In India, family planning services are part of larger Reproductive, Maternal, Newborn, Child plus Adolescent Health (RMNCH + A) strategy, which is central to the achievement of national health goals under the National Health Mission (NHM) and Sustainable Development Goal (SDG3). RMNCH + A approach has been launched in 2013 and it essentially looks to address the major causes of morbidity and mortality among women and children as well as the delays in accessing and utilizing health care and services. The RMNCH + A strategic approach has been developed to provide an understanding of “continuum of care” to ensure equal focus on various life stages. Priority interventions for each thematic area have been included in this to ensure that the linkages between them are contextualized to the same and consecutive life stage. The RMNCH + A appropriately directs the States to focus their efforts on the most vulnerable population and marginalized groups in the country. Two more strategic approaches have been introduced in due course of time namely, Mission Parivar Vikas1 (MPV) in 2016 by the Ministry of Health and Family Welfare (MoHFW) and Aspirational Districts2 (AD) programme in 2018 by NITI Aayog. MPV programme focuses on districts of 7 states with total fertility rates (TFRs) ≥ 3 to reach replacement level fertility goal of 2.1 by 2025. It has identified 146 high focus districts for improved family planning programs. While AD programme aims to improve people’s ability to participate fully in the burgeoning economy, health & nutrition, education, agriculture & water resources, financial inclusion & skill development, and basic infrastructure in 117 selected districts across the country. The two new strategic approaches clearly envisage Government of India’s focus to shift to smaller administrative units like districts while implementing various health and developmental programs unlike earlier where larger administrative units like states were the focal points.
Reproductive health is intricately linked to the issues of woman and child health, the spread of sexually transmitted diseases, poverty, education, gender equality and human rights (United Nations Population Division, 1995). Improving access to reproductive health is thus central to the process of development, as reflected in the Millennium Development Goal 5 (MDG5) to achieve universal access to reproductive health by 2015 (United Nations, 2015). To track progress towards these goals, the United Nations Population Division (UNPD) publishes estimates and projections of contraceptive prevalence rates and unmet need for family planning at the global, regional, and country level every 2 years (UNPD, 2015). With the expiry of MDG5, there has been interest in setting targets around the indicators of modern contraceptive prevalence, unmet need for modern contraceptive methods and demand met by modern contraceptive methods for the post-2015 global development agenda in recent literature (Brown et al., 2014; Fabic et al., 2014, FP2020, 2014). In 2015, 17 SDGs were adopted by all United Nations Member States as a universal call to end poverty, protect the planet and ensure all the people enjoy peace and prosperity by 2030 (UNPD). Goals related to health and wellbeing were integrated in SDG3 with specific focus on ensuring universal access to sexual and reproductive health care services, including family planning services, information and education, and the integration of reproductive health into national strategies and programs subsumed into sub indicator 3.7.
In 2019, UNPD estimated that the percentage of women of reproductive age that are married or in union who are practicing any modern contraceptive method in India stands at 49.7 percent as opposed to 35 percent in 1990 and in absolute numbers, this translates to more than a doubling of women on modern contraceptive methods from 56.2 million in 1990 to 128.8 million in 2019 (UNPD, 2019). The unmet need for modern methods has fallen from 20.6 percent (32.9 million women) in 1990 to 17 percent (44.1 million women) in 2019, while the demand for family planning satisfied with modern methods has risen from 57.4 percent to 68.2 percent in the same period. This looks like progress however, such national figures mask disparities at smaller administrative units, especially in a country like India where high demographic diversity exists.
Uttar Pradesh is the largest state in India with a population of 199.81 million people (Census of India, 2011) covering 7.3 percent of country’s land area. Administratively the state has 75 districts, and its sheer population size attracts attention of professionals from different streams to estimate different health parameters and propose strategies for the state. While considering the progress of key family planning indicators in the state of Uttar Pradesh, it can be observed that as per NFHS-4 (2015-16), 31.7 percent of women of reproductive age that are married or in union are using modern contraceptive methods as opposed to 18.5 percent in 1992 (NFHS-1) in the state. In absolute numbers, this translates to more than two-and-half times increase in number of women using modern contraceptive methods from 4.57 million in 1992 to 11.54 million in 2015; in other words, the state contributes only one in eleven modern family planning users of the country even though one-sixth of country’s population resides in the state. The unmet need for modern family planning methods has fallen from 29.1 percent in 1992 to 18.1 percent in 2015, while the demand for family planning satisfied with modern methods has increased from 37 percent to 56.7 percent in the same period in the state. When compared with India’s progress in key family planning indicators as explained before, the progress made by the state of Uttar Pradesh is quite modest which shows the disparity in terms of progress in contraceptive behavior exists in the country. Similar huge difference in contraceptive behavior can be observed within the state of Uttar Pradesh (districts) as mCPR measured by NFHS-4 vary between 2.7 percent in Balrampur district and 59.2 percent in Lalitpur district. Due to wide variations in mCPR and also in unmet need and demand satisfied within the districts of the state, all 75 districts have been included in the study.
