Family Planning and Young and Low Parity Couples: Learnings from Rural India

Abstract

This chapter presents a research study on contraception among young and low-parity couples in India. It used the community scorecard method to understand their knowledge, attitude, perception, and use of contraception, and the barriers they face in accessing and obtaining contraceptive methods. The study also examined partner involvement and inter-spousal communication. The study reported higher awareness of FP methods among women than among men but poor knowledge of FP method availability and accessibility among both. Further, there was a positive perception of CHW’s role and a high perception of barriers in terms of social norms, lack of knowledge, and limited access to services among women. A bidirectional relationship between spousal support and method satisfaction was observed. The inter-spousal communication and decision-making by women were moderately reported by women. Findings provide insights for policymakers to address family planning needs. Focusing on young couples is important due to their higher unmet need for family planning. The study emphasizes the role of men in family planning decision-making highlighting the need for improved communication between partners. In summary, this chapter presents a scientifically rigorous study on contraception among young couples in India, offering insights to address their family planning needs using robust research methods.

1. Introduction

India’s family planning program was launched in 1952 to control population growth and improve maternal and child health outcomes. The program initially focused on providing maternal and child health services, including antenatal and postnatal care, immunization, and family planning services, through a network of government-run health facilities. Over the years, the family planning program has undergone several changes in policies, strategies, and approaches to address emerging challenges and meet the evolving needs of the population. The program’s key components include increasing access to contraceptive methods, promoting maternal and child health, and providing sexual and reproductive health education and counseling services.

Despite these efforts, the unmet need for family planning remains high, particularly among young and low-parity couples. According to the National Family Health Survey (NFHS-4), the percentage of unmet needs for family planning among currently married women aged 15–49 years was 12.9%, with the highest proportion of unmet needs reported among women aged 15–24 years. The unmet need for family planning is associated with several factors, including limited access to contraceptive methods, inadequate quality of family planning services, sociocultural norms and beliefs, and gender inequality.

In recent years, the Government of India has taken several initiatives to address the unmet need for family planning and improve the quality of family planning services. These initiatives include expanding the range of contraceptive methods, strengthening the delivery of family planning services through public-private partnerships, increasing the involvement of men in family planning decision-making, and promoting the use of technology and social media for family planning education and counseling. Given the high unmet need for family planning among young and low-parity couples in India, it is essential to understand their knowledge, attitudes, and perceptions of contraception and family planning services. The existing literature provides limited insights into the experiences of young couples regarding family planning, especially from a community perspective. Moreover, men’s role in family planning decision-making is often overlooked in such studies, despite their significant influence on family planning outcomes. While we say this, it is important to consider an effective method that can help increase the chances of improving these outcomes.

Community Score-Card is a tool for bridging the gaps by strengthening the relationship between the community and government engagement on improving QoC. This suffices with the findings from various studies, like Ho et al. [1] analyzed the impact of community scorecards in the conflict-affected provinces of two provinces of eastern Democratic Republic of Congo where village development committee, health committee, community members and healthcare providers were the stakeholders. Blake et al. [2] analyzed a pilot intervention by Evidence for Action (E4A) programme (2011–2015) done to improve maternal and new born health services using a social accountability approach in two regions of Ghana. Gullo et al. [3] evaluated the effects of CARE’s CSC in Malawi using a cluster-randomized control design. The study evaluated the effects of CARE’s community score card on reproductive health outcomes including modern contraceptive use, antenatal and postnatal care service utilization, and service satisfaction. It is very evident that community score card has a direct impact on increasing the transparency and community participation in health facility management, and improving quality of care in terms of increased access to services, improving patient-provider relationships, improved performance of service providers, and improving maintenance of physical infrastructure. In addition, changes occurred through many different mechanisms including provider actions in response to information, pressure from community representatives, or supervisors; and joint action and improved collaboration by health facility committees and providers.

Judith Bruce [4] in her paper outlined quality of care standards which according to her are the neglected dimensions of family planning programme monitoring and evaluation. Hence for the community-led score card, a detailed tool was developed the taking into consideration the Judith Bruce framework of quality of care which focuses on the clients’ perspectives on quality of care in family planning, service provider’s self-evaluation on provision of quality of care and facility readiness.

2. Overview of family planning in India

Therefore, this study aimed to examine the knowledge, attitude, perception, and use of contraception among young and low-parity couples in India, with a particular focus on partner/husbands’ involvement in family planning decision-making, using community score card method. The study also explored the perceived barriers to accessibility and availability of current contraceptive methods, providing valuable insights for policymakers and program makers to address the unmet need for family planning among this demographic group. The study used a rigorous research design to ensure scientific soundness and contribute to the existing literature on family planning in India.

The study explored the following research questions.

• What is the level of knowledge, attitude, perception, and use of contraception among young and low-parity couples in India?

• What are the perceived barriers to accessibility and availability of current contraceptive methods among this demographic group?

• What is the level of partner/husband involvement in family planning decision-making among young and low-parity couples?

• What is the level of inter-spousal communication regarding family planning among this demographic group?

The objectives of the study were:

• To assess the level of knowledge, attitude, perception, and use of contraception among young and low-parity couples in India.

• To explore the perceived barriers to accessibility and availability of current contraceptive methods among this demographic group.

