Contraceptive Use Dynamics in South Asia: The Way Forward

Contraceptive Use Dynamics in South Asia: The Way Forward Authors Manas R. Pradhan 1, H. Reddy 2, N. Mishra 3, H. Nayak 4, Draft Paper for Presentation in the Poster Session 103 at the 27 th IUSSP Conference, 26-31 August 2013, Busan, South Korea 1 Assistant Professor, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, India. Email: manas@iips.net 2 Monitoring & Evaluation Expert. Futures Group International, New Delhi, India. Email: hreddy@futuresgroup.com 3 Program Manager: Monitoring & Evaluation, Population Foundation of India, New Delhi, India. Email: nihar@populationfoundation.in 4 Operations Research Coordinator, FHI 360, New Delhi, India, Email: HNayak@uhi-india.org 1

Introduction Population stabilization has been recognized as an issue requiring urgent attention, and has thus led to formulation of national population policies and programs in South Asian countries of India, Pakistan, Bangladesh and Nepal. 1-4 Nevertheless, the limited success of the Family Welfare/Planning Programs may be due its direction, emphasis and strategies in India, 5 erosion in political will and certain systemic issues in Bangladesh, 6 neglect of family planning programs due to historical political conflict and cultural restrictions on women in Pakistan, 7 and socio-cultural and service delivery challenges in Nepal. 8 Stalling in the upward course of contraceptive use questions the effectiveness of program related investments and implies failure to reduce unmet needs. By reducing the Total Fertility Rate ( TFR), contraception significantly influences population stabilization, which is important for socioeconomic development of the aforesaid countries; comprising 23% of world s population. 9 The present study assesses the contraceptive use dynamics and, its program as well as policy implications in India, Pakistan, Bangladesh and Nepal. Data and Methods The study used data from three rounds of Demographic and Health Survey (DHS) in each of the aforementioned countries. Specifically, the National Family Health Survey (NFHS) round 1 (1992-92), round 2 (1998-99) and round 3 (2005-06) of India; Pakistan Demographic and Health Survey (PDHS) in (2006-07), Status of Women, Reproductive Health and Family Planning Survey (2001-03), and Pakistan Fertility and Family Planning Survey (1996-97); Bangladesh Demographic Health Survey (BDHS) in 2007, BDHS (1999-2000), and BDHS (1993-94); and Nepal Demographic Health Survey (NDHS) 2011, NDHS (2006), and NDHS (2001) were used. The currently married women aged 15-49 years of the latest DHS were considered for detailed analysis; sample sizes were 93089 for India, 10192 for Bangladesh, 9556 for Pakistan, and 9608 for Nepal. IBM-SPSS software (Version 20.0) was used for bivariate and multi-variate analyses with a significance level of 5%. Results Trends in contraceptive use and method mix The current contraceptive prevalence rate (CPR) of Nepal is 50%, and the annual growth was 1.7 points between NDHS-1(2001) and NDHS-2 (2006), which was reduced to 0.3 points between NDHS-2 (2006) to NDHS -3 (2011) (table-1). Further, female sterilization acceptance had declined ( -0.6 point per year), while male sterilization had increased (0.3 points annually) during the last five years. In-between NFHS-1 (1992-93) to NFHS-3 (2005-06), the CPR in India increased by 1.2 point annually, and currently 56% of the women are using any contraception. However, modern spacing method use increased at merely 0.4 point per year. With an annual increase of 0.9 point between BDHS-1 (1993-94) to BDHS-3 (2007), the current CPR of Bangladesh is 56%. The CPR increased at 0.3 point annually between BDHS-2 (1999-2000) to BDHS-3 (2007) as against 1.5 point between BDHS -1 (1993-94) to BDHS-2 (1999-2000). Female sterilization declined at 0.2 point between 2

