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Spatial heterogeneity and socio-economic correlates of unmet need for spacing contraception in India: Evidences from National Family Health Survey, 2015-16

Open AccessPublished:March 27, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101012

      Highlights

      • Unmet need for spacing (UNS) was found significantly high in India.
      • A clear spatial heterogeneity of UNS was observed in India.
      • Likelihood of UNS was noticeably high among the multiparous women, OBCs, rural areas and South region compared to their counterparts.
      • This study suggests an extensive remodeling of the existing family planning policies for spacing contraception.

      Abstract

      Background

      The unmet need for spacing (UNS) is one of the key concerns of family planning programme in India despite the country achieving the replacement level of fertility.

      Objectives

      The current study aims to identify spatial heterogeneity and factors associated with the unmet need for Spacing (UNS) in India.

      Data and methods

      The present study used data from the National Family and Health Survey, 2015–16. The outcome variable was the unmet need for contraception for delaying subsequent births for two or more years (UNS), and the explanatory variables were socio-cultural and demographic factors. The current study included 56,742 currently married women (aged 15–49 years) who had demand for spacing during the survey. Descriptive statistics, bivariate with chi-square significance test, spatial natural break technique, and multivariate logistic regression were used to accomplish the study objectives.

      Results

      Almost 51% of women were not using contraception to delay their next birth in India. It was found high across all socio-economic and demographic groups except higher-level education and richest groups. Spatial analysis confirms 248 districts had remarkably high UNS (68% and above). Findings of the multivariate analysis suggest women's education, autonomy, and household wealth status were important factors in reducing UNS. The likelihood of UNS was noticeably higher among women with parity three or more (AOR: 1.42 [1.3–1.55]) compared to their counterparts. Similarly, it was found 44% (AOR: 1.44[1.38–1.51]) more likely among the OBCs than the General caste. It was found 1.24 times more likely in rural (AOR: 1.24[1.19–1.30]) compared to urban. Among the geographical regions, it was found comparatively high in the South (AOR: 6.19 [5.76–6.65]) compared to other regions.

      Conclusion

      Dealing with the UNS necessitates increasing women's education and autonomy, planning to make client choice-based services more accessible, and promoting birth-spacing focused family planning policies.

      Keywords

      Abbreviations:

      FP (Family planning), LMICs (Lower-and Middle-income countries), UFP (Unmet need for family planning), UNS (Unmet need for Spacing), NFHS (National Family Health Survey), DHS (Demographic and Health Survey), IIPS (International Institute for Population Sciences), OBC (Other backward class), SC/ST (Scheduled Caste and Scheduled Tribes), TFR (Total fertility rate)

      1. Introduction

      Effective contraception provides both health and social benefits to mothers and their children by reducing unintended pregnancies and facilitating family planning.
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      National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis.
      Demand for family planning includes women who report wanting to space their next birth for at least two or more years (spacing demand) or desire no additional birth (limiting demand).

      Ewerling F, Victora CG, Raj A, Coll CV, Hellwig F, Barros AJ. Demand for family planning satisfied with modern methods among sexually active women in low-and middle-income countries: who is lagging behind?. Reprod Health. 201; 15(1):1-0.

      The high unmet need for family planning is one of the main hindrances to achieving SDG-3 goals in lower-and middle-income countries (LMICs).
      • Jansen W.H.
      Existing demand for birth spacing in developing countries: perspectives from household survey data.
      Unmet need for family planning (UFP) denotes “the number of currently married women or in the union who are fecund and want to either terminate or delay childbearing altogether as well as women with a mistimed or unwanted births, but not using any contraceptive method".
      • Fabic M.S.
      • Choi Y.
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      • et al.
      Meeting demand for family planning within a generation: the post-2015 agenda.
      The UFP decreased from 21.2% in 1990 to 16% in the developing world in 2010.
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      • Kantorova V.
      • Menozzi C.
      • Biddlecom A.
      National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis.
      Globally, UFP was found among 153 million women, and nearly 90% of them were living in LMICs in 2015.

      Ewerling F, Victora CG, Raj A, Coll CV, Hellwig F, Barros AJ. Demand for family planning satisfied with modern methods among sexually active women in low-and middle-income countries: who is lagging behind?. Reprod Health. 201; 15(1):1-0.

