regional variations in unmet need of family planning in ... - medIND

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media, while it is 14.5 per cent only those having media exposure. The means of possible solufion to meet the unmet need of family planning services advocated ...
Health and Population Perspectives and Issues 36 (1 & 2), 26-44, 2013

REGIONAL VARIATIONS IN UNMET NEED OF FAMILY PLANNING IN RAJASTHAN Sherin Raj T.*, V.K. Tiwari** and J.V. Singh1*** ABSTRACT The objectives of this study were to assess the extent of regional variations in unmet need of contraception among married women of reproductive age group in Rajasthan and to study the factors influencing unmet need for contraception using the District Level Household Survey (DLHS-3) data. The state has been divided into four regions as per NFHS classification. Age group, caste, religion, place of residence, women education, wealth index, media exposure, death of the children are found to be significantly affecting the unmet need. The findings of the study also show that southern region has a lower unmet need and the north-eastern region has the highest unmet need of family planning in Rajasthan. It was found that 99.2 per cent of the currently married women in the age group of 15-49 years knew any kind of modern method of family planning in the state. The contraceptive prevalence rate (CPR) for any method had changed marginally by 6.6 per cent points from 40.3 to 46.9 per cent from DLHS-1 to DLHS-2 and it has increased by 17 points to 58.1 per cent in DLHS-3. Unmet need for spacing is 17.3 per cent among the younger women in the 15-24 years age group while for limiting, the figure is 6.1 per cent; it means older women are not interested to get pregnant may be due to social taboos. It is seen that the mean age at marriage in the north-eastern region is 17.4 years, and nearly 42 per cent of the marriages occurred below the legal age of marriage. It is observed that age of women, their place of residence, religion, education level, wealth index, media exposure, number of livebirths, and experience of child-loss were significantly associated with the unmet need of family planning across the state and among the regions. Muslim women have the highest (23.9%) unmet need than other religions in Rajasthan. Illiteracy was high among Muslims in the state.

Assistant Research Officer; **Professor, Department of Planning and Evaluation, National Institute of Health and Family Welfare, Munirka, New Delhi. ***Director, UP Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh. *

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Due to availability of health care facilities and services including private facilities in the urban areas, there is a low unmet need in the urban areas in comparison to rural areas. The gap between unmet need for spacing and limiting is very large in cases of women who are illiterate while gap is less among women with education of 5-9 years, 10 years and above. Total unmet need in Rajasthan is 16.8 per cent among the women without exposure to media, while it is 14.5 per cent only those having media exposure. The means of possible solution to meet the unmet need of family planning services advocated by the authors include delay the age at marriage, identifying all pregnant women in the population and offer them the basic desired health care services. Key words: Unmet need, Family planning methods, Spacing, Limiting, Regional variation.

More than 100 million women in less developed countries, or about 17 per cent of all married women, would prefer to avoid a pregnancy but are not using any form of family planning. More than one-fourth of the births world-wide are unplanned1. In many countries, established national targets for increasing contraceptive prevalence and declined fertility rate could be achieved by eliminating the unmet need2. In South Central Asia and South-east Asia, the proportion of women with unmet need is lower at 18 per cent and 14 per cent respectively. It is estimated that more than 100 million women in South Central and South-east Asia have an unmet need.3 About twenty two per cent (21.8%) of currently married rural women in India had an unmet need for family planning in the District Level House Hold SurveyIII (2007-2008).4 Even where the proportion of women with the unmet need is declining, the absolute number with unmet need may be growing because the population is growing (population report, 1997).5 In a non-contracepting society, the individual women’s need to limit reproduction increases with age and parity level, while birth-spacing needs generally occur early in her reproductive career. Rajasthan is one of the largest states by area in the country with a very high population growth rate. There are 32 districts in Rajasthan and have different rates of acceptance of various family planning methods. The possible reasons for the lower acceptance include cultural backgrounds, attitudes towards family planning, meagre knowledge of family planning methods, attitude of the service providers towards these communities, lack of accessibility and availability of services, and prevalence of traditional methods of birth control.6 NFHS found that with regard to education and residence, the differences between SC/ST and non27

