Introduction

The success of any family planning programme must ultimately be judged by its ability to meet all the family planning needs of the population, as well as the need for specific methods, whether they are for spacing or limiting. About fifteen percent (14.6%) of currently married rural women in India had an unmet need for family planning during the National Family Health Survey III (2005-2006)¹, i.e., they are not using contraception though they do not want more children or want to wait at least for two years before their next child. The concept of unmet need points to the gap between some women^’s reproductive intentions and their contraceptive behaviours².

Unmet need rises as more women want to control their fertility and it falls as more use contraception. Even where the proportion of women with the unmet need is declining, the absolute number with unmet need may be growing because the population is growing³. While family planning is one of the fundamental pillars of safe motherhood and a reproductive right, more than 100 million women in less developed countries or about 17% of all married women would prefer to avoid a pregnancy but are not using any form of family planning⁴. More than one-fourth of the births world-wide are unplanned⁵. Among the reasons for unmet need for family planning, the common ones are inconvenient unsatisfactory services, lack of information, fears about contraceptive side effects and opposition from husbands or other family members³.

In order to explore these areas, this community based cross sectional study was undertaken in the rural area of Haryana.The specific objectives of the study were:(a) to estimate the magnitude of unmet need for family planing among women of reproductive age group; (b) to find out the association of socio-demographic factors with the unmet need for family planning & contraceptive users; (c) to explore common reasons for unmet need for family planning.

Materials And Methods

The present cross-scctional study was carried out in Primary Health Training Centre (PHTC), Agroha , which is the Rural Field Training Centre attached to the Department of Community Medicine, Maharaja Agrasen Medical Institute of Education and Research, Agroha, Hisar (Haryana).

The Primary Health Training Centre (PHTC), Agroha covers seven villages namely Agroha, Mirpur, Kuleri, Siwani Bolan, Saberwas, Khasa Mahajan & Fransi. The approach adopted for this community based study was cross sectional one. Sample size estimation was based on the basis of current contraceptive prevalence rate of rural areas. As per literature search, National Family Health Survey III (2005-2006) and a pilot study conducted in Agroha village, current contraceptive prevalence rate ranged from 34-56% and thus taking a middle course, a prevalence rate of 45% was assumed. By taking this prevalence and permissible level of error as 10%, sample size was computed as 469. Taking 5% of the eligible couples as non-responsive estimated sample size was 492. To cover the desired sample size 71 eligible couples from each of the 7 villages were selected by simple random sampling. A total of 497 eligible couples were selected from the area and of them 483 willing couples were included in the study.

Married women in the reproductive age group were interviewed to screen out the unmet need group, contraceptive user group and intended group using the standard formulation⁶. Unmet group included all fecund women who were married and presumed to be sexually active, who were not using any method of contraception and who either did not want to have any more children or wanted to postpone their next birth for at least two more years. Those who want to have no more children were considered to have unmet need for limiting birth or limiters, while those who want more children but not for at least two more years were considered to have unmet need for spacing birth or spacers. The unmet need group also included all those pregnant and lactating mothers whose current or previous pregnancies were unwanted or mistimed and who became pregnant because they were not using contraception. Similarly, women who recently have given birth but were not yet at risk of becoming pregnant because they were amenorrhic postpartum were considered to have an unmet need if their pregnancy were unintended. Those whose pregnancies were unwanted were considered to have unmet need for limiting birth, while those pregnancies were mistimed were considered to have unmet need for spacing birth. Intenders were those non pregnant women who wanted a child soon (within 2 years) and not using contraception or pregnant or lactating women whose pregnancies were intended.

Detailed information was collected on a pre-designed and pre-tested questionnaire. The questionnaire was pre-tested by doing a pilot study in the field practice area of the department of Community Medicine, Maharaja Agrasen Medical Institute of Education and Research, Agroha, Hisar (Haryana). The data was collected on different socio-demographic factors and about the main reasons of not using contraception. Data were analysed using appropriate statistical techniques i.e. proportions and chi square (epi Info).

Results

Table No.1 shows 41.61% women were in unmet need group for family planing. Only 12.84% were intenders, as either they wanted child soon or their present pregnancy status was intended. Among the nonpregnant women not using contraception 24.02% wanted no more children and out of the pregnant women 1.45% had unwanted pregnancies.

Figure 1

Table 1: Distribution of Women according to Status of Unmet Need for Family Planing

Table No. 2 shows that overall unmet need was high for limiting methods (25.46%) then spacing methods (16.15%). Contraceptive use rate increased significantly with the advancement of age. In the unmet need group of 15-19 years, the proportions of limiters and spacers were equal (50%). Limiters increased significantly with advancement of age with proportionate decrease of spacers.

Figure 2

Table 2: Age wise Distribution of Women according to Unmet Need and Contraceptive Practices

Table No. 3 shows that the unmet need was more (47.53%) for females belonging to joint family than the nuclear family (38.63%), and the difference was statistically non significant.

Figure 3

Table 3: Distribution of Women according to Type of Family, Unmet Need and Contraceptive Practices

Table No. 4 Prevalence of unmet need was high among primary literacy group (51.61%) and illiterate women (46.41%), compared to that in the higher educational groups. Contraceptive use rate increased significantly with higher educational level. Also, proportion of spacers in the unmet group increased significantly from 24.74% in the illiterate group to 83.33% in the highest educational status group with reciprocal decrease in the proportion of limiters.

