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Issues and Strategies Emerging from the NFHS-4 (2015–16)

Repositioning of the Family Planning Programme in India

Critical issues in the stagnation of the family planning programme in India are highlighted and the tangible barriers are identified to suggest few possible strategies to enhance its use and effectiveness in achieving the Sustainable Development Goals relating to sexual and reproductive health. Findings from the National Family Health Survey-4 (2015–16) indicate a strong need to reposition the FPP to meet the unmet need of contraceptives by improving the quality of care and promoting the spacing methods of contraception by minimising the 12-month contraceptive discontinuation rate in India.

Family planning is a prerequisite for the universal access to sexual and reproductive health components of the Sustainable Development Goals (SDGs) and an essential indicator for tracking progress on improving maternal health (Dockalova et al 2016). In developing countries, about 818 million sexually active women of reproductive age (15–49 years) want to avoid pregnancy or delay childbearing for at least two years or want to stop pregnancy and limit their family size. About 140 million (17%) of these women are not using any method of family planning, while 75 million (9%) are using less effective traditional methods (Darroch et al 2011). In Southern, Central, and Southeast Asia, the use of modern contraceptives are less than the global average with only 47% of married women, aged 15–49 years, using modern contraceptives, although higher proportions want to prevent pregnancy (Najafi-Sharjabad et al 2013; United Nations Population Fund 2009). That is why SDG target 3.7 focuses on ensuring universal access to sexual and reproductive healthcare services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes by 2030 (Dockalova et al 2016).

The estimates of contraceptive prevalence among currently married women, aged 15–49 years, in 2015–16 revealed that 48% women in India were using some modern method of contraception. This has reduced from 49% in 2005–06. Unmet need of contraception (National Family and Health Survey [NFHS-4]) was reported by 13%, marginally reduced from 14% of women who reported the same a decade back. This stagnation in family planning in India has been followed by two episodes of slowdown. First, in 1977, in the post-Emergency recoil and recovery of the programme in the country. Second, after the International Conference on Population and Development (ICPD) 1994, when the Government of India was one of the signatories of the ICPD Programme of Action (PoA). Hence, it promptly adopted the reproductive and child health (RCH) approach, where acceptor-based family planning targets were abolished in April 1995. Against this backdrop, this paper aims to highlight the changing scenario of the family planning programmes (FPP) in India, and issues and strategies emerging from the evidence generated from the recently conducted NFHS-4, which may be vital for the repositioning of the FPPs in India.

Data and Methods

This paper is based upon two rounds of the NFHS conducted in 2005–06 (third round) and 2015–16 (fourth round). The primary objective of the NFHS was to provide essential data to policymakers on health and family welfare, and on emerging issues at the national, state, and, from 2015 onwards, district levels. The sampling design of the NFHS-4 was developed considering the need to provide estimates of population, health, and family welfare indicators at district, state/union territory, and national levels with a reasonable level of precision. A stratified two-stage sampling design was adopted in rural and urban areas of the 640 districts (as on 31 March 2014). Within each rural stratum, villages were selected from the sampling frame using probability proportional to size (PPS) with explicit stratification based on the percentage of the Scheduled Caste (SC) and Scheduled Tribe (ST) population and female literacy. The NFHS-4 covers about 6,01,509 households with 6,99,686 eligible women aged 15–49 years and eligible men aged 15–54 years from a subsample of primary sampling units (PSUs)/households in 28,583 PSUs, comprising villages in rural areas and census enumeration blocks (CEBs) in urban areas. The selection of households is based on the sampling frame prepared from mapping and listing households in all PSUs identified across 640 districts. NFHS-4 uses four survey schedules: household, woman’s, man’s, and biomarker—canvassed in local languages using computer assisted personal interviewing (CAPI). The study uses univariate and bivariate analysis followed by logistic regression to draw inferences from the data and discuss evidence for strategies to reposition the FPP in India.

