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Evaluation of family planning services in Uttar Pradesh- findings from a recent household survey carried out under Track20 project
By Jay PRAKASH
Extended Abstract
Over the years, fertility has been declining in India and across all the states along with increase in two of the proximate determinants - use of contraception and age at marriage. The states have shown mixed responses in both the two indicators. Recent surveys (DLHS4/AHS3) carried out in the country shows that CPR has declined in about 16 states at varying pace from 2007-08 (DLHS 3) to 2012-13 (DLHS4/ AHS3). This decline is seen mostly in some of the good performing states such as Chandigarh, AP, A&N Islands, Karnataka, Punjab, etc. Even low performing states like Manipur, Meghalaya and Goa have also shown decline in CPR. There is an urgent need to address these issues in states with low performing and declining CPR.
The unmet need has also increased in such type of states. In addition, there is high proportion of women in almost all the states with two children who do not want any additional child (DLHS 4). Addressing the need of such women may lead to better coverage of the family planning performance and bring further decline in fertility of the country. With the increased number in institutional birth, there is an opportunity to motivate women to adopt post-partum spacing (PPIUCD) and limiting methods (PPS). Also with increased schooling and age at marriage, it is expected that more people will adopt family planning method and soon fertility may further decline in high fertility states.
In order to track the progress made under the FP program initiatives, regular (periodical) data on FP indicators is necessary. Service statistics provide some, but not all, of the data needed to measure the priority FP2020 indicators. However, service statistics data need to be supplemented with other data. One particularly promising source of data is continuing surveys at some intervals. If relevant indicators are captured through some surveys at an acceptable cost, such surveys may provide an ideal source for many of the indicators for which service statistics are not a feasible option.
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The Present Study
Keeping in view the data limitations for assessment of the current level of program performance, a study was designed in 10 districts of Uttar Pradesh with the view to have an estimate of key FP indicators at the state level. Also, it was decided to design the study in such a way so that reliable district level estimates can be obtained. The study was executed by Track20 project of Avenir Health, USA, funded by Bill & Melinda Gates Foundation for the execuition of study. The study has been carried out with the following objectives:
1. Assess the current use of contraceptives among the eligible population; 2. Level of reach for FP services under the new program initiatives; 3. Identification of barriers, which prevent the couples in adoption and continuation of methods; 4. Unmet need for modern contraceptive methods addressed. In addition, the study also makes comparison of results with other surveys such as AHS/ DLHS.
Methodology
The proposed rapid assessment study of FP program has been designed to provide estimate of CPR and other key indicators in Uttar Pradesh based on 10 selected districts of Uttar Pradesh spread across different zones in the state. For this purpose, a statistical household survey was carried out among the reproductive age couple.
Sample size and sampling design
To obtain minimum sample size for the rapid assessment survey, the information on level of indicator to be estimated, permissible error, confidence intervals and the design effect are required. The state level CPR was used for estimation of sample size. Considering a prevalence of 50 per cent for CPR (conservative estimate) with 5 per cent of tolerance limit and at 95 per cent of confidence interval, a sample of 384 households is needed. Using a design effect of 1.5, minimum sample required is estimated as 580 households with an eligible couple. Therefore, sample size of 600 (rounding up) currently married women was decided for each of the selected 10 districts.
In each selected district, the entire sample was sub-divided into rural and urban household as per the proportion of population in two segments. From each selected district, a representative sample was obtained using probability proportionate to size (PPS) method. A two stage sampling procedure was adopted. At first stage, 30 clusters from rural and urban areas in the ratio of 21:9 were selected using Census of India 2011 data with probability proportionate to size (PPS) method from each district.
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At second stage, approximately 20 households with at least one eligible couple were selected in each village or urban ward constituting the cluster. From each selected household, only one currently married woman in the age group 15-49 years was interviewed.
