If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Spatial heterogeneity and socio-economic correlates of unmet need for spacing contraception in India: Evidences from National Family Health Survey, 2015-16
Department of Geography, University of Gour Banga, Malda, West Bengal, 732103, IndiaDepartment of Geography, Malda College, Malda, West Bengal, 732101, India
Unmet need for spacing (UNS) was found significantly high in India.
•
A clear spatial heterogeneity of UNS was observed in India.
•
Likelihood of UNS was noticeably high among the multiparous women, OBCs, rural areas and South region compared to their counterparts.
•
This study suggests an extensive remodeling of the existing family planning policies for spacing contraception.
Abstract
Background
The unmet need for spacing (UNS) is one of the key concerns of family planning programme in India despite the country achieving the replacement level of fertility.
Objectives
The current study aims to identify spatial heterogeneity and factors associated with the unmet need for Spacing (UNS) in India.
Data and methods
The present study used data from the National Family and Health Survey, 2015–16. The outcome variable was the unmet need for contraception for delaying subsequent births for two or more years (UNS), and the explanatory variables were socio-cultural and demographic factors. The current study included 56,742 currently married women (aged 15–49 years) who had demand for spacing during the survey. Descriptive statistics, bivariate with chi-square significance test, spatial natural break technique, and multivariate logistic regression were used to accomplish the study objectives.
Results
Almost 51% of women were not using contraception to delay their next birth in India. It was found high across all socio-economic and demographic groups except higher-level education and richest groups. Spatial analysis confirms 248 districts had remarkably high UNS (68% and above). Findings of the multivariate analysis suggest women's education, autonomy, and household wealth status were important factors in reducing UNS. The likelihood of UNS was noticeably higher among women with parity three or more (AOR: 1.42 [1.3–1.55]) compared to their counterparts. Similarly, it was found 44% (AOR: 1.44[1.38–1.51]) more likely among the OBCs than the General caste. It was found 1.24 times more likely in rural (AOR: 1.24[1.19–1.30]) compared to urban. Among the geographical regions, it was found comparatively high in the South (AOR: 6.19 [5.76–6.65]) compared to other regions.
Conclusion
Dealing with the UNS necessitates increasing women's education and autonomy, planning to make client choice-based services more accessible, and promoting birth-spacing focused family planning policies.
Effective contraception provides both health and social benefits to mothers and their children by reducing unintended pregnancies and facilitating family planning.
National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis.
Demand for family planning includes women who report wanting to space their next birth for at least two or more years (spacing demand) or desire no additional birth (limiting demand).
Ewerling F, Victora CG, Raj A, Coll CV, Hellwig F, Barros AJ. Demand for family planning satisfied with modern methods among sexually active women in low-and middle-income countries: who is lagging behind?. Reprod Health. 201; 15(1):1-0.
Unmet need for family planning (UFP) denotes “the number of currently married women or in the union who are fecund and want to either terminate or delay childbearing altogether as well as women with a mistimed or unwanted births, but not using any contraceptive method".
National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis.
Ewerling F, Victora CG, Raj A, Coll CV, Hellwig F, Barros AJ. Demand for family planning satisfied with modern methods among sexually active women in low-and middle-income countries: who is lagging behind?. Reprod Health. 201; 15(1):1-0.
Globally, the existing demand for family planning, particularly for birth spacing, is noticeably low, especially in developing countries.1 This is because the demand for Spacing is only significant among early reproductive women (aged 15–24 years) with low parity (two or less).
However, the unmet need for contraception is significantly high among the women who have a demand for Spacing. The unmet need for contraception for spacing birth (UNS) denotes “the number of currently married women or in the union who are fecund and want to delay next births for at least two years or more, but not using any contraceptive method”.
UNS is negatively associated with millions of unintended births, mistimed births, neonatal mortality, pregnancy loss, induced abortions, small size births, and malnutrition.
The risk of maternal death, the third trimester bleeding, and anemia was 2.5, 1.7, 1.3, and 1.8 times, respectively higher among the women who followed shorter inter-pregnancy intervals (less than two years) compared to longer inter-pregnancy intervals.
Similarly, the risk of small size birth and pre-time birth was found 40% higher among the women with shorter inter-pregnancy intervals than longer ones.