Situation Analysis of the Use of FPP in India

The situation analysis of progress in the FPP in India, after independence, reveals a number of complexities hampering the effectiveness of the programme. India launched a nationwide the FPP in 1952, a first of its kind among the developing countries with the objective of “reducing the birth rate to the extent necessary to stabilise the population at a level consistent with the requirement of the national economy” (Planning Commission 1997). Even after 70 years of the FPP, India still has a substantial proportion of couples (13%) with unmet needs. According to the recent round of the NFHS (2015–16), a considerable percentage of women still have distanced themselves from any method of contraception during their reproductive period (NFHS-4). However, the situation of fertility and family planning varies significantly across different states.

In India, southern states and states like Maharashtra, Himachal Pradesh, Jammu and Kashmir, Punjab, West Bengal, and Odisha, have experienced a low level of fertility. However, bigger states, such as Uttar Pradesh (UP), Bihar, Rajasthan, Madhya Pradesh (MP), and Jharkhand need to reduce their fertility level, which is still higher than the replacement level. Further, because of their larger population base, these states drive the high population growth rate of the country. The 2011 Census results showed that India continued to have one of the most rapidly growing populations in the world, by adding 181 million people in the decade preceding the census. Between 2001 and 2011, the decadal growth rate of the population was estimated at 17.6%, which was lesser by 3.9% points from the growth rate of 1991–2001 (21.5%) (Census of India 2011).

The FPPs of countries like China, Malaysia, and Thailand, though launched later than India, have been far more instrumental in reducing the infant and maternal mortality rates, as well as achieving lower fertility rates in a substantially shorter span of time. A notable difference in the programmes adopted by other countries and India in the context of family planning was the emphasis on birth spacing methods in the initial stages of the programme and limiting methods, that is, sterilisation, further along the way for the countries like China, Malaysia, Taiwan, Hong Kong, etc. On the contrary, India stressed on adoption of limiting methods early on after the launch of the FPP. In contrast, spacing methods like condoms, intrauterine devices (IUDs), and oral contraceptive pills initially found few takers (Srinivasan 2017). Two decelerated phases characterise the Indian FPP in the achievement of its stipulated targets. The 1971 Census demonstrated the annual population growth rate to be the highest during 1961–71. This indicated a deficient outcome of the population stabilisation programme during this period. Thus, the government experienced a need for launching a camp-based family planning approach in the 1970s. The first instance of the slackened pace in the programme was experienced by the country after the Emergency, 1975–77. Predominantly due to coercion from the government’s side, to adopt sterilisation and birth control on a mass scale, which was met with widespread resistance, there emerged a general disdain towards family planning as a whole, and an eventual change in the ruling party in India. The forceful implementation of the FPP scathed the public to such an extent that the next political party that came into power had to rechristen the FPP into an all-encompassing and more holistic-sounding one. This took all the issues related to maternal and child health, nutrition and mortality under its purview, putting them into sharp perspective along with the ominous issue of family planning.

The second instance of the slackened pace in the programme came after the conclusion of the ICPD held at Cairo in September 1994. It was decided that concrete steps regarding the unmet need of couples for spacing and limiting methods will be undertaken. The East Asian countries carried out an assertive programme. They brought down their fertility rates close to the replacement level in a short period, ignoring individual choices and women’s rights in the process. As a result, the ICPD conference specifically focused on these facets of the course of action to be adopted, namely women’s rights, reproductive health, poverty alleviation and even sustainable development. These would all play monumental roles in the decline of the unmet need of contraception in these countries. The holistic approach adopted then saw more programmes finding themselves merged with the FPP in India, intending to improve all the aspects of a woman’s life by the concept of integration and decentralisation. A set of 13 programmes were merged with the FPP with the vision of maternal and child health services’ utilisation affecting and strengthening the family planning services. Though, in this process, child survival and safe motherhood took precedence, and the FPP took a backseat after 1995. This resulted in the second wave of the slackened pace of the FPP in India. The impact of these policy changes is evident until now in the persistent stagnant proportion of couples using modern contraceptives in India since the last decade. On the other hand, 48 million couples in the country, describing the unmet need scenario in the country, demand reorganisation and repositioning of the FPP in India. The issues raised in India and other developing countries likewise provided substantial cues to initiate a new programme called Family Planning (FP2020), where a group of 70 countries expressed their shared concern and strategised the repositioning of their respective the FPPs.