BDHS-1(1993-94) to BDHS-3(2007), while use of oral pills increased at 0.9 points annually. Contraceptive use in Pakistan increased at 0.6 point annually between PFFPS (1996-97) to PDHS (2006-07). The CPR increased steadily from 24% in PFFPS (1996-97) to 32% in SWRHFFPS (2001-03) at 1.3 point per year, and declined thereafter to 30% in PDHS (2006-07) at 0.6 point per year. Additionally, modern spacing method use declined at 0.7 point during 2003-07. Female sterilization continued to dominate the modern contraceptive methods used in India (77%), Pakistan (38%) and Nepal (35%). Majority (60%) of the modern contraceptive users in Bangladesh were using pills. Across the countries, the pace of CPR was faster in rural areas as against urban areas. Determinants of contraceptive use Multivariate analysis reveals (table 2) that higher health care autonomy enhances the likelihood of contraceptive use in India [OR=1.06(1.01-1.10)], but not in Nepal [OR=.59(.52-.68)] and Bangladesh [OR=.52(.45-.59)]. Working women were significantly more likely to accept any contraception than their non-working peers in India, Nepal and Bangladesh. However, Indian working women were less likely to use any modern spacing method [OR=0.89(0.85-0.93)] contrary to their counterparts in Nepal [OR=1.21(1.06-1.39)] and Bangladesh [OR=1.44(1.31-1.58)]. Nepali women with a surviving son were 6 times more likely to adopt female sterilization than those without a surviving son. The corresponding figure was 10 times, 5 times and 2 times respectively for women in Pakistan (statistically insignificant), India and Bangladesh. Across countries, women exposed to any family planning messages were more likely to use any contraception and modern spacing method. Exposure to family planning messages increases the chances of sterilization acceptance in Pakistan [OR=1.32(1.11-1.57)] contrary to India [OR=0.92(0.88-0.96)] and Nepal [OR=0.71(0.62-0.82)]. First use of contraception Six percent of ever married women in India and Nepal began using contraception when they did not have any children; while the corresponding figure was 20% in Bangladesh. Again, 27% Indian women started using contraception after having two children. The corresponding figure was 23% in Nepal and 17% in Bangladesh. Younger cohorts of women found to initiate family planning use at lower parities (Bangladesh: 44% of those aged 15-19 had started using with zero parity compared to 4% of those aged 45-49; India: 13% Vs. 3%; and Nepal: 6% Vs. 0.1%). Discontinuation and switching The one-year discontinuation rate of any method of family planning was 27% in India, 51% in Nepal, and 57% in Bangladesh. About 6% Indian and 7% of the Nepalese women who started but stopped using any particular method had switched to another method. The major reasons for contraceptive discontinuation were husband away (26%) in Nepal and desire to become pregnant (8%) in India. Discontinuation rates vary by method. In Nepal the discontinuation rates were highest for pill (71%), followed by male condom (63%) and 3