      Globally, the existing demand for family planning, particularly for birth spacing, is noticeably low, especially in developing countries.1 This is because the demand for Spacing is only significant among early reproductive women (aged 15–24 years) with low parity (two or less).
      • Jansen W.H.
      Existing demand for birth spacing in developing countries: perspectives from household survey data.
      However, the unmet need for contraception is significantly high among the women who have a demand for Spacing. The unmet need for contraception for spacing birth (UNS) denotes “the number of currently married women or in the union who are fecund and want to delay next births for at least two years or more, but not using any contraceptive method”.
      • Jansen W.H.
      Existing demand for birth spacing in developing countries: perspectives from household survey data.
      UNS is negatively associated with millions of unintended births, mistimed births, neonatal mortality, pregnancy loss, induced abortions, small size births, and malnutrition.
      • Conde-Agudelo A.
      • Belizán J.M.
      Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study.
      The risk of maternal death, the third trimester bleeding, and anemia was 2.5, 1.7, 1.3, and 1.8 times, respectively higher among the women who followed shorter inter-pregnancy intervals (less than two years) compared to longer inter-pregnancy intervals.
      • Zhu B.P.
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      Effect of the interval between pregnancies on perinatal outcomes.
      Similarly, the risk of small size birth and pre-time birth was found 40% higher among the women with shorter inter-pregnancy intervals than longer ones.
      • Conde-Agudelo A.
      • Belizán J.M.
      Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study.
      The risk of maternal and infant mortality and morbidities can be abridged by reducing the UNS in LMICs.
      • Norton M.
      New evidence on birth spacing: promising findings for improving newborn, infant, child, and maternal health.
      Previous literature was predominantly examined the trends, patterns, and socio-economic correlates of spacing demand, globally.
      • Wulifan J.K.
      • Jahn A.
      • Hien H.
      • et al.
      Determinants of unmet need for family planning in rural Burkina Faso: a multilevel logistic regression analysis.
      • Yadav D.
      • Dhillon P.
      Assessing the impact of family planning advice on unmet need and contraceptive use among currently married women in Uttar Pradesh, India.
      • Deitch J.
      • Stark L.
      Adolescent demand for contraception and family planning services in low-and middle-income countries: a systematic review.
      Global pattern of demand for family planning shows that the spacing demand was considerably higher in Muslim populated countries than their counterparts.
      • Bongaarts J.
      The impact of family planning programs on unmet need and demand for contraception.
      The demand for Spacing was higher among the Muslims because of religious beliefs and faiths suggested by many previous studies.
      • Srikanthan A.
      • Reid R.L.
      Religious and cultural influences on contraception.
      ,

      Pinter B, Hakim M, Seidman DS, Kubba A, Kishen M, Di Carlo C. Religion and family planning. Eur J Contracept Reprod Health Care. 201; 21(6):486-495.

      In India, spacing demand was found comparatively higher among the women in the young age group, Muslims, and residents of the North-east region.
      • Jansen W.H.
      Existing demand for birth spacing in developing countries: perspectives from household survey data.
      Several previous studies examined the association between spacing births and maternal and child mortality and morbidities in India and elsewhere.
      • Yadav D.
      • Dhillon P.
      Assessing the impact of family planning advice on unmet need and contraceptive use among currently married women in Uttar Pradesh, India.
      Some studies also attempt to understand the patterns and socio-economic correlates of unmet need for Spacing (UNS) in LMICs.
      • Wulifan J.K.
      • Jahn A.
      • Hien H.
      • et al.
      Determinants of unmet need for family planning in rural Burkina Faso: a multilevel logistic regression analysis.
      ,
      • Nzokirishaka A.
      • Itua I.
      Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study.
      Women's age, parity, level of education, wealth status, place of residence, and mass media exposure were found to be significant determinants of UNS in Burundi and Burkina Faso.
      • Wulifan J.K.
      • Jahn A.
      • Hien H.
      • et al.
      Determinants of unmet need for family planning in rural Burkina Faso: a multilevel logistic regression analysis.
      ,
      • Nzokirishaka A.
      • Itua I.
      Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study.
      India achieved below replacement level TFR except for a few states and socio-economic groups in 2015–16.
      • Iips I.C.F.
      India National Family Health Survey NFHS-4 2015–16.
      This success was largely due to a sustained focus on family planning, the promotion of incentives based on male and female sterilization, and socio-economic progress.
      • Verma P.
      • Singh K.K.
      • Singh A.
      • Srivastava U.
      Population control under various family planning schemes in Uttar Pradesh, India.
      ,
      • Gupta H.K.
      PSF process in India: achieving rapid population control using financial incentives.
      Simultaneously, chronic child malnutrition, abortion, and maternal death remain challenging issues, which are all linked to the unmet need for Spacing.
      • Nzokirishaka A.
      • Itua I.
      Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study.
      National Family Health Survey (NFHS) 2015-16 suggested that the unmet need for contraception was almost three times higher among the women who desired to delay their next childbirth than their counterparts in India.
      • Iips I.C.F.
      India National Family Health Survey NFHS-4 2015–16.
      Previous studies attempted to contextualize the patterns and socio-economic correlates of demand and unmet need for family planning in India. However, few research has focused on patterns of family planning for spacing birth.
      • Jansen W.H.
      Existing demand for birth spacing in developing countries: perspectives from household survey data.
      ,
      • Jejeebhoy S.J.
      • Santhya K.G.
      • Zavier A.F.
      Demand for contraception to delay first pregnancy among young married women in India.
      With this backdrop, the present study examines district-level spatial patterns of unmet need for Spacing, as well as its socio-economic determinants.