SC/ST populations were significant in the state.7 In view of regional variations in Rajasthan, it is imperative to assess the extent of regional variation in unmet need of family planning among married women of the reproductive age group, and to study the reasons and factors influencing unmet need for contraception for both spacing as well as limiting. METHODOLOGY Data for the analysis of unmet need of family planning in Rajasthan was taken from the District-Level Household Survey-III (DLHS-III, 2007-‘08). A multi-stage stratified systematic sampling design was adopted for DLHS-3 in the state. In the state of Rajasthan, DLHS-III sample covered a total of 38797 currently married women in the age group of 15-49 years. Detailed description of sampling procedure is given in the DLHS-III, Rajasthan report.8 For regional analysis, the state has been divided into four regions according to the National Family Health Survey 2 (NFHS-2) as given in the following Table 1. TABLE 1 REGIONAL CLASSIFICATION OF DISTRICTS IN RAJASTHAN

Region Western Region (13629)* North-eastern Region (14527)* Southern Region (4735)* South-eastern Region (5906)*

Districts Ganganagar, Bikaner, Churu, Jaisalmer, Jodhpur, Nagaur, Pali, Barmer, Jalor, Sirohi, Hanumangarh (11 districts ) Jhunjhunu, Alwar, Bharatpur, Dhaulpur, Sawai Madhopur, Jaipur, Sikar, Ajmer, Tonk, Bhilwara,Dause, Karauli (12 districts) Dungarpur, Banswara, Udaipur, Rajasmond (tribal dominated) Chhitaurgarh, Bundi, Kota, Jhalawar, Baran (Hadoti Area)

* Sample size in each region from DLHS-3 given in bracket, Source: NFHS-II Chi-square test was applied to find out the association between the unmet need and other independent variables. Logistic regression technique has been applied to study the net effect of each variable. Cross tables have been generated on awareness of contraceptive methods, CPR, age group, religion, caste, place of residence, wealth index, education of women, media exposure, number of living children and children died with unmet need by region using SPSS software.

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FINDINGS In the District Level House Hold Survey report, 2007-08, it was found that 99.2 per cent of the currently married women in the age group of 15-49 years knew any kind of modern method of family planning in Rajasthan. The regional analysis shows that the awareness on modern method of family planning was more than 98 per cent in all the regions. Knowledge of contraception was widespread even among adolescents. Knowledge on male and female sterilization method was also more than 90 per cent in all the regions except north-eastern Table 2. TABLE 2

Any modernmethod

Male sterilization

Female sterilization

IUD

Pill

ECP

Condom/Nirodhd

Female condom Rhy

Rhythm method

Female Literacy Rate, 2011 Census

Western Region

99.9

98.9

94.1

99.9

79.8

94.8

34.5

87.8

5.9

53.2

49.67

NorthEastern Region

98.3

98.2

87.6

97.7

74.3

86.9

40.7

81.8

9.7

46.7

56.55

Southern Region

99.9

99.9

99.4

99.9

82.1

98.0

34.7

98.4

2.6

75.1

47.25

SouthEastern Region

99.0

98.9

92.4

98.4

69.4

91.2

27.8

83.9

7.70

48.3

53.10

Rajasthan

99.2

99.1

92.0

98.8

76.4

91.6

34.5

86.2

7.2

52.6

44.80

Regions

Any meth-od

AWARENESS OF CONTRACEPTIVE METHODS AMONG THE CURRENTLY MARRIED WOMEN IN RAJASTHAN

Source: DLHS-III, 2007-‘08 and Census of India, 2011.

A significant variation was observed in the knowledge of IUD that varied from 69.4 per cent (south-eastern region) to 82.1 per cent (southern region). Awareness on emergency contraceptive pills (ECP) was above 50 per cent. Knowledge on female condom was found to be very less, less than 10 per cent in all the regions and in southern regions it was the lowest with 2.6 per cent. Awareness on condom was above 80 per cent in all the regions. The traditional method, like rhythm was found to be 52 per cent amongst the women in Rajasthan. With regard to the contraceptive prevalence rate, it is quite lower than the awareness level which indicates a gap between knowledge and practices of any type of family planning method due to various barriers. 29