injectables (55%), while in India injectables (53%), followed by pill (49%) and male condom (45%) topped the list of discontinuation rate. Discontinuation rates were higher for condoms (76%), withdrawal (67%) and pills (54%) than other methods in Bangladesh. Expressed need for contraception, Percent of need satisfied, and Unmet need: Analysis reveals that (figure 1) the total demand (met need + unmet need) for contraception was 77% in Nepal, of which merely 65% were met (figure 1). In Bangladesh 77% of the total contraceptive demand (73% was the total demand) were met, while in India 82% of the total demand (69% was the total demand) were met. In Pakistan, 55% of the currently married women were in need of contraception, of which only 54% women s need were satisfied. A staggering 27% of women in Nepal have an unmet need for family planning, with 10% having an unmet need for spacing and 17% having an unmet need for limiting. Again, 25% Pakistani women had an unmet need; 11% for spacing and 14% for limiting. The unmet need prevalence was 17% (7% spacing and 10% limiting) in Bangladesh and 13% in India (6% spacing and 7% limiting). Further analysis of the unmet need type found that the prevalence varies across socio-demographic characteristics of the women. Across countries women married before 18 years of age had relatively more unmet need for limiting than spacing.. In Nepal and Pakistan, 9% of the women with knowledge of IUD, Pills and Condoms had unmet need for spacing. The corresponding figure is 6% in India and 5% in Bangladesh. Again, 10% women with knowledge of both permanent methods were with unmet need for limiting in Nepal and Bangladesh, which was 8% in Pakistan and 7% in India. Except Pakistan, higher percent of educated women were found to have unmet need for spacing than limiting. About 28% of the Nepali women with higher health care autonomy had unmet need for limiting. Determinants of unmet need: The multivariate analysis (table 3) reveals that across the countries women married at 18+ years at the time of marriage, are more likely to have unmet need for spacing compared to those married before 18 years; significant for India (OR-1.217 [1.144-1.295]) and Bangladesh (1.392 [1.152-1.682]). Women who got married after 18 years of age are less likely to have unmet need for limiting in Bangladesh (OR -.782 [.645-.949]) and Pakistan (OR -841 [.747-.946]) contrary to their India counterparts (OR -1.061 [1.000-1.25]). Correct knowledge of ovulatory cycle, significantly reduces the chances of unmet need for spacing in India (OR -.717 [.658-.781]) and Nepal (OR-.833 [.702-.989]). Knowledge about spacing methods (oral pills, IUD, and condoms) is inversely associated with unmet need for spacing in all the countries. Only in India, knowledge of both limiting methods of contraception significantly reduces the unmet need for limiting (OR-.850[.792-.912]). Compared to those non-literates, women with 10+ years of schooling are significantly more likely to have unmet need for spacing but less likely to have unmet need for limiting. Exposure to family planning message through print/electronic media is further found to reduce the likelihood of unmet need for both limiting and spacing. Women with higher healthcare autonomy were less likely to have unmet need for spacing than those women with lower healthcare autonomy in India (OR-.599 4