      2. Data and methods

      2.1 Data source

      The fourth round of the National Family Health Survey (NFHS), an Indian version of the Demographic and Health Survey (DHS) carried out during 2015–16, was used in this study. The main objectives of the survey are to provide reliable and detailed information on fertility and family planning, maternal and child health, nutritional status of children, utilization of maternal and child health care services, and women's autonomy. The details of the sampling design process and sample size estimation procedure are provided elsewhere.
      • Iips I.C.F.
      India National Family Health Survey NFHS-4 2015–16.
      The NFHS collected data using different interview schedules, i.e., household schedule, eligible women/individuals, and men schedule. The present study utilized the data from women's schedule. Women's schedule was collected information from a total weightage sample of 5,11,377 of currently married women in India. The present analysis was based on the weightage sample of 56,742 of currently married aged 15–49 years and fecund women, those who had demand for Spacing (all the women whose pregnancy was mistimed; amenorrhoeic women whose last birth was mistimed; and fecund women who were neither pregnant nor amenorrhoeic, and say they want to wait two or more years for their next births).
      • Bradley S.E.
      • Croft T.N.
      • Fishel J.D.
      • Westoff C.F.
      Revising unmet need for family planning.
      The details of the sampling weights are given in the NFHS reports.
      • Iips I.C.F.
      India National Family Health Survey NFHS-4 2015–16.
      The correspondent data file was downloaded from the International Institute for Population Sciences (IIPS) website.
      • Iips I.C.F.
      India National Family Health Survey NFHS-4 2015–16.

      2.2 Outcome variable

      The outcome variable of the present study was the unmet need for Spacing (UNS). Bradley et al. (2012) revised definition of unmet need for Spacing was used to define the outcome variable.
      • Bradley S.E.
      • Croft T.N.
      • Fishel J.D.
      • Westoff C.F.
      Revising unmet need for family planning.
      Denominator includes all the total currently married women (aged 15–49 years); whose pregnancy was mistimed; amenorrhoeic women whose last birth was mistimed; and fecund women who were neither pregnant nor amenorrhoeic, and desired to wait two or more years for their next births during the survey. The numerator includes all the women whose pregnancy was mistimed; amenorrhoeic women whose last birth was mistimed; and fecund women who were neither pregnant nor amenorrhoeic, and said they wanted to wait two or more years for their next births, but they were not using any contraception during the survey.
      • Bradley S.E.
      • Croft T.N.
      • Fishel J.D.
      • Westoff C.F.
      Revising unmet need for family planning.

      2.3 Predictor variables

      A range of socio-economic and demographic variables was used in the analyses that have been documented to be significantly associated with the unmet need for family planning in India and elsewhere in the available published literature.
      • Nzokirishaka A.
      • Itua I.
      Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study.
      • Verma P.
      • Singh K.K.
      • Singh A.
      • Srivastava U.
      Population control under various family planning schemes in Uttar Pradesh, India.
      • Gupta H.K.
      PSF process in India: achieving rapid population control using financial incentives.
      These variables are respondent's age (15–19, 20–24, 25–29 and 30+ years), parity (0, 1, 2, 3+ children), have at least one son child (yes, no), level of education (illiterate, primary, secondary and higher education), women's autonomy (yes, no), household wealth index (poorest, poorer, middle, richer and richest), religion (Hindu, Muslim and others) and caste (General, Other Backward Class [OBC], Scheduled Caste and Scheduled Tribes [SC/ST]), listening family planning massage thorough TV/radio/newspaper or mass media exposure (yes, no), place of residence (urban, rural) and geographical region (North, Central, East, North-east, West, and South). The division of geographical regions is based on the NFHS-4 report.