Figure 4

Table 4: Literacy wise Distribution of Women according to Unmet Need and Contraceptive Practices

Table No. 5 shows that the unmet need for spacing was the hightest (26.94%) in women having one child and gradually decreased with each additional child. On the other hand unmet need for limiting births was the lowest (19.17%) in women having one child and gradually increased with each additional child.

Figure 5

Table 5: Distribution of Women according to Number of Living Children, Unmet Need and Contraceptive Practices

Table No. 6 shows that the major reason for unmet need was opposition from husband and family members (34.83%).

Figure 6

Table 6: Reasons for unmet need for family planning

Discussion

Although unmet need has considerable demographic and social significance, its root causes are still largely unknown⁷. Demographic and social factors are assumed to be the underlying determinants of the unmet need for family planning. This study had focused on examination of factors associated with unmet need for family planning in rural area of Haryana. Attempts have also been made to assess major reasons for nonuse of contraceptives among women with unmet need. At the same time, the analysis underscores the importance of recognizing that demographic and social factors impact women’s unmet need for spacing and limiting differently.

The extent of unmet need for family planning in our study was 41.61%, almost equal to the results observed by Bhattacharya et al (41.67%)⁸ and greater than the findings of National Family Health Survey III (13.2%)¹, Anand et al(16%)⁹ and Robey et al(20%)¹⁰. The unmet need for spacing births was 16.15%. Results were comparable with the findings of Bhattacharya et al⁸ (15.83%) but greater than that reported by NFHS-III (6.3%)¹ and lower than that reported by Jena (63%)¹¹. Unmet need for limiting method was 25.46%. Similar findings were observed in various studies viz. Anju et al¹² (22.6%) & Bhattacharya et al⁸ (25.84%) but lower results had been reported by NFHS-III (6.8%)¹. The differences in unmet need may arise due to differences in demographic profile of the community under study, along with other social factors affecting the need.

Several studies^13,14 show that clear relationship emerges between women^'s age and level of unmet need (i.e. more in younger age group) and also when unmet need is divided into its spacing and limiting components⁸. As per NFHS-III¹ the unmet need was found to be highest among women below age 20, the need was almost entirely for spacing rather than for limiting and the need was getting reduced with advancement of age. In this study most unmet need among younger women was for spacing birth because younger women still want to have more children. In the unmet need group of 15-19 years, the proportions of limiters were equal to the spacers because women who married before the age of 16 exhibited a lower demand for spacing than women who have been married after the age of 16. Alternatively, the former group displayed a higher demand for limiting the number of children. Among older women, most unmet need was for limiting births because older women have had as many children as they want and often more.

Unmet need was more for females belonging to joint family (47.53%) than the nuclear family (38.63%). Similar results were observed by Devi et al¹⁵ in a study done in UP where unmet need was higher in joint families. This may be because nuclear families lack relatives in the home to help with child care and they tend to have more privacy in discussing about using family planning⁹.

One of the important parameter that detemines unmet need for family planning is level of education^15,16,17. In this study when the unmet need for family planning was determined against level of education of married women, it was evident that with increasing level of education decline in unmet need for family planning was observed. Almost similar results were observed in other studies also( Bhattacharya et al (52.10%)⁸, Anand B et al⁹ (29.27%) .Unmet need for family planning had been significantly influenced by their literacy status. This may be because educated women are better informed about various methods, availability and have greater access to family planning⁹. However NFHS-III¹ found that unmet need varied only within a narrow range by women’s education (10.7-13.6%). Variations could be attributed to differences in socio-cultural practices, level of socio-economic development and values attached to the preference of male child, that should be confirmed by further studies.

There was no apparent relationship between the no. of children and the overall level of unmet need. About forty six percent of the women of unmet group had only one child which indicates that even after first child the women were interested in controlling fertility. Similar results were observed in other studies also^8,18. But in a study by Ram et al¹⁹, 92% of the women with unmet need had 2 or more children. The differences in unmet need may arise due to difference in demographic profile of the community under study, along with other social factors affecting the need.

The major reason for unmet need for contraception was opposition from husband and family members followed by lack of knowledge about existing contraceptive methods. Similar results were also observed by Bhattacharya et al⁸ (i.e. 32 & 24% respectively). The reason behind opposition was found to be want of more children.

Conclusions

Prevalence of unmet need was higher in more fertile age group (i.e.<30 years), therefore family planning program should focus more on this age group. Spacing methods are more applicable to younger age group and permanent methods to older age group. Neither the type of family nor the number of living children was significantly associated with the unmet need for family planning. Women’s education seems to be one of the major determinent of unmet need for family planning. Improving women’s access to education and encouraging continuous and constant exposure would significantly increase use of family planning and reduce unmet need. Strategies have to be devised to reach the large segment of the rural community with family planning information and services. In a traditional society like India, where men are dominant in decision-making, encouraging spousal communication and involving both men and women equally in family planning decision-making is important in bridging the gap between met and unmet need.