[.555-.645]), Bangladesh (OR-.874 [.683-1.119]) and Nepal (OR-.670 [.559-.804]). However situation is just the reverse so far as the unmet need for limiting is concerned. Unmet need and its demographic impact Twenty seven percent women Nepal had unmet need, which was 25% in Pakistan, 17% in Bangladesh, and 13% in India. Unmet need for contraception, if satisfied/met, has a significant impact on fertility. The same had been investigated using Bongaarts s (1990) regression model (TFR= 7.178-0.0682 CPR + e). The TFR of Nepal, Bangladesh and Pakistan would be greatly reduced, from 2.6 to 1.9 births (25%), 2.7 to 2.2 births (18%) and 4.1 to 3.5 births (1 6%) respectively, if the unmet need for contraception was met (table-4). Only in the case of India would the corresponding decline be marginal: from 2.7 to 2.5 births (9%). Future intention to use contraceptives Across the countries, majority of the non-users intend to use family planning method in future (Nepal -81%, Bangladesh-70%, India-57%, and Pakistan 50%). Female sterilization (64%) and pill (14%) were the two most preferred methods for future use in India, while it was pill (43%) and injectables (15%) in Bangladesh. Many of those women not intending to use family planning in future (80% in Nepal, 74% in Bangladesh, 66% in India and 58% in Pakistan) cited fertility related reasons (figure-2). Again, 10% women in Nepal, 12% each in India and Pakistan, and 8% in Bangladesh had cited method related reasons for negative future intention. Conclusion and policy recommendations The study found that the countries under study differ in CPR, trends, method mix and the determinants. Bangladesh and Nepal were in a stage of contraceptive plateau while the CPR in Pakistan was declining. Modern spacing method use in India was in a plateau as well. Various policy and program issues along with socio-cultural norms had influenced the trends and method mix. These countries would become closer to replacement level fertility of 2.1 births per woman, if women with unmet need for contraception became contraceptive users. Results suggest broadening of method choices with quality service delivery, reconsideration/ review of program focus along with strengthening private sector, expansion of supply lines with increased infrastructure or strengthening existing network, repositioning spacing methods in national programs, and demand assessment through monitoring age-sex distribution; all with country specific modifications are pertinent for enhanced contraceptive use. References 1. Government of Pakistan (GoP). 2010. Draft National Population Policy 2010, Ministry of Population Welfare, Government of Pakistan. 5

2. Government of the People's Republic of Bangladesh (GoB). 2009. Bangladesh Population Policy, Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh. 3. Goverment of India (GoI). 2000. National Population Policy 2000, National Commission on Population, Government of India. 4. Government of Nepal (GoN). 1997. Second Long Term Health Plan, 1997-2017, Ministry of Health and Promotion, Government of Nepal. 5. Santhya, K. G., 2003. Changing Family Planning Scenario in India: An overview of recent evidences. New Delhi, Population Council. 6. Barkat-e-Khuda and S. Barkat., 2010. The Bangladesh Family Planning Programme: Achievements, Gaps and the Way Forward. UNFPA - ICOMP REGIONAL CONSULTATION, Bangkok, Thailand. 7. Hardee, K. and E. Leahy., 2008. Population, Fertility and Family Planning in Pakistan: A Program in Stagnation. Research Commentary 3. Washington, DC, Population Action International. 8. Anand, T. and Subedi, G. et al. 2010. The Status of Family Planning and Reproductive Health in Nepal. UNFPA - ICOMP REGIONAL CONSULTATION, Bangkok, Thailand. 9. United Nations. 2011. World Population Prospects: The 2010 Revision, United Nations, Department of Economic and Social Affairs, Population Division. 6