It is thus important to have the ability to track progress towards the target at more and more low geographical levels from national to provincial (state) and to sub-provincial (district). Such subgroups can be defined geographically (e.g., states, urban/rural residence, districts) or based on socioeconomic factors (e.g., household wealth quintiles, religion, caste). This shift in emphasis from national assessments and targets to sub-national ones is particularly pertinent considering the equity focus on the SDG agenda. Additionally, it is also crucial to empower stakeholders at state and district levels to take agency in planning, monitoring and evaluation at local level, which is only possible if they understand the heterogeneity and have the capability to generate the relevant estimates and projections of indicators of access to reproductive health with little external support. SDGs have provided a global development framework for expanding the progress achieved through the MDGs with the motto of “no one leaves behind”, which recommends disaggregating data according to income, sex, age, race, ethnicity, migration status, disability, geographic locations, and other relevant dimensions (ADB, 2020). An appropriate Small Area Estimation (SAE) technique through which it is possible to estimate key family planning indicators at district level.
To our knowledge, previous studies related to the analysis of rates and trends in family planning indicators for states/union territories (UTs) in India, have mainly relied on state/UT level observations available from household surveys (e.g., Kumar & Singh, 2013; Jain & Jain, 2010). In this paper, we present a user-friendly web application, the Family Planning Estimation Tool (FPET)3, which can achieve the afore mentioned purpose of state and district level monitoring at the local level and provide an annual series of estimates and projections of rates and trends in indicators of use of contraceptive, unmet need and met demand for family planning at the state and district level in largest populous state in India i.e., Uttar Pradesh from 1991 to 2025 produced with FPET. A previous attempt to estimate these indicators using FPET for India and 29 States & Union Territories was carried out and published in the Lancet (New et al., 2017).
1.2. Study Objective
In view of the recent advancement in the FPET methodologies (Cahill et al., 2018; Wheldon et al., 2018; and United Nations Population Division, 2019), it has been proposed to conduct small area estimation (SAE) and projection of three key family planning indicators for all the districts of the state Uttar Pradesh in India. FPET now allowed to produce either national or subnational estimates depending on what data is entered into the tool (Track20, http://www.track20.org/pages/track20_tools/FPET.php). Since the availability of input data is ensured for all the 75 districts of Uttar Pradesh state, we tried to estimate and project three key family planning indicators -contraceptive prevalence of modern methods (mCPR), unmet need and met demand for all the 75 districts of the state using FPET in this paper.
2.1. State Selection
This study selected the state of Uttar Pradesh and all its 75 districts to meet two strategic decisions, 1) the state has considerable impact in achieving India’s ambitious SDGs and 2) the state is technically supported by the Bill & Melinda Gates Foundation (BMGF). As described earlier, the state’s progress in family planning is disproportionately diverse among districts. To ensure more equitable progress among districts, it is necessary to estimate the district wise family planning indicators and know the list of districts that are not performing well, which helps to focus the family planning programme.
The contraceptive prevalence rate is defined as the percentage of women currently using any contraceptive method, while the modern contraceptive prevalence rate is the same but limited to women using any modern contraceptive method, including sterilization (male & female), injectables, intrauterine devices (IUDs/PPIUDs), contraceptive pills, implants, condoms (male & female), diaphragm, foam/jelly, the standard days method, lactational amenorrhea method, and emergency contraception. The unmet need for family planning is defined as the percentage of women who do not want any more children or want to delay the birth of the next child and yet are not using any contraceptive method. Demand for family planning satisfied with modern methods is defined as the percentage of women who use modern contraceptive methods divided by total demand for family planning, where total demand is the sum of total contraceptive prevalence and unmet need for family planning. All these indicators are restricted to women of reproductive age who are married or in union in this paper to align with the Indian context.
