CHAPTER II CONTRACEPTIVE USE

Transcription

1 CHAPTER II CONTRACEPTIVE USE In a major policy and programmatic shift in April 1996, India s National Family Welfare Programme was renamed the Reproductive and Child Health Programme. This programme enunciated a new goal: the provision of a comprehensive programme to meet the health needs of women and children. The changed approach focused on the target-free promotion of contraceptive use among eligible couples, the provision of a wide range of contraceptive s (including condoms, oral pills, the IUD, and male and female sterilization), and an emphasis upon quality services. In 2000, the Government of India further adopted a new National Population Policy, with a focus on addressing the unmet need for contraception in order to reduce the total fertility rate to replacement level by the year One of the 14 national socio-demographic goals identified for this purpose was to achieve universal access to information, counselling, and services for fertility regulation, and specifically to make available a comprehensive range of contraceptive s (Ministry of Health and Family Welfare, 2000). The NFHS-2 Follow-up Survey provides an opportunity to understand more recent changes in contraceptive behaviour in the four states under study, and to assess changes and trends over time, since the promulgation of these new policies. In this section, we present data on contraceptive use at two points in time - at baseline using the NFHS-2 data ( ) and at the Follow-up Survey ( ). 1 The two surveys cannot be viewed as independent random samples of women from the same population at the two points of time. The Follow-up Survey data are from re-interviews of a cohort of women aged years who were interviewed at baseline (NFHS-2). In all the subsequent tables where a comparison is made, attempts have been made to keep the two samples as comparable as possible. A sample of women aged years at the time of the NFHS-2 (irrespective of whether they were part of the Follow-up Survey) is compared with the follow-up sample which reflects women aged years at the time of the Follow-up Survey. Given sample attrition in all four states, however, unresolved questions exist regarding sample selectivity among respondents in the Follow-up Survey. In order to understand the presence of any selectivity bias section B of this report describes some of the differences between complete and incomplete cases with respect to several background characteristics (Table ). In Bihar and Tamil Nadu, the women who were missed were significantly younger than those who were re-interviewed. However, for other two states age distributions were not significantly different. When we examine selectivity bias with respect to baseline contraceptive use (not shown in Table ), we find that again in Bihar and Tamil Nadu, women who were not interviewed were less likely to use contraceptive at that time. Hence any interpretation of the following comparisons in contraceptive use should be taken cautiously in view of some selectivity bias in these two states. Current use of Contraception Table 2.1 highlights the levels of current contraceptive use (both modern and traditional s) from the NFHS-2 as well as the Follow-up Survey in the four states. In both the baseline and follow-up surveys, women were asked whether they were using any contraceptive at the time of the survey and if so, to name the. The NFHS-2 findings indicate higher any use among currently married women aged years in Maharashtra (68 percent) and Tamil Nadu (51 percent), whereas Bihar and Jharkhand show lower levels of use, 1 In this section, baseline survey and follow-up survey are interchangeably used with NFHS-2 and Follow-up Survey respectively. The NFHS-2 was conducted in and the Follow-up Survey in

2 23 percent and 27 percent. Use of any family planning appears to have increased in all four states during the inter-survey period. In Maharashtra, there has been an increase of 12 percentage points in contraceptive prevalence and in Tamil Nadu the increase is approximately 15 percentage points. While both Bihar and Jharkhand exhibit some increase in contraceptive use during the inter-survey period, the change is smaller only six percentage points for Bihar and seven percentage points for Jharkhand. The proportion of current users of modern contraceptive s is very high among all current users in all states at both the NFHS-2 and Follow-up Surveys. Around percent and 97 percent of current users, respectively, in Maharashtra, and Tamil Nadu are using a modern of contraception. Similarly, among current users of all s, about percent in Bihar and 88 percent in Jharkhand reported using a modern at both the surveys. The proportion of modern use compared to all use remained largely unchanged during the inter-survey period. Use of traditional family planning s in Maharashtra and Tamil Nadu is much lower, comprising 2-3 percent of all users in these states. Use of traditional s constitutes a somewhat higher percentage of overall use in Bihar and Jharkhand, although use of such s is also low in these states. Table 2.1 Current use of contraception Percent distribution of currently married women age by specific contraceptive 'currently' used at baseline (NFHS- 2) in and at follow up (Follow-up Survey) in , by state Bihar Jharkhand Maharashtra Tamil Nadu Method NFHS-2 Follow-up NFHS-2 Follow-up NFHS-2 Follow-up NFHS-2 Follow-up modern Pill Condom IUD/Loop Injectables Female sterilization Male sterilization traditional Rhythm/safe period Withdrawal 1.5 Other s 1 Not using Number of women Includes both modern and traditional s that are not listed separately Note: The table uses a weighted comparable sample of age at both the surveys 18

