Sources of Family Planning: India

Publication date: 2019

Understanding where women obtain their family planning methods can help programs to better target their resources and increase overall access to modern contraception. This brief is one of a series of country briefs that examines where women obtain modern contraception by method, geography, age, and socioeconomic status. Through a secondary analysis of the 2015–16 India Demographic and Health Survey, the brief explains where married modern contraceptive users obtain their method and examines the contribution of the private sector to family planning in India. Key Findings • India’s modern contraceptive prevalence rate (48%) is stagnating among married women, despite increased use of short-acting methods in rural areas, due to declining use of short-acting methods in urban areas and declines in sterilization and IUD use overall. • The public sector is the primary source of modern contraception for married users (69%). This is because most men and women who are sterilized obtained the service in the public sector. • More than one-half (56%) of married women rely on the private sector for family planning methods, with the exception of sterilization. • More than half of the poorest reversible contraceptive users rely on the private sector. Sources of Family Planning India Photo: © 2012 Meagan Harrison, Courtesy of Photoshare This is one in a series of briefs that examines sources of family planning methods in USAID priority countries. View the data at Modern contraceptive prevalence rate and method mix Nearly half (48 percent) of married women in India use modern contraception. Sterilization is the dominant method among married women (36 percent), and the majority of sterilized women (82 percent) received the procedure in a public facility. Fewer women are currently opting for sterilization. This brief excludes sterilization from the analysis to better examine source patterns for other modern methods and to identify opportunities for the public and private sectors to increase contraceptive access and choice in India. This brief focuses on currently married women only. Excluding sterilization, India’s reversible method modern contraceptive prevalence rate (mCPR) increased slightly between 2005–06 and 2015–16 from 10.2 to 11.4 percent. Use of short-acting methods (SAMs) increased from 8.5 to 9.9 percent due to higher use of pills and condoms in rural areas despite a decline in these methods in urban areas. There was a slight decline in the use of IUDs (from 1.7 to 1.5 percent), the only long-acting reversible contraceptive (LARC) on the market in India.1 1 SAMs include injectables, contraceptive pills, male condoms, female condoms, and fertility-awareness methods. LARCs include IUDs and implants (though there is no measurable implant use in India). The lactational amenorrhea method and “other modern” methods are excluded from this analysis, as the Demographic and Health Survey does not systematically ask women about sources for these methods. This analysis shows which methods women use. It does not reflect which methods women might choose if they had access to all methods. Sources of modern contraception among married women 26% Private sector Public sector Other 69% Sources of modern contraception among married women, excluding sterilization 56% 18% 26% Use of reversible methods among married women increased slightly 2005-06 2015-16 5.6% 1.5% 4.1% 5.2% 11.4% 10.2% 1.7% 3.1% IUDs LARCs SAMs Condoms Pills Injectables Other Private sector’s contribution to method mix More women in India rely on the private than the public sector to obtain SAMs (5.7 versus 2.1 percent, respectively). Between 2005–06 and 2015–16, use of SAMs increased in both the private sector (from 4.8 to 5.7 percent) and the public sector (from 1.2 to 2.1 percent). This was primarily due to higher use of pills, followed by condoms. Public sector provision of IUDs remained relatively constant, and private IUD provision decreased slightly from 0.9 to 0.6 percent. Among users of condoms, India’s leading reversible method—responsible for nearly one-half of the reversible method mix—17 percent rely on public sources and 52 percent on private sources. The remaining 30 percent rely on other sources, mostly husbands. The majority of pill users obtain their method from the private sector (65 percent), while 27 percent rely on public sources. Sources for family planning methods Including sterilization, the public sector is the primary source of modern contraceptives in India (69 percent), which has not changed since 2005–06. However, when sterilization is excluded from the analysis, the private sector becomes the primary source (56 percent). Just over one-quarter of reversible method users (27 percent) rely on public sources, and 18 percent rely on other sources— primarily husbands who provided condoms to their wives.2 Reliance on other sources decreased from 25 percent in 2005–06, while public sector use increased from 19 percent to the current level of 27 percent. 