Table 1: Level and trends of contraceptive prevalence rate among currently married women aged 15-49 years in selected South Asian countries Country India (last 13 years) Bangladesh (last 13 years) Nepal (last 10 years) Pakistan (last 10 years) Indicators Round-3 Round-2 Round-1 Annual growth 2011 2007 2006 2006 2003 2000 1999 2001 1997 1994 1993 R 3- R 2 R 2- R 1 R 3- R 1 CPR 56.3 48.2 40.7 1.2 1.3 1.2 CPR_Urban 64.0 58.2 51.1 0.8 1.2 1.0 CPR_Rural 53.0 44.7 37.1 1.2 1.3 1.2 Any Modern Method 48.5 42.8 36.5 0.8 1.1 0.9 Any Modern Spacing Method 10.1 6.8 5.5 0.5 0.2 0.4 Female Sterilization 37.3 34.2 27.4 0.4 1.1 0.8 CPR 55.8 53.8 44.6 0.3 1.5 0.9 CPR_Urban 62.0 60.0 54.0 0.3 1.0 0.6 CPR_Rural 54.0 52.0 43.0 0.3 1.5 0.8 Any Modern Method 47.5 43.4 36.2 0.6 1.2 0.9 Any Modern Spacing Method 41.8 35.2 27.0 0.9 1.4 1.1 Female Sterilization 5.0 6.7 8.1-0.2-0.2-0.2 CPR 49.7 48.0 39.3 0.3 1.7 1.0 CPR_Urban 59.6 60.0 62.2-0.1-0.4-0.3 CPR_Rural 48.2 45.9 36.9 0.5 1.8 1.1 Any Modern Method 43.2 44.2 35.4-0.2 1.8 0.8 Any Modern Spacing Method 20.2 19.9 13.9 0.1 1.2 0.6 Female Sterilization 15.2 18.0 15.0-0.6 0.6 0.0 CPR 29.6 32.0 24.0-0.6 1.3 0.6 CPR_Urban 41.1 NA NA NA NA NA CPR_Rural 23.9 NA NA NA NA NA Any Modern Method 21.7 24.0 16.0-0.6 1.3 0.6 Any Modern Spacing Method 13.4 16.0 10.0-0.7 1.0 0.3 Female Sterilization 8.2 8.0 6.0 0.0 0.3 0.2 7

Table 2: Adjusted odds ratios (with 95% Confidence Intervals) for multivariate logistic regression analysis of contraceptive use among currently married women aged 15-49 years in India, Bangladesh, Nepal and Pakistan Background characteristics India (2005-06) Bangladesh (2007) Nepal (2011) Pakistan (2006-07) Any method Any modern spacing method Female sterilization Any method Any modern spacing method Female sterilization Any method Any modern spacing method Female sterilization Any method Any modern spacing method Female sterilization Current age of women 15-24 years 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 25-29 years 2.31[2.20-2.42] a 1.14[1.07-1.21] a 3.33[3.12-3.56] a 1.37[1.21-1.56] a 1.18[1.04-1.33] a 8.06[4.20-15.45] a 1.74[1.51-2.00] a 1.24[1.06-1.45] a 3.67[2.53-5.33] a 1.50[1.25-1.80] a 1.38[1.12-1.71] a 3.32[1.60-6.89] a 30-49 years 3.44 [3.30-3.59] a.56[.53-.60] a 6.62[6.24-7.02] a 1.24[ 1.11-1.38] a.65[.58-.72] a 19.00[10.28-35.11] a 2.98[2.61-3.39] a.95[.82-.1.10] 6.43[4.53-9.11] a 2.44[2.08-2.87] a 1.18[.97-1.43] 17.57[9.03-34.15] a Current education of women Non-literate 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 < 10 years of schooling 1.28[1.23-1.33] a 1.43[1.34-1.52] a 1.15[1.01-1.09] a 1.26[1.14-1.39] a 1.40[1.26-1.55] a.50[.43-.62] a 1.00[.89-1.12] 1.31[1.15-1.48] a.50[.42-.58] a 1.51[1.32-1.72] a 1.51[1.29-1.78] a 1.07[.87-1.13] 10 and above years of schooling 1.11[1.05-1.17] a 2.57[2.39-2.76] a.45[.42-.47] a 1.58[1.36-1.84] a 1.61[1.39-1.86] a.32[.22-.48] a 1.12[.95-1.32] 1.62[1.36-1.94] a.21[.15-.28] a 1.40[1.18-1.65] a 1.70[1.40-2.07] a.54[.40-.73] a Current occupation of women Not-working/household work 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Work outside the household 1.32[1.27-1.36] a.89[.85-.93] a 1.43[1.38-1.48] a 1.57[1.43-1.73] a 1.44[1.31-1.58] a 1.11[.91-1.35] 1.35[1.20-1.53] a 1.21[1.06-1.39] a.77[.65-.92] 1.10[.98-1.23] 1.05[.91-1.22] 1.14[.95-1.36] Number of living son No living son 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 At least one living son 4.34[4.17-4.51] a 1.69[1.60-1.78] a 5.42[5.14-5.72] a 2.49[2.25-2.75] a 2.19[1.97-2.43] a 2.09[1.50-2.92] a 3.03[2.69-3.42] a 1.84[1.60-2.11] a 6.99[4.79-10.19] a 4.87[4.10-5.77] a 3.80[3.06-4.71] a 10.93[5.79-20.65] Frequency of watching television Not at all 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Less than once/at least once a week 1.23[1.17-1.29] a 1.11[1.02-1.20] a 1.22[1.16-1.28] a 1.28[1.14-1.44] a 1.10[.98-1.23] 