3 Among users of all family planning s in the Follow-up Survey, female sterilization remains the dominant : in Maharashtra and Tamil Nadu, this accounts for 89 percent and 93 percent, respectively, of all current users. The use of male Figure 2.1 Current Use of Contraception: NFHS-2 ( ) and Follow-up Survey ( ) BIHAR NFHS-2 23 Follow-up 29 JHARKHAND NFHS-2 27 Follow-up 33 MAHARASHTRA NFHS-2 68 Follow-up 80 TAMIL NADU NFHS-2 51 Follow-up 66 sterilization is very low in all states. Overall, users of permanent s of contraception (female and male sterilization) constitute more than 90 percent of modern use in both Maharashtra and Tamil Nadu. The proportion of permanent users among all contraceptive users increased slightly during the inter-survey period-- from 91 percent to 93 percent in Maharashtra and from 93 percent to 94 percent in Tamil Nadu. The results also show that, in contrast to Maharashtra and Tamil Nadu, the share of permanent users among current users of any modern in Bihar and Jharkhand declined marginally during the inter-survey period, from 90 percent to 87 percent in Bihar, and from 94 percent to 90 percent in Jharkhand. This decline in the proportion of permanent users in these states was largely offset by a marginal increase in temporary use (mainly oral pills) during the same period. The percentage of respondents reporting oral pill use in both states, although still small, increased during the inter-survey period. In contrast, the percentage of women reporting oral pill use in the states of Maharashtra and Tamil Nadu actually declined slightly during this period among those women surveyed. It is evident that female sterilization dominates the contraceptive -mix in all the four states, with much higher prevalence levels in Maharashtra and Tamil Nadu. The current use of any of contraception in formerly Bihar (which included Jharkhand) is far below the national average of 48 percent (IIPS and ORC Macro, 2000). However, a slight increase is evident in reports of temporary use in both Bihar and Jharkhand, particularly in the use of oral pills. The other temporary s, condoms and the IUD, do not show any significant increase in reported use during the follow-up period in any of the states. In fact, there is a decline in the prevalence of these s in all four states, with the exception of a marginal 19

4 increase in Bihar. The use of traditional s--rhythm/safe period and withdrawal--is low in all states, comprising about one to three percent among all current users of contraception. However, traditional s appear to be slightly more popular in Bihar and Jharkhand than in Maharashtra and Tamil Nadu. These findings have important programme and policy implications as the National Family Welfare Programme attempts to increase contraceptive choice and improve the quality of services within its Reproductive and Child Health Programme. Current Contraceptive use by Socio-economic Characteristics Table shows contraceptive prevalence levels by age and education groups in the two surveys, for comparable samples of year respondents at both the surveys. Within all age categories, increases in the use of any contraceptive were observed between the baseline survey and the follow-up study, in all four states (except for Bihar and Maharashtra for age 40 years or over). In Bihar and Jharkhand, the increase was lower in younger age groups, highest among middle age groups, and again low among older age groups. In these two states, therefore, the increase in contraceptive prevalence comes mainly from increased acceptance among women aged 25 to 34 years. In contrast, in Maharashtra and Tamil Nadu, the increase in contraceptive use occurred largely among women younger than 25 years. The percent increase diminishes as age increases, with the lowest increase found among women between ages years. Interesting patterns emerge in assessing the increase in contraceptive use by education level. In all four states, the increase in prevalence was highest among the more educated groups. In Bihar, for example, while there was an increase of five percentage points in contraceptive use among women with no education in the time between the two surveys (24 percent in the follow-up study compared to 19 percent in the baseline survey), the same figure for women with a completed high school education was 20 percentage points (60 percent in the follow-up study compared to 40 percent in the baseline survey). Thus, the apparent increase in contraceptive use between the two surveys was most pronounced among more educated respondents in each state. Tables.1 through 2. provide information on current use of contraceptive s by selected background characteristics of currently married women at follow-up ( ) for each of the four states. The information is presented by age and education collected at the follow-up survey, and by caste/tribe and a standard of living index from data collected during the baseline survey. As expected, the relationship between current contraceptive use and women s age is largely linear, increasing steadily through ages years, and then declining slightly among women aged 40 years or older. This trend is observed in all states with the exception of Jharkhand. In Maharashtra, current use is quite high even at the youngest ages, starting at about 53 percent for women younger than 25 years and peaking at 90 percent for women between the ages of 35 to 39 years. In Tamil Nadu, prevalence increases from 45 percent among women below 25 years of age to as high as 75 percent among for women age 35 to 39 years. 20

