Decomposing the Gap in Contraceptive Use Among Female Adolescents and Young Women Aged 15-24 in India: An Analysis of Appended Datasets of NFHS-4 and 5

Abstract

Purpose

Owing to the reproductive health needs of the budding adolescent and young population, the present study aims to determine the factors associated with and decomposing the gap in contraceptive use among adolescents and young women in India.

Design

Cross sectional design.

SettingThe present study is based in India using the appended datasets (IV and V rounds) of the Indian Demographic Health Survey (DHS), also known as National Family Health Survey (NFHS) conducted in 2015-16 and 2019-21.

Sample

The adequate sample size was 475,294 adolescents and young women in NFHS-4 and 229,705 in NFHS-5, totaling 704,999 adolescents (appended for NFHS-4 and 5) for the present study.

Measures

Sociodemographic, sexual and reproductive history and contraceptive measures.

Analysis

Descriptive statistics, chi-square tests, and a binary logistic regression model were executed. Additionally, a decomposition technique called Fairlie decomposition was employed to identify the primary causes of the difference in the prevalence of contraceptive use between the two survey periods.

Results

Almost 96% of young women aged 15-24 knew about contraception, but only 12% used it. Regression analysis revealed that contraceptive use was associated with higher age (AOR 1.09), higher education (AOR 1.28), married adolescents (AOR 4.08), richest wealth quantile (AOR 2.95), joint decision making (AOR 4.40), knowledge of ovulatory cycle (AOR 1.47), interaction with a health worker about any methods of family planning (AOR 3.29) and three and above children ever born (AOR 18.54). Decomposition analysis showed that factors like decision-making of contraception, age, interaction with family planning worker, the intention of last pregnancy, place of residence and age at first sex contributed to increasing the probability of contraceptive use from NFHS-4 to 5.

Conclusion

A target-based approach dedicated to understanding the mindset of adolescents and keeping up with their unique needs is the need of the hour.

Keywords

contraception adolescents young India women decomposition

Purpose

Developing countries have been a central hub of the youth population, wherein almost every fifth person is aged between 15 and 24. India is also considered the land of young people, with the world’s largest youth population. Approximately 66% of the total population of India (more than 808 million) is below the age of 35.¹ As per the National Youth Policy of India, nearly 40% of India’s population is aged between 13 to 35 years.² Youth in the age group of 15-29 years comprise 27.5% of the population. Currently, about 34% of India’s Gross National Income (GNI) is contributed by the youth aged 15-29 years.² A country comprising a young population means more economical and workforce avenues, but there are also some risks which become part and parcel of this young population. The adolescents and young population are required to have not just good mental and physical health but also good reproductive health. For ensuring safe and healthy reproductive health, a thorough knowledge of contraceptives, access to comprehensive reproductive health services and safe sexual involvement among the youth population is essential.

In this regard, preventing unintended pregnancy is essential to improving adolescents’ sexual and reproductive health and their social and economic wellbeing. About half of the pregnancies among adolescent women aged 15-19 living in developing regions are unintended, and more than half of these end in abortion, often under unsafe conditions.³ Unintended pregnancies are highly significant, with negative social, mental and physical outcomes for women and children both. An estimated one-fourth and two-fifths of maternal deaths could be averted if unplanned pregnancies were prevented.^4,5 Adolescents and youth are at greater risk of unplanned or unintended pregnancy, gender-based violence, and sexually transmitted diseases, as well as education and other basic life choices. The sexually active youth population, including newly married couples, are in constant need of contraceptives for disease protection and to reduce unintended pregnancy.⁶ Amongst other sociocultural blockades, the use and non-use of contraception and traditional methods pose a high risk of unintended pregnancy among young women. Girls, especially adolescent girls in particular, can face an increased risk of early pregnancy/motherhood, sexual coercion, exploitation and violence. These situations can have a serious mental and physical impact on them as well as their families and communities.⁷

There are several factors beyond individual control that are responsible for better adolescent and youth reproductive health, mainly involving the role of interventions to influence community-level normative change towards healthy reproductive behavior among the young population.⁸ Knowing the potential of the country’s large youth population and realizing the importance of adolescent health and wellbeing, the government of India made various reforms in the adolescent health sector in the early 2000s.⁹ This started with the Ministry of Health and Family Welfare (MoHFW) strengthening its programmes and systems for adolescents in 2005 with the Adolescent Reproductive and Sexual Health Strategy until 2013, later converted into the Rashtriya Kishor Swasthya Karyakram (RKSK) from 2014 onwards. The RKSK is a health programme launched for adolescents aged 10-19 which majorly revolves around improving their nutritional status, reproductive health and substance abuse. The programme includes facilities like adolescent-friendly health clinics, counselling, adolescent health days, peer education and weekly iron-folic acid supplementation.¹⁰

