirical studies have aptly demonstrated that contraception had always been the most significant catalytic factor and cost-effective strategy for fertility regulation1.

Major paradigm shifts in India’s population policies have occurred after the International Conference on Population and Development in Cairo in 1994. The earlier method-mix target-oriented approach had shifted to a client-centered demand-driven approach to reproductive and child health. This new approach was enshrined in the National Population Policy 2000, with tangential reference to fertility control. The policy calls for a vigorous promotion of the small family norm to achieve the replacement levels of fertility by 2010. Official efforts have succeeded in averting about 443 million births till 2010-112.

More importantly, using contraception to curtail fertility has been stressed for accelerating population stabilization in developing countries3-4. The extent of unintended pregnancies, that is, unwanted or mistimed ones, is still around one in four worldwide5. Reducing the unmet demand for contraception would help couples achieve their reproductive goals and reduce unintended pregnancies that lead to abortions and unwanted births, both of which are unacceptably high in many developing countries6-7. One particular harmful consequence of unintended pregnancies is unsafe abortion leading to high rates of maternal morbidity and mortality in less/under-developed countries. An estimated 18 million unsafe abortions take place in these countries annually, resulting in high rates of maternal death and injury in these regions8. Conceptual modifications to the measurement of unmet need for contraception have brought forth a lot of literature recently9-11.

Unwanted fertility is likely to be nearly non-existent at the two extreme stages of transition- initially when fertility desires are mostly unrestricted; and at the end of the transition, when couples have nearly complete control over their fertility12.

Reducing the unmet need for contraception is also important for helping couples achieve their reproductive goals and enhancing well being of women and children7 and may help in reducing unintended pregnancies that lead to abortions and unwanted births; both of which are unacceptably high in many developing countries6. Interestingly, unwanted fertility or proportion of unwanted births was discerned to be low in countries with very low or very higher levels of fertility and highest in countries with intermediate levels of fertility13-14. One particularly harmful consequence of unintended pregnancies is unsafe abortion.





However, promotion of contraception as a fertility regulation strategy seems to have been pushed to the back in India in late 1990’s, especially since ICPD conference in 1994, despite the fact that almost all the empirical studies had demonstrated that contraception had always been the most significant catalytic 116 factor and cost-effective strategy for fertility control in almost in all circumstances.

Nevertheless, a report submitted by the working group on population stabilization constituted by the Planning Commission of India has aptly concluded that there appears to be an urgent need for bringing back promotion of contraception as the main concern of Family Welfare programmes in the high fertility states of India and thus, the couples’ felt-need for contraception should be fully met15. According to National Rural Health Mission (NRHM) 2013, the total unmet-need for family planning in India as per DLHS estimates was still around 21.3 per cent in 20070816.

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OBJECTIVES

The study intends to analyze the factors influencing different components of the total demand for contraception viz. met as well as unmet-need for spacing as well as limiting births in demographically backward empowered action group (EAG) states of India. For the purpose, some selected socio-economic, demographic and programme factors affecting met and unmet need for contraception in India have been studied. Identification of the key contributing factors and their relative significance in impacting the different components of the total need of contraception would be elicited using multinomial logit regression analysis.

Multiple classification analysis would elicit likelihood or probabilities of met and unmet need of contraception for spacing and limiting births; and nonuse of contraception methods for women with different socio-economic and demographic parameters.

METHOLODOGY

The third National Family Health Survey (NFHS-3) collected detailed information on fertility, mortality, family welfare, and important aspects like nutrition, sexual behaviour, domestic violence, adolescent reproductive health, testing of adult population for HIV, etc. Primary data from 29 states comprising about 99 per cent of India’s population and union territories of the country got collected from 109041 households, 124385 women aged 15-49 years, and 87925 currently married women aged 15-49 years who cohabiting with their husbands17. This study tries to elicit the effects of selected socio-economic and demographic factors on met and unmet-demand for contraception in the EAG states of India. Hence, data on non-users and users of contraception pertains to 30285 currently married women aged 15-49 years in the EAG states. The detailed definitional aspects of unmet and met need for spacing as well as limiting births are provided in the third National Family Health Survey (NFHS-3) report, conducted in 2005-0617.

This study employs the multinomial logit regression analysis to highlight the important predictors of met and unmet-demand for contraception. The response 117 variable has been categorized into five mutually exclusive and exhaustive categories: i) respondents not using any type of contraception, ii) respondents with unmet-need for spacing births, iii) respondents with unmet-need for limiting births, iv) respondents using spacing methods and v) respondents using limiting methods. The reference category ‘i’ comprises of respondents who are not using any contraceptive method and have not expressed any need for the same. Each respondent can fall into only one of the five mutually and exhaustive categories.