      2.4 Statistical analyses

      Descriptive statistics, bivariate, and multivariate analyses were applied in this study. Descriptive statistics were used to examine the background characteristics of the study sample. Bivariate analysis with Chi-square significance test was carried out to examine the levels and patterns of unmet need for Spacing (UNS) by background characteristics. The binary logistic regression analysis was performed to determine the socio-economic correlates of UNS. The result obtained from the regression analysis was presented in the form of both unadjusted (UOR) and adjusted odds ratios (AOR) with a 95% confidence interval (CI). The entire analysis was carried out through STATA 14.1. In binary logistic regression, the outcome variable was dichotomous –using contraception (0) and unmet need for contraception (1).

      3. Results

      3.1 Distribution of demand for family planning in India

      Almost 66.4% of women had demand for family planning out of total currently married women in India in 2015–16. Out of total demand for family planning, the Spacing and limiting demand was 16.7% and 83.3%, respectively. The majority of women were not using any contraception (UNS), those who had demand for Spacing (Fig. 1).
      Fig. 1
      Fig. 1Graphical presentation of sample distribution, National Family Health Survey 2015-16.

      3.2 Existing demand for spacing

      The demand for Spacing decreased with increasing women's age and parity. It was noticeably higher among women aged 15–19 years (87%) or 20–24 years (57.4%). Similar patterns were also found among the women, whose parity was zero (89%) and one (62.8%). It was almost six times higher among women with no son (52.3%) than those with at least one son (9.4%). It was increased with increasing women's level of education. It was four times higher among the higher educated women as compared to illiterates (33.5 vs. 8.3%). It was somewhat high among Muslims (23.7%) compared to their counterparts (Fig. 2). Regional variability in spacing demand was noticeable, ranging from 33% in the North-east region to 10% in the South region (Fig. 3). The spacing demand was significantly high (ranges from 30 to 43%) in fifty districts, and very high (more than 43%) covered 29 districts. The majority of districts of the North-eastern states and some districts of Jammu and Kashmir, Bihar, and Uttar Pradesh were under high zone (Fig. 4).
      Fig. 2
      Fig. 2Existing demand for spacing among currently married women, those who had demand for family planning by (a) women's age, (b) parity, (c) number of sons, (d) women's education, (e) wealth quintile, (f) religion, (g) caste, (h) place of residence in India, NFHS-4 (2015–2016) Source: Author's calculation based on NFHS-4 (2015–2016).
      Fig. 3
      Fig. 3Regional patterns of existing demand for spacing among the currently married women aged 15–49 years, those who had demand for family planning in India, 2015-16.
      Source: Author's calculation based on NFHS-4 (2015–2016).
      Fig. 4
      Fig. 4District level patterns of existing demand for spacing among the currently married women aged 15–49 years, those who had demand for family planning in India, 2015-16.
      Source: Author's calculation based on NFHS-4 (2015–2016).

      3.3 Descriptive statistics of the sample

      Table 1 shows background characteristics of currently married women (15–49 years) who had demand for Spacing in India, 2015–16. Most of the women were aged 20–24 years (41.6%), had single parity (56.5%), had no son (53.5%), and were secondary educated (53.6%). Almost 23% of women belonged to the richest, followed by richer (21%) household wealth quintile. Among the religion and caste, most women belonged to Hindu (76.7%) and OBC (40.9%) in India.
      Table 1Background characteristics of currently married women (15–49 years) those who had demand for spacing in India, 2015-16.
      Characteristics (n = 56742)nPer cent
      Age group
      15–195,95210.5
      20–2423,59541.6
      25–2918,19132.1
      30–346,53211.5
      35+2,4724.4
      Parity
      08,95815.8
      132,03856.5
      210,46318.4
      3+5,2839.3
      Have at least one son
      Yes26,40046.5
      No30,34253.5
      Level of education
      Illiterate9,10916.1
      Primary6,07310.7
      Secondary30,40053.6
      Higher11,15919.7
      Wealth status
      Poorest9,58416.9
      Poorer11,15219.7
      Middle10,77419.0
      Richer11,94221.0
      Richest13,29023.4
      Religion
      Hindu43,50076.7
      Muslim9,82617.3
      Others3,4166.0
      Caste
      General1718930.3
      OBC2319340.9
      SC/ST1635128.8
      Place of residence
      Urban19,54134.4
      Rural37,20165.6
      Region
      North8,28014.6
      Central13,23023.3
      East16,25328.6
      North-east3,7056.5
      West7,42713.1
      South7,84713.8
      Mass media exposure
      No18,64332.9
      Yes38,09867.1
      Women's autonomy
      Yes5,95559.7
      No4,02340.3
      Missing46,764
      Total56,742100