Owing to persistently low use of contraception and high rates of early childbearing combined with unintended pregnancies among the young population, there is a need to address the drivers of contraceptive use and increase accessibility and knowledge among adolescents and the young population in India.^11,12 Despite efforts from the government to strengthen the adolescents' sexual and reproductive health policies, the participation and motivation of youth to use contraception remain less than expected. Little is known about factors contributing to contraceptive use among Indian adolescents and the young population. There are a few studies conducted which have explored this topic, but none of them has special concerns about the young and vulnerable young population in India. Moreover, no study has ever dealt with examining the inequality in contraceptive use among adolescents and young people in India. Therefore, the present study effectively aims to address the reproductive health needs of the young population in India by assessing and decomposing the factors with contraceptive use among young women in India.

Methods

Design

The present study is cross-sectional in nature as it utilized the appended datasets (IV and V rounds) of the National Family Health Survey (NFHS) conducted in 2015-16 and 2019-21, respectively. NFHS is a large-scale cross-sectional survey which provides information on population, health, and nutrition for India, each state/union territory (UT), and 707 districts as on March 31 2017. Funded by the MoHFW, Government of India, the NFHS sample is a stratified two-stage sample. The 2011 census served as the sampling frame for the selection of Primary Sampling Units (PSUs). PSUs were villages in rural areas and Census Enumeration Blocks (CEBs) in urban areas. The final sample PSUs and CEBs were selected with Probability Proportional to Size (PPS) systematic sampling. The Woman’s Questionnaire collected information from all eligible women aged 15-49, who were asked questions on a large variety of topics comprising background characteristics, reproduction history, family planning, knowledge and use of contraception, maternal and child health, fertility preferences and women empowerment.¹³

Sample

In total, 699,686 women in NFHS-4 and 724,115 women in NFHS-5 were successfully interviewed. The effective sample size was 475,294 women in NFHS-4 and 229,705 women in NFHS-5, making a total of 704,999 women (appended for NFHS-4 and 5) for the present study. Adolescents and young women in the age group 15-24 were selected for the final sample of the study.

Measures

The sociodemographic measures in the study included age (categorized as 15-19 and 20-24), education (categorized as none, primary, secondary and higher), marital status (categorized as never married, married and widowed/divorced/separated), place of residence (categorized as urban and rural), caste (categorized as Scheduled caste (SC), Scheduled Tribe (ST), Other Backward Castes (OBC) and Others/don’t know) and wealth (categorized as poorest, poorer, middle, richer and richest). In NFHS, the wealth index was generated through household scores based on the ownership of consumer and household goods and amenities such as toilet facilities, sources of drinking water, and flooring material. These scores were used to classify all households into wealth quantiles. The lowest quantile has the poorest 20%, while the uppermost quantile has the wealthiest 20%.¹⁴

Measures of sexual and reproductive history included age of sexual debut (categorized as never had sex, 8-14 years, 15-19 years, 20-24 years and at first union), lifetime number of sexual partners (categorized as 1, 2, 3 and 4 and above), children ever born (categorized as 1, 2 3 and 4 and above), the intention of last pregnancy (categorized as planned and unplanned), heard of Sexually Transmitted Infections (STIs) (categorized as No and Yes), undergone cervical screening (No and Yes), interaction with a health worker about family planning (categorized as No and Yes). Contraceptive measures included knowledge and awareness of contraceptive methods, current contraceptive use, source of current contraception and use decision maker for contraception.

Use of modern contraception among females was the dependent variable which (0 = No method, 1 = Traditional method and 2 = Modern method) was evaluated by the question: “Are you [and your partner] currently doing something or using any method to delay or avoid getting pregnant?” Participants who reported ‘yes' were then asked to list all current methods. Current contraceptive method use was recorded as per the responses and was categorized as none, traditional method (defined as rhythm or withdrawal methods) and modern methods (defined as female and male sterilization, Intrauterine device (IUD), injectable, implant, pill, male or female condom, lactational amenorrhea method, diaphragm, foam/jelly, or emergency contraception).