Global pattern of demand for family planning shows that the spacing demand was considerably higher in Muslim populated countries than their counterparts.
Women's age, parity, level of education, wealth status, place of residence, and mass media exposure were found to be significant determinants of UNS in Burundi and Burkina Faso.
This success was largely due to a sustained focus on family planning, the promotion of incentives based on male and female sterilization, and socio-economic progress.
Simultaneously, chronic child malnutrition, abortion, and maternal death remain challenging issues, which are all linked to the unmet need for Spacing.
National Family Health Survey (NFHS) 2015-16 suggested that the unmet need for contraception was almost three times higher among the women who desired to delay their next childbirth than their counterparts in India.
Previous studies attempted to contextualize the patterns and socio-economic correlates of demand and unmet need for family planning in India. However, few research has focused on patterns of family planning for spacing birth.
With this backdrop, the present study examines district-level spatial patterns of unmet need for Spacing, as well as its socio-economic determinants.
2. Data and methods
2.1 Data source
The fourth round of the National Family Health Survey (NFHS), an Indian version of the Demographic and Health Survey (DHS) carried out during 2015–16, was used in this study. The main objectives of the survey are to provide reliable and detailed information on fertility and family planning, maternal and child health, nutritional status of children, utilization of maternal and child health care services, and women's autonomy. The details of the sampling design process and sample size estimation procedure are provided elsewhere.
The NFHS collected data using different interview schedules, i.e., household schedule, eligible women/individuals, and men schedule. The present study utilized the data from women's schedule. Women's schedule was collected information from a total weightage sample of 5,11,377 of currently married women in India. The present analysis was based on the weightage sample of 56,742 of currently married aged 15–49 years and fecund women, those who had demand for Spacing (all the women whose pregnancy was mistimed; amenorrhoeic women whose last birth was mistimed; and fecund women who were neither pregnant nor amenorrhoeic, and say they want to wait two or more years for their next births).
The outcome variable of the present study was the unmet need for Spacing (UNS). Bradley et al. (2012) revised definition of unmet need for Spacing was used to define the outcome variable.
Denominator includes all the total currently married women (aged 15–49 years); whose pregnancy was mistimed; amenorrhoeic women whose last birth was mistimed; and fecund women who were neither pregnant nor amenorrhoeic, and desired to wait two or more years for their next births during the survey. The numerator includes all the women whose pregnancy was mistimed; amenorrhoeic women whose last birth was mistimed; and fecund women who were neither pregnant nor amenorrhoeic, and said they wanted to wait two or more years for their next births, but they were not using any contraception during the survey.
A range of socio-economic and demographic variables was used in the analyses that have been documented to be significantly associated with the unmet need for family planning in India and elsewhere in the available published literature.
These variables are respondent's age (15–19, 20–24, 25–29 and 30+ years), parity (0, 1, 2, 3+ children), have at least one son child (yes, no), level of education (illiterate, primary, secondary and higher education), women's autonomy (yes, no), household wealth index (poorest, poorer, middle, richer and richest), religion (Hindu, Muslim and others) and caste (General, Other Backward Class [OBC], Scheduled Caste and Scheduled Tribes [SC/ST]), listening family planning massage thorough TV/radio/newspaper or mass media exposure (yes, no), place of residence (urban, rural) and geographical region (North, Central, East, North-east, West, and South). The division of geographical regions is based on the NFHS-4 report.
2.4 Statistical analyses
Descriptive statistics, bivariate, and multivariate analyses were applied in this study. Descriptive statistics were used to examine the background characteristics of the study sample. Bivariate analysis with Chi-square significance test was carried out to examine the levels and patterns of unmet need for Spacing (UNS) by background characteristics. The binary logistic regression analysis was performed to determine the socio-economic correlates of UNS. The result obtained from the regression analysis was presented in the form of both unadjusted (UOR) and adjusted odds ratios (AOR) with a 95% confidence interval (CI). The entire analysis was carried out through STATA 14.1. In binary logistic regression, the outcome variable was dichotomous –using contraception (0) and unmet need for contraception (1).
