Background
Worldwide, the unmet need for family planning is highest among women who are younger than 20 years of age, and lowest among women aged 35 years and older; these differences are widest in South Central Asia, including India [
1,
2]. In India, women give birth to their first child at a relatively young age. The median age at first birth in India is 21 years for women aged 25–49 years [
1]. Relatively low age at first birth is still persisting despite the reduction in fertility rate and increase in age at marriage as well as educational status. As per NFHS-4, 26.8% of women are married before 18 years of age while this was 47.4% in NFHS-3. This data clearly shows a decreasing trend in age at marriage but still a larger section is married before 18 years.
It is observed that the percentage use of contraceptives has declined, which is a serious concern for healthcare because we are still a victim of population growth as well as maternal deaths. Maternal deaths are projected to be 1.8 times higher in women without contraceptive use [
3]. Among many interventions, contraceptive use to prevent unwanted pregnancies is one of the most cost-effective ways of reducing maternal deaths [
4]. The less use of contraception and still having an unmet need in the population will increase the unwanted pregnancy which is directly going to increase the abortion in society. Greater contraceptive use allows births to be spaced better and reduces the chances of accidental pregnancies and population rise.
Family Planning 2020 is an initiative to expand contraceptive use to 120 million additional women and girls by 2020 [
5]. India has continued its efforts to expand the range and reach of contraceptive options through rolling out new contraceptives and delivering a full range of family planning services at all levels. A recent analysis of DHS data from 52 developing countries found that a large proportion of women cite fear of contraceptive side effects and infrequent sex as reasons for not using contraception [
6].
Meeting the unmet need for contraception to delay first birth is vital for several reasons. Above all, it enables countries to respect the reproductive rights of young women and protect them from early and risky pregnancies [
7]. It also provides an opportunity to promote population stabilization by delaying first birth and thus increasing the spacing between generations [
8]. There is not much literature available regarding the demand for contraception to delay first birth and the hindrances that prevent married young women who wish to postpone their first pregnancy.
In India, cultural norms force young people to prove their fertility as soon as possible after marriage, and that promoting birth spacing until after the first birth is futile [
9‐
11]. As a result of this, neither family elders nor health care providers attempt to facilitate contraceptive use among the young couple especially before first birth. The other possible obstacles discouraging use of contraception before first birth are young women’s have lack of knowledge of how pregnancy occurs and about the contraception and where its supplies are available; limited access to sex education in the school and home; limited mobility and freedom to access clinics and contraceptives; unequal power relations within marriage and the experience or fear of spousal violence that can inhibit young women from acting on their desire to space births; the cost of supplies and of reaching supply outlets; and barriers relating to quality of care, notably the attitude of providers [
12]. Early pregnancies can cause a serious threat to women’s health conditions [
13]. Thus, delaying the risk of first pregnancy in early marriage is desired for the health of the mother as well as a child because one of the main factors responsible for morbidity and mortality among women in a reproductive age group are the complications associated with pregnancy and childbirth. It has also been studied how various socio-demographic characteristics of the households in which the woman belongs affects the behavior of women to use the contraceptive.
The purpose of the current study is to determine whether changes have occurred in the prevalence of contraceptive use before first birth in India during the past decade and to focus on levels and trends of use before first birth for ever-married women aged 15–34 years of India.
Methods
Study design and data source
For the present study and analysis, data is derived from a large scale survey named National Family Health Survey (NFHS) conducted by the International Institute for Population Sciences (IIPS), Mumbai with the funding of ORC Macro and Bill & Melinda Gates Foundation. NFHS is the multi-round survey started in the year 1992–93 and continuously performed at every 5 year interval except the last round of the survey, completed in the year 2015–16. Till now four rounds of surveys have been conducted starting from NFHS-1 (1992–93), NFHS-2 (1998–99), NFHS-3 (2005–06) and NFHS-4 (2015–16) by IIPS under the supervision of Ministry of Health and Family Welfare, Government of India. It gathered information from women and men who were in their reproductive age groups 15–49 years and 15–54 years respectively. As per the objective survey provides estimates of fertility, mortality, maternal and child health, family planning practices and reproductive health, HIV/AIDS and awareness, nutritional status, utilization and quality of health and family planning services across 29 states/union territories and India. It is specially designed to measure the utility and success of family planning services among the Indian population. The detailed description of the study design, sampling procedure, frame, and non response rate are published in the round specific reports (IIPS, 1995; 2018). In total, 699,686 women were successfully interviewed (aged 15–49 years) in NFHS-4 and in the present analysis, we have included 279,896 ever-married women aged 15–34 years at the time of the survey. To compare the changing behavior in the use of contraception before first birth we have made use of NFHS-3, NFHS-2 and NFHS-1 data.