Data collection Tools
Keeping in view objectives of the assessment, a short interview format was developed which was administered among the eligible respondent. The key themes in the questionnaire include:
a. Socio-demographic profile b. Awareness of FP schemes c. Past use of contraceptive methods, duration of use and reasons for discontinuation d. Current use of contraceptives – method wise, duration of use e. Knowledge about sources of availability of methods f. Interaction with peripferal level health workers g. Reasons of non-use of contraceptives h. Unmet need for family planning methods Coverage
In order to obtain state level estimate, the study was conducted in following 10 districts: Sl. No. Name of District Sl. No. Name of District 1 Sitapur 6 Gorakhpur 2 Varanasi 7 Etah 3 Banda 8 Ghaziabad 4 Lalitpur 9 Bareilly 5 Bahraich 10 Kanpur Dehat
I. Background Characteristics A total of 6012 households were sampled and one currently married woman in the reproductive age group was interviewed from each selected household. As per the sampling plan, approximately 600 households were selected from each district.
Age distribution
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Age distribution data show that 73% women were below the age 35 years and remaining 27% were more than 35 years. Only 1.5% women were adolescents in the sample. The average age of respondents was 31.3 years. The age distribution of women across districts was almost similar which is good for comparison of results across the districts.
Age at first marriage
Generally the respondents were married when they were in the age group of 15-20 years (81%) but 9% were married before 15 years of age. Only 10% were married after 20 years of age. The average age at marriage in UP was 17.3 years. However, more women got married before 15 years of age in Sitapur (16%) and Bareilly (12%) whereas this proportion was lower in Ghaziabad (5.8%) and Banda (6.2%).
Education
Education level data show that 46% of women across 10 districts were illiterate with a higher proportion in the districts of Sitapur (57%), Bahraich (61%) and Bareilly (65%). Only 9% of respondents across the districts had studied upto graduate level and above. As per the Census 2011, the proportion of females who are illiterate in the age group of 15-49 years is 44 percent. This information matches with the sample of women in the present study. Thus the sample may be considered representative of the state.
Residence
Nearly 70% of respondents were from rural area and 30% from urban area across the districts.
Caste
Caste wise information show that 46% respondents belonged to OBC, 20% to Scheduled Caste, 18% to general category and 1% to Scheduled Tribe. OBC were less in Sitapur (22%) and higher in Etah (65%) whereas ST were higher in Varanasi (7%). General category was more in Lalitpur (22%) and Ghaziabad (26%).
The proportion of Scheduled Caste population in the state of UP is 20.7 percent as per Census 2011 which matches with the proportion in the sample. However, the proportion of Scheduled Tribe population (1.4%) in the sample is slightly at higher side than the state average (0.6%).
Religion
The Hindu-Muslim proportion in the sample is slightly distorted as compared to the Census population figures. In the sample, most of the respondents belonged to Hindu religion (85%) and 15% were Muslim. However, as per the Census 2011, there are 80 percent Hindus and 19 percent Muslims.
Occupation
Nearly 96% of women were housewives whereas 1.6% were in farming or agriculture (higher in Sitapur-9%) and 1% each were doing Government /private job and daily wage labour.
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II. Preg a y a d Child Birth
Pregnancy Outcome
Nearly 94% respondents reported to have given birth at the time of survey. The age at first pregnancy was 19-21 years for 49% of respondents, below 19 years for 31% and 22 years or more for 20% of the respondents.
Number of boys born alive was reported as one by 43%, 2 by 35%, 3-4 by 19% and only 3% reported 5 or more boys. Number of girls born alive was reported as one by 44%, 2 by 29%, 3-4 by 23% and 4% reported 5 or more girls.
Number of surviving boys was reported as one by 47%, 2 by 36%, 3-4 by 15% and only 2% reported 5 or more boys. Number of surviving girls was reported as one by 48%, 2 by 29%, 3-4 by 20% and 3% reported 5 or more surviving girls.
The total number of surviving children was reported as one by 17%, 2 by 27%, 3-4 by 40% and 5 and above by 16% of respondents.
Antenatal care and place of delivery
The responses of currently married women by antenatal care received, outcome of last pregnancy and place of delivery, are presented in Table 3.2.
Nearly 60% of respondents, who became pregnant, reported 1-3 times antenatal care received and only . % recei ed or ore a te atal care hereas % did t recei e a y a te atal care (Sitapur-43% and Bareilly-40%). Only in Ghaziabad, 26% women reported to have received antenatal care 4 or more times.