3. Results
3.1 Distribution of demand for family planning in India
Almost 66.4% of women had demand for family planning out of total currently married women in India in 2015–16. Out of total demand for family planning, the Spacing and limiting demand was 16.7% and 83.3%, respectively. The majority of women were not using any contraception (UNS), those who had demand for Spacing (Fig. 1).
Fig. 1Graphical presentation of sample distribution, National Family Health Survey 2015-16.
The demand for Spacing decreased with increasing women's age and parity. It was noticeably higher among women aged 15–19 years (87%) or 20–24 years (57.4%). Similar patterns were also found among the women, whose parity was zero (89%) and one (62.8%). It was almost six times higher among women with no son (52.3%) than those with at least one son (9.4%). It was increased with increasing women's level of education. It was four times higher among the higher educated women as compared to illiterates (33.5 vs. 8.3%). It was somewhat high among Muslims (23.7%) compared to their counterparts (Fig. 2). Regional variability in spacing demand was noticeable, ranging from 33% in the North-east region to 10% in the South region (Fig. 3). The spacing demand was significantly high (ranges from 30 to 43%) in fifty districts, and very high (more than 43%) covered 29 districts. The majority of districts of the North-eastern states and some districts of Jammu and Kashmir, Bihar, and Uttar Pradesh were under high zone (Fig. 4).
Fig. 2Existing demand for spacing among currently married women, those who had demand for family planning by (a) women's age, (b) parity, (c) number of sons, (d) women's education, (e) wealth quintile, (f) religion, (g) caste, (h) place of residence in India, NFHS-4 (2015–2016) Source: Author's calculation based on NFHS-4 (2015–2016).
Fig. 3Regional patterns of existing demand for spacing among the currently married women aged 15–49 years, those who had demand for family planning in India, 2015-16.
Fig. 4District level patterns of existing demand for spacing among the currently married women aged 15–49 years, those who had demand for family planning in India, 2015-16.
Table 1 shows background characteristics of currently married women (15–49 years) who had demand for Spacing in India, 2015–16. Most of the women were aged 20–24 years (41.6%), had single parity (56.5%), had no son (53.5%), and were secondary educated (53.6%). Almost 23% of women belonged to the richest, followed by richer (21%) household wealth quintile. Among the religion and caste, most women belonged to Hindu (76.7%) and OBC (40.9%) in India.
Table 1Background characteristics of currently married women (15–49 years) those who had demand for spacing in India, 2015-16.
3.4 Unmet need for spacing by background characteristics
The percentage of UNS was found considerably high among the women aged 15–19 years (61.8%), parity 3+ (62.8%), and illiterate (62.9%), belonging from poorest wealth quintile (64.7%), and South region (75.7%). The percentage of UNS was decreased with increasing women's education and autonomy and household wealth status. Religious differential was minimal, ranging from 52% in Hindus to 43.1% in others. Similar patterns were also found among caste groups. However, the rural-urban gap in UNS was 10.4%, which was 54.2% in rural and 44.6% in urban. The percentage of UNS was found significantly low among the women those who listening mass media than their counterparts. A wide-ranging regional gap in UNS was found between the North-east (32.5%) and the South (75.7%) (Table 2).
Table 2Patterns of unmet need for spacing among currently married women aged 15–49 years by background characteristics in India, 2015-16.
3.5 Spatial heterogeneity of unmet need for spacing
The percentage of UNS was found very high (80%–100%) in 127 districts, followed by high (68%–79%) in 121 districts, medium (50%–67%) in 138 districts. The clusters of very high UNS were mostly found in Uttar Pradesh, Bihar, Jharkhand, Chhattisgarh, Andhra Pradesh, Tamil Nadu, Karnataka, Kerala, Arunachal Pradesh, Nagaland, and Manipur (Fig. 5).
Fig. 5District level patterns of percentage of unmet need for spacing among the currently married women aged 15–49 years, those who had demand for spacing in India, 2015-16.