Analysis

All the analyses were performed using Stata (Version 15), and the statistical tests were anticipated at a significance level of P-value <.05. Descriptive statistics and chi-square tests were used. A binary logistic regression model was executed to investigate the predictors of modern contraceptive use among women. All the variables were used as binary or categorical predictors, with one category selected as the reference group based on a large sample size and/or meaningful comparison. In order to identify the primary causes of the difference in the prevalence of contraceptive use between the two survey periods (NFHS-4 and 5), a decomposition technique called Fairlie decomposition was employed. It is an extension of the Blinder-Oaxaca decomposition technique, which is the most famously used method for the identification and quantification of contributions of measurable variables in outcomes. However, this technique has one genuine drawback it cannot be applied if the outcome is binary in nature and the coefficients are from a logit or probit model.¹⁵ It is in this regard that an extension of the Blinder-Oaxaca decomposition technique, Fairlie decomposition, comes into the picture. A Fairlie decomposition uses estimates from a logit or probit model and provides reliable estimates.¹⁶ This method of decomposition permits us to compute the absolute contribution of factors explaining the group differences (over two groups) in the probability of using contraceptives among adolescents and young women.¹⁷

Results

Sociodemographic and Reproductive Health Profile of the Respondents

Table 1 presents the sociodemographic, sexual and reproductive health profiles of the respondents. An almost equal percentage of respondents belonged to ages 15-19 and 20-24. The majority of the respondents had secondary education (65.6%). More than 80% of the respondents were Hindus (81.4%), while most belonged to Other Backward castes (45.5%). The majority of the respondents resided in rural areas. Wealth-wise, most of the respondents hailed from the poorer and middle wealth index (21.3%), followed by richer (20.5%) and poorest (19%). The majority of the respondents (60.7%) were never married, almost 39% were married, and .6% were either widowed, divorced or separated.

Table 1.

Sociodemographic and Sexual and Reproductive Health Characteristics of Female Adolescents Aged 15-24, India, NFHS-4 and 5.

Characteristics
	n	%
Sociodemographic Factors
Age
15-19	352,964	50.1
20-24	352,035	49.9
Education level
None	64,509	9.2
Primary	56,269	8.0
Secondary	462,336	65.6
Higher	121,884	17.3
Religion
Hindu	573,528	81.4
Muslim	96,887	13.7
Others	34,584	4.9
Caste
SC	159,664	22.7
ST	70,199	10.0
OBC	320,943	45.5
Others/Don’t know	154,193	21.9
Residence
Urban	219,046	31.1
Rural	485,953	68.9
Wealth index
Poorest	133,631	19.0
Poorer	149,963	21.3
Middle	150,456	21.3
Richer	144,598	20.5
Richest	126,351	17.9
Marital status
Never married	427,789	60.7
Married	272,977	38.7
Widowed/divorced/separated	4233	0.6
Sexual and Reproductive history
Age of sexual debut
Not had sex	414,008	58.7
8 to 14	9211	1.3
15 to 19	120,439	17.1
20 to 24	43,776	6.2
At first union	117,566	16.7
Children ever born
None	520,792	73.9
1	107,124	15.2
2	60,950	8.7
3 and above	16,132	2.3
Last pregnancy intention
Unintended	12,448	7.3
Intended	157,706	92.7
Ever undergone a screening test for cervical cancer
No	221,597	99.5
Yes	1149	0.5
Total lifetime number of sexual partners
1	42,170	97.0
2	518	1.2
3	46	0.1
4 and above	734	1.7
Knowledge of ovulatory cycle
No	147,768	21.0
Yes	557,231	79.0
Ever heard of a sexually transmitted infection (STI)
No	22,953	19.8
Yes	93,058	80.2
Told by a health worker about any methods of family planning
No	525,373	78.1
Yes	147,644	21.9
Total sample size	704,999	100

Almost 17% of respondents made their sexual debut at their first union (marital union), while almost 59% of the respondents reported that they never had sex. 17.1% of respondents made their sexual debut by the age of 15 to 19. 73.9% of the respondents had no children ever born, while almost 16% of them had one child, followed by 8.7% per cent having two children. 7.3% of the total respondents reported their current pregnancy as unintended, whereas 92.7% of them reported their current pregnancy as intended. Only 0.5% of the total young respondents had ever undergone a cervical cancer screening. The majority of the respondents had one-lifetime sexual partner, 1.2% of them had two sexual partners, and 1.7% had four and above sexual partners in life. The majority of them had knowledge about the ovulatory cycle (79%), and 80.2% of them had heard about sexually transmitted infections (STIs). Lastly, the majority of the respondents (78.1%) were never told by a health worker about any methods of family planning.

Figure 1 presents the knowledge and prevalence of contraceptive use among female respondents aged 15-24 in India. It shows that the majority of respondents (96.15%) knew about any method of contraception, but only 12% of them were using contraception at the time of the survey.

