Which States and Union Territories Falling Behind in Meeting Family Planning Needs in India

Background

Unmet need for family planning is defined as the percentage of fecund and sexually active women who are not using any contraceptive method but wish to avoid or delay pregnancy. In 2021, an estimated 164 million women globally had an unmet need for family planning. The Sustainable Development Goal (SDG) of good health and well-being aims to ensure healthy lives and promote well-being for all ages. Various indicators are used to measure progress towards this goal, including SDG indicator 3.7.1, which quantifies the proportion of women aged 15-49 years whose family planning needs are satisfied with modern methods, also known as demand satisfied by modern methods. This indicator includes components such as contraceptive prevalence and unmet need for family planning. Unmet need is further categorized into spacing—women who do not want another child for at least two years or are uncertain about their timing, and limiting—women who do not want any more children.

The International Conference on Population and Development (ICPD), established in 1994 with representatives from 179 governments, recognizes reproductive health and women’s empowerment as crucial factors for sustainable development. In its 25-year review (ICPD+25) held in 2019, the conference set a target to achieve zero unmet need for family planning information and services by 2030 to achieve universal access to sexual and reproductive health and rights. The ICPD+25 emphasized that reproductive rights and health can only be achieved with adequate access to family planning services, including education and contraception, which empower women to make informed choices and improve reproductive health outcomes.

Projections indicate that the global unmet need for family planning will exceed 10% by 2030. As the world’s most populous country, with 1.4 billion people, India’s role is critical in the global effort to reduce unmet needs. This success depends on India’s ability to identify high-risk populations and implement measures tailored to the needs of diverse population segments. Research has shown that demographic and socioeconomic factors such as age, place of residence, and education level are determinants of unmet needs in developing countries, including India, where there are significant subnational geographic variations.

India, a federation of 28 states and 8 Union Territories (UTs) exhibits substantial differences in population health and well-being indicators across these regions. States have their legislatures and fall under state government jurisdiction, while UTs are governed by the central government and may have their own legislatures. This article aims to provide a comprehensive analysis of the trends in the unmet need for family planning among married or in-union women aged 15-49 years across India and its 36 states and UTs from 1993 to 2021. Understanding the geographical distribution of unmet needs is crucial for developing state-specific policies. Besides prevalence, it is important to consider the absolute burden, or headcount, of women with unmet needs, as this measure ensures that services are adequately provided in all regions. Therefore, we estimated the headcount of women with unmet needs for family planning for 2021 in India and its states/UTs and analyzed unmet need patterns across basic demographic and socioeconomic characteristics. Lastly, we assessed which states/UTs are on track to achieve zero unmet needs by 2030.

How unmet need for family planning changed over the years across Indian states and union territories?

Fig: 1

The prevalence of unmet need for family planning refers to the percentage of women who meet one or more of the following criteria: Women who are not pregnant, not postpartum amenorrhoeic, are considered fecund, and want to postpone their next birth for two or more years or stop childbearing altogether, but are not using any contraceptive method, or women who have a mistimed or unwanted current pregnancy or women who are postpartum amenorrhoeic and whose last birth within the past two years was mistimed or unwanted.

The Standardized Absolute Change (SAC) is used to measure the annual change, in the prevalence of total unmet needs between two specific periods. A negative SAC value indicates a decline in the total unmet need. In contrast, a positive SAC value signifies an increase, suggesting a worsening situation as the total unmet need moves further from the goal of zero unmet need by 2030.

In 1993, the total unmet need in India was 20.6%, which decreased significantly to 9.4% by 2021. However, some states still exhibited high unmet needs in 2021, with Meghalaya at 26.9%, Mizoram at 18.9%, and Bihar at 13.6%. On the other end of the spectrum, Andhra Pradesh (4.7%), NCT Delhi (6.1%), and Karnataka (6.4%) had the lowest unmet needs in the country. Analyzing the change in total unmet need prevalence across states and Union Territories from 1993 to 2021 reveals that the largest standardized absolute changes (SAC) indicate worsening prevalence with positive values.

Fig: 2

In 1993, twelve states had a prevalence greater than 20%, but by 2021, only Meghalaya remained above this threshold. For nearly all states, the unmet need decreased between 1993 and 2021. The top five states showing the highest decline in SAC of total unmet needs were Nagaland (-0.8%), Uttar Pradesh (-0.71%), Odisha (-0.62%), Chhattisgarh (-0.54%), and Madhya Pradesh (-0.53%). Conversely, some states and Union Territories experienced an increase in SAC, such as Kerala (0.01%) and Mizoram (0.24%) (fig: 1, fig: 2).

Fig: 3

Analysis revealed a significant inverse relationship (r = -0.73) between the total unmet need prevalence in 1993 and the standardized absolute change observed between 1993 and 2021. This indicates that states with higher unmet need prevalence in 1993 tended to experience a greater decline on average over the period (fig: 3).

Fig: 4

Focusing on the recent period from 2016 to 2021, the states with the highest SAC decline in the prevalence of total unmet needs for women aged 15-49 years were Manipur (-3.58%), Nagaland (-2.64%), Sikkim (-1.96%), and Goa (-1.82%). In contrast, Meghalaya (1.14%), Punjab (0.74%), and Puducherry (0.44%) recorded notable increases in SAC during this period (fig: 4).

Fig: 5

The absolute burden, or the current headcount of women with a total unmet need for family planning in India for 2021, was estimated based on the Census of India Population Projections for that year. Utilizing the method provided by the Integrated Public Use Microdata Series (IPUMS) and assuming a total population of 362,865,000 women in India in 2021, it was estimated that 24,194,428 women had an unmet need for family planning. Notably, Uttar Pradesh (21.25%), Bihar (12.78%), Maharashtra (9.65%), and West Bengal (6.72%) together accounted for half of this headcount (fig: 5).