      3.4 Unmet need for spacing by background characteristics

      The percentage of UNS was found considerably high among the women aged 15–19 years (61.8%), parity 3+ (62.8%), and illiterate (62.9%), belonging from poorest wealth quintile (64.7%), and South region (75.7%). The percentage of UNS was decreased with increasing women's education and autonomy and household wealth status. Religious differential was minimal, ranging from 52% in Hindus to 43.1% in others. Similar patterns were also found among caste groups. However, the rural-urban gap in UNS was 10.4%, which was 54.2% in rural and 44.6% in urban. The percentage of UNS was found significantly low among the women those who listening mass media than their counterparts. A wide-ranging regional gap in UNS was found between the North-east (32.5%) and the South (75.7%) (Table 2).
      Table 2Patterns of unmet need for spacing among currently married women aged 15–49 years by background characteristics in India, 2015-16.
      Characteristics (n = 56742)nUnmet need for spacingMet need for spacingChi2 significance test
      Age group
      15–195,95261.838.2p < 0.001
      20–2423,59553.546.5
      25–2918,19147.252.8
      30–346,53243.256.8
      35+2,47246.853.2
      Parity
      08,95858.641.5p < 0.001
      132,03845.654.4
      210,46354.645.4
      3+5,28362.837.2
      Have at least one son
      Yes26,40050.849.2p < 0.001
      No30,34251.049
      Level of education
      Illiterate9,10962.937.1p < 0.001
      Primary6,07353.047
      Secondary30,40049.151
      Higher11,15945.055
      Wealth status
      Poorest9,58464.735.3p < 0.001
      Poorer11,15252.747.3
      Middle10,77451.648.4
      Richer11,94248.751.3
      Richest13,29040.959.2
      Religion
      Hindu43,50052.048p < 0.001
      Muslim9,82648.551.5
      Others3,41643.156.9
      Caste
      General1718940.259.8p < 0.001
      OBC2319358.241.8
      SC/ST1635151.848.2
      Place of residence
      Urban19,54144.655.4p < 0.001
      Rural37,20154.245.8
      Region
      North8,28038.461.6p < 0.001
      Central13,23055.444.6
      East16,25345.954.2
      North-east3,70532.567.5
      West7,42750.849.2
      South7,84775.724.3
      Mass media exposure
      No18,64359.240.8p < 0.001
      Yes38,09846.853.2
      Women's autonomy
      Yes5,95545.654.5p < 0.001
      No4,02353.946.1
      Total56,74250.949.1

      3.5 Spatial heterogeneity of unmet need for spacing

      The percentage of UNS was found very high (80%–100%) in 127 districts, followed by high (68%–79%) in 121 districts, medium (50%–67%) in 138 districts. The clusters of very high UNS were mostly found in Uttar Pradesh, Bihar, Jharkhand, Chhattisgarh, Andhra Pradesh, Tamil Nadu, Karnataka, Kerala, Arunachal Pradesh, Nagaland, and Manipur (Fig. 5).
      Fig. 5
      Fig. 5District level patterns of percentage of unmet need for spacing among the currently married women aged 15–49 years, those who had demand for spacing in India, 2015-16.
      Source: Author's calculation based on NFHS-4 (2015–2016).