Live birth was reported as the outcome of last pregnancy by 97% of respondents and only 2% reported abortion and 1% reported stillbirth. Abortion was reported more (3-4%) in Sitapur, Ghaziabad and Etah districts. Stillbirths were higher (2%) whereas live births were less (95%) in Sitapur district.
Home as the place of delivery, was reported by 45% (54% in Bahraich and Etah each and 52% in Bareilly), Government facility by 35% and private facility by 20%. Delivery in Govt. facility was much higher in Banda (52%) and Lalitpur (55.5%) whereas delivery in private facility was much lower in these districts.
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III. I tera tio ith ASHA
Surprisingly about one-third of the total women (32%) in the reproductive age did not know the ASHA in the community. Only 68% of respondents knew ASHA of the village in the state of Uttar Pradesh. Awareness about ASHA was lowest in Ghaziabad (47%) and Sitapur (52%) while it was highest in Banda (80%), Gorakhpur (79%), Lalitpur (78%) and Bahraich (78%). Among the women who knew ASHA of the village, half (51%) of them informed that ASHA visited their home to talk about their last pregnancy and childbirth. The frequency of visit of ASHA at home during current pregnancy was reported as 1-2 by 54%, 3- 4 by 41%. The last contact with ASHA was mentioned by half of the women within the last month. There is possibility that ASHA prefers interacting with women of high fertile age group (20-29 years); most likely who are pregnant and older age women are intentionally not getting adequate attention by them.
Emphasis on Home Delivery of Cotraceptives (HDC) by ASHA has started showing positive results in the field in the form of increased interactions. Improved interactions with ASHA in the community about family planning are reported. About 41% respondents said that they received counselling/ advice on family planning during the pregnancy/ child birth. Of these women, 43% received advice from ASHA, 20% from ANM, 5% from AWW and 32% from others, which largely included husband/family members (61%), doctor/private doctor (20%) and neighbour/relative/Mass Media (20%).
Information on family planning methods was largely received at home (36%) followed by Sub-centre (21%), PHC (11%), Village Health and Nutrition Day (6%) and 27% from others (mainly ASHA home visit/Anganwadi worker, doctor /private or Govt. hospital and neighbor/in village). Information received at home was higher in Bahriach (46%), Ghaziabad (40%) and Bareilly (39%).
The information received about methods was mainly female sterilization (76%) followed by condom/Nirodh (53%), Copper T (48%), OCP (40.5%), injectables (22%), PPIUCD (8.5%) and male sterilization (4.7%). It is possible that even ASHA do not motivate for adoption of male sterilization. Moreover, in spite of not yet introduced in Public Health Program, the injectable contraceptives are being popularized in the State of Uttar Pradesh.
About 19% of women reported to have received advice on family planning by AWW/ ASHA during the last 12 months preceding the survey during home visit or visit to a heath facility. This proportion was comparatively reported higher in Varanasi (35%) and Gorakhpur (31%) districts.
In addition, 40.5% reported to have visited a health facility or camp for themselves or children and among them, 41% said that any staff member at the health facility or camp talked to them about family planning methods.
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IV. E er use of fa ily pla i g ethods
Ever use of any family planning method to avoid or delay the pregnancy was reported by 34.5% in Uttar Pradesh. The first use of family planning method was reported after 18 years of age. Most of the women (66%) reported first time use after the age of 24 years and 28% reported after 28 years of age.
The first method used was largely sterilization (48%) followed by condom (23%), OCP (8%) and IUCD (5%). Most of the women opted directly for sterilization without trying out any spacing method.
Sterilization failure was reported by 1.5% of women which quite high. About 80 percent women stopped the use of male condom and 50 percent OCP because they wanted to become pregnant; however in case IUCD 62% women stopped the use because they felt problem in using the and continuing the method.
V. Curre t use of fa ily pla i g ethods
Current use
In the state of Uttar Pradesh, half of the women (51%) were using any method for avoiding or delaying the birth of a child. Only 36.4% reported to using modern method of contraception. Use of modern method was reported to be higher in Lalitpur (57.3%), Gorakhpur (46.7%), Banda (46%) and Varanasi (44.5%) while it was lowest in Etah (19.6%), Sitapur (22.9%), Kanpur Dehat (27.4%) and Bareilly (28.5%). The method mix shows that female sterilization was 19.2% followed by condom (12.6%), OCP 2.3%, IUCD 1.3%, injectable 0.5% and PPIUCD 0.3%.