In the London Summit on Family Planning in 2012, 70 developing countries, including India, adopted FP2020. The objective of this is to address the unmet need for contraception, spacing births as well as limiting births by 2020. For India, the vision is not only limited to providing contraceptive services to the new 48 million couples, but also extending to avoiding 23.9 million births, 1 million infant deaths, and over 42,000 maternal deaths by 2020. Under FP2020, an array of the programme has been integrated. It focuses on the improvement of the quality of care as well as provides the luxury of choice for the adoption of various family planning methods and services to its users. In this regard, spacing methods like IUDs, oral pills, and condoms are garnering more attention as compared to sterilisation (MoHFW 2014).

Results and Discussion

Despite putting sufficient effort into enhancing the alternative methods for family planning, the share of female sterilisation among all other methods is still very high. It is evident from Table 1 that female sterilisation has a two-thirds share in both the rounds of NFHS at 66% in 2005–06 and 67% in 2015–16. The share of condoms and pills have marginally increased from 2005–06 to 2015–16. However, the percentage of IUD/postpartum intrauterine contraceptive devices (PPIUD) in the contraceptive method mix has reduced during the same period. Female sterilisation was the most popular method among illiterate and less educated women in both the rounds of the survey. In the NFHS-4, the share of female sterilisation was 79% among women who never attended school, whereas it was only 45% for women who had 12 or more years of schooling.

Similarly, the share of female sterilisation was higher among women belonging to Christian (79%), Buddhist (77%), and Hindu (70%) religions. On the contrary, this share was the lowest among Muslims (46%) and Sikhs (52%). The percentage of condom and IUD/PPIUD use showed an increasing trend with increasing years of schooling. It was also higher among women who were not employed and belonged to Sikh and Jain religions in both rounds of the survey. Further, the share of condom use and IUD/PPIUD methods for family planning were found more among the women who belonged to other castes (15% and 3.5%) and the highest wealth quintile (20% and 5%).

Overall, the share of pills in the family planning method has increased from 3% to 8% from NFHS-3 to NFHS-4. The highest percentage of use of pills has been found among women who belonged to other religions (40%) and Muslims (18%), other caste groups (12%) and those who were among poor (11%) and poorest (11%) wealth quintiles. This share was the lowest among women who never went to school (4.8%), belonging to Jain (2.4%) and Sikh (3.5%) religions, among Other Backward Classes (OBC) and among those women who belonged to the highest wealth quintile (4.4%).

Figures 1–3 (p 53) show the changes from 2005–16 in the share of three primary modern methods of contraception among currently married women, aged 15–49 years, India. It is evident that 14 states are showing a declining trend in the share of female sterilisation (Figure 1). Between 2005–06 and 2015–16, the maximum reduction in sterilisation took place in Mizoram (22 percentage points), followed by Arunachal Pradesh (17 percentage points), and Odisha (16 percentage points). Few states in the northern (Delhi and Punjab), central (Chhattisgarh and MP), eastern (Bihar and Jharkhand), and north-eastern (Mizoram and Sikkim) regions showed an increasing trend of female sterilisation. While the share of female sterilisation has increased in all the western and southern states, Kerala is the only state among all the southern states to show a sub-ninety percent (86%) share of female sterilisation in 2015–16. Andhra Pradesh had the highest percentage of 98%. The southern states were the first in achieving below-replacement-level fertility and their total fertility rate (TFR) now stands at 1.8 and below. This shows the impact of sterilisation and past target-based programmes on fertility. In most of the northern, eastern, and north-eastern states, the share of female sterilisation was less than 60%. In UP, the share of female sterilisation was 38% in 2015–16, which has reduced from 2005–06. Whereas, in Bihar, the share of female sterilisation was 86% during NFHS-4, which is 16 percentage points higher in comparison to NFHS-3.