• To examine the level of partner/husband involvement in family planning decision-making and inter-spousal communication regarding family planning among this demographic group.

• To provide evidence-based recommendations for policymakers and program makers to address the unmet need for family planning among young and low-parity couples in India.

India’s pace of decline in childbearing throughout the country’s population has been significant since the past two decades [5, 6]. The percentage decline in population growth rate was the sharpest in 1991–2001, with a decrease of 2.52 percentage points [5]. Since then, a steady decline in population growth has been continuing [5]. India witnessed a population growth rate of about 1.6 percent per year between the Census periods 2001–2011 [5]. Many states, such as Kerala, Goa, Andhra Pradesh, and Tamil Nadu, have reached the replacement level of fertility of 2.1, which was the key objective of the Population Policy of India [5]. Uttar Pradesh alone contributes to 16% of India’s population as of the 2011 census, with an average population of 199.8 million [5]. The total fertility rate of Uttar Pradesh stands at 2.4, and it is among the top five states in India where girls are married before the age of 18 years [7]. About 15.8 percent of women aged 20–24 years in the state are married before the age of 18 years [7]. Studies have indicated that Uttar Pradesh presents the biggest challenge towards meeting SDG 3.7 in terms of absolute numbers [8].

When it comes to the choice of spacing methods, traditional methods are the most accepted methods by currently married women aged 15–49 years in Uttar Pradesh compared to the country as a whole (22 percent vs. 9 percent, respectively) [8]. However, evidence suggests that greater reliance on traditional methods of family planning and low demand for modern contraception translate into lesser utilization of modern contraceptives [8]. Family planning and dropping fertility rate have far-reaching benefits that go beyond health, impacting all 17 Sustainable Development Goals (SDGs) [9].

The government of Uttar Pradesh has been working towards achieving the FP2020 goals and recently launched new methods of contraception like ‘Antara’ and ‘Chayya’ [8]. However, the state still has much ground to cover in terms of achieving the desired population and development goals, especially in promoting the nascent ‘Mission Parivar Vikas’ strategy [8]. The country has taken recent efforts towards addressing Quality of Care (QoC), including access to contraceptive choices, quality counseling services, information, and follow-ups [10]. Community participation has been recognized as a precondition for sustainable development, ensuring good quality care and increased use of contraceptives [11]. The unmet need for family planning among young and low-parity couples, particularly in the context of India, remains a significant challenge [12]. Despite the progress made in recent years, a substantial number of young couples in India continue to lack access to modern contraception methods or face barriers to utilizing them effectively [13]. This unmet need can have far-reaching consequences for individuals, families, and society as a whole. Unplanned and closely spaced pregnancies can lead to increased health risks for both mothers and children, contribute to population growth, strain limited resources, and impede efforts to improve the overall quality of life [14]. It is crucial to address this unmet need through targeted interventions, such as improving awareness about family planning options, expanding access to affordable and quality reproductive healthcare services, and promoting comprehensive sexuality education [15].

Studies have shown that while many young couples in India are aware of contraception, there are gaps in their understanding of the available methods, their effectiveness, and correct usage [16]. Limited knowledge often leads to misconceptions, myths, and fears about contraception, hindering its adoption.

Attitudes towards contraception vary among young couples in India. Some hold positive attitudes, recognizing the importance of family planning for personal well-being, economic stability, and maternal and child health [17]. However, cultural and social factors, such as gender norms, traditional beliefs, and pressure from families, can influence negative attitudes towards contraception and limit its use [18].

Perceptions of contraception are influenced by various factors. Cost, accessibility, privacy concerns, and fear of side effects are common barriers reported by young couples in India [19]. Misconceptions about the impact of contraception on fertility and overall health can also affect perceptions and decision-making.

The use of contraception among young couples in India remains suboptimal. Factors contributing to low utilization include limited access to quality services, inadequate counseling, lack of awareness about different methods, and sociocultural barriers [16]. Additionally, concerns about method effectiveness, side effects, and discontinuation rates contribute to inconsistent or non-use of contraception among young couples.

Efforts are being made to address these challenges. Comprehensive Sexuality Education programs are being introduced to enhance knowledge and dispel myths surrounding contraception [20]. Initiatives that improve access to affordable and quality reproductive healthcare services, including contraceptive methods, are being implemented. Furthermore, involving men as partners in family planning discussions and decision-making can positively influence contraceptive use among young couples [17]. The role of men in family planning decision-making is crucial and can significantly impact contraceptive use and reproductive choices [17]. Men’s involvement and support are essential for effective family planning outcomes [19]. Engaging men in discussions and decision-making regarding contraception helps to foster a sense of shared responsibility and promotes mutual understanding and communication between partners [17]. When men are actively involved, it increases the likelihood of contraceptive use, encourages consistent and effective method use, and reduces the risk of unintended pregnancies [12, 17]. Men’s support also influences women’s access to reproductive healthcare services, including contraceptive methods, as they can provide financial, emotional, and logistical support [17]. By promoting positive attitudes, addressing gender norms, and involving men as partners in family planning interventions and programs, we can create an enabling environment that empowers couples to make informed choices and promotes reproductive health and well-being for both men and women [16, 17].