Figure 1.

Knowledge and use of contraception among adolescent and young women aged 15-24 in India, NFHS 2015-2021.

Contraceptive Knowledge and Use

Knowledge and use of contraceptive methods among adolescents aged 15-24 are presented in Table 2. Most of the young women had knowledge about the modern methods of contraception (96.08%), whereas 3.85% of them didn’t know about contraception at all. Only 12% of the adolescent and young population reported current contraceptive use, while 88% of them did not use contraception at the time of the survey. The most popular birth control method among young people was male condoms (4.9%), followed by female sterilization (4%). The least preferred methods counted in standard days method, emergency contraception, foam/jelly, female condom, lactational amenorrhea, male sterilization and diaphragm.

Table 2.

Awareness of and Attitude Towards Contraceptive Methods Among Female Adolescents Aged 15-24, India, NFHS-4 and 5.

Characteristics
	n	%
Knowledge of Contraceptive Methods
Knows no method	27,149	3.85
Knows only folkloric method	61	.01
Knows only traditional method	456	.06
Knows modern method	677,333	96.08
Current contraceptive method
Not using	620,938	88.08
Traditional	18,953	2.69
Modern	65,108	9.24
Contraceptive use by type of method
Not using	620,938	88.08
Pill	13,046	1.85
IUD	5130	.73
Injections	875	.12
Diaphragm	6	0
Male condom	23,149	3.28
Female sterilization	20,502	2.91
Male sterilization	86	.01
Periodic abstinence	10,851	1.54
Withdrawal	8102	1.15
Lactational amenorrhea (Lam)	2119	0.3
Female condom	98	.01
Foam or jelly	5	0
Emergency contraception	63	.01
Standard days method (SDM)	29	0
Source of last method
Government clinic/Pharmacy	25,918	47.23
Government home/Community delivery	1231	2.24
Ngo	164	0.3
Private clinic/Delivery	8730	15.91
Pharmacy	8972	16.35
Shop, church, friend/Others	9864	17.97
Decision maker for contraception
Respondent	6089	8.27
Husband/Partner	6322	8.58
Joint	61,116	82.96
Others	143	.19
Total sample size	704,999	100

Almost half of the total respondents obtained their last method of contraception from a government clinic or pharmacy (47.2%). On the other hand, the least preferred source of contraceptives was NGOs (.3%). After the government clinic or pharmacy, the majority of the females acquired their chosen method through a local shop or friends (17.9%), followed by the pharmacy (16.3%) and private clinic (15.9%). Lastly, the majority of the respondents reported that they mutually take decisions to use contraception with their partners (82.9%), followed by husband/partner (8.58%) and respondents themselves (8.27%).

Predictors of Contraceptive Use Among the Young Female Population

Table 3 shows the results of binary logistic regression for contraceptive use among adolescents and young women. Female adolescents of age 20-24 were significantly more likely to use contraception than those of age 15-19 [OR 1.09, CI (1.05-1.13), P < .000]. Respondents were 28 and 23% significantly more likely to report contraceptive use if they had primary and secondary education than those with no education. Respondents from Muslim and Christian religions were 24 and 18% less likely to report contraceptive use than Hindu women. Women from the Other Backward caste were 6% significantly less likely to use contraception than the SC women [OR .94, CI (.92-.96), P < .000]. Women residing in rural areas were 9% significantly less likely to use contraception than their urban counterparts [OR .91, CI (.89-.94), P < .000]. Wealth-wise, respondents who hailed from richer and richest wealth indexes were 2.11 and 2.95 times significantly more likely to use contraception than the poorest ones. Married women were 4.08 times significantly more likely to use contraception than unmarried ones.

Table 3.

Predictors of Contraceptive Use Among Female Adolescents in India, NFHS-4 and 5.