Parametric estimates of the regression coefficients in the multinomial logit model are elicited using maximum likelihood estimation procedure. The estimated regression coefficients, in turn, facilitate estimation of probabilities or likelihood of respondents being in different categories of non-users or users stated earlier with different background characteristics. A note on cautious interpretations of increase or decrease in the odd ratios in the multinomial regression analysis is provided in some studies1,18 conducted earlier.

Method-Mix Usage of Contraception

The current usage of contraception of any method in the eight EAG states has been drawn from the 30285 currently married women aged 15-49 years. The use of any method of contraception turns out to be around 67 per cent. The use of any modern method of contraception turns out to be around 57.3 per cent whereas still 9.3 per cent of the couples use traditional methods like withdrawal, rhythm, or other methods.

The pie chart depicts that almost 49.9 per cent of the couples are not using any contraception in the EAG states. Among the users of contraceptive methods, the

authors find almost 29.9 per cent of women are:

Pie Chart of Methods-mix Usages in the EAG states of India (NFHS-3) using female sterilization, which amounts to almost 60 per cent of the usage of contraception of any kind. Second most widely used method is condom by 7.6 per cent of male partners, which amounts to almost 15 per cent of the contraception usage. Out of modern spacing methods of contraception, it was found that pills are used by 2.9 per cent and IUD by

1.3 per cent of the female users.

Interestingly, 7 per cent of the users of contraception still report usage of 118 traditional methods like withdrawal, rhythm and other methods, which is slightly lower than all India average of 7.8 per cent. However, usage of the traditional methods in the EAG states is reported to be as high as 14.3 per cent in Uttar Pradesh, 6.1 per cent in Odisha and 2.8 per cent in Rajasthan.

Main Reasons for Non-Use and No Intention to Use Contractive Methods in Future Too It is, certainly, interesting to examine the reasons for non-use of contraception and no intention to use anytime in future; as they could provide important clues about the demand-side and supply-side constraints for contraception19. Distribution of women not using and no intention to use contraception in future too is provided in depicted in Table 1.

Data presented in Table 1 reveal that women who are not using and do not intend to use any type of contraception in future expressed fertility-related reasons (63.8%), societal or husband’s opposition to use (14.5%), lack of knowledge (2.9%), method-specific reasons (9.9%), etc. Predominant among fertility-related reasons are infrequent/no sex (12.3%), infecundity or sub-fecundity (25.2%), menopause or a hypersectomy (14.3%), and wanted more children (4.6%). Some women expressed opposition to the use from husband (4.6%), religion (5.5%), and others (0.5%). Very few women expressed lack of knowledge about FP methods (1.9%) or source for acquiring FP methods (0.9%). The method specific reasons given were fear of side-effects (3.4%) and health risks (4.5%).

–  –  –

Most of the reasons cited for non-use and no intention to use contraceptives in future too are primarily because of wrong perceptions about FP methods or possibly lack of follow-up of some contraception methods where minor clinical interventions are needed at the time of adoption like IUD insertions, tubectomy or vasectomy. Thus, the demand for family planning can be improved through proper sensitization of women and alleviation of method-specific misapprehensions and alleviation of opposition to use amongst the 27.2 per cent of the women who cited such reasons for non-use and no-intention to use in future too.

Multinomial Logit Regression Results

Parametric estimates of the multinomial logit regression coefficients with all the predictor variables are analysed in Table 2. The estimated coefficient (βi) depicts the additive effect of one-unit change in the predictor variable (Xi) on the log of odds (log Ω) of the response variable. Equivalently, the term (e βi) depicts the multiplicative effect on the odds-ratio or the ratio at which the odds of the response variable would increase or decrease depending upon the positive or negative sign of the coefficient, respectively. Parametric estimates of the coefficients and levels of significance of underlying models for unmet and met-need for contraception for spacing and limiting births are presented in Table 2.

–  –  –

Note: µ: Level of Significance, n: Number of Observations in each category n= 30285 is total number of currently married women, n=11072 women are in the reference category, and the reference category includes women with no use and no demand of contraception.

Perusal of Table 2 reveals that the effects of demographic variables such as women’s age, age at marriage, number of living children, and number of living sons significantly impact all the four components of demand for contraception.

Moreover, the relationship of the number of living sons turns out to be non-linear.



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