5 Table Trends in contraceptive use Percentage of currently married women using contraceptive s by age and education in the NFHS-2 & Follow-up Survey, according to state NFHS-2 Follow-up Survey BIHAR modern modern spacing traditiona l No. of women modern modern spacing traditiona l No. of women Age** <= Education** Illiterate Literate, <middle school completed Middle school completed High school completed Age** <= JHARKHAND Education** Illiterate Literate, <middle school completed Middle school completed High school completed * (62.5) * (46.9) * (15.6) Age** <= MAHARASHTRA Education** Illiterate Literate, <middle school completed Middle school completed High school completed Age** <= TAMIL NADU Education** Illiterate Literate, <middle school completed Middle school completed High school completed Note: The table uses a weighted comparable sample of age at both the surveys **For NFHS-2, NFHS-2 age & education have been used and for Follow-up Survey, Follow-up Survey age & education have been used. 1Includes both modern and traditional s that are not listed separately *Percentage not shown; based on fewer than 25 unweighted cases ( ) Based on unweighted cases

6 In all four states, with regard to modern temporary s, oral pills and condoms are more frequently used than the IUD/loop or injectables. However, the proportion of users is notably small. With the exception of condom use in Maharashtra and IUD use in Tamil Nadu, there is little variation in temporary use according to age. In Maharashtra, condom use increases from about two percent for women below 25 years of age to nearly four percent for women age 30 to 34 years. The use of the IUD/loop is somewhat higher among younger women aged 25 to 29 years (three percent) as compared to older women (less than one percent for women aged 30 to 34 years). The proportion of women who are sterilized is relatively high overall, and in every age group in all the four states. The use of female sterilization shows significant differentials by age. For example, in Bihar and Jharkhand, the percentage of women under 25 years of age who are sterilized is six percent. However this figure increases sharply to 34 and 37 percent, respectively, for women aged 35 to 39 years. Interestingly, the proportion of older women who are sterilized is lower in Bihar but higher in Jharkhand. It should be noted that in Maharashtra, almost 44 percent of women under 25 years of age are sterilized, increasing to 83 percent for women 35 to 39 years, and thereafter declining to 75 percent for women older than 40 years. In Tamil Nadu, among current users of contraception, female sterilization is the reported by 40 percent of women below 25 years of age, 70 percent of women between 35 to 39 years, and 64 percent of women aged 40 years and above. These results suggest that despite the increased emphasis on contraceptive choice and on modern spacing s in the Reproductive and Child Health Programme, and women s increasing knowledge of modern temporary s, female sterilization continues to dominate the -mix. In all the four states, modern temporary s account for only a small fraction of total contraceptive use. Striking differences are evident between Maharashtra/Tamil Nadu and Bihar/Jharkhand in the relationship between education and current contraceptive use. In Maharashtra and Tamil Nadu, use of contraception remains high and comparable across all educational groups. In Maharashtra, and to a lesser extent in Tamil Nadu, an interesting pattern emerges when modern use is further disaggregated: permanent use declines with educational level, temporary use increases with educational level. In contrast to Tamil Nadu and Maharashtra, current contraceptive use for Bihar and Jharkhand shows a strong positive relationship with education, and this relationship holds for women s use of both permanent and temporary s. In these two states, the use of the oral pill, IUD and condom increases with higher levels of education. In Bihar, oral pill use was only one percent for illiterate women compared to five percent for women with middle school or higher completed. Similarly, in Jharkhand, both oral pill and condom use are higher for better-educated women. The most striking result for condom use, although the proportions of women reporting use of this in each state are small. In Bihar, Jharkhand and Maharashtra, women with a completed high school education or higher are between two and four times more likely to report condom use compared to women who either have no education or have only a primary education. 22