Predictors	Odds Ratio	P > z	[95% Conf.]
Socioeconomic factors
Age
15-19®	1
20-24	1.09	.000	1.05	1.13
Education
No education®	1
Primary	1.28	.000	1.23	1.34
Secondary	1.23	.000	1.19	1.27
Higher	1.09	.000	1.04	1.15
Religion
Hindu®	1
Muslim	.76	.000	.73	.79
Christian	.82	.000	.79	.85
Others
Caste
SC®	1
ST	.83	.000	.81	.86
OBC	.94	.000	.92	.96
Others/DK	1.06	.000	1.03	1.09
Residence
Urban®	1
Rural	.91	.000	.89	.94
Wealth
Poorest®	1
Poorer	1.51	.000	1.46	1.57
Middle	1.78	.000	1.72	1.85
Richer	2.11	.000	2.02	2.19
Richest	2.95	.000	2.82	3.09
Marital status
Never married	1
Married	4.08	.000	4.04	4.13
Widowed/divorced/separated	2.03	.000	1.89	2.17
Sexual and Reproductive history
Age at first sex
Not had sex®	1
8 to 14	5.50	.000	2.28	13.26
15 to 19	4.27	.000	1.77	10.28
20 and above	3.60	.000	1.49	8.67
At first union	6.05	.000	2.51	14.57
Lifetime number of sexual partners
1®	1
2	1.22	.088	.97	1.54
3	1.28	.550	.57	2.91
4	.66	.000	.53	.84
Never had sex	.48	.000	.40	.58
Intention of last pregnancy
Unplanned®	1
Planned	1.78	.000	1.66	1.92
No child/not had sex	.95	.018	.90	.99
Children ever born
0®	1
1	7.85	.000	7.34	8.40
2	17.06	.000	15.89	18.31
3 and above	18.54	.000	17.13	20.07
Told by a health worker about any methods of family planning
No®
Yes	3.29	.000	2.56	4.24
Knows no method/no interaction with health worker	.93	.000	.91	.95
Knowledge of ovulatory cycle
No®	1
Yes	1.47	.000	1.41	1.53
Ever heard of a sexually transmitted infection (STI)
No®	1
Yes	1.32	.000	1.23	1.41
Never had sexual intercourse	2.25	.000	1.87	2.71
Decision maker for contraception
Respondent®	1
Husband/Partner	.85	.679	.39	1.84
Joint	4.40	.000	2.20	8.78
Not using contraception	.00	.000	.00	.00

The respondents used more contraception at younger ages of their sexual debut. Women who had their sexual debut between 8 to 19 years were significantly 5.50 and 4.27 times more likely to use contraception than those who never had sex. For those who had their sexual debut at age 20 and above, the likelihood of contraceptive use was 3.60 times, while it was 6.05 times among those who had sex at their first union than those who never had sex. Similarly, women having two and three-lifetime sexual partners were 22 and 23% significantly more likely to use contraception than those having one sexual partner in a lifetime. A significantly higher likelihood of contraceptive use was observed when the last pregnancy was planned [OR 1.78, CI (1.66-1.92), P < .000]. Women with three and above children ever born were 18.54 times significantly more likely to use contraception than those with no child. A significantly higher likelihood of contraceptive use was reported among women when they were informed by a health worker about family planning methods than those who were not told [OR 3.29, CI (2.56-4.24), P < .000]. Women who heard about STIs and knew about the ovulatory cycle were 32% and 47% significantly more likely to use contraception as compared to those who did not know about it. Lastly, women were 4.40 times significantly more likely to use contraception when the decision-making was joint in nature compared to the decision making by respondent alone.

Table 4 presents the results of Fairlie’s decomposition analysis conducted to assess the contribution of sociodemographic factors in defining the gap in contraceptive use among female adolescents from NFHS-4 to 5. The results showed that the predicted probability of contraceptive use among female adolescents in NFHS-4 was 9.26%, which increased to 13.92% in NFHS-5. The model, despite of considering all possible sociodemographic variables, explained only up to 74.47% of the variation for contraceptive use among female adolescents from NFHS-4 to 5. It means that there must be some other factors which affect the use of contraception among adolescents. A positive contribution from a variable represents that it helps in widening the gap of contraceptive use among female adolescents over time, while a negative contribution represents vice versa. Looking at the contribution effect of each endowment, it was apparent that the major contributors in defining the gap in contraception use among female adolescents between two survey periods were explained by the decision-making of contraception, religion, age, wealth, marital status, caste, heard of STI, place of residence and intention of last pregnancy.

Table 4.

Fairlie Decomposition Analysis Depicting Contribution of Selected Characteristics in the Difference of Contraceptive Use Among Female Adolescents in India, NFHS-4 and 5.