The contraceptive prevalence rate (CPR) for any method had changed marginally by 6.6 per cent points from 40.3 to 46.9 per cent from DLHS-1 to DLHS-2 and it has increased by 17 points to 58.1 per cent in DLHS-3. CPR for any method is the highest in southern region (61.2%) and the lowest in north-eastern region (52.3%). A huge gap has been observed between rural and urban CPR in each region. CPR by modern methods also has similar kind of variations among the regions. Figures in Table 3 show that traditional methods were accepted by very few (2.7%) couples in Rajasthan. TABLE 3 CONTRACEPTIVE PREVALENCE RATE (CPR) BY REGION AND PLACE OF RESIDENCE CPR of any Method

CPR of any Modern Method Rural

Rural

Urban

Total

Western

54.5

61.8

55.9

NorthEastern

50.3

60.0

52.3

Southern

59.8

71.8

61.2

SouthEastern

52.8

62.9

55.0

Rajasthan

56.4

64.3

58.1

Urban

Total

CPR of Traditional Method Rural

Urban

Total

52.5

58.7

53.7

2.0

3.0

2.2

47.6

56.8

49.5

2.5

3.1

2.6

56.3

68.9

57.8

3.4

2.8

3.4

50.2

60.3

52.4

2.5

2.4

2.5

53.6

61.0

55.3

2.6

3.1

2.7

Source: Prepared from DLHS-3 data 2007-08.

The levels of unmet need vary substantially by the women’s social, economic and demographic characteristics. Unmet need has a close relationship with the age of women. Younger women (15-24 years) have a greater unmet need for spacing than limiting. Unmet need for spacing is 17.3 per cent among the women in the 15-24 years age group while for limiting, the figure stands at 6.1 per cent. But the total unmet need in this age group is 23.4 per cent in the state. It may be due to the fact that immediately after marriage, young women are not ready to become pregnant/mothers. On the other hand, even after first birth, many couples tried to use contraception to protect themselves from conception for at least 4 to 5 years. At the same time, the pattern of unmet need among women in the age group of 35-49 years is reversed. Here, the pattern of unmet need for spacing is much lower than the pattern of unmet need for limiting. The reason may be that at the age of 35–40 years, most of the couples in India reached their desired family size. Similarly, a woman who conceived children in quick succession or at an early age or continue to have children when grand children have started arriving; may be criticised by the society. At this stage, the demand for limiting family is more important than spacing. So, in latter age, the unmet need for family planning is

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basically due to either they had completed their desired fertility-level or women are not ready to get pregnant at an older age due to social constraints/taboos. Table 4 reveals a statistically significant association in each region with unmet need of spacing and total unmet need in the age groups. Unmet need of spacing is the highest in the western region amongst all the age groups, and the lowest in the southern region. The north-eastern region has the highest unmet need of limiting (11.2%) and southern region has the lowest (4.2%). A high level of unmet need of family planning persists in the north-eastern region. The north-eastern region consists of Jhunjhunu, Alwar, Bharatpur, Dhaulpur, Sawai Madhopur, Jaipur, Sikar, Ajmer, Tonk, Bhilwara, Dausa and Karauli districts. As per the DLHS-3 report, mean age at marriage in this region is found to be 17.4 years, and nearly 42 per cent of the marriages occurred at below the legal age at marriage. TABLE 4 UNMET NEED BY AGE GROUP OF CURRENTLY MARRIED WOMEN AND REGION Spacing

Limiting

15-24

2534

3549

Western Region ***£ ££ ᵴᵴᵴ

20.4

5.8

0.9

North-Eastern *** ᵴᵴᵴ

17.7

4.9

0.4

*** Southern ᵴᵴᵴ

13.4

3.2

0.1

South-Eastern *** ᵴᵴᵴ

13.4

4.4

0.5

***Rajasthan ᵴᵴᵴ

17.3

4.9

0.6

Total Unmet

Total

1524

2534

3549

Total

7.2

5.5

11.3

10.2

9.5

6.9

7.7

13.5

11.7

11.2

4.5

3.3

6.5

2.3

4.2

5.7

5.3

10.0

7.7

7.8

6.6

6.1

11.2

9.5

9.2

1524

2534

3549

Total

25.9

17.1

11.1

16.7

25.4

18.3

12.1

18.1

16.7

9.6

2.4

8.7

18.7

14.4

8.3

13.5

23.4

16.1

10.1

15.8

Source: Calculated from DLHS-3,, 2007-08. Significant unmet at ***P< 0.001, Significant unmet spacing at ᵴᵴᵴP