7 Table.1 Current contraceptive use by background characteristics - Bihar Percent distribution of currently married women by specific contraceptive, according to selected background characteristics, Follow-up Survey, Background characteristics modern Pill IUD/ Loop Injectables Condom Female Sterilizatio n Male Sterilizatio n traditional Rhythm/ safe Withdrawal Other 2 Not using percent Number of women Age* < Education* Illiterate Literate, < primary school completed Middle school completed High school completed & above Caste/tribe** Scheduled caste/tribe Other backward class Other Standard of living index** Low Medium High *As reported in Follow-up Survey **From NFHS-2 ( ) 1Not belonging to scheduled caste, scheduled tribe or the other backward class 2Includes both modern and traditional s that are not listed separately

8 Table.2 Current contraceptive use by background characteristics - Jharkhand Percent distribution of currently married women by specific contraceptive, according to selected background characteristics, Follow-up Survey Background characteristics modern Pill IUD/ Loop Injectables Condom Female Sterilizatio n Male Sterilizatio n traditional Rhythm/ safe Withdrawal Other 2 Not using percent Number of women Age* < Education* Illiterate Literate, < primary school completed Middle school completed High school completed & above Caste/tribe** Scheduled caste/tribe Other backward class Other Standard of living index** Low Medium High *As reported in Follow-up Survey **From NFHS-2 ( ) 1Not belonging to scheduled caste, scheduled tribe or the other backward class 2Includes both modern and traditional s that are not listed separately

9 Table.3 Current contraceptive use by background characteristics - Maharashtra Percent distribution of currently married women by specific contraceptive, according to selected background characteristics, Follow-up Survey, Male Background characteristics modern Pill IUD/ Loop Injectables Condom Female Sterilization Sterilizatio n traditional Rhythm/ safe Withdrawal Other 2 Not using percent Number of women Age* < Education* Illiterate Literate, < primary school completed Middle school completed High school completed & above Caste/tribe** Scheduled caste/tribe Other backward class Other Standard of living index** Low Medium High *As reported in Follow-up Survey **From NFHS-2 ( ) 1Not belonging to scheduled caste, scheduled tribe or the other backward class 2Includes both modern and traditional s that are not listed separately

10 Table.4 Current contraceptive use by background characteristics Tamil Nadu Percent distribution of currently married women by specific contraceptive, according to selected background characteristics, Follow up Survey, Male Background characteristics modern Pil l IUD/ Loop Injectables Condom Female Sterilization Sterilizatio n traditional Rhythm/ safe Withdrawal Other 2 Not using percent Number of women Age* < Education* Illiterate Literate, < primary school completed Middle school completed High school completed & above Caste/tribe** Scheduled caste/tribe Other backward class Other Standard of living index** Low Medium High *As reported in Follow-up Survey **From NFHS-2 ( ) 1Not belonging to scheduled caste, scheduled tribe or the other backward class 2Includes both modern and traditional s that are not listed separately

11 The differences in use of contraception by caste/tribe and standard of living (as measured by the constructed Standard of Living Index--SLI) are also shown in Tables.1 through.4. These two background characteristics of women were collected during the baseline study (the NFHS-2). The findings suggest that across the four states, women from a scheduled caste or tribe (SC/ST) report lower contraceptive use than women not from either of these groups. However, there are slight variations in the use of male and female sterilization in Maharashtra and Tamil Nadu. The results for Maharashtra indicate higher male sterilization for the scheduled caste or tribe groups than for the `other caste groups. Similarly, in Tamil Nadu, female sterilization is slightly higher in the scheduled caste or tribe group compared to the other caste groups. The differentials in contraceptive use by standard of living across the four states suggest higher contraceptive use among women from the `high group compared to the `low or `middle SLI groups in Bihar and Jharkhand; less systematic relationships are evident for Maharashtra and Tamil Nadu. Table and Figure provide further insight into contraceptive practice within the cohort of women during the inter-survey period. They show the extent of new acceptors and those who switched to a new during the inter-survey period. As previously observed, in India the use of spacing s is low and as a consequence the proportion of women who switch from one spacing to another is also low. Figure Contraceptive Behaviour in the Inter-Survey Period, P e r c e n t Bihar Jharkhand Maharashtra Tamil Nadu Was not using, currently not using Was not using, but currently using limiting Was using, currently continuing the same Was not using, but currently using spacing Was using, but currently not using Was using, but currently using a different Among the new acceptors during the inter-survey period, the majority adopted a permanent, specifically female sterilization. This is particularly true in Tamil Nadu and Maharashtra where contraceptive services are more accessible and available than in Bihar and 27