Predictors	Coefficients	Percent Contribution
Age	−.0066	14.05
Residence	.0109	−23.38
Wealth	−.0049	10.51
Caste	−.0024	5.15
Religion	−.0214	45.90
Marital status	−.0026	5.51
Age at first sex	.0032	−6.91
Intention of last pregnancy	.0041	−8.88
Lifetime number of sexual partners	−.0017	3.71
Interaction with FP worker	−.0015	3.15
Heard of STIs	.0187	−40.20
Decision maker of contraception	−.0307	65.86
Total		74.47
Total number of observations	704999
N of OBS G = 0	475294
N of OBS G = 0	229705
Predictive mean for contraceptive use among female adolescents in NFHS-4	9.260
Predictive mean for contraceptive use among female adolescents in NFHS-5	13.921
Difference	−4.662
Total explained	−4.071

Figure 2 depicts the contribution of predictors in the gap in contraceptive use among females in India from NFHS-4 to NFHS-5. The major contributor to widening the gap in contraception use among female adolescents is explained by the decision-making of contraception (65.86), followed by religion (45.90), age (14.05), wealth (10.51), marital status (5.51) and caste (5.15). On the other hand, factors like heard of STIs (−40.20), place of residence (−23.38), the intention of last pregnancy (−8.88), age at first sex (−6.91) were responsible for narrowing the gap in contraceptive use among adolescents and young women from NFHS-4 to 5.

Figure 2.

Results of firlie decomposition showing percentage distribution of each covariate to the gap in contraceptive use among adolscents and young women from NFHS-4 to 5.

Discussion

The present study first demonstrated the level of awareness and use of contraception among female adolescents and young women of age 15-24 in India. It also revealed the specific sexual and reproductive nature of the youth and decomposed the difference in the use of contraception between the two survey periods (NFHS 4 to 5). The results clearly showed that almost 96% of young women had knowledge about contraception. However, this knowledge of contraception did not articulate into use, as only 12% of the young women in age 15-24 used contraception, majorly among younger ages (15-19). This finding corroborates the findings found in a former study.¹⁸ A plausible explanation for this finding is that young women aged 20-24 have a better understanding of the repercussions of getting involved in unsafe sexual acts compared to those aged 15-19.¹⁹

Additionally, the present study revealed that women who were sexually active at younger ages and had multiple sexual partners were using more contraception. The possible reason for these findings can be linked to the association between contraceptive use and marital status. Earlier studies have elucidated that unmarried adolescents and young women are more likely to use contraception in order to prevent unintended pregnancies.^20,21 This is appropriate, specifically among those whose age at first sex is below 20 years, as it is most likely to take place outside the wedlock.²²

Despite the high level of awareness, young women seem to be disinclined towards using contraception, except condoms. In the present study, the most popular birth control method among young women was a male condom (4.9%), followed by female sterilization (4%). It can be linked to the fact that there are several misconceptions about how contraceptive use hampers the health of individuals and that use of contraception promotes promiscuity among women.²³ Not just awareness about contraceptives, women who were aware of STIs and their ovulatory cycle were more likely to use contraception, the present study reveals. The study through its findings states that awareness and knowledge play an essential role in empowering adolescents and young women about the matters of family planning.

Low socioeconomic background acts as an obstacle to contraceptive use, especially when adolescents and young women are at stake. Earlier studies conducted in this regard also reveal the same picture. The use of contraception among female adolescents is low and socioeconomic factors contributed substantially to it.²⁴ The results of this study revealed that adolescents residing in rural areas showed a low preponderance of using contraception. Uneducated women, women from the poorest strata of society and belonging to disadvantageous social groups like the OBCs, used less contraception as a result of their socioeconomic profile. These findings go in tune with previous studies which have acknowledged the importance of socioeconomic factors as facilitators and barriers to the uptake of modern contraceptive use among adolescents.^25-27 Another important socioeconomic factor affecting contraceptive use was religion. Respondents from Muslim and Other religions showed a low preponderance of using contraception. Religious and cultural factors do affect the use and acceptance of contraception by individuals/couples from different religious backgrounds.²⁸ This finding also aligns with past studies, which revealed that Muslim women are hesitant to use contraception as their religion disapproves of contraception.²⁹

It is apparent from the present study that contraceptive use and planned pregnancy were positively associated. Women used more contraception when their last pregnancy was planned. Earlier studies have shown that almost every woman is at risk of unintended pregnancy throughout their reproductive span, and women at risk of non-use of contraception demonstrate a similar pattern to that of women at risk of unintended pregnancy.³⁰ Moreover, women having a say in decision-making showed a positive association with contraceptive use as well. Contraceptives were mostly used when it was a joint decision. Women contributing to decision-making reflects that women may have perceived behavioural control to utilize contraceptives as compared to those who are socioeconomically disadvantaged,³¹ and hence they don’t have any contribution in the contraceptive decision-making as well.