1.79[1.39-2.31] a 1.24[1.10-1.40] a 1.06[.92-1.22] 1.20[.99-1.44] NA NA NA Almost every day 1.58[1.51-1.67] a 1.09[1.01-1.18] a 1.79[1.69-1.89] a 1.43[1.25-1.64] a 1.37[1.17-1.54 ] a 1.71[1.24-2.37] a -- -- -- NA NA NA Final say on healthcare Husband/partner/someone else 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Respondent alone 1.06[1.01-1.10] a 1.13[1.07-1.20] a.99[.95-1.03].52[.45-.59] a.56[.49-.65] a.98[.74-1.29].59[.52-.68] a.75[.64-.88] a.86[.70-1.07] NA NA NA Respondent and husband/partner 1.02[.98-1.06] 1.17[1.11-1.23] a.87[.83-.90] a 1.09[1.00-1.09] a 1.08[.99-1.19].97[.79-1.20] 1.41[1.25-1.59] a 1.34[1.18-1.52] a.82[.68-.98] a NA NA NA Religion Hindu 1.00 1.00 1.00 - - - 1.00 1.00 1.00 Muslim $.55[.52-.58] a 1.38[1.29-1.47] a.44[.42-.47] a 1.00 1.00 1.00 - - - NA NA NA Others.58[.55-.62] a 1.22[1.13-1.30] a.56[.52-.59] a 1.23[1.07-1.41] a 1.00[.875-1.15] 1.91[1.48-2.48] a 0.75[0.66-0.86] a 1.43[1.24-1.65] a.39[.31-.50] a NA NA NA Caste Scheduled caste (SC) 1.00 1.00 1.00 Scheduled tribe (ST).67[.63-.71] a.97[.88-1.07].68[.63-.72] a NA NA NA NA NA NA NA NA NA Other backward class (OBC).89[.85-.93] a.80[.75-.86] a 1.07[1.02-1.13] a NA NA NA NA NA NA NA NA NA General caste 1.01[.97-1.07] 1.20[1.12-1.28] a.80[.76-.84] a NA NA NA NA NA NA NA NA NA Number of household members < 5 members 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 >=5 members 1.09[1.05-1.13] a 1.09[1.04-1.14] a 1.01[.98-1.05] 1.04[.95-1.14] 1.13[1.03-1.23] a.71[.58-.87] a 1.28[1.16-1.41] 1.44[1.29-1.61] a 1.07[.93-1.23] 1.66[1.38-2.00] a 1.56[1.23-1.98] a 1.31[.94-1.82] Wealth index Poorest 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Poorer 1.27[1.20-1.35] a 1.31[1.16-1.49] a 1.31[1.23-1.40] a 1.02[.88-1.17] 1.07[.93-1.24].87[.64-1.19] 1.38[1.19-1.60] a 0.98[.82-1.16] 2.49[1.93-3.20] a 1.39[1.16-1.68] a 1.94[1.47-2.54] a.84[.63-1.11] Middle 1.45[1.37-1.54] a 1.49[1.32-1.67] a 1.50[1.40-1.59] a.93[.81-1.07].99[.86-1.15].75[.55-1.04] 1.74[1.49-2.03] a 0.98[.82-1.17] 3.67[2.85-4.74] a 1.93[1.60-2.32] a 2.36[1.80-3.10] a 1.12[.85-1.47] Richer 1.65[1.54-1.76] a 1.78[1.58-2.01] a 1.59[1.49-1.71] a.80[.69-.93] a.88[.75-1.02].79[.56-1.10] 1.69[1.43-2.00] a 0.86[.71-1.04] 4.04[3.08-5.29] a 2.44[2.01-2.96] a 2.70[2.04-3.57] a 1.27[.95-1.70] Richest 1.72[1.60-1.85] a 2.48[2.19-2.82] a 1.30[1.21-1.41] a.80[.67-.95] a.86[.72-1.02].72[.49-1.07] 2.20[1.82-2.66] a 1.05[.85-1.29] 4.46[3.30-6.02] a 2.96[2.38-3.68] a 3.24[2.39-4.39] a 1.46[1.05-2.03] a Type of place of residence Urban 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Rural.93[.89-.96] a.84[.80-.89] a 1.00[.96-1.04].73[.66-.81] a.77[.70-.85] a.90[.72-1.13].84[.75-.95] a.72[.63-.82] a 1.02[.87-1.21].76[.67-.85] a.82[.71-.94] a.80[.66-.96] a Exposed to family planning messages No 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Yes 1.24[1.19-1.29] a 1.51[1.42-1.61] a.92[.88-.96] a 1.25[1.12-1.38] a 1.18[1.07-1.31] a 1.01[.79-1.28] 1.24[1.12-1.37] a 1.34[1.19-1.51] a.71[.62-.82] a 1.43[1.28-1.59] a 1.27[1.11-1.46] a 1.32[1.11-1.57] a a P <0.05, Confidence intervals are given in square brackets, NA indicates data not available and not included in the model, Reference category, $ Reference category for Bangladesh 8