12 Table Contraceptive behaviour in the inter-survey period (1998/ ) Percent distribution of currently married women by contraceptive use status in the inter-survey period by state Past and current status Bihar Jharkhand Maharashtr a Tamil Nadu Was not using, currently not using Was not using, but currently using: Spacing Limiting Was using, but currently not using Was using, currently using the same Was using, but currently using a different percent Number of women Jharkhand. For example, among new acceptors in Tamil Nadu and Maharashtra, 88 percent and 84 percent, respectively, accepted a permanent. In contrast, among new acceptors in Bihar and Jharkhand, only 63 percent and 61 percent, respectively, adopted a permanent. Five percent of women in both Bihar and Jharkhand who were users of temporary s at the time of the baseline survey, discontinued use of the : three percent stopped using any altogether, and the remaining two percent switched to a different. Background Characteristics of Non-users of Contraception There is significant variability in contraceptive use status among currently married women who were not using any of contraception at the time of the baseline survey (the NFHS-2). More than three-fifths of the respondents in Bihar and Jharkhand, who were not using any of contraception when interviewed in the NFHS-2, reported not using a when re-interviewed at follow-up. In contrast, the corresponding proportions in Tamil Nadu and Maharashtra were only 32 percent and 18 percent, respectively. For more detailed insight into the dynamics of contraceptive use during the inter-survey period, it is of interest to identify the characteristics of those currently married women who did not adopt any of contraception during this period. Overall, the proportion of women who were still not using a contraceptive at follow-up is the highest for Bihar (67 percent), followed by Jharkhand (64 percent), with notably lower figures for Tamil Nadu (32 percent) and Maharashtra (18 percent) (Figure ). Table 2.5 presents select background characteristics of those currently married women not using any of contraception at follow-up ( ) and who also reported not using any of contraception at baseline ( ). While analyzing the variation in the proportion of these women by their current age (at the Follow-up Survey), it is worth noting that non-use of family planning during the inter-survey period among younger women may be rooted in their incomplete family size. However, the proportions of nonusers of contraception among currently married women 35 years and older in the four states have definite programmatic implications. It is evident from Table 2.5 that in Bihar more than half of the currently married women 35 years and older (55 percent) who were non-users at baseline, and almost half of older women in Jharkhand (47 percent), remained contraceptive non-users at follow-up. The corresponding proportions were much lower in Tamil Nadu and Maharashtra-- 26 percent and 12 percent, respectively. 28

13 Table 2.5 Background characteristics of non-users of contraception Percentage of currently married women not using a contraceptive at the time of both the NFHS- 2 ( ) and Follow-up Survey ( ) by select background characteristics and state Background characteristics Bihar Jharkhand Maharashtra Tamil Nadu Age <= Education Illiterate Lit. <middle school completed Middle school completed High school & above Number of living children <= Births since NFHS Wants at least one additional child Yes No Other Other includes undecided, declared infecund etc. Figure Percentage of Currently Married Women who were not using a Contraceptive Method at the time of both the NFHS-2 ( ) and the Follow-up Survey ( ) Bihar 67 Jharkhand 64 Maharashtra 18 Tamil Nadu 32 29