2 Public sector sources include hospitals, dispensaries, health centers, health posts, mobile clinics, and community-based workers. Private sector sources include hospitals and clinics; faith-based organizations and NGOs including mobile clinics and trust hospitals; and pharmacies, drug stores, and shops. Other sources include friends, relatives (including husbands), dais (traditional birth attendants), and women who did not know or report the source. This analysis shows where women obtained their most recent method. It does not reflect where women might choose to go if they had access to all sources of care. Public and private sector SAM provision increased 2005-06 2015-16 IUD Public IUD Private LARCs SAMs Other Public Private2.1% 0.9% 0.6% 5.7% 1.2% 2.0% 2.5% 0.9% 0.8% 4.8% P h o to : Je ss ic a Sc ra n to n Private sector sources Among private sector users, nearly two-thirds (64 percent) use a pharmacy or shop, one-third rely on a private hospital or clinic, and less than 4 percent rely on a NGO or trust hospital. The majority of private sector condom users reported going to a pharmacy or shop, though 22 percent obtained the method from a clinic or hospital. In addition, one-third of private sector pill users obtained the method from a clinic or hospital. Rural and urban areas Excluding sterilization, the mCPR is higher in urban (15 percent) than in rural (10 percent) areas. When sterilization is included, the disparity lessens to just two percentage points due to high rural reliance on public- sector sterilization. Urban contraceptive users are more likely to purchase their reversible method from the private sector (61 percent) compared with rural users (52 percent). The private sector is a more common source for urban than rural users Urban Rural 61% 52% 31% 21% Percent of users in each group who obtain modern contraception from each source Private sector Public sector Other P h o to : Je ss ic a Sc ra n to n Contraceptive source by state Source patterns for reversible methods vary substantially by state, as well. Private sector use is highest (70 percent or higher) in Tripura, Telangana, Goa, Bihar, Maharashtra, and Assam, and lowest (40 percent or lower) in Sikkim, Uttar Pradesh, Himachal Pradesh, Uttarakhand, Rajasthan, and Puducherry. As expected, in states with high private sector use, condoms and pills make up a large portion of the reversible method mix. The states with the lowest private sector use are generally also those with the highest reported reliance on other sources. These states generally have high condom use—in Uttar Pradesh, Himachal Pradesh, Uttarakhand, and Rajasthan, condoms make up 70 percent or more of the reversible method mix—and in three of these states, more users reported obtaining condoms from a friend or relative than from a public or private source. Most states with higher levels of public sector use also have high levels of IUD use: more than two-thirds of the method mix in Puducherry and more than half in Tamil Nadu and Nagaland is IUD use, and all of these states have higher-than-average public sector use. Private sector use varies substantially by state3 Percent of users in each group who obtain modern contraception from each source Private sector Public sector Other 3 Lakshadweep, Dadra and Nagar Haveli, Andhra Pradesh, and Daman and Diu all have fewer than 50 married reversible method users, and so are not shown separately in this graph. These states are included in all other figures. 52% 53% 53% 53% 55% 60% 61% 67% 67% 69% 70% 72% 75% 75% 86% 87% 43% 24% 39% 29% 31% 39% 39% 33% 25% 28% 28% 24% 21% 15% 11% 13% Jammu & Kashmir Jharkhand Kerala Chandigarh Punjab Arunachal Pradesh Manipur Meghalaya West Bengal Gujarat Assam Maharashtra Bihar Goa Telangana Tripura 19% 35% 36% 38% 40% 40% 41% 42% 43% 45% 46% 49% 49% 49% 52% 52% 80% 25% 23% 40% 12% 59% 55% 38% 54% 45% 40% 49% 49% 50% 27% 31% Puducherry Rajasthan Uttarakhand Himachal Pradesh Uttar Pradesh Sikkim Andaman & Nicobar Haryana Karnataka Odisha Chhattisgarh Nagaland Mizoram Tamil Nadu Madhya Pradesh Delhi Contraceptive source by age Across age groups, contraceptive source patterns do not vary. Condoms are the leading method for all users, constituting just under half of the method mix. Pills