Table 3: Adjusted odds ratios (with 95% Confidence Intervals) for multivariate logistic regression analysis of unmet need for spacing and limiting among currently married women aged 15-49 years in India, Bangladesh, Nepal and Pakistan Background characteristics India (2005-06) Bangladesh (2007) Nepal (2011) Pakistan (2006-07) Spacing limiting Spacing limiting Spacing limiting Spacing limiting Age at first marriage <18 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 18+ years 1.217[1.144-1.295] a 1.061[1.000-1.25] a 1.392[1.152-1.682] a.782[.645-.949] a 1.134[.968-1.328] 1.038[.925-1.165] 1.026[.901-1.167].841[.747-.946] a Correct knowledge of ovulatory cycle No 1.000 1.000 NA NA 1.000 1.000 NA NA Yes.717[.658-.781] a.901[.835-.973] a NA NA.833[.702-.989] a 1.070[.942-1.216] NA NA Knowledge of iud+pill+condom No 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 Yes.790[.737-.846] a 1.301[1.216-1.392] a.451[.376-.541] a 1.129[.948-1.346].569[.457-.709] a 1.324[1.117-1.571] a.744[.674-.855] a 1.178[1.035-1.340] a Knowledge of both limiting methods No 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 Yes.620[.579-.664] a.850[.792-.912] a.643[.539-.767] a.900[.771-1.050].716[.496-1.033] 1.156[.829-1.614].699[.602-.812] a 1.003[.881-1.142] Current education of women Non-literate 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 < 10 years of schooling 1.533[1.430-1.643] a.774[.725-.825] a 3.005[2.413-2.742] a.677[.588-.779] a 3.936[3.253-4.763] a.955[.846-1.079] 1.261[1.073-1.483] a.691[.588-.811] a 10 and above years of schooling 1.459[1.331-1.599] a.707[.648-.772] a 2.532[1.880-3.411] a.481[.374-.620] a 6.417[5.026-8.193] a.556[.456-.678] a 1.109[.900-1.366].611[.497-.751] a Exposed to family planning messages No 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 Yes.795[.745-.850] a.608[.572-.647] a.949[.802-1.124].722[.623-.837] a.836[.704-.992] a.937[.830-1.059].917[.797-1.056].855[.753-.972] a Final say on own healthcare Husband/partner/someone else 1.000 1.000 1.000 1.000 1.000 1.000 NA NA Respondent alone.599[.555-.645] a 1.099[1.025-1.178] a.874[.683-1.119] a 3.278[2.762-3.889] a.670[.559-.804] a 2.393[2.092-2.737] a NA NA Respondent and husband/partner.699[.655-.746] a 1.042[.977-1.112].817[.688-.969] a 1.057[.905-1.235].383[.319-.458] a.935[.816-1.072] NA NA Husband is justified to beat wife, if she refuses sex No 1.000 1.000 1.000 1.000 1.000 1.000 NA NA Yes.903[.829-.982] a.946[.874-1.024] a.917[.689-1.221] 1.212[.986-1.490].667[.084-5.270] 1.179[.325-4.283] NA NA a P <0.05, Confidence intervals are given in square brackets, NA indicates data not available and not included in the model, Reference category 9

Table 4: Estimated total fertility rate using regression equation (TFR = 7.178-0.0682 CPR + e) Country Current TFR Current CPR Unmet Need Total demand for contraception Estimated TFR if total demand for contraception satisfied % reduction in TFR if total demand for contraception satisfied India 2.7 56.3 12.8 69.1 2.5 8.7 Bangladesh 2.7 55.8 17.1 72.9 2.2 18.3 Nepal 2.6 49.7 27 76.7 1.9 25.1 Pakistan 4.1 29.6 24.9 54.5 3.5 15.6 10

Figure 1: Total demand for contraception, met and unmet need, in selected South Asian Countries Total demand for contraception, met and unmet need Pakistan (2006-07) Demand Limiting Spacing 54.5 37.1 17.4 6.5 10.9 23.1 29.6 14.0 24.9 Bangladesh (2007) Nepal (2011) Demand Limiting Spacing Demand Limiting Spacing 77.2 61.8 15.3 5.4 9.6 77.2 51.3 21.6 15.0 6.6 40.8 44.3 49.7 17.4 55.8 10.5 27.0 17.1 India (2005-06) Demand Limiting Spacing 11.04.86.2 58.1 69.1 51.5 56.3 6.6 12.8 Demand Met Unmet 11

Figure 2: Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use in the future, by main reason for not intending to use in selected South Asian countries Don t know 11.5 15.2 8.1 12.0 10.1 12.1 5.1 23.0 Other Method-related reasons 65.6 74.1 79.8 58.4 Lack of knowledge Opposition to use India (2005-06) Bangladesh (2007) Nepal (2011) Pakistan (2006-07) Fertility-related reasons 12