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Meeting the Unmet Need a Choice-Based Approach to Family Planning

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Meeting the Unmet Need a Choice-Based Approach to Family Planning Meeting the Unmet Need A Choice-Based Approach to Family Planning Introduction Family planning is an important tool for altogether, but are not using a fulfilling people’s reproductive health and contraceptive method, or fertility needs and has rightly been at the (2) have a mistimed or unwanted current heart of political and programmatic pregnancy, or interventions in India as well as globally. (3) are postpartum amenorrhoeic and their However, India’s family planning last birth in the last two years was programme, despite its numerous mistimed or unwanted”1. successes, has had to contend with misconceptions, lack of information around Unmet need can be further disaggregated contraceptives, and a continuing gap in into unmet need for limiting births and public perception on the importance and unmet need for spacing births2. Unmet need need for family planning. There has also also varies across parameters, like been a recognition of the persisting unmet geography, age, education, religion, caste, need for family planning (henceforth, unmet and economic status, among others (New et need), which can be a barrier to women’s al. 2017). In India, women in rural areas realisation of their optimal reproductive report a higher unmet need than their urban health and fertility needs. counterparts and there are interstate variations in unmet need.3 Unmet need also Simply put, unmet need refers to the varies across social indices, with “condition of wanting to avoid or postpone contraception use at its lowest (45%) among childbearing but not using any method of women from Scheduled Tribes, followed by contraception” to do so (Casterline and Other Backward Classes (47%) and those Sinding 2000: 3). Per National Family Health from Scheduled Caste (49%) (NFHS–4). Survey–4 (NFHS–4 2015-2016), unmet need in India is defined as the “proportion of Women’s unmet need is dynamic and can women who: change over a period of time as their fertility (1) are not pregnant and not postpartum desires alter, when women want to change amenorrhoeic, are considered fecund, their contraceptive method, or when and want to postpone their next birth for deciding to return to contraception following two or more years or stop childbearing childbirth (Jain et al. 2012). During these 1 National Family Health Survey 2015–16, henceforth pregnancies that did not result in births (see, Casterline NFHS–4. Although, and as the definition above indicates, and Sinding 2000 for a more comprehensive account). unmet need can be assessed through a gap between DFR (Desired Fertility Rate and TFR (Total Fertility Rate), or 2 In NFHS–4, unmet need for spacing methods was 5.6% through childbirths that are classified as “unwanted”, and 7.2% for limiting methods. scholars have emphasised not using “unwanted” births as a unit of measurement, owing to its susceptibility to 3 As per NFHS–4, overall unmet need was highest in underestimate “unwanted” births. For example, many Manipur (30.1%), Nagaland (22.3%) and Sikkim (21.7%), women, post-birth, are likely to classify a live birth as and lowest in Andhra Pradesh (4.6%), Punjab (4.6%) and wanted even though the pregnancy was unwanted; Chandigarh (6.2%). unwanted births also does not capture unwanted Population Foundation of India 1 phases, women’s met need may convert into and programmes. Following in the footsteps unmet need if the period of contraceptive of the approach put forth during the non-use is prolonged due to factors like International Conference on Population and inability to access quality care, find Development (ICPD), the choice-based contraceptives that match their needs and approach recognises that women have desires, or if women are unable to get quality different choices and individual preferences counselling to help them with their for their fertility, family planning and contraceptive choices. Various global studies contraceptive use, and aims to build policies have documented such conversion–of met and programmes that ensure that women need into unmet need–particularly due to have options to choose from, accurate and contraceptive discontinuation, which can complete information to facilitate their subsequently lead to unwanted fertility and choice, and the freedom to exercise their childbirths (Jain et al. 2014; Casterline et al. choice. This paper ends with specific 2004). recommendations that can uphold and engender choice in developing and This paper examines factors that contribute strengthening programmes and policies in to unmet need in India and proposes a India to reduce the unmet need and choice-based approach while formulating addressing social and cultural determinants and implementing family planning