In conclusion, addressing the knowledge gaps, promoting positive attitudes, dispelling misconceptions, and improving access to contraception are essential for empowering young couples in India to make informed reproductive choices. By implementing comprehensive and integrated strategies, India can enhance the uptake of contraception, reduce the unmet need for family planning, and contribute to better health outcomes for individuals, families, and society as a whole.

3. Methodology

The study adopted a Score Card methodology at large, and considered two sets of respondents–the service receivers i.e. the Young and Low Parity Couples (YLPCs) and service providers/community health workers (ASHA and ANM). The beneficiaries included Young and Low Parity Couples (with 0–1 child), between the ages 18–24 years. All the community health workers from the selected villages were included in the study.

4. Sampling

A multistage-stage sampling design was used. In the first stage blocks were selected, in the second stage villages were selected and in the third stage eligible respondents from the villages were selected. Based on the sample size, the respondents were selected from the villages with the maximum density of the target population.

5. Selection of districts

The districts were selected based on a composite index developed using two indicators namely, current use of any modern contraception method and unmet need for spacing from NFHS-42015–16 data for the districts of Uttar Pradesh. For the calculation of the composite index, women in the age group of 15 to 24 were considered. There were 37 districts that presented data above the state average. From the 37 districts, two districts were selected based on the recommendation of the State government, Banda and Kaushambhi.

6. Selection of blocks and villages

Two blocks from each district were selected based on convenience. The location of the Primary Health Centre (PHC) was the base factor in selecting the blocks – one nearest to the block head quarter and the other furthest from the block head quarter. The sub-centers with the maximum population density were selected in consultation with the Medical Officer In-charge (MOIC) at the selected PHCs. All ASHAs under the selected sub-centers were asked to share the list of YLPCs with the MOICs and the sampling frame was prepared. Finally, villages with a minimum 10 YLPC couples residing in the study area were identified and selected. A total of 12 villages were selected for the study. Figure 1 details the names of the blocks and villages selected in each study district.

Figure 1.

Blocks and villages selected.

7. Sample size calculation

In order to determine the optimal sample size, the primary outcome of knowledge of family planning methods and services in the community was considered. Considering the assumption of 50% of the primary outcome, anticipate that the knowledge of family planning methods services in the community for young and low parity couples will increase to 15 percent point during the study duration, with 80% power, 95% confidence interval and design effect 1.2, the sample size was calculated to be 202 for each district. Therefore, a total of 404 Young Low Parity Couples i.e. 806 respondents (403 women and 403 men) were covered in the study at baseline. The sample of 30 Community Health Workers (ASHA, AWW and ANM), i.e. 15 from each district were covered under the study. Table 1 details the respondent categories and the number of respondents.

Respondent Categories		Numbers	Total
YLPC Couples	Women	403	806
	Men	403
CHW	ASHA	21	30
	ANM	7
	AWW	2

Table 1.

Respondents categories and number of respondents.

8. Ethical considerations

Before collecting the data, informed written consent was obtained from the respondents. The data collectors explained an informed sheet prepared in Hindi language and asked for consent. Participation in the study was fully voluntary. All information gathered was kept anonymous to protect confidentiality. The ethical clearance of the study was done by Internal Review Board (IRB).

9. Data collection

The data were collected by young people within the age group 18–24 years, who were identified and trained in data collection. They were residents of the selected villages. Prior to data collection, eighteen data collectors were trained for two days by the MAMTA research team. The training program consisted of an overview of the study objectives, a briefing on the questionnaires, the sampling methodology, mock interviews, ethics, and hands-on practice in the field. Both male and female data collectors were selected from each village. The data collection was completed in 30 days.

The minimum eligibility criteria for data collectors:

• At least Matric Pass to participate as data collectors

• Able to mobilize, speak and explain in the local language and can relate to YLPC issues

• Able to facilitate a group meeting/interview

• Preferably a resident of the area

• Preferably a person who has already worked in an NGO/government organization at any position

10. Quality control mechanism

The Principal Investigator (PI) and Co-Principal Investigator (Co-PI) led the quality assurance mechanism. Weekly supervisory and field support calls were conducted. Spot checks/Back checks were done. Standard quality checks before data entry (editing, scrutiny, and coding) and during data entry (like double entry, validity, range, and consistency checks) were done.

10.1 Data analysis

Statistical software CSPRO and Excel were used for data storage and analysis. The data entry was followed by the data crosscheck and data cleaning.

The Community Score Cards Scorings for YLPC (Women and Men) generated through pre-decided benchmarks framed by using results from NFHS-4 (2015–2016) for each indicator and for CHW by using results from MPV guidelines and NFHS-4 (2015–2016) {See Annexure I}. Followed by comparing the State Average based on comparable data from the same referred reports and guidelines. Each indicator is a composition of multiple variables. All indicators are on a 3-point Likert scale and they range from ‘0’ to ‘2’. Positive responses on the Likert scale were recoded into ‘2’ as a numerical value, Moderate responses were recoded into ‘1’, and negative response was recoded into ‘0’. The responses were summed up to calculate the minimum and maximum scores. Subsequently, indicators are categorized into ‘Green’, ‘Yellow’, and ‘Red’ on the basis of the pre-decided benchmark.