Sterilization for limiting method and condom use for spacing of births are the two major contributors in the mCPR. The use of sterilization was higher than the State average in Lalitpur (39%), Varanasi (28.8%), Banda (28.7%) and Gorakhpur (27.5%) while it was lowest in Etah (5.6%), Kanpur Dehat (11.2%) and Sitapur (12%). The use of condoms was highest in Bahraich (17.7%), Gorakhpur (14.8%), Lalitpur (14%) and Banda (13%) while it was lowest in Sitapur (9.2%), Varanasi (10.2%), Bareilly and Etah (10.5% each). Use of PPIUD and injectables was highest in Ghaziabad (1.3% and 1.2% respectively).
The variation in the use of sterilization is larger as compared to any other spacing method use in the State.
Use of traditional methods in Uttar Pradesh was 14.7%, which mainly included standard days (safe period) method. Only few women (0.8%) reported use of withdrawal method (except Sitapur district). Use of traditional methods was very high in Bahraich (27%), Varanasi (21%), Gorakhpur (20%) and Banda (16%).
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Acceptance of modern method use in urban area was significantly higher (42.2%) than in rural area (34.0%) except Banda where prevalence in rural area is slightly more than urban area. Once again the evidnce shows that the focus of the FP program needs to be more enhanced in rural pockets.
While the CPR is higher in urban population, use of female sterilization is lower in these areas (16.8%) than in rural counterpart (20.3%). Also use of male condom is more popular in urban population (18%) than in rural areas (10%). The use of condom is yet to be popularizing among the rural population. Knowledge, availability and accessibility of condoms may be one of the reasons for low use in rural areas. It is disheartening that inspite of so much of effort, the use of OCP, IUCD, ECP has not been picking up so far and still at very low level ranging between 2-3 percent. The use of injectables reported by about 0.5 percent of women and not yet introduced in the Govt. health system, has got equal popularty among the rural and urban population. This may be considered a kind of indication for the good acceptance of injectables among the women who are willing to use FP method.
Place of sterilization and quality of care Althogh sterilizations services are mostly availed at Govt. facilities (90%), private facilities are also used by about 10% of the couples. In the district of Etah- the lowest performing sterilization, one-third cases are conducted at private facilities.
More than 90 percent of females opted for sterilizations between the age 20-35 years and 44% in the age 26-30 years. The districts with good performing in mCPR, the sterilizations are conducted at youger ages where women are protected from the exposure of pregnancy for a longer period. In the district of Lalitpur, 38 percent of sterilization cases are conducted in the age group 20-24 while in Bahraich only 12% women are sterilized in this age group. Thus, the preference for early age sterilization may lead to better performance in the mCPR of the district.
In general the quality of care was reported as good by almost 95% women and almost half of them reported to be very good. In the district of Bahraich, out of 3 women only one reported that the sterilizations services were very good. This shows a direct linkage between the perception of comminuty about the quality of FP services and its utilization. Similar is also observed in Etah district which has shown lowest level of sterilization cases and a substantial number of women opted to get sterilized at private facilities. The quality of care received was mentioned bad or not so good by substantial number of women (approximately 6%) who had undergone for sterilization operation in Sitapur, Banda and Bahraich districts. In addition, 2% regretted after getting sterilization in Uttar Pradesh which was highest in Kanpur Dehat (5.9%) and Etah (5.6%).
Packet of Oral pills/Condom shown
Users of condom and OCP were asked to show the packets of these contraceptives as an evidence of use. One out of five users of condom/ oral contraceptive pills showed the packet of these contraceptives. It was higher in Lalitpur (36%), Banda (31%) and Bahraich (27%) while it was lowest in Kanpur Dehat (10%) and Etah (11%).
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Knowledge of sources of obtaining family planning methods
Many recent surveys (DLHS) have revealed a large gap in the knowledge about the method and sources for obtaining those methods among the reproductive age women. In order to assess the level of knowledge of sources for obtaining FP methods, all women were asked if they knew the various sources. Responses are given below:
PPIUCD: Only 42% reported correct sources for obtaining PPIUCD.