The use of oral pills as a choice of family planning method is more prevalent in the north-eastern and eastern states in comparison to other parts of the country. It was the highest in Meghalaya with a share of 49%, followed by Assam (42.2%) and Tripura (41%). Oral pills’ share was less than 1% in almost all the southern states (Figure 2). In Bihar, where TFR is the highest among all the states, the share of oral pills showed a declining trend from NFHS-3 to NFHS-4. From Figure 3, it is evident that the use of condoms is maximum in the northern region compared to the other parts of the country. All the states of this region show an increasing trend of using condoms as a spacing method of family planning. The share of condoms was 37% in Delhi and 30% in Uttarakhand, which is the highest among all the states. The southern states show a declining pattern for condoms as a choice of family planning method. Overall, the recent findings of NFHS-4 show that the dominance of female sterilisation is still high in all the states. Spacing methods, especially oral pills and IUD/PPIUD, are not getting much preference.

Table 2 (p 53) presents the changes in unmet needs of family planning and demand for contraception satisfied among currently married women aged 15–49 years by some selected background characteristics. Overall, from 2005–06 to 2015–16, there is negligible change in unmet need (12.9%) in India. The age-wise distribution shows that unmet need among women belonging to 15–19 year age group has reduced from 27% to 22% in the last decade. Whereas, unmet need among women belonging to 20–24 year and 25–29 year age groups was 21% and 16% in 2005–06. This has increased to 22% for 20–24 year age groups and 19% for 25–29 year age groups in the last one decade. Results of logistic regression also show a strong association between age and unmet need. The unmet need of women belonging to 20–24 and 25–29 year age groups was more than seven times higher in comparison to women belonging to the 15–19 year age group. The level of demand satisfaction has reduced among all the ages from NFHS-3 to NFHS-4, except for women of 15–19 year age group. The demand for the family planning method is very high among younger generations.

Educated women were less likely to have an unmet need in comparison to illiterate women in both the rounds. Unmet need was found to be the highest among others (18.3%), followed by Muslim (16.4%) women, and it was the lowest among Sikhs (6.4%) in 2015–16. Results indicate that Hindu women are more likely to have an unmet need than women of other religions. Across all groups, it can be seen that the programme has not been able to address the need for family planning. This unmet need is also contributing to population growth in the form of unwanted and unplanned pregnancies. Investing in the adolescent is the most effective way to achieve population stabilisation in the nick of time. Therefore, there is a strong need to focus on newly married couples.

In the last six decades, the FPP in India has witnessed several changes. Although it has brought the TFR down below the
replacement level in 17 states, in 11 states, which are mostly the bigger states of central and northern part of India, the TFR is still above the replacement level (Table 3). As a result, there is a wide variation among states in the form of achieving the
targets. Even in those states where the TFR is less than 2.1, unmet need is high and demand satisfaction is less. Most of the northern states achieved the replacement level of fertility after the southern states. Higher use of the spacing method of family planning is an essential factor in achieving this target. Besides, the unmet need is very high in all the states, including those which have achieved replacement-level fertility. Therefore, spacing methods like oral pills, IUD/PPIUD, and condoms will be more effective. Thus, there is a need to reposition the 
FPP to meet the unmet need, stabilise the population, and ensure the reproductive and sexual rights of young women. Limiting methods of family planning will not contribute enough to the reduction of unmet needs in these states.