The likelihood of UNS was significantly decreased with women's age, level of education, autonomy, and household wealth status (Table 3). It was found 59% (AOR: 0.41; CI: 0.36–0.45) were less likely among the women aged 35+ than women aged 15–19 years. It was noticeably high among the women whose parity was 3+ (AOR: 1.42; CI: 1.3–1.55) compared to their counterparts. The higher educated women have 30% (AOR: 0.70; CI: 0.65–0.76) less likely UNS than illiterates. In terms of economic aspects, the richest women had a lower likelihood of UNS (AOR: 0.41; CI: 0.38–0.44) than the poorest. Among the religious groups, Muslim women (AOR: 0.86; CI: 0.82–0.9) had lower odds of UNS than Hindus. The likelihood of UNS was found 44% (AOR: 1.44; CI: 1.38–1.51) and 9% (AOR: 1.09; CI: 1.04–1.15) more likely among the OBC and the SCs/STs, respectively compared to the General caste. Women in rural areas were 24% (AOR: 1.24; CI: 1.19–1.30) more likely not using any contraception than their urban counterparts. The likelihood of the unmet need for Spacing was significantly higher in the South (AOR: 6.19; CI: 5.76–6.65), followed by the Central (AOR: 1.52; CI: 1.43–1.61), and the West (AOR: 1.80; CI: 1.68–1.92) region compared to North region. Compared to their counterparts, women who were listening to FP messages through mass media had 20% less likely UNS (AOR: 0.80; CI: 0.77–0.84).
Table 3Likelihood estimates of unmet need for spacing among currently married women who had demand for spacing aged 15–49 years in India, 2015–16 n = 56742.
This report found demand for Spacing was significantly lower than limiting in India. Previous studies also suggested that family planning in India is highly skewed toward limiting family planning methods.
India will not be able to overcome the burden of child malnutrition and infant/maternal mortality without evading close-spacing births. There is a need to promote spacing family planning to minimize the burden of maternal and child malnutrition in India.
The spacing demand was found mainly among the women in the early reproductive age group (15–24 years), lower parity, had no son child in India. Previous studies also found that the spacing demand predominantly concentrated among young women and low parity.
The spacing demand was found somewhat high among Muslims in India. However, the impact of religious belief on family planning is not reasonable in recent times.
Nevertheless, the effects of religious bigotry on acceptance of family planning and use of contraception cannot be fully denied, especially for those who are illiterate, poor, and live in remote areas in India.
The demand for spacing family planning was low across the regions except North-east region in India. A qualitative study is needed to explore the reasons behind the high demand for Spacing in the North-east region.
The present study highlighted that half of the women had unmet need for Spacing (UNS) in India in 2015–16; the result is consistent with NFHS-4 report.
Therefore, the present study recommends that there is a need for family planning policy review and extensive extension of spacing family planning services. Furthermore, if the government somehow doesn't implement adequate policies immediately, UNS will ultimately become the principal cause of maternal and child health disasters. The present study also suggested that women's age, parity, level of education, autonomy, wealth status, religion, caste, place of residence, region, and mass media exposure are significant determinants of UNS in India. The result is consistent with the previous studies.
The UNS was significantly higher in early reproductive age, illiteracy, and the poorest populations. Previous studies also suggested that the use of modern contraceptives was strongly determined by the women's education level, wealth status.
The findings of the current study also revealed a positive association between women's autonomy and using conception to delay pregnancy in India. Sujatha and Reddy (2009) also found a similar relationship between women's household decision-making and the use of contraception methods.
The overall autonomy score predicted contraceptive use to a lesser extent than the decision-making autonomy score, which may be due to the effects of the two dimensions of autonomy (physical mobility and decision-making).
The UNS was significantly high among the woman who resides from rural and socio-economically backward groups caste (OBCs, SCs/STs). Previous studies found that socioeconomic backwardness is one of the strongest factors of the unmet need for modern spacing contraception in India.
In rural India, the lack of women's autonomy and knowledge about spacing contraceptive methods negatively links family planning suggested by previous studies.
The current study also discovered that locations with low TFR had a considerably higher risk of UNS (South and West region). In both regions, the spacing demand was less than 15%. However, there is a low demand for Spacing, and probably less attention is paid to spacing family planning services, increasing the UNS. The district-level heterogeneity of UNS suggests there is a need to implement a district-level demand-based family planning program, particularly among high UNS clusters in India. Unmet need for contraception was found to be low among those women who were listening to family planning messages through mass media, similar to the previous studies elsewhere.
