Findings from this study demonstrate that nearly three in every four (72%) partnered women in need of contraception in India are using a modern method. This is a negligible improvement from DFPS observed in 2005 data, which was at 70% [3]. Further, three-quarters of this use is represented by female sterilization, again demonstrating inadequate progress in the promotion of reversible contraceptive use in the nation in the past decade. Further, 43% of sterilized women are under 25 years of age, with the fastest increase in sterilization prevalence occurring between ages 19–25 years [8]. This directly corresponds with India's median age at first birth of 21 years, median birth interval of 32 months, and total fertility rate of 2.2 children [8]. India's reliance on female sterilization is largely due to a historical legacy of government policy that promoted sterilization to control population growth [12, 13], as well as patriarchal norms that view vasectomy as a threat to masculinity and sexuality [14, 15]. Importantly, there is some indication of increasing modern contraceptive use based on preliminary state level data collected in 2019–2020, under the NFHS-5, although sterilization continues to be the dominant form of contraceptive used [16].
Reliance on SARC or LARC was much less common (20.7% and 3.2%, respectively). Several factors likely contribute to these low shares. There is an ongoing fear of side effects and health issues associated with the use of different SARC and LARC methods [17]. Additionally, research on contraceptive use in India suggests that familial pressure, as well as gender and social norms, play a strong role and that these norms have shifted little over time [17,18,19]. Many women do not use contraception following marriage in order to demonstrate their fertility, and as a result of pressure from husbands, in-laws and communities [20,21,22]. Deviation from these norms may facilitate greater uptake and sustained use of these methods, thus reducing reliance on sterilization. Our results showed that the highest share of SARC and LARC use were found among women with higher socioeconomic status, education and empowerment levels. Even though these subgroups of women presented higher reliance on non-permanent methods, they have lower DFPS with modern methods, which reinforces the difficulty of using contraception that is not sterilization. After infrequent sex, the most common reasons women reported for not using contraception in India were the opposition of the husband or someone else (19.7%), lack of access (9.8%), fatalistic approach (9.1%), respondent opposition (8.1%) and health concerns (7.4%) [19]. Across age groups, LARC use was highly invariant. However, at younger ages, there is a much higher share of SARC methods, that is almost linearly exchanged to permanent methods as women get older. Evidence shows that, even among sexually active unpartnered women, sterilization is the most commonly used contraceptive method in India [8]. We may, however, see a change when new data become available due to the Mission Parivar Vikas, a government initiative launched in 2016 to promote modern contraceptives in 146 high fertility districts via financial incentives for women and family planning providers (financial incentives apply for injectable contraception, IUD and sterilization) [23].
There is evidence to suggest that women from more marginalized backgrounds achieve higher levels of family and community status, as well as greater freedom of movement, only following their sterilization [24]. For these women, therefore, current social structures may impede their ability to access some of the rights enjoyed by wealthier, more educated and more empowered women prior to sterilization. These findings highlight the need not only for more targeted efforts to support access and uptake of SARC and LARC methods among more socially vulnerable women, but also a need to understand in greater detail how normative, structural and economic barriers may affect their contraceptive decision-making. Our results also offer caution regarding sterilization, however. One in five sterilized women were not told that their procedures meant that their childbearing would be complete, and well more than half (62%) received financial incentives for undergoing sterilization. In the context of a long history of forced and coercive sterilizations [12], in which sterilization targets and financial incentives for women who undergo sterilization and health workers who enable those procedures [25] still exist, these results indicate a need for a greater understanding of women's information, choices and autonomy regarding these procedures. Sterilization regret, while a concern at any level, was very low in this sample (7%). However, given the large proportion of women undergoing sterilization, the number of women experiencing regret are considerable [26]. We estimate that more than 92 million women in reproductive age are sterilized in India, thus around 6.5 million women regret having undergone the procedure. Additionally, sterilization levels were similar across wealth quintiles, indicating that incentivization alone is not driving this high prevalence. Given the substantial geographic heterogeneity in the prevalence of demand for family planning satisfied with permanent methods, with higher coverage in the south, central and west of India, and lower coverage in the north and east, in line with previous research, additional geospatial analyses may be warranted [20].
Importantly, this study was able to identify the ways women meet their need for family planning across both types of contraception and domains of empowerment. The least socially independent women (e.g. those with lower levels of information access, educational attainment, and age at first marriage and childbirth, and with higher gaps in age and education between spouses) have the highest reliance on permanent methods. These findings correspond with extensive research from India, consistently showing greater uptake of sterilization and younger age at sterilization among socially marginalized relative to more privileged women [8, 13, 24, 27,28,29].
This study has some limitations. Data were derived from a self-reported survey and are thus subject to recall bias. Causality cannot be inferred from this observational, cross-sectional analysis. Due to the unique history of contraceptive uptake in India, as well as the current highly skewed method mix, results may have limited generalizability beyond India. Also, we know that contraceptive use has increased since 2015–16, when these data were collected, based on preliminary findings from state level data collected in 2019–2020 [16]. However, the current analyses use the only nationally representative data available from India, and more recent data show similar patterns of contraceptive use as seen in these 2015–16 data, albeit at higher rates.