      3.6 Results from multivariate logistic regression

      The likelihood of UNS was significantly decreased with women's age, level of education, autonomy, and household wealth status (Table 3). It was found 59% (AOR: 0.41; CI: 0.36–0.45) were less likely among the women aged 35+ than women aged 15–19 years. It was noticeably high among the women whose parity was 3+ (AOR: 1.42; CI: 1.3–1.55) compared to their counterparts. The higher educated women have 30% (AOR: 0.70; CI: 0.65–0.76) less likely UNS than illiterates. In terms of economic aspects, the richest women had a lower likelihood of UNS (AOR: 0.41; CI: 0.38–0.44) than the poorest. Among the religious groups, Muslim women (AOR: 0.86; CI: 0.82–0.9) had lower odds of UNS than Hindus. The likelihood of UNS was found 44% (AOR: 1.44; CI: 1.38–1.51) and 9% (AOR: 1.09; CI: 1.04–1.15) more likely among the OBC and the SCs/STs, respectively compared to the General caste. Women in rural areas were 24% (AOR: 1.24; CI: 1.19–1.30) more likely not using any contraception than their urban counterparts. The likelihood of the unmet need for Spacing was significantly higher in the South (AOR: 6.19; CI: 5.76–6.65), followed by the Central (AOR: 1.52; CI: 1.43–1.61), and the West (AOR: 1.80; CI: 1.68–1.92) region compared to North region. Compared to their counterparts, women who were listening to FP messages through mass media had 20% less likely UNS (AOR: 0.80; CI: 0.77–0.84).
      Table 3Likelihood estimates of unmet need for spacing among currently married women who had demand for spacing aged 15–49 years in India, 2015–16 n = 56742.
      VariablesUOR [95% CI]AOR [95% CI]
      Age group
      15-19 (reference)1.001.00
      20–240.71*** [0.67–0.75]0.76*** [0.71–0.81]
      25–290.55*** [0.52–0.59]0.55*** [0.51–0.59]
      30–340.47*** [0.44–0.51]0.43*** [0.40–0.47]
      35+0.54*** [0.49–0.60]0.41*** [0.36–0.45]
      Parity
      0 (reference)1.001.00
      10.59*** [0.57–0.62]0.65*** [0.62–0.69]
      20.85*** [0.80–0.90]0.94 [0.88–1.01]
      3+1.20*** [1.12–1.28]1.42*** [1.3–1.55]
      Have at least one son
      Yes (reference)1.001.00
      No1.01 [0.98–1.04]0.97* [0.92–0.99]
      Level of education
      Illiterate (reference)1.001.00
      Primary0.66*** [0.62–0.71]0.73*** [0.68–0.78]
      Secondary0.57*** [0.54–0.60]0.69*** [0.65–0.73]
      Higher0.48*** [0.46–0.51]0.70*** [0.65–0.76]
      Wealth status
      Poorest (reference)1.001.00
      Poorer0.61*** [0.57–0.64]0.63*** [0.6–0.67]
      Middle0.58*** [0.55–0.61]0.56*** [0.53–0.6]
      Richer0.52*** [0.49–0.55]0.49*** [0.45–0.52]
      Richest0.38*** [0.36–0.40]0.41*** [0.38–0.44]
      Religion
      Hindu (reference)1.001.00
      Muslim0.87*** [0.83–0.91]0.86*** [0.82–0.9]
      Others0.70*** [0.65–0.75]0.91* [0.84–0.98]
      Caste
      General (reference)1.001.00
      OBC2.08*** [1.99–2.16]1.44*** [1.38–1.51]
      SC/ST1.60*** [1.53–1.67]1.09*** [1.04–1.15]
      Place of residence
      Urban (reference)1.001.00
      Rural1.47*** [1.42–1.52]1.24*** [1.19–1.30]
      Region
      North (reference)1.001.00
      Central2.00*** [1.89–2.11]1.52*** [1.43–1.61]
      East1.36*** [1.29–1.44]0.91** [0.85–0.96]
      North-east0.77*** [0.71–0.84]0.61*** [0.56–0.66]
      West1.66*** [1.56–1.77]1.80*** [1.68–1.92]
      South5.00*** [4.67–5.36]6.19*** [5.76–6.65]
      Mass media exposure
      No (reference)1.001.00
      Yes0.61*** [0.58–0.63]0.80*** [0.77–0.84]
      Women's autonomy
      Yes1.001.00
      No1.40*** [1.29–1.51]1.19*** [1.09–1.30]
      Note: UOR= Unadjusted Odds Ratios; AOR = Adjusted Odds Ratios; CI= Confidence Interval; ***p < 0.01, p**<0.05, p*<0.1.