The database for this study comprises observations of the family planning indicators like contraceptive prevalence rate and unmet need for family planning as well as estimates of the number of the base population of women for the state of Uttar Pradesh and its 75 districts. Values of these indicators for the state of Uttar Pradesh have been obtained from household surveys for the state and districts, specifically multiple rounds of the District Level Household & Facility Survey (DLHS), Annual Health Survey (AHS) and Demographic and Health Survey (DHS) (also known as the National Family Health Survey (NFHS)) conducted between 1992-93 and 2015-16. For district level indicators, contraceptive prevalence rate and unmet need for family planning has been taken from three rounds of DLHS from 1998-99 to 2012-13, three rounds of AHS from 2010-11 to 2012-13 and NFHS-4 during 2015-16.There are 483 (473 district level and 10 state level for Uttar Pradesh state) observations each of the total contraceptive prevalence rate, modern contraceptive prevalence rate and the unmet need for family planning from 1992-93 to 2015-16 from a total of 10 multiple rounds of different surveys listed above, as summarized in TableA1 and TableA2 (Annexure A) available as input data for FPET. The base population of women refers to women of reproductive age who are married or in union (MWRA). The projections of MWRA numbers for Uttar Pradesh were obtained from the report published by the National Commission on Population (2020). District projections of MWRA for 75 districts were proportionately allocated from the state projections using the proportion of MWRA obtained from Censuses 1991, 2001 and 2011 for each district.
By combining insights from population surveys and historical trends, FPET provides annual estimates of mCPR, unmet need and demand satisfied for family planning satisfied by modern methods between surveys and builds futuristic scenarios to help countries track progress and inform future programming needs. The most advanced version of FPET also estimates these key family planning indicators separately for all women and women in union/married with three different sets of confidence intervals.
2.3. Research Process
Subnational level data on family planning in India are primarily available from surveys. We searched PubMed and Scopus using a combination of text terms and subject headings, and open-ended search dates. We did not find studies that produced model-based estimates and projections at district level. Previous studies related to the analysis of rates and trends in family planning indicators at the subnational level states/union territories (UTs) in India have mainly relied on direct reporting of the survey results (Kumar & Singh, 2013; Jain & Jain, 2010). The current study is one of the first attempts in this direction.
Selection of FPET to conduct the analysis was naturally inspired as previous studies (Alkema et al., 2013; Cahill et al., 2018; Guranich et al., 2021) have shown that it brings reliable estimates of key family planning indicators at national and subnational levels. In the subnational implementation of the local FPET, each geography is considered as a separate “entity” within the subregion of its respective nation. For example, in district level implementation, districts are considered as countries within the subregion of India and consider model parameters as applicable. Since the FPET package automated to do these processes we as users of this tool are not typically face any issues. Further details of this tool and its functionalities are discussed in the following section.
2.4. Statistical Analysis
Statistical model for subnational estimates and projections builds upon the Bayesian hierarchical model that was used by the UNPD to assess progress towards MDG 5 (Alkema et al., 2013; UNPD, 2015). This model, which we refer to as the global family planning estimation model, combines systematic trends in total contraceptive prevalence and the ratio of modern to total prevalence, modeled by logistic growth curves, with a time series model for fluctuations layered around these trends.
This model was originally launched under the support of the Track20 Project as a tool popularly known as FPET to monitor progress towards the achievement of the goals of the global FP2020 initiative (FP2020, 2014). This tool was motivated by the need for a monitoring tool which is not only less intensive computationally and time consuming than the global family planning estimation model (which requires at least 10 hours of computation time on an average personal computer with 4 core processors) but is also simple enough to use for a local stakeholder without external support and any statistical programming skills. FPET allows the user to generate national or subnational estimates and projections of family planning indicators with either the default World Contraceptive. Use any of the default databases available in the FPET like UNPD 2021 or UNPD 2020 or UNPD 2019 (archive) or Track20 2021 or Track20 2020 or user’s own input database. This web-based application was created with the R package Shiny (RStudio, Inc., 2014) and runs using R (R Development Core Team, 2011) and JAGS (Plummer, 2003); however, all that is required for the user to run FPET is an internet connection and any modern web browser. More about the FPET model descriptions and its advancements over the period are available in the literature (Cahill et al., 2018; Alkema et al., 2013; New & Alkema, 2015).
In addition to provide national estimates, FPET can also be fitted to sub-national data to obtain sub-national estimates (e.g., MWRA for states and districts) annually. In this paper, we extended FPET to obtain district level estimates of key family planning indicators for the state of Uttar Pradesh by broadening the hierarchical structure used and captured spatial differentials where appropriate. The main challenge involved while constructing estimates for sub-populations is paucity of data. However, in India’s case, there are 10 multiple rounds of three surveys (DHS/NFHS, DLHS and AHS) spanned over 1991 to 2015 which provide input data at district and state level for the modeling purposes.