are most popular among users age 15–19, at 44 percent, and least popular among users 25 and older (34 percent). Conversely, IUDs are most common among users age 25 and older (14 percent) and least common among the youngest users (5 percent). Contraceptive sources are consistent across age groups Percent of users in each group who obtain modern contraception from each source Private sector Public sector Other 55% 27% 54% 29% 56% 26% 15-19 20-24 25+ Contraceptive source by socioeconomic status In India, the poorest women are less likely to use a modern reversible contraceptive method than the wealthiest women (9 percent versus 15 percent, respectively).4 The magnitude of this disparity remains when sterilization is included. Among the poorest users of modern reversible contraceptives, 52 percent rely on private sources. Fifty- six percent of the poorest urban and 51 percent of the poorest rural users of reversible contraceptives obtain their method from a private sector source. Almost 6 in 10 (58 percent) of the wealthiest reversible method users obtain their method from the private sector, while 2 in 10 (22 percent) rely on the public sector. Over one-half of the poorest reversible contraceptive users rely on the private sector Less than one-fourth of the wealthiest reversible contraceptive users use the public sector 4 The poorest women are those in the lowest two wealth quintiles as defined by the Demographic and Health Survey’s asset-based wealth index. The wealthiest women are those in the top two wealth quintiles. Photo: Jessica Scranton Implications Though moderately high, India’s mCPR is stagnating. This is largely because an increased use of SAMs in rural areas is offset by a decline in use of SAMs in urban areas and in sterilization and IUDs overall. India differs from many other countries where injectables and implants have fueled recent increases in mCPR growth. Injectables have only recently been included in India’s national family planning program and are not yet widely available, and implants are not registered for use. The government of India intends to increase method choice by adding progesterone-only pills, Centchroman (a non-hormonal weekly pill), and the depot-medroxyprogesterone acetate (DMPA) intramuscular injectable to the basket of products provided by the public sector (GOI 2017). India has a robust and mature commercial market relative to other middle- and low-income countries. The private sector, currently an important source of SAMs, can help expand contraceptive access and choice to a full range of methods. For example, the government plans to fund social franchises and accredit private health care providers that enable more women to access LARCs and the DMPA intramuscular injectable through the private sector (GOI 2017; MOHFW 2013). It is critical to accelerate and scale the government’s support of these models to reverse the private sector’s declining contributions to long-acting and permanent method provision. Complementary efforts by the private sector to increase availability and awareness of low-cost SAMs in rural private pharmacies and to demedicalize oral pills (which are permitted to be sold over the counter) could increase demand for, and use of, SAMs (MOHFW 2013; MOHFW 2017). This will help more women in underserved areas achieve their reproductive intentions. P h o to : © 2 0 14 J o h n N ic h o ls o n , SP R IN G P ro je ct , C o u rt e sy o f P h o to sh ar e Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AID- OAA-A-15-00067) funded by the United States Agency for International Development (USAID). The project strategically engages the private sector to improve health outcomes in family planning, HIV, maternal and child health, and other health areas. Abt Associates implements SHOPS Plus in collaboration with the American College of Nurse-Midwives, Avenir Health, Broad Branch Associates, Banyan Global, Insight Health Advisors, Iris Group, Population Services International, and the William Davidson Institute at the University of Michigan. This brief is made possible by the generous support of the American people through USAID. The contents are the responsibility of Abt Associates and do not necessarily reflect the views of USAID or the United States government. May 2019 Find Us References Government of India (GOI). 2017. “Family Planning 2020 Commitment.” Ministry of Health and Family Welfare (MOHFW), India. 2013. A Strategic Approach to RMNCH+A in India. Ministry of Health and Family Welfare (MOHFW), India. 2017. National Health Policy 2017. P h o to : Je ss ic a Sc ra n to n

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