Description of study variable and measurements
Dependent variable
The outcome variable of this study was contraceptive use which we have defined in such a way that it has two categories: It assigns a value 1 for the use of any form of contraceptive method to prevent or delay their first birth and 0 to all those who either never used any contraceptive method or used it after having their first birth. Data on contraceptive use was obtained through the women’s questionnaire.
The explanatory variables used in this study are
The background variables selected in the study are socio-economic variables i.e. place of residence, religion, caste, education, wealth index, current age group, age at marriage, media exposure and zonal classification. The place of residence of the respondent is classified into two groups’ urban and rural. Religion consists of three groups namely Hindu, Muslim and others. The others group consisted of Christians, Sikhs, Buddhist/Neo-Buddhist, Jain, Jewish, Parsi/Zoroastrian Donyi polo and others. Caste was categorized into three classes namely Scheduled Caste and Scheduled Tribe (SC/ST), Other Backward Classes (OBC) and others. The educational qualification of women was classified into four categories namely no education, primary, secondary and higher. Wealth index was grouped into three categories namely rich, middle and poor. The current age groups considered in our study were stratified into four age groups as 15–19, 20–24, 25–29, and 30–34 years age of women at the time of the survey. The age at marriage of the respondents was classified into three groups as ≤16, 17–22 and ≥ 23 years. Exposure to media variable was created using the information from three questions from the questionnaire: Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?, Do you listen to the radio almost every day, at least once a week, less than once a week or not at all? and do you watch television almost every day, at least once a week, less than once a week or not at all?. The final variable exposure to media was then recoded into the following three categories (i) not at all (ii) weekly or less than weekly and (iii) daily exposure. The final variable exposure to media was then recoded into the following three categories (i) not at all, if the answer to all the above three questions were “not at all”, (ii) weekly or less than weekly if at least any one of the answers being “at least once a week/less than once a week” and, (iii) daily exposure, if the response to any one of the above three questions is “every-day”. The twenty-nine states were stratified into four zones: North, South, East, and West. The states included in these zones are given in Table
1.
Table 1Classification of states and union territories under different zones
North | Uttar Pradesh, Bihar, Chhattisgarh, Madhya Pradesh, Rajasthan, Delhi, Haryana, Uttaranchal, Punjab, Himachal Pradesh, Jammu & Kashmir |
South | Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Telangana |
East | Orissa, West Bengal, Jharkhand, Tripura, Meghalaya, Assam, Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram |
West | Gujarat, Maharashtra, Goa |
Data management and analysis
After data cleaning and recoding some of the variables to suit the objective of this study, descriptive statistics was prepared to summarize the data. To identify the socio-demographic determinants governing the pioneering study behavior, multivariable techniques have also been used in the analysis. For the multivariate analysis, a statistical technique used in this study is logistic regression. Since the dependent variable used in this study contraceptive use is a dichotomous variable, logistic regression technique is employed to assess the net influences of multiple explanatory variables on the use of contraceptive use prior to first birth after controlling other relevant predictor variables. Hosmer Lemeshow statistics and Nagelkerke R square have been used to check how well the logistic regression model fits the data. Crude and adjusted odds ratios and their 95% confidence intervals (CI) were estimated. Cross-tabulation with frequencies and percentage of each variable was performed. Moreover, the statistical significance of the relationship between socio-demographic factors and contraceptive use prior to first birth was tested using a chi-squared test for association. Map showing the percentage use of contraceptives in different states and their zonal classification is made using ArcGIS version 10.3 software. The analysis is done by STATA software.
Discussion
Despite, the awareness regarding contraceptives has increased [
14,
15] our results surprise us with the decline in the percentage of contraceptive use before first birth (Fig.
1) which is a matter of concern. One of the possible reasons for the decline is because women are getting married late which prevents the delay of first birth after marriage. NFHS-4 reports clearly show an increase in age at marriage of Indian women [
1].
In the present analysis, women residing in urban areas have higher odds and were significantly more likely to use the contraceptive method before first birth as compared to those residing in rural areas and the difference is highly significant (Table
3). Similar results were reported in some previous studies [
12,
16]. In this study, we find there are certain religious groups like Muslims and others who use fewer contraceptives prior to first birth as compared to the Hindu religious group. There are certain social norms in different religions that affect the use of the contraceptive method before or after the first pregnancy [
16,
17]. This result is in consensus to many other such findings.