Based on the pre-decided benchmark, the cut-off percentage for the highest score is decided, from which a cut-off score value is generated as the highest mean percentage score of the maximum score for each indicator which marks the ‘Green’ color on the CSC scorecard. A moderate cut-off percentage is decided basis of the pre-decided benchmark from which a cut-off for moderate score value is generated which marks the ‘Yellow’ color. Further, the percentage value below moderate is considered as the lowest value basis and the lowest score value is generated which marks the ‘Red’ color. For example, for indicator one, there are eight sub-indicators with a minimum (negative) response coded as ‘0’ and a maximum (positive) response coded as ‘2’. After summing up the responses, the minimum score value is ‘0’ and the maximum score value is ‘16’ (8*2). Basis the pre-decided benchmark from NFHS-4 (2015–2016), a percentage of 90 or more should be considered as a ‘positive response’. Therefore, a cut-off value of 14.4 (90% of 16) is generated as the ‘positive’ score which marks the ‘Green’ color on the CSC scorecard. Further, 45–89% marks the moderate response which means a score between 7 and 14 is considered as the ‘moderate’ score which marks the ‘Yellow’ color on the CSC scorecard. Therefore, a score below 7 is considered a ‘negative/no’ response which marks the ‘Red’ color on the CSC scorecard. Likewise, the cut-offs for all the indicators have been generated and scored on the CSC scorecard.

The facility assessment scorings were done by using the Excel spreadsheet for all the health facilities of the Village, Block and District levels.

11. Results

Scores on Community Score Card (CSC) for various indicators (eight in number) related to Family Planning among men and women in the Young and Low Parity Couples (YLPCs) are presented in Table 2.

Table 2.

Scores on community score card (CSC) for various indicators related to family planning among men and women in the young and low parity couples (YLPCs) in the state of Uttar Pradesh.

Based on the responses from the YLPCs, the aggregate percentages were translated into scorecards in Green, Yellow, and Red to enable a quick visual way of their scores for the respective indicator.

11.1 Indicator one: awareness about family planning methods among young low parity couples

The results indicate that the overall awareness of family planning methods among young couples in the study area was relatively low. On the scorecard assessing awareness, only 5.7% of couples achieved green scores, indicating a positive response to 7 out of 8 questions. A majority of couples, 40.6%, received yellow scores, indicating a positive response to 3 to 6 out of 8 questions, while 53.7% of couples received red scores, indicating a positive response to less than 3 out of 8 questions. When comparing awareness between men and women, it was observed that women had better awareness overall. Among women, 8.7% achieved green scores compared to only 2.7% of men, and 42.9% of women achieved yellow scores compared to 38.2% of men. These results highlight the need for increased awareness and education about family planning methods among young couples.

11.2 Indicator two: knowledge of availability and accessibility of family planning services among young low parity couples

The results indicate the knowledge levels regarding the availability and accessibility of family planning (FP) services among young couples in the study area. On the scorecard assessing knowledge, 46.5% of couples achieved green scores, indicating a positive response to 8 out of 9 questions. A significant proportion of couples, 40.6%, received yellow scores, indicating a positive response to 4 to 7 out of 9 questions, while 12.9% of couples received red scores, indicating a positive response to less than 4 out of 9 questions.

In terms of gender-wise comparison, it was observed that men generally had better knowledge about the availability and accessibility of FP services compared to their female counterparts. Among men, 58.8% achieved green scores compared to only 34.2% of women. Additionally, 49.9% of women achieved yellow scores, while 15.9% achieved red scores, compared to 31.3% and 9.9% respectively for men.

The results suggest that there is a relatively balanced distribution of scores for green (46.5%) and yellow (40.6%) among the couples, indicating a moderate level of knowledge about the availability and accessibility of FP services. However, there is still room for improvement as less than 50% of couples have a good level of knowledge. Furthermore, the gender-wise comparison reveals that men generally have better knowledge than their female counterparts. These findings highlight the need to enhance knowledge and awareness regarding FP services, with a focus on reaching and educating women to improve their understanding of available resources and services.

11.3 Indicator three: interpersonal communication and decision-making among women

To assess husband-wife communication and decision-making on ideal family size and family planning use, only women were asked to score their level of discussion with their husbands regarding various topics, such as the number of children, timing of births, family planning methods, and joint decision-making. They were also asked about the influence of their parents or in-laws on these decisions and their own right to influence the use of contraception.

On the scorecard, 13.9% of women achieved green scores, indicating a positive response to 9 out of 10 questions. The majority of women, 76.4%, received yellow scores, indicating a positive response to 5 to 8 out of 10 questions, while 9.7% of women received red scores, indicating a positive response to less than 5 out of 10 questions.

The results show that overall, there is room for improvement in husband-wife communication and decision-making, as only a small proportion of women achieved green scores. The majority of women fell into the yellow score category, suggesting some level of discussion and decision-making but with space for further improvement. A smaller proportion of women received red scores, indicating limited involvement in decision-making regarding family size, timing of births, family planning methods, and joint decisions.

These findings highlight the need to enhance communication and decision-making within marital relationships to promote women’s autonomy and active participation in family planning decisions. There is a scope for strengthening communication channels between husbands and wives to ensure joint decision-making and involvement of women in determining their reproductive choices.