14 As might be expected, an inverse relationship between contraceptive non-use and education was evident in all four states, although the degree of association varies by state. In Bihar, approximately three-fourths of women with no education who were not using any of contraception at baseline reported not using any of contraception four years later at follow-up. The proportion of such women declined with increasing educational attainment, falling to 37 percent among those who had completed high school or above. The corresponding proportions among currently married women in Jharkhand ranged from 69 percent for illiterate women to 38 percent for those with the highest educational level. On the other hand, both Tamil Nadu and Maharashtra reflect relatively lower variations by educational level in the proportion of currently married women not using any of contraception at baseline and follow-up (19 to 16 percent in Maharashtra and 33 to 24 percent in Tamil Nadu). The number of living children is considered to be an important determinant of contraceptive use in almost all developing countries. It is evident from Table 2.5 that in Bihar, among non-users of contraception at the time of the baseline study, almost two-thirds of women with four or more living children were not using any family planning when interviewed in the Follow-up Survey. The corresponding proportions at follow-up in the other three states are 53 percent in Jharkhand, 27 percent in Tamil Nadu and 15 percent in Maharashtra. One factor that provides insight into the process of contraceptive use dynamics during the inter-survey period is the actual number of births that occurred to women during the same period. In Bihar and Jharkhand, one in every two non-users at baseline who had no birth during the inter-survey period reported not using a at follow-up. In comparison, only 10 percent of non-users at baseline in Maharashtra, and 28 percent of baseline non-users in Tamil Nadu, who had no births during the inter survey period reported not using a at follow-up. This difference may reflect several factors, notably: greater self-selection for sterility among women in Bihar and Jharkhand; lower exposure of such women to the risk of pregnancy, and/or increased reliance upon abortion in these two states. Another factor that has a direct influence on the use of a contraceptive in the inter-survey period is the respondent s desire for an additional child at baseline. It follows then that those who want an additional child at baseline would be least likely to use a contraceptive in the inter-survey period, particularly in a high fertility setting. This is reflected in the data indicating that 9 out of 10 women in Bihar and Jharkhand who reported wanting an additional child at baseline were non-users of contraception at both the baseline and follow-up surveys. However, the proportion of such women is substantially lower in the states of Maharashtra and Tamil Nadu (49 and 60 percent, respectively). Interestingly, even among women who wanted no more children in Bihar and Jharkhand, the proportion of non-users at baseline who remained non-users at follow-up was quite high - 69 percent and 63 percent, respectively. The gap between fertility preferences and contraceptive use for Bihar and Jharkhand, and to a lesser extent, Tamil Nadu, highlights the extent of unmet need for family planning among these women. 30

15 Profile of Sterilization Users at Baseline and Follow-up Survey It is evident from the contraceptive use dynamics identified in the two National Family Health Surveys (NFHS) that female sterilization is the dominant contraceptive in India, and concomitantly, the use of contraceptive s for spacing remains extremely limited. Despite the adoption of the Reproductive and Child Health approach by the Indian government in 1996, this appears to have yet to be translated into expanded choice in contraception, one of the hallmarks of this redirection in policy. The contraceptive prevalence rate (CPR) of India as a whole during the NFHS-1 ( ) was 41 percent, of which almost two-thirds was accounted for by female sterilization. The results of the NFHS-2 conducted in indicated an increase in contraceptive prevalence to 48 percent, of which almost 70 percent was attributable to female sterilization (IIPS and ORC Macro, 2000). In the period between the NFHS-2 and the Follow-up Survey, the majority of new contraceptive users, particularly in Tamil Nadu and Maharashtra, opted for sterilization. Consequently, the proportion of sterilization use compared to all use has increased across all four states (94 and 93 percent during the Follow-up Survey in Tamil Nadu and Maharashtra respectively, as compared to 93 percent and 91 percent at the time of the NFHS- 2). An interesting finding is the marginal decline in the share of female sterilization in the overall contraceptive prevalence rates for Bihar and Jharkhand, highlighting the small increase in the use of spacing s during the inter-survey period. However, the proportion of sterilization users even in these low prevalence states remains at almost 80 percent (Table 2.6 & Figure ). Table 2.6 Share of female sterilization in overall contraceptive prevalence Proportion of female sterilization in overall contraceptive prevalence in the NFHS-2 ( ) and the Follow up Survey ( ) by state NFHS-2 Follow up Survey Bihar Jharkhand Maharashtra Tamil Nadu So as to better understand life cycle effects and the decision-making process leading to female sterilization, an effort is made here to analyze the trends in female sterilization by acceptors background characteristics. In order to have better comparability in the characteristics of women who have undergone female sterilization as reported in the NFHS-2 ( ) and in the Follow-up Survey ( ), only sterilizations performed in the four years prior to the NFHS-2 are considered. Thus, a comparison of female sterilizations performed in the four years prior to NFHS-2 and those conducted during the inter-survey period is expected to provide a true picture of trends in female sterilization by state. Table 2.7 shows the percent of currently married women in each of the four states who adopted sterilization during the four-year period prior to the NFHS-2 and during the inter-survey period (four year period prior to the Follow-up Survey) by selected background characteristics. It is evident from the last row of Table 2.7 and from Figure 2.5 that the use of female sterilization has increased in all four states during this period. However, the pace of increase has not been uniform across states. As would be expected, the change in the level of use of 31