 

Using linear regression between TFR and contraceptive prevalence rate (CPR) obtained in NFHS-4, it is observed that a 1% increase in CPR will affect TFR by 0.026. Six major states, namely Bihar, Chhattisgarh, Jharkhand, MP, Rajasthan, and UP constitute more than two-fifths of the total population of the country. Differential efforts in the contraceptive promotion are required to achieve the replacement level of fertility. For example, Bihar is having a TFR of 3.4, and the percentage of currently married women aged 15–49 years using the modern methods of contraceptive is 23%. It needs to increase it to 73% to achieve the replacement level of fertility. Similarly, Chhattisgarh needs to increase the percentage of currently married women using modern methods of contraceptive from 55% to 58%, and from 38% to 53% for Jharkhand. The increase should be from 50% to 53% for MP, 38% to 58% for Rajasthan, and 32% to 55% for UP.

The estimation is based on the premise that the other proximate determinants of fertility like the index of post-partum infecundability, index of marriage, and index of induced abortion, which are deep-rooted in social and cultural factors prevailing in these Hindi heartland, remains unchanged.

Table 4 presents the percent of contraceptive use episodes discontinued within 12 months in the five years preceding the survey among women aged between 15 and 49 years. Among the three commonly used modern spacing methods, the contraceptive use episodes discontinued within the 12 months among 15–49 year women was the highest for condom (47%), followed by pills (42%) and IUD/PPIUD (26%). Most common reasons for discontinuing the modern spacing methods were: women wanted to get pregnant (11.3%), side effects/health concerns (11.2%), with a north–south divide reflecting at the differential quality of family planning services by the front-line workers. Prevalence of episodes of contraceptive-use discontinuation in the 12 months of use was the lowest in Andhra Pradesh (4%), where almost all the contraceptive users were using sterilisation. It was the highest in Punjab (47%).

The contraceptive discontinuation rates were different in northern and southern states included in this analysis. Consequently, the reasons for switching over to the terminal methods in the southern states and side effects/health concerns in the northern states were also different. Thus, the role of service providers becomes vital in the process of contraceptive use dynamics and demands for the repositioning of the FPPs in the country.

Conclusions and Recommendations

The findings of the study provide crucial strategies as a way forward in repositioning the FPP in India. The process of repositioning can be done using seven prone strategies:

First, there is a strong need to strengthen the capacity-building of health functionaries and staff. Emphasis on increased acc­ountability with transparent support and a conducive environment is equally important. Contraceptive discontinuation rates in these states are still very high because of reasons such as: method failure, side effects, health concerns, etc. Improvement in the quality of care is quite essential for the success of new methods of family planning. Increasing the reach of family planning services and better quality is vital to reduce unmet needs and levels of fertility. It includes the availability of various methods, information, and effective communication from health workers as well as better counselling. Health workers such as accredited social health activists (ASHA) and auxiliary nurse midwifery are a crucial part of family planning services. Although these service providers are playing an essential role in providing services and motivating people to use contraceptives, they need better training and knowledge about modern contraceptives so that they can offer better advice to the target population, multiplying the effects of these services. The use of the contemporary spacing method is shallow in the country (Figures 1–3). Episodes of contraceptive use discontinuation are also very high (Table 4). Trained health workers can solve method failure, side effects, and other issues. Along with that, they may be able to provide advice related to new and effective alternative methods. Further, maintaining a relationship with communities is also very important to propel the acceptance and use of modern methods. ASHA workers must be trained to convince and develop a good relationship with the beneficiaries. Door-to-door visits by health workers is the best way to provide these services and help people with issues related to the use of contraceptives.

Second, extending the concept of digital India to digitise the functioning of front-line workers with the concept of supportive supervision would be an essential strategy. In the era of digital India, with the use of modern technology, service providers and seekers can be easily connected. Providing mobile phones to health workers will help them communicate and follow the progress. It will also be beneficial to connect and solve the problems of newly married couples as well as those who are seeking information on the different methods of contraception available. Further, videos and information related to family planning can be imparted effectively to the ASHA workers as well as the clients. Such an innovative strategy would be effective.