11.4 Indicator four: role of community health workers among current users young low parity couples

To assess the role of community health workers (CHWs), the current contraceptive users among young couples were asked to score their experience with counseling about available family planning (FP) methods, clarification on FP methods, and the time provided to make decisions about contraceptive use. Out of the 403 men and 403 women interviewed, 95 men (23.6%) and 227 women (56.3%) were currently using contraceptives, and the scores on the scorecard represent the scores for these users. It is important to note that the total number of respondents differs here (95 men and 227 women) from the total number of respondents for the study (403 men and 403 women).

On the scorecard, 69.2% of couples achieved green scores, indicating a positive response to 3 or more out of 4 questions. The majority of couples, 20%, received yellow scores, indicating a positive response to 2 out of 4 questions, while 10.8% of couples received red scores, indicating a positive response to less than 2 out of 4 questions.

Overall, the results suggest that the role of CHWs in providing FP services was perceived positively by the current contraceptive users. A significant proportion of couples achieved green scores, indicating satisfactory experiences with counseling and information provision. However, there is room for improvement as a notable percentage of couples received yellow scores, suggesting that there are areas where the role of CHWs can be enhanced.

When considering gender differences, women tended to perceive the role of CHWs more positively compared to their male counterparts. A higher proportion of women achieved green scores, indicating a higher level of satisfaction, while men had a slightly higher percentage of yellow scores and red scores.

In conclusion, although the role of CHWs was generally perceived positively among current contraceptive users, there remains potential for further improvement. Efforts should be made to enhance the quality of counseling, clarification, and decision-making support provided by CHWs, ensuring that both men and women have access to accurate information and can actively participate in making informed choices about family planning.

11.5 Indicator five: methods used among current users young low parity couples

To evaluate the role of community health workers (CHWs), current contraceptive users among young couples were surveyed regarding their experiences with CHWs. They were asked to rate their interactions based on counseling about available family planning (FP) methods, clarification of FP methods, and the time given to make decisions on FP method use. Out of the 403 interviewed men and 403 women, 95 men (23.6%) and 227 women (56.3%) were currently using contraceptives, and the scores on the scorecard represent their evaluations. It’s important to note that the total number of respondents for the scorecard differs from the total number of respondents for the study.

On the scorecard, 69.2% of couples achieved green scores, indicating positive responses to 3 or more out of 4 questions. Yellow scores were obtained by 20% of couples, indicating positive responses to 2 out of 4 questions, while 10.8% of couples received red scores, indicating positive responses to less than 2 out of 4 questions.

Overall, the results indicate that among current contraceptive users, 69.2% of couples perceive a positive role of CHWs based on their counseling, clarification, and decision-making support. These findings emphasize the importance of effective engagement with CHWs to ensure access to accurate information and support for FP methods.

Regarding gender differences, women generally perceive the role of CHWs more positively than men when considering the combined data for both genders. A higher proportion of women achieved green scores (76%) compared to men (67.4%). Women also had a lower proportion of yellow scores (16%) and red scores (8%) compared to men (21.1% and 11.5%, respectively).

In conclusion, the results demonstrate that among current contraceptive users, 69.2% of couples perceive a positive role of CHWs in providing counseling, clarification, and decision-making support. Gender differences exist, with women generally perceiving the role of CHWs more positively. These findings highlight the significance of CHWs in promoting informed decision-making and ensuring access to comprehensive family planning services.

11.6 Indicator six: support from spouse among current users’ women

To assess the support received from spouses regarding contraception use, women who were current users of contraceptives were surveyed and asked to score their experiences. The scores on the scorecard represent the evaluations of 95 men (23.6%) and 227 women (56.3%) who were currently using contraceptives, which is different from the total number of respondents for the study (403 men and 403 women).

On the scorecard, 44% of women achieved green scores, indicating positive responses to 3 out of 3 questions. Yellow scores were obtained by 40% of women, indicating positive responses to 1 to 2 out of 3 questions, while 16% of women received red scores, indicating no positive responses to any of the 3 questions.

Overall, the results indicate a moderate level of support from spouses regarding contraception use among women. Among the current contraceptive users, 44% of women reported receiving support from their husbands, while 40% had partial support, and 16% had no support. This suggests that there is room for improvement in terms of spousal support for contraception use.

The findings suggest that women’s experiences with spousal support varied, with a significant proportion reporting positive support, some reporting partial support, and a minority reporting no support. These results highlight the importance of addressing spousal involvement and support in family planning programs and interventions. Enhancing spousal support can contribute to increased contraceptive use and better reproductive health outcomes for women.

It is crucial to focus on promoting communication and understanding between couples regarding contraception, including discussing the benefits, addressing concerns, and involving husbands in the decision-making process. By providing comprehensive information, education, and support to both men and women, we can foster a supportive environment for contraception use and empower couples to make informed choices about their reproductive health.

11.7 Indicator seven: barriers to accessibility and availability in current use of contraception among young low parity couples

To assess the hindrances in the accessibility and availability of contraception, current users of contraceptives were asked to score the obstacles they faced. These hindrances included issues related to the facility providing the contraceptive method, delays in the supply of preferred contraceptive methods, shortage of preferred contraceptive methods, and the influence of social norms on family planning decisions. They were also asked to rate their satisfaction with the place where the method was provided, their experience with staff interaction at the facility, the impact of cost factors on contraceptive use, and the influence of distance to health centers from their residence.