We present here the results on three key family planning indicators for the state of Uttar Pradesh and its 754 districts: namely, modern contraceptive prevalence, unmet need for modern contraceptive methods (a broader definition of unmet need that includes women currently using traditional contraceptive methods as having an unmet need for modern contraceptive methods, since traditional methods tend to have higher failure rates compared to modern ones) and demand for family planning satisfied with modern contraceptive methods, including an assessment of the uncertainty bounds in their levels for the years 1991, 2015 and 2025 and the progress made during this period.
3.1. State Results
Modeled estimates, trends, and projections of three key family planning indicators along with survey-based estimates for Uttar Pradesh state are presented here (Figure 1). The chart shows the modeled estimates match the level and trend of the DHS data closely for the state of Uttar Pradesh. The comparison of the modeled estimates with data points from other survey sources shows differences that are due to model assumptions and findings of the global model. Firstly, for non-standard data (e.g., non-standard other age group of women, circles labeled with “A”), the model considers potential biases associated with the non-standard characteristics in producing the estimates. Secondly, when fitting the model, data are classified into DHS, Multiple Indicator Cluster Surveys (MICS), national survey data or other survey data to provide weightages while modeling. Based on the global assessment of data of these different types of surveys, it was found that the random errors associated with non-DHS data are greater than those associated with DHS data, especially for measuring unmet need (Alkema et al., 2013). As a result of this assessment, error variances for non-DHS data are estimated to be higher than the error variance for DHS data, and the modeled estimates will be more informed by the DHS data as compared to data from other sources. This explains the discrepancy between the Annual Health Survey (AHS) data (in black square) and the modeled estimates for unmet need.
Figure 1. Modeled estimates and trends of modern contraceptive prevalence rate, unmet need for modern contraceptive methods and demand satisfied with modern contraceptive methods for Uttar Pradesh.
3.2. District Level mCPR
The estimates of mCPR, met demand for modern methods of contraceptives and unmet need for modern family planning methods with respective 95 percent uncertainty bounds for the years 1991 and 2015 for the state Uttar Pradesh and its 75 districts derived from FPET model have been presented in TableB1 (Annexure B). Modern contraceptive prevalence rate for the state has nearly doubled from 17.2 percent (95% UI: 13.4% - 21.4%) in 1991 to 32.0 percent (95% UI: 29.8% - 34.1%) in 2015, indicating an increase of 14.8 percentage points in nearly two and half decades. The district level mCPR ranges from a low of 4.8 percent (95% UI: 4.2% - 5.4%) in Balrampur district to a high of 59.1 percent (95% UI: 55.7% - 62.3%) in Lalitpur district in the year 2015. In 2015, mCPR of four districts namely, Lalitpur (59.1%), Jhansi (56.9%), Gautam Buddha Nagar (51.3%) and Hapur (51.2%) is found to be more than 50 percent, which is nearly one-half times more than the state average. Out of 75 districts in state, 10 have high prevalence where mCPR is greater than 45 percent in 2015 (Figure 2); performance of 19 districts was found to be modest with mCPR ranges between 40 and 50 percent and mCPR of the remaining 42 districts spans over 20 to 40 percent in the year 2015. However, 10 districts performed very poorly with mCPR less than 20 percent in 2015 (Figure 3). During 1991-2015 period, the maximum gain in
Figure 2. 10 districts where mCPR is >45% in 2015.
Figure 3. 10 districts where mCPR is <20% in 2015.
mCPR of 38 percent has been observed in Lalitpur district whereas mCPR declined in Balrampur and Shrawasti districts from the base year.
3.3. District Level Unmet Need for Family Planning
Regarding the second key family planning indicator, unmet need for modern family planning methods, the situation in the state has not improved as the model estimate shows 32.7 percent (95% UI: 29.3% - 37.2%) of MWRA have an unmet need for modern family planning methods in 2015, a marginal increase of nearly 1 percent from the 1991 estimate (31.9%). More than 40 percent of unmet need for modern contraceptives recorded in 11 districts, the unmet need ranges between 30 and 40 percent in 38 districts, the other 18 districts are in 25 - 30 percent range and 10 districts have shown less than 26 percent unmet need in the state in 2015 (Figure 4). Overall, the lowest unmet need for modern contraceptives was recorded in Jhansi district (18.6%, 95% UI: 15.4% - 22.9%) and the highest 44.9 percent (95% UI: 38.8% - 51.6%) in Kanshiram Nagar district in 2015. A significant decrease with 10 or more percentage point in unmet need has been observed in 9 districts, along with 61 districts who have also shown improvement during 1991 to 2015 period in the state. However, the situation has deteriorated in 5 districts during the above-mentioned period. There are ten districts which have unmet need greater than 40 percent in 2015 (Figure 5).