In the third stage, opening the clinics at the block level, under public–private partnerships, becomes important. Initially, it can be done for the empowered action group (EAG) states with active support from various corporate houses under their corporate social responsibility (CSR) commitments. These will be devoted to fulfilling the needs of the people for family planning, such as providing an excellent quality of contraceptive as well as making them well informed about the basket of choices available to them. The availability of safe abortion and post-abortion facilities would also be an essential service provided in these centres. Services available at these clinics should be free of cost for the poor and minimal for people who can afford it. In states with low fertility, these services can be provided at its actual price. However, in states with high fertility, there is a strong need to provide these services at a subsidised rate.

In the fourth stage, to improve the reach of the programme, partnerships with NGOs will be beneficial. For example, Janani is running Surya clinic in Bihar and Rajasthan. Similarly, Parivar Seva Sanstha is running Marie Stops clinic in different parts of the country. Population Services International is successfully running the Pehel project in UP, Rajasthan, and Delhi. It aims at providing affordable family planning services and knowledge about IUDs and abortions to people. These NGOs are effectively providing high-quality services for family planning. Several corporates are contributing to the health sectors through their CSR initiatives. However, only a few of them are focusing on family planning. They can play an essential role in imparting knowledge and improving the facilities, especially in high-focused pockets of the country where the reach of public services is minimal.

Further, removal of sterilisation incentives for service providers at different levels, especially for those states that have already achieved replacement-level fertility, is important. The use of this amount for providing incentives for PPIUD will also be helpful. In addition to that, stopping incentive-based sterilisation where fertility is already below the replacement level, like in the southern states and states like Punjab, West Bengal, and Maharashtra will help in cost-cutting. The budget saved by curtailing the incentives can be used to improve quality of services in the same states or other states that are struggling to reach the replacement level of fertility and in highly focused states and districts, where Mission Parivar Vikas is currently being implemented.

Ensuring an uninterrupted supply of various contraceptives to family planning centres and from these centres to users is very important to ensure sustained use of spacing methods. Tracking progress through intensified monitoring is equally essential for the success of any programme. Regular follow-ups and generation of data related to the use of family planning would be further helpful in making services better.

Lastly, the existing gap between knowledge and behaviour can be addressed by adopting and intensifying social marketing of contraceptives. Adopting the concept of brand promotion and product positioning through self-help groups among women will help in filling up the gaps in contraceptive development, especially in remote rural areas of the EAG states.

References

Darroch, Jacqueline E, Gilda Sedgh and Haley Ball (2011): Contraceptive Technologies: Responding to Women’s Needs, New York: Guttmacher Institute.

Dockalova, B, K Lau, H Barclay and A Marshall (2016): “Sustainable Development Goals and Family Planning 2020,” International Planned Parenthood Federation (IPPF)United Kingdom, pp 1–12.

Guttmacher Institute (2010): “Facts on Investing in Family Planning and Maternal and Newborn Health,” In Brief Update, http://www.guttmacher.org/pubs/FB-AIU-summary.pdf.

IIPS (2017): “National Family Health Survey (NFHS-4) 2015–16: India,” International Institute for Population Sciences, http://rchiips.org/nfhs/NFHS-4Reports/India.pdf.

MoHFW (2014): “India’s ‘Vision FP 2020,’” Ministry of Health and Family Welfare, Government
of India, Https://advancefamilyplanning.org/sites/default/files/resources/FP2020-Vision-Document%20India.pdf
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Najafi-Sharjabad, F, S Z S Yahya, H A Rahman, M Hanafiah and R A Manaf (2013): “Barriers of Modern Contraceptive Practices among Asian Women: A Mini Literature Review,” Global Journal of Health Science, Vol 5, No 5, p 181.

Planning Commission (1997): “Ninth Five Year Plan 1997–2002 Volume II Thematic Issues and Sectoral Programmemes.”

Srinivasan, K (2017): Population Concerns in India: Shifting Trends, Policies, and Programmes, SAGE Publishing India.

UNFPA (2009): “South Central and Southeast Asia, Facts on Investing in Family Planning and Maternal and Newborn Health,” United Nations Population Fund, Guttmacher Institute.

 

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Updated On : 8th Aug, 2022
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