In 2017, Antara and Chhaya, a new programme, were introduced to supply injectables and pills to expand contraceptive choice in the public health system.
For spacing pregnancies, both contraceptives are highly effective. These contraceptives are available in the district hospitals and medical colleges, particularly in Maharashtra, Uttar Pradesh, Madhya Pradesh, Rajasthan, Karnataka, Haryana, West Bengal, Odisha, Delhi, and Goa. However, the current study suggests that these contraceptives should be made available throughout 640 districts, particularly in areas where there is a significant unmet demand for birth spacing.
5. Policy implications
The findings of our present study recommend some policy implications. To begin with, more than half of the districts exceeded the national average of unmet need for contraception. As a result, an in-depth inquiry of the reasons for the high unmet need in these districts is required. Second, the Antara and Chhaya programmes must be strengthened in order to reduce family planning expenditure among socio-economically disadvantaged groups. Thirdly, current research reveals significant socio-economic disparities in unmet spacing contraceptive needs, indicating persistent socio-economic inequalities in health care facilities. The government should focus on socioe-conomically vulnerable sections by providing adequate spacing family planning services. Fourth, states with chronic child malnutrition child and mother mortality had a significantly higher unmet need for Spacing. As a result, access to spacing contraceptives is required to prevent close-spacing births, undesired pregnancies, and mistimed births, which will aid in the development of a healthy India. Finally, there is a need for national awareness programmes related to socio-economic and health benefits of birth spacing which will be helpful to spread appropriate knowledge about the need for family planning.
6. Strengths
This study examined district-level spatial heterogeneity and socio-economic correlates of Spacing in India using recently available data. The study findings will help policymakers identify the targeted population and district to reduce the high unmet need for spacing contraception.
7. Limitations
This study is limited to establishing causality relations between outcome and explanatory variables, nonetheless rather a mere association. Causality presumes the anteriority of explanatory variables to the outcome, which is not the case in cross-sectional data. A qualitative study is also needed to explore the concealed factors of UNS in India. This study examined the only association between women's background characteristics and UNS, and failed to draw the impact of men's attitudes on UNS in the Indian male-dominated society. It is important that further study explore male views and dichotomy between male and female perspectives on using contraception for Spacing, a dimension that was missing in the present study. On the other hand, further study is needed to explore district-level KAP (knowledge, attitude and practice) of contraception for spacing births in India. It will be supportive of drawing the community-level challenges and opportunities of availing family planning services in socio-cultural diverse India.
8. Conclusion
The present study examined the patterns and associated factors of unmet need for Spacing in India. Results suggested that unmet need for Spacing was significantly high among the women in early reproductive age group, and socio-economically disadvantageous groups. Women's education and autonomy are positively associated with using contraception for spacing birth. Mass media plays a positive role in lessening the unmet need for Spacing in India. To address high unmet need for Spacing, multi-level initiatives are needed, such as promoting spacing contraception services and community-level campaigns. Women's education, empowerment, autonomy as well as women empowerment are needed to battle against UNS in India.
Ethics approval and consent to participate
This study is based on secondary data which is available in the public domain. Therefore, ethical approval is not required for conducting this study.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors’ contributions
MR conceptualized the study aims and designed the study. MR and AR assisted with interpretation of the analysis/results and manuscript writing. MR, MJR and PC assisted with different parts of the manuscript editing/writing and prepared final draft of the manuscript. All authors read and approved the final manuscript.
Declaration of competing interest
The authors have no competing of interests.
Acknowledgements
We would like to thanks to Miss. Rumanara Khatun for her inconsistent support during this venture.
References
Alkema L.
Kantorova V.
Menozzi C.
Biddlecom A.
National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis.
Ewerling F, Victora CG, Raj A, Coll CV, Hellwig F, Barros AJ. Demand for family planning satisfied with modern methods among sexually active women in low-and middle-income countries: who is lagging behind?. Reprod Health. 201; 15(1):1-0.
00054-9&id=gr1.jpg){kind=link}
00054-9&id=gr2.jpg){kind=link}
00054-9&id=gr3.jpg){kind=link}
00054-9&id=gr4.jpg){kind=link}
00054-9&id=gr5.jpg){kind=link}