Figure 4. 10 districts where unmet need is <26% in 2015.
Figure 5. 10 districts where unmet need is >40% in 2015.
3.4. District Level Met Need for Demand for Modern Family Planning Methods
Uttar Pradesh has made considerable progress in the third key family planning indicator—the demand satisfied with modern family planning methods—as the estimate improved from 35.2 percent (95% UI: 28.4% - 41.6%) in 1991 to 49.5 percent (95% UI: 44.6% - 53.5%) in 2015. Performance in two districts, namely Jhansi and Lalitpur, is found to be far better with 75 percent demand satisfied with a modern contraceptive method in the state in the year 2015. The district Balrampur placed at the lowest in the list of 75 districts where only 12.7 percent (95% UI: 11.2% - 14.4%) of MWRA’s demand for modern methods satisfied in 2015. While considering the distribution of districts at different levels, more than 60 percent of women’s demand for modern FP methods was met in 14 districts, proportion of women in 40 districts have demand satisfied in the range of 40 - 60 percent, and 21 districts in the lowest category of less than 40 percent demand for modern FP methods met. Levels of this indicator have improved in all the districts in the state from 1991 to 2015 except for Shrawasti district where the percent of demand satisfied decreased in 2015 (18.7%) from the 1991 level (20.2%). There are 10 districts where demand satisfied with modern methods is greater than 60 percent i.e., highest and 10 districts where demand satisfied is less than 40 percent i.e., lowest (Figure 6 and Figure 7).
Figure 6. 10 districts where demand satisfied with modern method is >60% in 2015.
Figure 7. 10 districts where demand satisfied with modern method is <40% in 2015.
3.5. Summaries of District Level Estimates of Three Family Planning Indicators
To visualize the district-wise coverage of these three indicators, the district’s estimates have been plotted on state map as per FPET modelled. Figures 8(a)-(f) provide the details of mCPR, unmet need and demand satisfied with modern contraceptives, respectively for 2015 and 2025. Such plots will help the program implementers to identify the districts where programs are to be focused – likely that poor performing districts located in certain adjoining region. To distinguish the levels in indicators, five gradient colors are used in the map from dark brown that signifies districts with more than 50 percent mCPR (better performance) in 2015 & 2025 (Figure 8(a) and Figure 8(b)) gradually to lighter yellow color that signifies districts with less than 20 percent mCPR. Out of ten poor performing districts in 2015, two districts have shown no progress with less than 20 percent mCPR in 2015 and 2025 and need more attention in terms for programmatic view. They are situated in northern part of the state bordering Nepal and found to be geographically contiguous.
Figure 8. (a): Modelled estimates of mCPR in 2015; (b): Modelled estimates of mCPR in 2025; (c): Modelled estimates of unmet need in 2015; (d): Modelled estimates of unmet need in 2025; (e): Modelled estimates of met need in 2025; (f): Modelled estimates of met need in 2025.
poor performing districts to darker color for better performing districts unlike the color gradient in the previous maps (Figure 8(a) and Figure 8(b)). Women of married or in union in nearly three-fourth (35 out of 75) of the districts in the state have more than 30 percent unmet need for modern methods of contraception in 2015 and 2025 and most of these districts are in central and eastern part of the state.
Percent of demand satisfied by modern methods is plotted in Figure 8(e) and Figure 8(f) for the year 2015 and 2025. Color gradient applied in this map is like Figure 8(a) and Figure 8(b)—lighter color suggests poor performance and darker shades denote better performance. Accordingly, 16 of 75 districts have 60 percent or more met demand for modern family planning methods in the state in 2015 and 2025 which are ranged from 60 percent to 78.3 percent. It is worth noting that two districts namely Jhansi and Lalitpur maintain the consistency with 75 percent or more met demand for a modern family planning method in 2015 and 2025. Ten district’s MWRAs are found common with less than 40 percent demand satisfied for modern methods in both reference years i.e., 2015 and 2025.