Out of the 403 men and 403 women interviewed, 95 men (23.6%) and 227 women (56.3%) were currently using contraceptives, and their scores on the scorecard represent their responses. It’s important to note that the total number of respondents for the study differs from the number of current contraceptive users.

On the scorecard, 26.1% of couples achieved green scores, indicating positive responses to 7 out of 8 questions. Yellow scores were obtained by 71.4% of couples, indicating positive responses to 3 to 6 out of 8 questions, while 2.5% of couples received red scores, indicating positive responses to less than 3 out of 8 questions.

In terms of gender, the proportion of men and women with green scores was similar (26.3% for men and 25% for women). However, more men had yellow scores (72.6%) compared to women (66.7%), and a higher proportion of women (8.3%) had red scores compared to men (1.1%).

The results indicate that both men and women face hindrances in the accessibility and availability of contraception. While the overall scorecard shows a moderate level of hindrances, women perceive slightly more barriers compared to men. The scores suggest that there is room for improvement in terms of facility quality, supply availability, social norms, cost factors, and distance to health centers.

11.8 Indicator eight: role of the service provider in family planning use among young low parity couples

To assess the role of service providers in family planning (FP) use, Young Married Women (YLPC) were asked to score various aspects related to their interaction with ASHA/ANM/AWW. These aspects included generating awareness of FP methods, counseling on FP methods and delaying childbirth, discussing the side effects of FP methods, and providing information about the places where FP methods are available. They were also asked to rate their perception of the service providers’ capacity to address contraceptive needs and suggest solutions to side effects.

On the scorecard, 53.8% of couples achieved green scores, indicating positive responses to 5 or more out of 7 questions. Yellow scores were obtained by 25.4% of couples, indicating positive responses to 2 out of 5 questions, while 20.7% of couples received red scores, indicating positive responses to less than 2 out of 7 questions. The cut-off for these scores was determined based on the percentage of respondents who answered “Yes” to the question “ever told by a health or family planning worker about other methods they could use” in the NFHS-4 survey for the state.

Gender-wise analysis reveals that women perceived the role of service providers in FP use similarly to men. The proportion of men with green scores was 55.8% compared to women with green scores at 51.9%. The proportion of men with yellow scores was 29.5% compared to women with yellow scores at 21.3%. Similarly, the proportion of men with red scores was 14.6% compared to women with red scores at 26.8%.

The results indicate that approximately half of the couples rated the role of service providers in FP use positively, achieving green scores on the scorecard. However, there is a notable difference in the perception of service providers between men and women, with men rating them more positively overall. It is important to consider these gender differences in addressing the role of service providers and their impact on FP use.

12. Discussion

The findings from this study provide valuable insights into various aspects of family planning (FP) indicators in the rural regions in the state of Uttar Pradesh, India. These findings align with global and Indian contexts, highlighting both similarities and differences in FP-related factors.

The higher awareness of FP methods among women is consistent with studies conducted globally. For example, a study in sub-Saharan Africa found that women generally had higher levels of awareness of modern contraceptive methods compared to men [21]. Similarly, in India, the National Family Health Survey (NFHS-4) reported higher awareness levels among women compared to men [22].

The study reveals that women have poor knowledge of FP method availability and accessibility. This knowledge gap mirrors findings from other studies conducted in low-income countries. For instance, a study in Ethiopia found that women lacked knowledge about the availability of FP services in their community [23]. In the Indian context, regional variations in knowledge and accessibility have been observed, indicating the need for targeted interventions (NFHS-4, [22]).

The moderate level of inter-spousal communication and decision-making reported by women in this study aligns with research conducted globally. Studies have highlighted the importance of involving both partners in FP decision-making to improve contraceptive use [24]. In the Indian context, the NFHS-4 data also reflect a moderate level of spousal communication and decision-making [22].

The positive perception of CHWs’ role, especially among women in Kaushambi, resonates with studies conducted globally. CHWs play a crucial role in delivering FP information and services, particularly in resource-limited settings [25]. In India, the role of ASHAs (Accredited Social Health Activists) as CHWs has been recognized for their contributions to FP promotion and service delivery [26].

The moderate satisfaction levels reported by both men and women in this study are consistent with findings from other research. Studies have indicated that client satisfaction is influenced by factors such as method effectiveness, side effects, and ease of use [27]. However, it is worth noting that men had slightly higher satisfaction scores in this study, which may reflect their perspectives on method effectiveness and their limited involvement in method use decision-making.

The bidirectional relationship between spousal support and method satisfaction, as observed in this study, has been documented in previous research. Studies have found that spousal support positively influences contraceptive use and continuation [28]. Conversely, lack of support can lead to dissatisfaction and discontinuation of contraceptive methods. This relationship holds true both globally and in the Indian context.

The study highlights the greater perception of barriers among women compared to men. This finding aligns with studies conducted globally, which have identified barriers such as social norms, lack of knowledge, and limited access to services [21]. In the Indian context, regional variations in barriers have been documented, emphasizing the need for context-specific interventions (NFHS-4, [22]).

