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Corresponding author. Department of Fertility and Social Demography, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, 400088, Maharashtra, India.
Department of Fertility and Social Demography, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, 400088, Maharashtra, India
This study assesses the Method Information Index (MII) for sterilization use and its correlates in India.
Methods
National Family Health Survey-5 data (2019–21) was considered for analysis. The sample of women aged 15–49 who adopted sterilization in the last five years preceding the survey (n = 42,480) was included. Binary logistic regression was conducted to examine the adjusted association of socioeconomic and demographic characteristics with MII. Stata (v16.0) was used for the analysis with a 5% significance level.
Results
Compared to women who undergone sterilization in a government hospital, the women who had sterilization in a Camp/Mobile clinic/other public facility, Primary health centre/Sub-centre/Urban health post/Government dispensary, and Community Health Centre had respectively, 36% (OR = 0.64, CI = 0.56–0.73), 15% (OR = 0.85, CI = 0.79–0.90) and 14% (OR = 0.86, CI = 0.82–0.91) lower odds of receiving method information.
Conclusion
The MII for sterilization was found inadequate, with less than half of the sterilized women being informed about (a) other methods, (b) possible side effects, and (c) side-effects management before adopting the method. Sterilization counseling is positively associated with higher education, exposure to FP messages, social backwardness, urban residence, and services from a government hospital. Regular sensitization of health providers, especially in the lower order health facilities, on the importance of reproductive rights and informed choice seems pertinent. Improved sterilization counseling will also address women's reproductive health and rights and help attain SDG 3.
Female sterilization consisting of three-fourths of the modern contraceptive method users in 2019–21 continues to lead the Indian family planning program. Socioeconomic conditions
and enhances women's confidence and commitment to contraceptive use. Appropriate counseling with instructions women can understand ensures their right to information and reproductive self-determination.
Target 3.7 of the Sustainable Development Goals (SDGs) also demands universal access to sexual and reproductive healthcare services, including family planning, information and education, and the integration of reproductive health into national strategies and programs by 2030.
The MII can be considered as one way to measure the “information given to clients” component of the well-established quality of care framework of Judith Bruce.
The MII summarizes the adequacy of information provided by the service provider to the women when receiving family planning (FP) services. It serves as a proxy for the quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The client's perspective is helpful for service providers and programmers to understand the user's perception of service quality,
This study assesses the MII for sterilization use and its correlates among women in India.
2. Data and methods
2.1 Data
The study used data from the fifth round of the National Family Health Survey (NFHS), 2019–21. The NFHS-5 is a nationally representative survey of 636699 households that provides information for various monitoring and impact evaluation indicators of health, nutrition, and women's empowerment, including the family planning method used. The NFHS-5 is a stratified two-stage sample with a 98% response rate. The primary sampling units, i.e., the survey villages in rural areas and census enumeration blocks in urban areas, were selected using probability proportional to size (PPS) sampling. Trained research investigators gathered the data using computer-assisted personal interviewing (CAPI). Verbal/written informed consent was obtained from the participants. Only those respondents who gave voluntary consent were interviewed. The published survey report provides a more detailed description of the survey design, questionnaire, quality control measures, and survey management information.
The present analysis was conducted for women aged 15–49 who adopted sterilization in the last five years preceding the survey (n = 42,480).
2.2 Outcome variable
The outcome variable of this study is the MII for female sterilization. The MII consists of three questions: 1. Were you informed about other methods? 2. Were you informed about side effects? 3. Were you told what to do if you experienced side effects? The reported value is the percentage of women who responded “yes” to all three questions.
2.3 Predictor variables
The predictor variables considered for the analysis were: source of sterilization (government hospital, community health centers (CHC), primary health center-PHC/sub-center-SC/urban health post-UHP/government dispensary, camp/mobile clinic/other public facilities, private hospital, other private facilities), age of the women in years (15–24, 25–29, 30–34, 35–39, 40–44, 45–49), years of schooling (no schooling, up to nine years, ten and more years), number of surviving son (Nil, at least have one son), social group (scheduled caste-SC, scheduled tribe-ST, other backward classes-OBC, Non-SC/ST/OBC), religion (Hindu, Muslim, Others), number of household members (<5, ≥ 5) wealth quintile (poorest, poorer, middle, richer, richest), place of residence (urban, rural) and region (north, central, east, northeast, west, south). In India, public sector healthcare facilities are organised into three levels: primary (Subcentres, PHCs, UHP), secondary (CHCs, taluka hospitals), and tertiary (District hospital, medical colleges and teaching hospitals). They differ in terms of staff composition and service delivery; thus we have categorized them accordingly for this analysis.