4. Futuristic Scenarios
Until now, we looked at the past performances in terms of three key family planning indicators for the state and districts during 1991-2015 period. When considering the list of districts to prioritize in terms of service provision, we need to further examine how futuristic scenarios for the districts and state would look like in 2020 and 2025. Using FPET modeling, we can estimate mCPR, demand satisfied by modern methods and unmet need for modern contraceptives with respective 95 percent uncertainty bounds for districts and state beyond 2015.
The projected estimates of three key parameters for 75 districts and state for the year 2025. Coverage of modern family planning methods is expected to reach 39.6 percent (95% UI: 24.6% - 55.3%) of MWRAs in the state in 2025, resulting in a growth of 7.6 percentage points in 10 years. Prevalence rate is expected to cross 60 percent mark only in Lalitpur district-63.2 percent (95% UI: 47.5% - 76.5%). Districts Balrampur and Shrawasti with respective mCPR of 9.9 percent and 16.9 percent in 2025 ranked lowest among 75 districts. There are 10 districts where the projected estimates of mCPR will be greater than 50 percent (Figure 9) and 10 districts which have lowest mCPR less than 30 percent in 2025 (Figure 10).
In 2017, India updated its commitment to FP2020 by ensuring 74 percent of the demand for modern contraceptives satisfied by 2020 (FP2020 Commitment, GoI, 2017). Timeframe to achieve this goal for Uttar Pradesh and its districts has been revised in view of state’s below average performance and current level of contraceptive behavior. In this paper, we shall consider the target of 74 percent of the demand for family planning satisfied with modern contraceptive methods
Figure 9. 10 districts where mCPR is >50% in 2025.
Figure 10. 10 districts where mCPR is <30% in 2025.
by 2025 for the state and districts by extending five years to India’s time frame of 2020. The state is likely to achieve 57.5 percent demand satisfied by 2025 with two districts expected to cross 74 percent met demand target. Lalitpur tops the list with 78.3 percent followed by Jhansi with 75.3 percent demand satisfied with modern contraceptives by 2025. In contrast, Balrampur (22.7 percent) and Shrawasti (30.8 percent) are at the bottom list with nearby 30 percent of demand met with modern methods in the state. The projected results suggest that about half of the districts (32 districts) are likely to perform well and expected to achieve more than 60 percent of demand for modern methods met in 2025. There are10 districts which have demand satisfied with modern methods greater than 65 percent and 10 districts which have demand satisfied by modern methods in 2025 less than 40 percent (Figure 11 and Figure 12).
The unmet need scenario in 2025 for the state is not very encouraging. Only two districts (Lalitpur, 17.3 percent and Jhansi, 17.8 percent) in the state are likely to bring down unmet need for modern family planning methods below 26 percent in 2025 (Figure 13) and there are 10 districts where unmet need is >35% in 2025 (Figure 14). This suggests that the state is likely to face uphill task in managing unmet need scenario.
We further estimated the number of married women in reproductive age who will be using modern contraceptive methods whose demands for modern methods
Figure 11. 10 districts where demand satisfied with modern method is >65% in 2025.
Figure 12. 10 districts where demand satisfied with modern method is <40%in 2025.
Figure 13. 10 districts where unmet need is <26% in 2025.
met in 2020 and 2025 using the FPET model (TableB2(b) in Annexure B). These numbers help the family planning programme implementors to quantify their task to ensure enough supply of family planning products and services in the state and districts.
In terms of the absolute count of MWRA rather than the percentage, Uttar Pradesh presents the biggest challenge with an increase of more than 4.5 million MWRA on modern contraceptive methods required by 2025 to even reach
Figure 14. 10 districts where unmet need is >35% in 2025.
demand satisfied with modern method of 57.5 percent from 2015 (TableB2(a), Annexure B). Only two districts will reach demand satisfied with modern method of 74 percent (shaded green) by 2025 but to reach that level, they will need an increase of more than 58 thousand MWRA by 2025. A marginal increase can be observed in demand satisfied with modern methods from 53.2 percent in 2020 to 57.5 percent in 2025 with 2.56 million MWRA in the state. Some districts will attain demand satisfied with modern method more than 70% in 2025 as increase in mCPR from 2015 to 2025 (Figure 15).
Out of 75 districts, only 6 districts will attain more than 70 percent demand satisfied with modern method in 2025. Two districts namely Lalitpur and Jhansi found to be attaining more than 75 percent demand satisfied with a modern contraceptive method in the state in 2025 where percentage change in mCPR is 4.1 percent and 1.9 percent, respectively from 2015 to 2025.