13. Conclusion

The findings of this study shed light on various aspects of family planning indicators in rural regions of the state of Uttar Pradesh, India. The results align with both global and Indian contexts, highlighting the importance of addressing factors such as awareness, knowledge, inter-spousal communication, role of community health workers, satisfaction with current methods, spousal support, and barriers to accessibility and availability.

To improve family planning outcomes, interventions should focus on increasing awareness of FP methods, particularly among men. Efforts are needed to bridge the knowledge gap regarding the availability and accessibility of FP services, especially among women in Banda. Promoting inter-spousal communication and decision-making can enhance contraceptive use and continuation rates. Strengthening the role of community health workers, such as ASHAs, in providing comprehensive FP services and addressing women’s needs is crucial.

While overall satisfaction with current FP methods was moderate, understanding men’s perspectives and involving them in method-related discussions can further enhance user satisfaction. Addressing barriers to accessibility and availability, particularly for women, is essential to ensure equitable access to FP services and methods.

Certain limitations of the study are:

• The study’s findings are based on self-reported data, which may be subject to recall bias or social desirability bias.

• The study was conducted in specific regions of Kaushambi and Banda, limiting the generalizability of the findings to other contexts within India or globally.

• The study focused on heterosexual couples, excluding individuals who may have different FP needs and experiences.

• The cross-sectional nature of the study limits causal inferences and long-term trends.

• The study did not assess the impact of socioeconomic factors, cultural norms, or health system characteristics, which can influence FP indicators.

Further research is needed to explore the factors influencing FP indicators in different geographic areas and populations. Longitudinal studies and mixed-method approaches can provide a deeper understanding of the dynamic nature of FP decision-making, service utilization, and barriers faced by individuals and communities. Addressing the limitations and building upon the insights gained from this study can inform targeted interventions and policies to improve family planning outcomes and contribute to achieving national and global FP goals.

Annexure I: benchmarks for YLPCs (women and men) and CHWs.

Women

Indicators	Selected questions	Benchmark
Individual Respondent’s Score in awareness of Contraceptive methods	Aware of: Condom / Nirodh	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Aware of: Antara (Injectable contraceptive
	Aware of: Chhaya (Contraceptive pill -weekly)
	Aware of: IUD
	Aware of: Withdrawal
	Aware of: OCP (Oral contraceptive pill)
	Aware of: Rhythm method
	Aware of: Sterilization
Individual Respondent’s Score in Knowledge of accessibility and availability of FP among YLPCs	Do you think that using contraceptive will be helpful to avoid unwanted pregnancy & space between pregnancies?	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Do you feel that young women who want to delay first child after marriage are aware of place where family planning services available locally?
	Do you feel that young women who want to give space between first and second child are aware of place where family planning services available locally?
	Do you feel that young women who want to delay first child after marriage are able to easily access family planning services from local public health service provider?
	Do you feel that young women who want to give space between first and second child are able to easily access family planning services from local public health service provider?
	Do you feel that young women who want to delay first child after marriage are able to discuss with frontline health workers (ASHA & ANM) to get advice on family planning use?
	Do you feel that young women who want to give space between first and second child are able to discuss with frontline health workers (ASHA & ANM) to get advice on family planning use?
	Do you feel that young women who want to delay first child after marriage are able to approach other (non-governmental) or private health service provider to get advice on family planning use?
	Do you feel that young women who want to give space between first and second child are able to approach other (non-governmental) or private health service provider to get advice on family planning use?
Individual Respondent’s Score Husband-wife communication & Decision making on ideal family size and family planning use	Have you and your spouse ever discussed about the number of children to have?	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Have you and your spouse ever discussed when do you want to have your first child?
	Do you jointly make decision with your spouse on how many children you should have?
	Do you jointly make decision with your spouse on when to have first child after marriage?
	Do you agree that your parents or in-laws have a say on how many children you want to have?
	Do you agree that your parents or in-laws have a say on when to have the first child?
	Do you agree that your husband has final say in the number of children to have?
	Do you agree that your husband has “final say” on when to have first child?
	Have you and your spouse ever discussed about using family planning methods?
	Do you agree that your parents / in-laws have the right to influence your decision on using contraception?
Current users: Individual Respondent’s Score on role of CHW	Did the health worker guide/ assist /accompany/ you to consult medical professionals to seek treatment for side effects (if any) when you informed them?	66% and above (of the total score) = Green, 33–65% = Yellow and less than 33% = Red
	Do you agree that you are given enough time to take decision on using current contraceptive method by health service providers?
	Do you agree that you are explained of available methods of contraception by health service provider before choosing the current method?
	Do you agree that you have clarified your doubts about the contraceptive method from the health service providers before you choose the current method?
Current users: Individual Respondent’s Score on methods used	Have you ever thought of discontinuing the current method for any reason?	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Have you ever regretted for using the current method for any reason?
	Have you ever faced disruption in supply of contraceptives that you use?
	Have you ever experienced side effects due to current use of contraceptives?
Current users: Individual Respondent’s Score on Support from Spouse	Has your husband supported and encouraged you to use contraception?	100% (of the total score) = Green, 45–99% = Yellow and less than 45% = Red
	Has your husband accompanied you to health facility centre to avail contraceptives?
	Has your husband accompanied you to health facilities to get treatment in case of side effects (if any)?
Current users: Individual Respondent’s Score on Hindrances in accessibility and availability in current use of contraception	Have you ever faced hindrances in accessing the place where contraceptives are available?	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Have you ever faced delay in supply of contraceptives from the place you avail contraceptives?
	Have you ever faced shortage in supply of contraceptives from the place you avail contraceptives?
	Have you ever faced hindrances due to social norms (pro-natal social norms, pregnancy expectations early in marriage, to produce multiple sons, family resistance to adopt contraceptives, lack of husband’s involvement on family planning issues) in availing contraception?
	How satisfied are you with the place of getting the method?
	How was your experience with the staff at the place of getting methods?
	Do you feel that cost factors / price of contraceptives act as hindrance to avail contraceptives?
	Do you feel that distance to health centres from your residence act as hindrance to you for availing contraceptives?
Individual Respondent’s Score on Role of service provider in family planning use	Do ASHA/ANM/AWW visit your home in regular interval and generate awareness on health education especially on family planning services?	66% and above (of the total score) = Green, 33–65% = Yellow and less than 45% = Red
	Does she explain about available family planning methods for delaying first child for females?
	Does she explain about available family planning methods for spacing?
	Does she explain about side effects caused by contraceptive methods?
	Does she provide information about the places you will get family planning services?
	Are you confident that ASHA/ANM/AWW are capable of addressing your need for contraceptives?
	Are you confident that ASHA/ANM/AWW are capable of finding solution to side effects (if any)?