Which states and union territories made the largest progress towards the ICPD+25 target?

Fig: 6

The Annual Absolute Change (AAC) is a specific instance of SAC, calculated for the period between 2016 and 2021. The Required Annual Change (RAC) represents the necessary annual change, in percentage points, needed to achieve a total unmet need prevalence of 0% by 2030. The calculation of RAC assumes that the trend observed between 2016 and 2021 will continue linearly until 2030. A comparison of AAC and RAC provides insight into progress towards the 2030 target. If the AAC is less than the RAC, it indicates that the state or union territory (UT) is on track to meet its 2030 target, as the actual rate of change is faster than the required rate of change.

As of 2021, 17 states and Union Territories in India are not projected to meet the ICPD+25 target for the prevalence of total unmet needs by 2030. Conversely, 19 states are on track to meet this target. The Average Annual Change (AAC) in these states is significantly higher than the Required Annual Change (RAC) in states such as Manipur, Nagaland, and NCT Delhi, indicating that these states are well-positioned to achieve their 2030 targets. However, Meghalaya, Mizoram, Punjab, Puducherry, and Kerala are among the states lagging in progress and are at risk of not meeting the 2030 target of 0% unmet needs.

Over the past 30 years, India has made significant strides in reducing unmet needs for family planning. Since 1993, the prevalence of total unmet need has decreased by 11.2 percentage points. Additionally, inequalities in total unmet need prevalence across states and union territories (UTs) have notably decreased by 3.5 percentage points between 1993 and 2021. Despite these advancements, several states and UTs had prevalence values higher than the national estimate in 2021, and no state or UT met the ICPD +25 target of zero unmet need for family planning (fig: 6).

Geographical disparities in total unmet need prevalence were evident in 2021, with some southern states showing the lowest values. States and UTs with higher total unmet need prevalence in 1993 experienced a greater standardized absolute change between 1993 and 2021. Despite the overall progress, India still has a significant number of women with unmet needs for family planning, with Uttar Pradesh, Bihar, Maharashtra, and West Bengal accounting for half of this population. This highlights the importance of considering headcount in addition to prevalence when prioritizing regions for the National Family Planning Programme. For instance, Meghalaya had the highest prevalence of total unmet needs in 2021.

Strategies for fulfilling the unmet need for family planning in India

Indian states and union territories, with their vast and diverse population, face a significant challenge in addressing the unmet need for family planning. These issues have been critical for the country’s socio-economic development, health outcomes, and gender equality for a long time. Despite considerable efforts, a substantial proportion of the population still needs access to effective family planning services. Addressing this gap requires a multi-faceted approach involving policy intervention, education, healthcare infrastructure, and community engagement.

A robust policy framework is essential to address the unmet family planning needs. The Indian government has made several initiatives such as Mission Parivar Vikas and National Family Planning Program, which focus on improving access to contraceptives and reproductive health services. However, policies need to be more inclusive and adequately funded to close the gap further. Ensuring consistent supply and distribution of contraceptives across all the regions, primarily focused on rural and underserved areas, is crucial. Additionally, integrating family planning services with other health programs can provide a holistic approach to reproductive health.

Lack of awareness and education remained as a significant barrier to effective family planning in India. Comprehensive sex education should be incorporated into the school curriculum to educate young people about reproductive health and family planning options. Community-based awareness programs can also play a crucial role. These programs should target both men and women to address cultural and societal norms that often hinder the use of contraceptives. Empowering women through education and awareness is particularly important, as it enables them to make informed choices about their reproductive health.

Improving healthcare infrastructure is vital for providing accessible family planning services. Many rural and remote areas need more healthcare facilities, making it challenging for rural residents to access contraceptives and reproductive health services. Expanding the network of primary healthcare centres and ensuring they are well-equipped and staffed is essential. Training healthcare providers in family planning services and counselling can enhance the quality of care. Mobile health units can also be an effective solution for reaching remote populations.

Cultural and social barriers significantly influence the uptake of family planning services in India. Traditional beliefs, gender norms, and misinformation can discourage individuals from seeking contraceptives. Involving community leaders and influencers can help shift attitudes and promote acceptance of family planning. Importantly, engaging men in family planning discussions can help address gender biases, foster shared decision-making within families, and promote a more equitable approach to reproductive health.

Economic barriers also play a role in the unmet need for family planning. Many individuals cannot afford contraceptives or related healthcare services. Providing free or subsidized contraceptives can significantly improve access. Additionally, integrating family planning services with existing social welfare programs can ensure that economically disadvantaged populations receive the necessary support.

Continuous monitoring and evaluation of family planning programs are required to assess their efficacy and make necessary adjustments. Establishing a robust data collection system can help track progress and identify gaps. Regular feedback from communities can also provide insights into the barriers they face and how interventions can be improved.

Addressing the unmet need for family planning in India is a complex challenge, and solving these challenges requires a coordinated and comprehensive approach. By strengthening policy frameworks, improving education and awareness, enhancing healthcare infrastructure, addressing cultural barriers, leveraging technology, ensuring financial accessibility, and continuously monitoring progress, India can make significant strides in fulfilling this need. Your role in implementing these strategies is crucial.

References

About Author: Pankaj Chowdhury is a former Research Assistant at the International Economic Association. He holds a Master’s degree in Demography & Biostatistics from the International Institute for Population Sciences and a Bachelor’s degree in Statistics from Visva-Bharati University. His primary research interests focus on exploring new dimensions of in computational social science and digital demography.

Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the views of 360 Analytika.

Acknowledgement: The author extends his gratitude to the The Lancet for providing data support.

This article is posted by Sahil Shekh, Editor at 360 Analytika.