In this paper, we have presented estimates and projections of rates and trends in modern contraceptive prevalence, unmet need for and demand satisfied with modern methods in Uttar Pradesh and all 75 districts of the state in India with associated uncertainty intervals. The estimates illustrate differences across districts both in terms of current levels and past progress from 1990 to 2015 that are masked by looking solely at state averages. Subnational projections also highlighted great differences across districts and the comparison with the target of having 75% of demand for family planning satisfied with modern contraceptive methods by 2030 indicated which districts should be prioritized based on the difference between the projected and required percentage and number of MWRA using modern contraceptive methods. Area specific policy recommendations are necessary to address these different situations.
Modelling results on three key family planning parameters suggest that the overall progress made by the state is quite modest in the last two and half decade.
Figure 15. Districts which will attain >70% demand satisfied with modern method in 2025 as increase in mCPR from 2015 to 2025.
5.1. Prevalence of Modern Contraceptives
District wise performances suggest wide gap in levels and trends in the FP indicators with two districts viz. Jhansi and Lalitpur performed exceedingly well. Three districts like Balrampur, Basti and Shrawasti performed very poorly where the prevalence of modern contraceptive users is less than 20 precent and unmet need for family planning is comparatively high among 75 districts of Uttar Pradesh. The poor performing districts with lowest mCPR and highest unmet need for family planning in 2020 were Balrampur, Basti and Shrawasti (Figure 16).
Poor performing districts are found to be geographically clustered around the international border with Nepal making easy target for better planning and thereby specially focusing this area to improve the programme coverage. Additionally, district level analysis enables the state policy makers and programme implementers to draw district specific strategies by categorizing districts as per their performances and number of users to be provided with the basket of family planning choices to achieve the expected prevalence rates. Without such analysis it is a humongous task to identify the pressure points among 75 districts and make tailor-made district specific strategies.
5.2. Demand Satisfied
Family planning is key for reducing unintended pregnancies and their health consequences. It is important to analyze the coverage of demand satisfied with a modern contraception which measures state’s success in providing family planning services to those who are in need. Results from the projected modelling exercise suggest that the state is not likely to achieve the set goal of meeting 74 percent of demand for modern methods even by 2025 five years after the national target. Only two districts in the state are likely to succeed in achieving this goal by 2025 implying a lot of efforts to be done by the state health functionaries.
5.3. Unmet Need
The third key parameter analyzed—unmet need for family planning, brings another
Figure 16. Districts with lowest mCPR and highest unmet need in 2020.
grim picture for the state. This indicator measures the gap between women’s reproductive intentions and their contraceptive behavior which is one of the FP2020 core indicators and included in the list of SDGs (Indicator 3.7.1) as noted in Figure 13 and Figure 14.
Expanding access to contraception and ensuring that demand for family planning is satisfied using effective contraceptive methods are essential for achieving universal reproductive health care services listed in the 2030 agenda for Sustainable Development. Thus, ensuring family planning services with the provision of basket of choices without leaving any geographical community or population group is essential to fulfil the aspirations of emerging country.
In this paper we have been able to show that the FPET Global model successfully extended by fitting subnational and sub-provincial (here district) data and able to draw projected estimates of three key family planning parameters at district level when input data are available. This modeling exercise was conducted under the normal user level conditions without any coding or software programming skills. Typically, such exercises would immensely help policy makers and implementors at state and district level especially for a large state like Uttar Pradesh, where stark diversity in performance of health indicators exists to track and monitor the progress of family planning program indicators. The state’s contribution to achieve India’s FP2020 commitment is highly significant and thus justifies the selection of the state for this exercise.
6. Recommendations/Actions for Programme Planners
• Identification of low performing districts in terms of progress of family planning indicators is the first crucial step towards preparation of evidence-based programme strategy for the large state like Uttar Pradesh.
• The study has identified 10 districts where mCPR is <30% (Figure 10), another 10 districts where demand satisfied with modern methods is <40% (Figure 12) and 10 districts who have unmet need > 35% in 2025 (Figure 14) need to be given priority in the family planning program.
• Monitoring and follow-up mechanism should be strengthened to increase the accessibility and availability of modern contraceptive methods at the health facilities and community as well.
• Ensure uninterrupted availability of family planning products and services in these districts as many remote health facilities are found to have supply and logistic issues.
• Supportive supervision visits may allow programme personnel to address the challenges of providing family planning services at the health facilities. They can provide handhold support to the new providers and health facilities on spot.
• Involvement of community leaders to advocate the use of modern family planning methods in their community.