The results of the study reflected that almost half of the female adolescents sought contraception from a government clinic or pharmacy. This signifies that the young population is also inclined towards facilities and services provided by the government with respect to family planning and contraception. After the paradigm shift in 2012, India witnessed a new integrated Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A) approach, which was dedicated to achieving the goals of Family Planning by 2020. This involved more responsive approaches towards family planning demands of the population, assuring quality, identifying and catering to indigent states through Mission Parivar Vikas. The next government strategy that came up in the contour was India’s Vision Family planning 2030. It envisaged catering to the varied needs of the couples by strengthening the ASHA workforce at the community level in the country.³² The government also envisaged a regular and sustained supply of quality contraceptive methods at affordable rates at the government health centers.³³ A positive association between interaction with health workers and contraceptive methods was observed. Those who had interacted with a health worker and were being told about the methods of family planning had higher odds of using modern contraceptives.²⁷ Health workers play an important role in disseminating knowledge amongst adolescents, training them to communicate their reproductive choices with partners and parents. The PRACHAR initiative, for instance, implemented in Bihar aimed to delay the age at first birth by delaying the age at marriage and increasing voluntary contraceptive use among young nulliparous married women. Through this initiative, rural health service providers were trained on reproductive health issues and contraception.³⁴ Lastly, the study highlighted a significant gap in contraceptive use among the young population of females from NFHS-4 to NFHS-5. The study found a significant increment in the probability of contraceptive use among female adolescents in India from 2015-16 to 2019-2021. The results of decomposition analysis reveal that factors like decision-making of contraception, age, interaction with family planning worker, the intention of last pregnancy, place of residence and age at first sex were responsible for contributing to the gap in contraceptive use from NFHS-4 to 5.

Strengths and Limitations of the Study

The biggest strength of the study lies in the fact that it uses data from two rounds of a nationally representative sample survey in India (NFHS-4 and 5). Moreover, the present study is one of its kind, depicting the levels, correlates of contraceptive use among adolescent young females in India and decomposing the contribution of each covariate as well. However, one limitation of this study is that it uses data from a cross sectional survey and therefore no causal linkages could be established.

So what?

What is already known on this topic?

Previous literature has focused on the level, trends and correlates of contraceptive use among the women of reproductive age group (15-49). However, adolescents and young women aged 15-24 represent a different contraceptive use pattern and have unique reproductive and family planning needs.

What does this article add?

In this context, the present study adds something new to the literature on adolescent reproductive health in India. High awareness and low uptake of contraception depicts a non-inclined attitude of the young females towards contraception in India.

What are the implications for health promotion practice or research?

The findings indicate towards improving the intervention of health care providers like ASHA/ANM and front line workers to entertain the targeted needs of adolescent and young women. There is a need for more comprehensive family planning services for adolescents to improve their awareness and knowledge about family planning, especially younger adolescents. More focused approach of involving adolescents into family planning programmes should be encouraged through social media campaigns, workshops in community settings.

Footnotes

Authors’ Contribution/Roles

HS proposed and conceptualized the paper. HS analyzed and interpreted the data. HS was the major contributor in writing the manuscript while SKS supervised and reviewed the entire work. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

The study is based on a secondary dataset; hence, no ethical approval from any institutional board was required. Procedures and questionnaires for standard DHS surveys have been reviewed and approved by ICF Institutional Review Board (IRB). Additionally, country-specific DHS survey protocols are reviewed by the ICF IRB and typically by an IRB in the host country. Before each interview or biomarker test is conducted, an informed consent statement is read to the respondent, who may accept or decline to participate. A parent or guardian must provide consent prior to participation by a child or adolescent. DHS ensures that the privacy of the respondents and the confidentiality of the data is maintained. More information can be read about it at .

Data Availability Statement

The data given this article are the datasets used for the present research paper are available in the data repository of the official website of Demographic Health Surveys, following the links: (1) https://dhsprogram.com/methodology/survey/survey-display-541.cfm, (2) (2019).

ORCID iD

Himani Sharma

References

Decent Work for Youth in India . Indian Labour Organisation. http://www.ilo.org/newdelhi/info/WCMS_175936/lang--en/index.htm

National Youth Policy , Ministry of Youth Affairs and Sports, Government of India; 2014.

Darroch

Woog

Bankole

. ADDING IT UP : Costs and Benefits of Meeting the Contraceptive Needs of Adolescents. New York Guttmacher Inst; 2016:1-16.

Sedgh

Singh

Hussain

. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann. 2014;45(3).

Campbell

Graham

LMSS steering group.

Strategies for reducing maternal mortality: getting on with what works. Lancet (London, England). 2006;368(9543):1284-1299.