IUCD: Nearly 90% reported correct sources of obtaining IUCD which can be called universal.
Oral Contraceptive Pills: About 37% women knew of availability of OCP from Govt. facility, 27.5% knew its availability from Private facility and 26% from medical store. Only 5% mentioned its availability from ASHA and ANM.
Injectable contraceptive: Nearly 25% in Uttar Pradesh mentioned its availability from Govt. facility, which is wrong.
Condom/Nirodh: The knowledge of sources of availability of condom was very good though its availability with ASHA and ANM was known to only 18% and 12%, respectively (higher in Varanasi).
ECP: Knowledge about availability of ECP from Govt. or private facility was very low (3% each). Its availability from medical store was known to 11% in Uttar Pradesh (higher in Varanasi-22% and Gorakhpur- 20%). Its availability with ANM was mentioned by very few in Varanasi and Etah.
It is also evident that knowledge on the availability of contraceptives was not very good except in the case of IUCD; awareness on the availability of condoms, OCPs and ECPs with ASHA was extremely low among the women of reproductive age. This is an important issue for the program implementation that inspite of more than 3 years of launch of Home Delivery of Contraceptive (HDC) Scheme by ASHA, the program has not shown the desired results.
Payments made for obtaining the method
About 37% of respondents in Uttar Pradesh reported to have paid money for obtaining family planning method (higher in Ghaziabad and Sitapur-43% each, Bahriach-67% and Etah-63%). The method paid was largely condom (80%) followed by OCP (8%) which shows that these users were purchasing it from market. The payment for IUCD was mentioned by 8% (higher in Ghaziabad-50%) whereas 4% mentioned payment for injectables (not in Govt. programme). Few users of PPIUCD in Etah and Ghaziabad also mentioned payment for PPIUCD (Table 6.8).
Payment for ECP was reported by <1%.
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Counselling about family planning methods other than most recently used
The findings show that information on the side effects of the contraceptive use is not conveyed properly/ effectively to the adoptor by the providers. Only 19% respondents in Uttar Pradesh reported that providers informed them about the side effects of the method and 83% of them said that they were informed about what to do in case of any side effects experienced after use of method.
In addition, only 9% of users reported that the health worker informed them about other methods other than most recent/current method they can use. Nearly 57% of them informed that they obtained the method to delay or avoid the pregnancy during the visit of the health worker.
Reasons for non-use of contraceptive methods currently
The main reasons for non-use of any contraceptive method were-currently pregnant (19%), wanted to become pregnant (33%) and infrequent sex/husband away (13%) which was negligible in Lalitpur, Bahraich and Banda. Non-availability of method was reported by 3% and 4% said that method did t suit the . Nearly 21% gave other reasons, which included health problem, undergone hysterectomy and menopausal. The ost striki g as the reaso that a su sta tial proportio of o e 8% did ’t ha e k o ledge of any contraceptive method. In the distri ts like Sitapur a d Ka pur Dehat, 18% a d 16% o e did ’t know about the methods.
Adoption of sterilization by the couple in case they feel that family is complete
About 64% of currently married women said that their family was complete but only 32% reported that she/husband had opted for sterilization. The reasons for not adopting sterilization if the family was complete included health issues (20%), family barrier (17%) and social barrier (12%) whereas 29% said that they were not interested and 16% gave other reasons which mainly included afraid of method-25%, breastfeeding-27%, lack of knowledge and menopausal -17%each, and undergone hysterectomy-6%.
The reasons were similar across districts in varying proportions.
Future Use of Contraception
The non-users of family planning methods currently, were asked if they would like to use any family planning method in next 6 months or in near future. To this, nearly 13.5% said that they would like to use in next 6 months whereas 41.4% wanted to use in future. This shows that there is great potential for adoption of family planning in the State. For the method choice, about 30% expressed the desire for sterilization and 19% wanted to opt for spacing method. Further about 7% wanted to opt for condom followed by injectables (5%), OCP (4%) and IUCD (3%). Surprisingly desire for PPIUCD insertion was not expressed by any women while unlaunched injectables are expressed by a substantial number of women in the State. The desire for injectable contraceptive was highest in Bahraich (10%) and Gorakhpur (8%). This is a latent desire for ijectables.
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