16 female sterilization in all four states mirrors the overall change in contraceptive prevalence in these states. This suggests that even during period, the increase in contraceptive prevalence is primarily due to female sterilization (see Table 2.1). Table 2.7 and Figure 2.5 also show that Tamil Nadu experienced the greatest increase in the use of female sterilization during the inter-survey period as compared to the period four years prior to the NFHS-2 (18 percent compared to 12 percent) followed by Maharashtra (20 percent compared to 16 percent) and Bihar (9 percent compared to 6 percent). Variation in the adoption of female sterilization by age of currently married women at the time of sterilization underscores the increase in the use of female sterilization at younger ages. The observed variations are considerably higher in Tamil Nadu and in Maharashtra, where currently married women below 25 years of age are 1.5 times more likely to get sterilized than those in the age group years at the Follow-up Survey. This pattern is in direct contrast to that observed among currently married women sterilized in the four years prior to the NFHS-2 in the two states. On the other hand, in Bihar and Jharkhand, the pattern of adoption of female sterilization during the inter-survey period remains the same as that observed in the four years before the NFHS-2, despite the marginal increase in the level of female sterilization in the later period. Figure Share of Female Sterilization in Overall Contraceptive Prevalence in the NFHS-2 ( ) and the Follow-up Survey ( ) Bihar Percent Jharkhand Maharashtra Tamil Nadu NFHS-2 Follow-up 32

17 Table 2.7 Profile of sterilization users Percentage of currently married women who accepted sterilization or whose husbands adopted sterilization in the four years prior to the NFHS-2 ( ) or prior to the Follow-up Survey ( ) by selected background characteristics and state Background characteristics Bihar Jharkhand Maharashtra Tamil Nadu NFHS- 2 Follow-up Survey NFHS-2 Follow-up Survey NFHS-2 Follow up Survey NFHS-2 Age <= Education Illiterate Lit. <middle school complete Middle school complete High school & above Number of living children <= percent Note: The table uses a weighted comparable sample of age at both the surveys Follow-up Survey Figure 2.5 Percentage of Currently Married Women who Accepted Sterilization in the Four Years Prior to the NFHS-2 ( ) or Prior to the Follow-up Survey ( ) Tamil Nadu Percent Maharashtra Jharkhand Bihar Four years prior to the NFHS-2 Four years prior to the Followup Survey In all the four states, the reported use of female sterilization is higher for the inter-survey period than for the four-year period prior to the NFHS-2, irrespective of women s educational status (with the exception of women in Maharashtra with no education or with middle school completed or above). Overall, the extent of increase is markedly higher in Maharashtra and Tamil Nadu compared to Bihar and Jharkhand. The significant increase in female sterilization at 33