2.4 Statistical analysis
Bivariate analysis was used to assess the socioeconomic and demographic differentials in the MII for female sterilization. Binary logistic regression was conducted to examine the adjusted association of socioeconomic and demographic characteristics with MII. The predictor variables included in the regression analysis were finalized after checking multicollinearity through Variance Inflation Factor (VIF) method (Table 1). Sample weights were used to adjust the non-response. Stata (V 16) was used for analyses, and the results were reported at a five percent significance level with two-tailed alternate hypothesis.
Table 1Variance Inflation Factor (VIF) for the predictor variables.
3.1 Socioeconomic and demographic differentials in MII for female sterilization
Of the total sterilized women, nearly two-thirds (65%) were told about other possible methods of contraception, about three-fifths (59%) were told about its side effects, and about a half (51%) were told about side-effect management before accepting the method (Table 2). Only 46% of the sterilization acceptors were informed about all three indicators mentioned above. Half of the women receiving sterilization from a government hospital were informed about all three indicators. The corresponding figures were 46%, 45%, 44%, 39%, and 38%, respectively, for those who received the method from a PHC/SC/UHP/Government dispensary, private hospital, CHC, Camp/Mobile clinic/other public facilities, and Other private facilities, respectively. The MII was 47% for the women aged 25–39 years, 44% for women aged 15–24 years, 42% for those aged 40–44 years, and 33% for women aged 45–49 years. With increasing years of schooling, the method information had increased, i.e., from 40% for women with no schooling to 51% for women with ten or more years of schooling. A higher percentage of the women (51%) exposed to family planning messages were informed about the method than their counterparts without mass media exposure (38%).
of women aged 15–49 who undergone sterilization during last five years preceding the survey by method information index and background characteristics, India, 2019-21.
Among the social groups, the women from the ST community (50%) had the highest percentage with method information, followed by OBC (48%), SC (47%), and Non-SC/ST/OBC (43%). With increasing wealth status, the method information had also increased. For example- 41% of the sterilization acceptors from the poorest households were informed about all three indicators, and the percentages increased to 52% for the women from households of the richest category. Every second sterilization user from the urban area was informed about the method compared with 45% of their rural counterparts. Fifty-four percent of the women from the central and north-eastern regions were informed about the method. The corresponding figures were 50% for women from the southern region, 44% for the north, 43% for the west, and 38% for those from the eastern region. The method information varied considerably among states and Union Territories (UT) of India (Fig. 1). Among the bigger states, 73% of the sterilization users from Tamil Nadu were informed about the method compared to a mere 20% of the users from Andhra Pradesh. Half of the sterilization acceptors in 18 out of 36 state/UTs were not informed about all three indicators of MII.
Fig. 1Method information index by state/Union Territories, India, 2019-21.
3.2 Determinants of female sterilization counseling
Table 3 presents the adjusted odds ratio of MII for female sterilization. Compared to women who undergone sterilization in a government hospital, the women who had sterilization in Other private facilities, Camp/Mobile clinic/other public facility, Private hospital, PHC/SC/UHP/Government dispensary, and CHC had respectively 37% (OR = 0.63, CI = 0.54–0.73), 36% (OR = 0.64, CI = 0.56–0.73), 24% (OR = 0.76, CI = 0.72–0.80), 15% (OR = 0.85, CI = 0.79–0.90) and 14% (OR = 0.86, CI = 0.82–0.91) lower odds of receiving method information … With increasing years of schooling, women had higher odds (OR = 1.10, CI = 1.06–1.13) of receiving method information. Women not exposed to family planning messages had 62% (OR = 0.62, CI = 0.60–0.65) lower odds of receiving method information than those exposed. Compared to Non-SC/ST/OBC women, ST, OBC and SC women had respectively 55% (OR = 1.55, CI = 1.43–1.68), 20% (OR = 1.20, CI = 1.13–1.27) and 14% (OR = 1.14, CI = 1.07–1.21) more chance of receiving method information. The likelihood of receiving method information was 16% (OR = 1.16, CI = 1.06–1.28) higher among women from the richest household compared to their counterparts from the poorest households. Rural women were less likely (OR = 0.94, CI = 0.89–0.98) to receive the method information than their urban counterparts. Compared to southern region, women of central and north-eastern region had respectively 35% (OR = 1.34, CI = 1.26–1.43) and 32% (OR = 1.31, CI = 1.07–1.60) higher odds whereas women from the east and west region both had 23% (OR = 0.77, CI = 0.73–0.83) and northern region had 13% (OR = 0.87, CI = 0.81–0.94) lower odds of receiving method information.
of method information index by background characteristics of women aged 15–49 who undergone sterilization during last five years preceding the survey, India, 2019-21.