Female education, particularly completion of primary school and secondary school, has emerged as strongly related to lowered fertility [
16]. As many studies have shown concerning contraceptive use more generally [
14], women’s education and household economic status are associated with the practice of contraception—in this case with contraceptive use among young women reporting a demand for contraception to delay their first pregnancy. A similar result is observed in this study. A significant increase in the odds ratio is noticed as we move from women with no education to women with higher education who have ever used contraceptives before first birth.
In most developing nations, there is a wide gap between the socioeconomic statuses of the poor and rich that interferes with the policies of the family planning program. The odds ratio for rich women is 1.61 times higher than the poor which is statistically significant. A similar result is obtained in many earlier studies [
18‐
20].
Considering the current age composition the maximum use of contraceptives before first birth is in the age group 20–24 years which declines with an increase in age. However, the use of contraceptives prior to first birth in the age group 15–19 years is less as compared to the age group 20–24 years which is one of the high spots of this study. This is a clear indication that there is a decline in contraceptive use before first birth in the younger age group (15–19 years) as compared to the previous survey i.e. NFHS-3 [
21]. A similar pattern of variation in the age group can be observed in other studies [
16,
22]. An increase in age at marriage is accompanied by an increase in the use of contraceptives prior to the first birth. The odds for age at marriage group 17–22 years are 1.13 which is significantly higher than the age at marriage group <=16 years, the odds for age at marriage group 22–34 years is highest and is 1.25. This gives a clear picture of increasing odds with an increase in age at marriage which states that when women are married late still there is a higher chance that they will use contraceptives before first birth. 8% of women between 15 and 19 years of age were either already mothers or pregnant [
1]. NFHS-4 data also reveals that between 2005 and 2006 and 2015–2016, the percentage of women whose current age is 20–24 years, married before 18 years of age dropped by 21%.
An increase in media exposure shows increased use of contraception before first birth. The odds for married women using contraceptives before first birth and exposed to media every day is higher than those who are exposed weekly or less weekly or no media exposure (Table
3). This is similar to a previous study showing that exposure to mass media can be an important means to improve knowledge and initiate women to practice any form of modern contraception before first birth or to increase the spacing between two births [
22]. Several other studies have shown that women of developing countries who had exposure to the media family-planning campaigns were more likely to opt for a contraceptive technique than the women without any exposure to mass media [
23‐
26]. Regional patterns generally displayed distinctions consistent with the previous studies [
14,
16]. As compared to the north zone we found that women of the south zone are less likely to use contraceptives before first birth. This finding may be attributed to the later age at marriage of young women in southern states as compared to the northern region.
Strength and limitations
The present study must be considered in light of certain limitations. The chances of under-reporting cannot be ruled out as we are aware that the use of contraceptives is a sensitive and often stigmatized subject in our nation, young women may be reluctant to disclose their contraceptive use status. The analytical sample is restricted to fecund, ever-married (currently or formally) women of age group 15–34 years. This criterion may lead us to suffer from selection bias. Also, we have focused extensively on the use of contraception prior to first birth and not on the type of method used because of the unavailability of information about this aspect in NFHS data. Some other variables that could be used to enrich this kind of study are variables governing women’s autonomy and decision making but due to fewer observations, we have skipped them. One of the main strengths of this study is using all the four rounds (1992–93, 1998–99, 2005–06, and 2015–16) of published NFHS data for comparison. This article canvassed the socio-demographic factors determining the levels and trends in the use of contraceptive methods before first birth as well as evokes the curiosity to evaluate and initiate a discussion to help and investigate the reasons for the recent decline. The use of a nationally representative dataset reveals a true representation of the situation of this sub-group of women in the country. Also the association of socio-demographic variables governing the behavior of contraceptive use among women before first birth adds value to the present research.
Conclusion
The study examined factors influencing contraceptive use before first birth in Indian women. It was evident that education, wealth index, exposure of media, age at marriage, regional classification, caste and religion reveals a significant key relation with the use of contraception before first birth. Findings from the study also noted a decline in the use of contraception before first birth in the past decade (Fig.
1). This finding may be attributed to the later age at marriage of young women. The success of India’s family planning program to a large extent depends upon the shoulders of policymakers, researchers, users and service providers. So, there is a need to ensure and intensify the existing family planning programs and incorporate a focus on young married women making them realize the hazards associated with early childbearing and equipping them with the skills and resources to delay their first birth if they desire.
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