18 every educational level in each state over the two time periods indicates that female sterilization is a popular family planning regardless of educational status. It is important to note, however, that the pattern of increase is not uniform across the four states and differs significantly in accordance with the overall contraceptive prevalence in these states. An interesting pattern in the increased use of female sterilization in the inter-survey period as compared to the four years prior to the NFHS-2 is to be found across the four states when the data are stratified by a woman s number of living children at the time of sterilization. In all four states, there has been an increase in the acceptance of female sterilization during the inter-survey period among women with two or fewer living children. However, variations in the level of female sterilization correspond to the relative increase in the overall contraceptive prevalence rates in each state. Maharashtra shows the highest increase between the two time periods (20 percent versus 11 percent), followed by Tamil Nadu (an increase from 9 to 15 percent). Also evident from this analysis is the substantially greater increase in female sterilization in Maharashtra and Tamil Nadu compared to Bihar and Jharkhand among currently married women with lower parity during the two periods. These findings highlight the apparent shift toward sterilization acceptance at increasingly younger ages and lower parities in the states of Maharashtra and Tamil Nadu. These differentials also clearly reveal different stages of fertility regulation across the states included in the study, on the one hand, and the dominance of female sterilization irrespective of the level of contraceptive prevalence on the other. Demand for Children and Future use of Contraception Contraceptive prevalence is closely related to the demand for children. Demand for children, as reflected in the desire to have additional children, was ascertained in both surveys. Table 2.8 shows the percent of women either desiring no more children or currently using sterilization (these women were assumed to desire no additional children in the surveys), by the number of currently living children. Two main findings emerge from this table. The first is the much lower parities at which women in Maharashtra and Tamil Nadu wish to curtail childbearing. For example, in the Follow-up Survey, while 48 percent and 50 percent of women at parity 2 in Bihar and Jharkhand, respectively, either have been sterilized or desire no more children, the corresponding figures in Maharashtra and Tamil Nadu are 92 and 91 percent, respectively. Table 2.8 Desire to have no more children Percentage of currently married women who want no more children or currently using sterilization by number of living children, NFHS-2 ( ) and Follow-up Survey ( ) Bihar Jharkhand Maharashtra Tamil Nadu Number of children NFHS- 2 Follow up Survey NFHS- 2 Follow up Survey NFHS- 2 Follow up Survey NFHS- 2 Follow up Survey

19 Second, between NFHS-2 and Follow-up Surveys, there appears to have been a modest but discernible increase in the demand to curtail childbearing in all four states. In Maharashtra and Tamil Nadu, this change was concentrated among women at parities 1 and 2, while in Bihar the increase in demand to stop childbearing was evident among women at parities 2 and 3. In both surveys, questions regarding future intention about the use of contraception were asked of those women who were not using a at the time of interview. It is of interest to prospectively examine the link between stated family planning intentions and subsequent contraceptive behaviour (Table 2.10 and Figure 2.6). A majority of women who were not using any contraception at the time of the baseline survey, but who expressed an intention to use contraception in the future, either continued to express such intent or were using a when interviewed at the time of the Follow-up Survey. In Maharashtra and Tamil Nadu, among women who in the NFHS-2 had expressed an intention to use a in the future, a significant proportion reported using a at follow-up (62 percent and 51 percent, respectively). In contrast, in Bihar and Jharkhand, among women who had stated, at baseline, an intention to use a in the future, 21 percent and 24 percent, respectively, were using a at follow-up, whereas a much larger proportion (48 percent and 50 percent, respectively) were not using, but continued to express the intent to use a contraceptive in the future. Thus, women in Maharashtra and Tamil Nadu were much more likely to act on their stated contraceptive intentions in a timely manner. Table 2.9 Future use of contraception Percent distribution of non users of contraceptive at NFHS-2 ( ) by future contraceptive use intention as stated in Follow-up Survey ( ) according to their intention of use as stated at NFHS-2 by state Non-users at NFHS-2 but intended to use contraception in future (as stated in NFHS- 2) Future intention of use in Followup Survey Bihar Jharkhand Maharashtr a Tamil Nadu Non-users at NFHS-2 and did not intend to use contraception in future (as stated in NFHS-2) Biha r Jharkhand Maharashtra Tamil Nadu Did not intend to use Not using but intend to use Currently using Number of women Among women who reported non-use of a at baseline and no intention to use a in the future, only eight percent in Jharkhand and 10 percent in Bihar were found to be using a at follow-up. The percentages were higher in Tamil Nadu and Maharashtra, with 19 percent and 26 percent, respectively, of these women using a contraceptive. It is evident that a question on intention to use is a fairly reliable indicator of future demand for family planning. These data suggest that the congruence between intention to use a and actual use is much higher in an environment where family planning is the norm and use is 35

20 widespread. Nevertheless, our findings indicate that programs should not ignore women who might initially express no intention of using family planning in the future, as a vast pool of potential users might be lost. Our findings indicate that a sizeable proportion of women who at baseline stated they did not intend to use a in the future changed their mind, and were using a at follow-up. Additionally, a significant proportion of women who initially had no intention to use a at baseline indicated at follow-up that they intended to use a in the future. Figure 2.6 Contraceptive Use Status at the Follow-up Survey ( ) of Non- Contraceptive Women at the NFHS-2 ( ) who Intended to Use Contraceptives in Future Currently using Not using but intend to use Did not intend to use Bihar Jharkhand Maharashtra Tamil Nadu 36