The MII for sterilization is inadequate, with less than half of the sterilized women being informed about (a) other methods, (b) possible side effects, and (c) side-effects management before adopting the method. Sterilization counseling is positively associated with higher education, exposure to FP messages, social backwardness, urban residence, and services from a government hospital. The result conforms with earlier studies that, although the most adopted method, informed choice is inadequate along with wide variation in the provision of information.
Among the public health facilities, the quality of sterilization counseling deteriorates among the lower order facilities, and the women sterilized in camps/mobile clinics are least likely to receive method information. This result conforms to an earlier study.
It prompts the need for improving service delivery in the health facilities at the bottom level to reinforce the credibility of the public health care delivery system. The study found that educated women had higher odds of a high score on the index, indicating that not enough health care providers spend time informing non-literate women about different aspects of sterilization. This agrees with a past study that reveals the quality of sterilization counseling varies and that there are specific groups of more affected women.
this study reveals that women exposed to FP messages have received better sterilization counseling.
The study found that sterilization counseling is better among socially backward communities. Women from backward communities typically have less control over their healthcare
and are more likely to be less educated, which limits their understanding of the service quality and expectations from the service providers; therefore, they reported to have received the method information. Additionally, they are more likely to have obtained the compensation money and undergone sterilization in a public facility, which may have influenced their reporting. The MII was lower for rural women than their urban counterparts. An earlier study also found higher odds of receiving low-quality care in sterilization services among rural women than urban women.
Women from the eastern and western regions are found to be least counseled, albeit wide regional variation in the quality of sterilization counseling. According to earlier research, women from the western region have less autonomy in choosing family planning methods,
Barriers to Use Contraceptive Methods Among Rural Young Married Couples in Maharashtra, India: Qualitative Findings. vol. 5. Diva Enterprises Private Limited,
2015https://doi.org/10.5958/2249-7315.2015.00132.x
This limits women's access to high-quality counseling. Another study in the eastern state of Odisha also found low adherence to essential procedures at public health facilities during female sterilization service provision, often due to inadequate human resources and infrastructure.
Effectiveness of a quality improvement intervention to increase adherence to key practices during female sterilization services in Chhattisgarh and Odisha states of India.
and regret, especially for women without a son and child loss. Female sterilization at a young age may result in low condom use, which is crucial for preventing RTI/STI and HIV/AIDS, particularly among young women who continue to be susceptible in traditional settings like India. Women's decision to undergo female sterilization has been proven to be influenced by a lack of knowledge or misinformation about spacing procedures and fewer opportunities to use modern spacing methods.
Our results suggest better counseling of potential sterilization acceptors to ensure informed decision-making and to avoid possible post-use concerns.
There are several strengths of this study. Firstly, the results are based on large-scale, nationally representative data of NFHS-5 with a robust sampling design; thus, the results are contemporary and relevant. Secondly, the results contribute to the evidence on sterilization counseling and reproductive rights violations. Thirdly, the findings are helpful for customized, targeted efforts to improve the method information among the most deprived/disadvantaged group/area. Regarding limitations, as with any cross-sectional study, causality is impossible to establish for the factors covered. The other limitation is recall bias, which might occur due to memory lapse.
5. Conclusion
The MII for sterilization is inadequate and varies by region and socioeconomic profile of the women in India. Poor counseling is a barrier to informed method choice and might lead to higher post-use health concerns and regret, adversely affecting women's health and welfare. Regular sensitization of health providers, especially in the lower order health facilities, on the importance of reproductive rights and informed choice seems pertinent to enhance the quality of sterilization counseling. Improved sterilization counseling will ensure informed method choice addressing reproductive health and rights of women and help attain SDG 3- ensuring healthy lives and promoting well-being for all.
Sources of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Barriers to Use Contraceptive Methods Among Rural Young Married Couples in Maharashtra, India: Qualitative Findings. vol. 5. Diva Enterprises Private Limited,
2015https://doi.org/10.5958/2249-7315.2015.00132.x
Effectiveness of a quality improvement intervention to increase adherence to key practices during female sterilization services in Chhattisgarh and Odisha states of India.
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