Men

Indicators	Selected questions	Benchmark
Individual Respondent’s Score in awareness of Contraceptive methods	Aware of: Condom / Nirodh	80% and above (of the total score) = Green, 40–79% = Yellow and less than 40% = Red
	Aware of: Antara (Injectable contraceptive
	Aware of: Chhaya (Contraceptive pill -weekly)
	Aware of: IUD
	Aware of: Withdrawal
	Aware of: OCP (Oral contraceptive pill)
	Aware of: Rhythm method
	Aware of: Sterilization
Individual Respondent’s Score in Knowledge of accessibility and availability of FP among YLPCs	Do you think that using contraceptive will be helpful to avoid unwanted pregnancy & space between pregnancies?	80% and above (of the total score) = Green, 40–79% = Yellow and less than 40% = Red
	Do you feel that young men who want to delay first child are aware of place where family planning services are available locally?
	Do you feel that young men who wants to give space between first and second child are aware of place where family planning services are available locally?
	Do you feel that young couple who want to delay first child or give space between children are able to easily access family planning services from local public health service provider?
	Do you feel that young women who wants to delay first child or give space between children are able to discuss with ASHA/ANM/AWW to get advice on family planning use?
Current users: Individual Respondent’s Score on role of CHW	Did the health worker guide/ assist /accompany/ you to consult medical professionals to seek treatment for side effects (if any) when you informed them?	66% and above (of the total score) = Green, 33–65% = Yellow and less than 33% = Red
	Do you think that you are given enough time to take decision on using current contraceptive method by ASHA/ANM/AWW?
	Do you think that you are explained of available methods of contraception by ASHA/ANM/AWW before choosing the current method?
	Do you think that you have clarified your doubts about the contraceptive method from ASHA/ANM/AWW before you choose the current method?
Current users: Individual Respondent’s Score on methods used	Have you ever thought of discontinuing the current method for any reason?	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Have you ever regretted for using the current method for any reason?
	Have you ever faced disruption in supply of contraceptives that you use?
	Have you ever experienced side effects due to current use of contraceptives?
Current users: Individual Respondent’s Score on Hindrances in accessibility and availability in current use of contraception	Have you ever faced hindrances in accessing the place where contraceptives are available?	90% and above (of the total score) = Green, 45–89% = Yellow and less than 45% = Red
	Have you ever faced delay in supply of contraceptives from the place you avail contraceptives?
	Have you ever faced shortage in supply of contraceptives from the place you avail contraceptives?
	Have you ever faced hindrances due to social norms (pro-natal social norms, pregnancy expectations early in marriage, to produce multiple sons, family resistance to adopt contraceptives, lack of husband’s involvement on family planning issues) in availing contraception?
	How satisfied are you with the place of getting the method?
	How was your experience with the staff at the place of getting methods?
	Do you feel that cost factors / price of contraceptives act as hindrance to avail contraceptives?
	Do you feel that distance to health centres from your residence act as hindrance to you for availing contraceptives?
Individual Respondent’s Score on Role of service provider in family planning use	Do ASHA/ANM/AWW visit your home in regular interval and generate awareness on health education especially on family planning services?	66% and above (of the total score) = Green, 33–65% = Yellow and less than 33% = Red
	Does she explain about available family planning methods for delaying first child for females?
	Does she explain about available family planning methods for spacing?
	Does she explain about side effects caused by contraceptive methods?
	Does she provide information about the places you will get family planning services?
	Are you confident that ASHA/ANM/AWW are capable of addressing your need for contraceptives?
	Are you confident that ASHA/ANM/AWW are capable of finding solution to side effects (if any)?