• More emphasis should be laid in promotion of new methods introduced such as injectable (Antara, a national programme to promote the use of injectables in the public sector by the Ministry of Health and Family Welfare) and Post-partum IUCD to increase prevalence of modern contraceptive methods.
FPET is essentially a formidable tool to apply and estimate key family planning parameters at sub-provincial level (small area estimation). Programme implementors and policy makers require smallest possible administrative level information to draw and adapt specific strategies which effectively improve the performance of family planning programs. The state of Uttar Pradesh constitutes districts which are heterogeneous with varying levels of mCPR levels and degrees of performances. In this paper, we have identified a list of districts with very low mCPR (<30%), demand satisfied with modern methods (<40%) and high unmet need (>35%) in 2025 which need to be given special attention. Similarly, many districts those are geographically adjoining and bordering Nepal in the northern part of the state, require special attention. Efforts to increase the coverage of FP services by strengthening supply delivery and demand for family planning services in these districts are crucial in achieving state and there by national family planning goals set for both FP2020 and SDGs.
We are thankful to the staff involved in large number of surveys in the collection and publication of the data that we analyzed. We would also like to thank anonymous reviewer(s) for the constructive comments on the manuscript.
NKR created input data sets. YPG and NKR carried out the data analysis. YPG prepared the first draft of the manuscript. All authors reviewed results and provided inputs and comments on the paper.
Track20, Avenir Health through a grant from the Bill & Melinda Gates Foundation.
1) Data for the subnational analysis of Uttar Pradesh
An overview of the data series and observations available at the subnational (state/UT-level) in India used in the estimation process is given in TableA1. Links to the data sources are provided in TableA2.
Table A1. Overview of data series and observations for Uttar Pradesh and 75 districts.
Table A2. Links to data series for UP and its districts.
2) The Family Planning Estimation Tool (FPET)
FPET is a web-based application available at http://fpet.track20.org that allows users to generate view and compare national and subnational estimates and projections of family planning indicators.
With FPET user can:
• View the data used and results of an existing run
• Start a new run using the default database or his own data and view the results of the new run
• Compare the results of two different runs.
• Get information about how realistic/ambitious a specific goal would be given the current model projections for target-setting purposes. For example, the user would provide a target level of modern contraceptive prevalence for the year 2030 and the app would then give the estimated probability that that target would be reached in that year given the current model projections. Vice versa a target could be based on the modern contraceptive prevalence level in 2020 for which the current projected probability of obtaining is only 10%.
• Result tables can be downloaded as CSV files and result figures as PDF files.
Table B1. Estimates and 95 percent uncertainty intervals (percent) of modern contraceptive prevalence, demand and unmet need for modern contraceptive methods in 1991 and 2015 and their percentage points change between 1991 and 2015 for Uttar Pradesh and its districts.
Table B2. Estimates and 95% uncertainty intervals (%) of modern contraceptive prevalence, demand and unmet need for modern contraceptive methods in 2025 and the increase in the modern contraceptive prevalence needed from 2015 to attain 74% met demand for modern methods by 2025. Districts that can’t attain 74% met demand for modern methods in 2025 have a shaded display in the last column. (a) Estimates of increase required in MWRA from 2015 using modern contraceptive methods to achieve specified demand satisfied with modern methods by 2025. (b): Estimates and 95% uncertainty intervals of the number of MWRA on modern methods, percentage of demand satisfied with modern methods in 2020 and 2025 and the number of MWRA from 2020-2025 using modern methods.
*Key Message: It is hoped that the analysis presented here will be helpful to planners and implementers of family planning program in Uttar Pradesh, India.
1The main objective of Mission Parivar Vikas is to accelerate access to high quality family planning choices based on information, reliable services, and supplies within a right-based approach. http://www.nhmmp.gov.in/WebContent/FW/Scheme/Scheme2017/Mission_Parivar_Vikas.pdf.
2More about AD program by NITI Aayog is available on http://www.niti.gov.in/about-aspirational-districts-programme
3FPET is a web-based application available at http://fpet.track20.org that allows users to generate, view and compare national and subnational estimates and projections of family planning indicators. This tool was launched under the auspices of the Track20 Project to monitor progress towards the attainment of the goals of the global FP2020 initiative (See Annexure-1 for more information).
4As per Primary Census Abstract of Census of India 2011, the state Uttar Pradesh had 71 districts but later four new districts were created namely, Amethi, Hapur, Sambhal and Shamli. MWRA numbers for newly created four districts were calculated by adding block level numbers that constituted these four new districts. Other input data for these four new districts were kept the same as that of respective parent districts obtained from surveys.
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