policies of meeting unmet need. Unmet Need and Family Planning – Global Context Although unmet need for family planning informed consent and disregarded their has been deduced in the perceived gap choice and fertility preferences (Garcia- between women’s reproductive intentions Moreno and Claro 1994). Instead, ICPD and their contraceptive use (previously urged for a human rights-based approach to known as the KAP-gap–or gap between address population concerns, emphasising knowledge, attitude and practice), the the possibilities of achieving a desired family concept itself came to prominence with the size through striving for wider gender International Conference on Population and development, such as, ensuring gender Development (ICPD) in 1994 (Bradley et al. equality, working for women’s 2012; Bradley and Casterline 2014; Visaria empowerment, improving their education and Ved 2016). ICPD was a watershed and economic independence, and making moment that marked a paradigm shift in the quality reproductive healthcare accessible to focus of family planning programmes from all (UNFPA and PATH 2008; Kulkarni 2020; achieving targets to improving and Sen 2010; Hardee et al. 2014). strengthening the provision of reproductive health-related information and services. Subsequently, meeting the unmet need of Critical of target-oriented population policies women has emerged as a critical measure of and family planning programmes, the ICPD reproductive health and family planning that Plan of Action (PoA) rejected them on could align the two distinct aspects of family grounds that they often led women into planning programmes–achieving population unwanted and coercive sterilisations– stabilisation and enhancing reproductive measures that violated women’s right to health–while upholding individual choice Population Foundation of India 2 and striving for social change, particularly and girls” by ensuring universal access to through gender development. Over the sexual and reproductive health and years, unmet need has been mobilised as “a reproductive rights (United Nations, rationale for increasing investments in Sustainable Development Goals). Most family planning programs; to evaluate recently, the FP2020 initiative aimed at national family planning programs and adding additional 120 million contraceptive measure [their] progress…”, and to set global users globally by 2020 (UNFPA and PATH development goals, such as the Sustainable 2008; Hardee and Jordan 2019; Hardee et al. Development Goal (goal 5) to “…achieve 2014). gender equality and empower all women Unmet Need and Family Planning - India India launched its Family Planning first cohort of countries who committed to Programme in 1952, with goals to stabilise the FP2020 initiative in 2012. These population growth rate, reduce fertility commitments were revitalised in 2017 with levels and improve maternal health. Since the country working to increase modern then, India has traversed a long path to contraceptive prevalence rate from 53.1% to make sexual and reproductive health 54.3% and to ensure that 74% of the demand services, including family planning, available for modern contraceptives would be to a large population in its reproductive age satisfied (Family Planning 2020–India). group (15-49 years). As a signatory to the ICPD PoA, India committed to an approach To realise these commitments, the that would focus on people rather than government of India has undertaken various numbers, and address the unmet need by initiatives that strengthen its family planning increasing access, availability and choice of programme. India has promoted the use of contraceptives, ensuring quality of care, and modern contraceptives and steadily working towards last-mile reach and expanded its basket of contraceptive connectivity through expanding the choices, with the most recent addition in penetration of reproductive healthcare 2017, of three new spacing methods: through frontline workers (Rao 2003). Injectable contraceptive DMPA (Antara)–a 3- Subsequently, India’s National Population monthly injection; Centchroman pill Policy (2000) reflected the government’s (Chhaya)–a non-hormonal once a week pill; commitment to voluntarism, informed and Progesterone-only Pills (POP). The choice and consent in availing reproductive government also launched Mission Parivar healthcare services. It also called for a Vikas for increasing access to contraceptives comprehensive approach to population and family planning services in 146 high stabilisation and for addressing the social fertility districts in 7 high focus states (Uttar determinants of health, promoting women’s Pradesh, Bihar, Rajasthan, Madhya Pradesh, empowerment and education, adopting a Chhattisgarh, Jharkhand and Assam) that target-free approach, encouraging reported a total fertility rate of 3 and above community participation and
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