      4. Discussion

      This report found demand for Spacing was significantly lower than limiting in India. Previous studies also suggested that family planning in India is highly skewed toward limiting family planning methods.
      • Pradhan M.R.
      • Dwivedi L.K.
      Changes in contraceptive use and method mix in India: 1992–92 to 2015–16.
      India will not be able to overcome the burden of child malnutrition and infant/maternal mortality without evading close-spacing births. There is a need to promote spacing family planning to minimize the burden of maternal and child malnutrition in India.
      • Rana M.J.
      • Gautam A.
      • Goli S.
      • et al.
      Planning of births and maternal, child health, and nutritional outcomes: recent evidence from India.
      The spacing demand was found mainly among the women in the early reproductive age group (15–24 years), lower parity, had no son child in India. Previous studies also found that the spacing demand predominantly concentrated among young women and low parity.
      • Jansen W.H.
      Existing demand for birth spacing in developing countries: perspectives from household survey data.
      The demand for Spacing was found higher among the women who had not son child can be explained by son preference.
      • Ghosh S.
      • Begum S.
      Influence of son preference on contraceptive method mix: some evidences from ‘Two Bengals.
      The spacing demand was found somewhat high among Muslims in India. However, the impact of religious belief on family planning is not reasonable in recent times.
      • Hoq M.N.
      Effects of son preference on contraceptive use in Bangladesh.
      • Quraishi S.Y.
      The Population Myth: Islam, Family Planning and Politics in India.
      Nevertheless, the effects of religious bigotry on acceptance of family planning and use of contraception cannot be fully denied, especially for those who are illiterate, poor, and live in remote areas in India.
      • Quraishi S.Y.
      The Population Myth: Islam, Family Planning and Politics in India.
      ,
      • Sujatha D.S.
      • Reddy G.B.
      Women's education, autonomy, and fertility behaviour.
      The demand for spacing family planning was low across the regions except North-east region in India. A qualitative study is needed to explore the reasons behind the high demand for Spacing in the North-east region.
      The present study highlighted that half of the women had unmet need for Spacing (UNS) in India in 2015–16; the result is consistent with NFHS-4 report.
      • Iips I.C.F.
      India National Family Health Survey NFHS-4 2015–16.
      Unmet need for spacing positively associated with risk of child and maternal health suggested by previous studies.
      • Norton M.
      New evidence on birth spacing: promising findings for improving newborn, infant, child, and maternal health.
      For instance, the unmet need for Spacing increased the risk of unwanted and mistimed births, induced abortion, and child malnutrition.
      • Conde-Agudelo A.
      • Belizán J.M.
      Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study.
      Therefore, the present study recommends that there is a need for family planning policy review and extensive extension of spacing family planning services. Furthermore, if the government somehow doesn't implement adequate policies immediately, UNS will ultimately become the principal cause of maternal and child health disasters. The present study also suggested that women's age, parity, level of education, autonomy, wealth status, religion, caste, place of residence, region, and mass media exposure are significant determinants of UNS in India. The result is consistent with the previous studies.
      • Jejeebhoy S.J.
      • Santhya K.G.
      • Zavier A.F.
      Demand for contraception to delay first pregnancy among young married women in India.
      The UNS was significantly higher in early reproductive age, illiteracy, and the poorest populations. Previous studies also suggested that the use of modern contraceptives was strongly determined by the women's education level, wealth status.
      • Rana M.J.
      • Goli S.
      The road from ICPD to SDGs: health returns of reducing the unmet need for family planning in India.
      It was high among illiterate women due to less knowledge about spacing contraceptive methods as documented by a previous study.
      • Rana M.J.
      • Goli S.
      Family planning and its association with nutritional status of women: investigation in select South Asian countries.
      The wealth condition reflects the affordability and purchasing power of contraceptive family planning methods.
      • Misra S.
      • Goli S.
      • Rana M.J.
      • et al.
      Family welfare expenditure, contraceptive use, sources and method-mix in India.
      These results are the same as an earlier study conducted in Burundi.
      • Nzokirishaka A.
      • Itua I.
      Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study.
      The findings of the current study also revealed a positive association between women's autonomy and using conception to delay pregnancy in India. Sujatha and Reddy (2009) also found a similar relationship between women's household decision-making and the use of contraception methods.
      • Sujatha D.S.
      • Reddy G.B.
      Women's education, autonomy, and fertility behaviour.
      The overall autonomy score predicted contraceptive use to a lesser extent than the decision-making autonomy score, which may be due to the effects of the two dimensions of autonomy (physical mobility and decision-making).
      • Sujatha D.S.
      • Reddy G.B.
      Women's education, autonomy, and fertility behaviour.
      The UNS was significantly high among the woman who resides from rural and socio-economically backward groups caste (OBCs, SCs/STs). Previous studies found that socioeconomic backwardness is one of the strongest factors of the unmet need for modern spacing contraception in India.
      • Rana M.J.
      • Cleland J.
      • Sekher T.V.
      • Padmadas S.S.
      Disentangling the effects of reproductive behaviours and fertility preferences on child growth in India.
      In rural India, the lack of women's autonomy and knowledge about spacing contraceptive methods negatively links family planning suggested by previous studies.
      • Rana M.J.
      • Jain A.K.
      Do Indian women receive adequate information about contraception?.
      The current study also discovered that locations with low TFR had a considerably higher risk of UNS (South and West region). In both regions, the spacing demand was less than 15%. However, there is a low demand for Spacing, and probably less attention is paid to spacing family planning services, increasing the UNS. The district-level heterogeneity of UNS suggests there is a need to implement a district-level demand-based family planning program, particularly among high UNS clusters in India. Unmet need for contraception was found to be low among those women who were listening to family planning messages through mass media, similar to the previous studies elsewhere.
      • Nzokirishaka A.
      • Itua I.
      Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study.
      Mass media plays a positive role to increase the knowledge, acceptance, and use of contraception in India proposed by existing literature in India.
      • Ghosh R.
      • Mozumdar A.
      • Chattopadhyay A.
      • Acharya R.
      Mass media exposure and use of reversible modern contraceptives among married women in India: an analysis of the NFHS 2015–16 data.
      In 2017, Antara and Chhaya, a new programme, were introduced to supply injectables and pills to expand contraceptive choice in the public health system.
      • Rana M.J.
      • Goli S.
      The road from ICPD to SDGs: health returns of reducing the unmet need for family planning in India.
      For spacing pregnancies, both contraceptives are highly effective. These contraceptives are available in the district hospitals and medical colleges, particularly in Maharashtra, Uttar Pradesh, Madhya Pradesh, Rajasthan, Karnataka, Haryana, West Bengal, Odisha, Delhi, and Goa. However, the current study suggests that these contraceptives should be made available throughout 640 districts, particularly in areas where there is a significant unmet demand for birth spacing.

      5. Policy implications

      The findings of our present study recommend some policy implications. To begin with, more than half of the districts exceeded the national average of unmet need for contraception. As a result, an in-depth inquiry of the reasons for the high unmet need in these districts is required. Second, the Antara and Chhaya programmes must be strengthened in order to reduce family planning expenditure among socio-economically disadvantaged groups. Thirdly, current research reveals significant socio-economic disparities in unmet spacing contraceptive needs, indicating persistent socio-economic inequalities in health care facilities. The government should focus on socioe-conomically vulnerable sections by providing adequate spacing family planning services. Fourth, states with chronic child malnutrition child and mother mortality had a significantly higher unmet need for Spacing. As a result, access to spacing contraceptives is required to prevent close-spacing births, undesired pregnancies, and mistimed births, which will aid in the development of a healthy India. Finally, there is a need for national awareness programmes related to socio-economic and health benefits of birth spacing which will be helpful to spread appropriate knowledge about the need for family planning.

      6. Strengths

      This study examined district-level spatial heterogeneity and socio-economic correlates of Spacing in India using recently available data. The study findings will help policymakers identify the targeted population and district to reduce the high unmet need for spacing contraception.

      7. Limitations

      This study is limited to establishing causality relations between outcome and explanatory variables, nonetheless rather a mere association. Causality presumes the anteriority of explanatory variables to the outcome, which is not the case in cross-sectional data. A qualitative study is also needed to explore the concealed factors of UNS in India. This study examined the only association between women's background characteristics and UNS, and failed to draw the impact of men's attitudes on UNS in the Indian male-dominated society. It is important that further study explore male views and dichotomy between male and female perspectives on using contraception for Spacing, a dimension that was missing in the present study. On the other hand, further study is needed to explore district-level KAP (knowledge, attitude and practice) of contraception for spacing births in India. It will be supportive of drawing the community-level challenges and opportunities of availing family planning services in socio-cultural diverse India.

      8. Conclusion

      The present study examined the patterns and associated factors of unmet need for Spacing in India. Results suggested that unmet need for Spacing was significantly high among the women in early reproductive age group, and socio-economically disadvantageous groups. Women's education and autonomy are positively associated with using contraception for spacing birth. Mass media plays a positive role in lessening the unmet need for Spacing in India. To address high unmet need for Spacing, multi-level initiatives are needed, such as promoting spacing contraception services and community-level campaigns. Women's education, empowerment, autonomy as well as women empowerment are needed to battle against UNS in India.

      Ethics approval and consent to participate

      This study is based on secondary data which is available in the public domain. Therefore, ethical approval is not required for conducting this study.

      Consent for publication

      Not applicable.

      Availability of data and materials

      The dataset analysed during the current study are available in the Demographic and Health Surveys (DHS) repository, https://dhsprogram.com/data/available-datasets.cfm.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Authors’ contributions

      MR conceptualized the study aims and designed the study. MR and AR assisted with interpretation of the analysis/results and manuscript writing. MR, MJR and PC assisted with different parts of the manuscript editing/writing and prepared final draft of the manuscript. All authors read and approved the final manuscript.

      Declaration of competing interest

      The authors have no competing of interests.

      Acknowledgements

      We would like to thanks to Miss. Rumanara Khatun for her inconsistent support during this venture.

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