Hardee

Pine

Wasson

. Adolescent and youth reproductive health in the ASIA/NEAR EAST region: Status, issues, policies, and programs; 2003.

Morris

Rushwan

. Adolescent sexual and reproductive health: The global challenges. Int J Gynecol Obstet. 2015;131:S40-S42. doi:10.1016/j.ijgo.2015.02.006

Nguyen

Costenbader

Plourde

Kerner

Igras

. Scaling-up normative change interventions for adolescent and youth reproductive health: An examination of the evidence. J Adolesc Heal. 2019;64(4):S16-S30. doi:10.1016/J.JADOHEALTH.2019.01.004

Denno

Hoopes

Chandra-Mouli

. Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support. J Adolesc Health. 2015;56(1).

10.

Barua

Watson

Plesons

, et al. Adolescent health programming in India: A rapid review. Reprod Heal. 2020;17(87).

11.

Sarkar

Chandra-Mouli

Jain

Behera

Mishra

SKMS

. Community based reproductive health interventions for young married couples in resource-constrained settings: A systematic review. BMC Publ Health. 2015;15.

12.

Macquarrie

KLD

. Unmet need for family planning among young women: Levels and trends. DHS comparative reports No. 34. Rockville, MD: ICF International; 2014.

13.

International Institute for Population Sciences (IIPS) and ICF . National Family Health Survey (NFHS-5), 2019- National Family Health Survey (NFHS-5), India: Volume I. IIPS; 2021.

14.

International Institute for Population Sciences (IIPS) and ICF . National Family Health Survey (NFHS-5); 2021.

15.

Fairlie

. An extension of the blinder-oaxaca decomposition technique to logit and probit models. SSRN Electron J. 2006;1. doi:10.2139/SSRN.497302

16.

Powers

Yoshioka

Yun

. Mvdcmp: Multivariate decomposition for nonlinear response models. Stata J. 2011;11:556-576.

17.

Sharma

Maheshwari

Jaiswal

Mehra

. Income-based inequality in full immunization coverage of children aged 12-23 months in Eastern India: A decomposition analysis. Clin Epidemiol Glob Heal. 2021;11(March):10-15. doi:10.1016/j.cegh.2021.100738

18.

Opoku Ahinkorah

Predictors of modern contraceptive use among adolescent girls and young women in sub-Saharan Africa: A mixed effects multilevel analysis of data from 29 demographic and health surveys. Contracept Reprod Med 2020;5(1):32. doi:10.1186/s40834-020-00138-1

19.

Mndiwa

Namondwe

Makwinja

AZC

. Factors associated withcontraceptive use among young women in Malawi: analysis of the 2015–16 Malawidemographic and health survey data. Contracept Reprod Med. 2018;3(1):1-8.

20.

Grindlay

Dako-Gyeke

Ngo

, et al. Contraceptive use and unintended pregnancy among young women andmen in Accra, Ghana. PLoS One. 2018;13(8).

21.

Ahinkorah

Seidu

A-A

Appiah

, et al. What has reproductive health decision-making capacity got to do with Aunintended pregnancy? Evidence from the 2014 Ghana demographic andhealth survey. PLoS One. 2019;14(10).

22.

Cremin

Mushati

Hallett

, et al. Measuring trends in age at first sex and age at marriage inManicaland, Zimbabwe. Sex Transm Infect. 2009;85:34-40.

23.

Grindlay

Dako-Gyeke

Ngo

, et al. Contraceptive use and unintended pregnancy among young women and men in Accra, Ghana. PLoS One. 2019;13(8):1-13. doi:10.1371/journal.pone.0201663

24.

Sharma

Singh

. Socioeconomic inequalities in contraceptive use among female adolescents in south Asian countries: a decomposition analysis. BMC Wom Health. 2022;22(1). doi:10.1186/S12905-022-01736-8

25.

Gakidou

Vayena

. Use of modern contraception by the poor is falling behind. PLoS Med. 2007;4(2):e31. doi:10.1371/JOURNAL.PMED.0040031

26.

Sheikh

QTAA

Sadaqat

Meraj

. Reckoning females’ education as a determinant of fertility control in Pakistan: An empirical approach. Int J Soc Econ. 2017;44(3):414-444. doi:10.1108/IJSE-01-2015-0007/FULL/XML

27.

Singh

Shukla

Thulaseedharan

Singh

. Contraception for married adolescents (15-19 years) in India: Insights from the National Family Health Survey-4 (NFHS-4). Reprod Health. 2021;18(1). doi:10.1186/S12978-021-01310-9

28.

Srikanthan

Reid

. Religious and cultural influences on contraception. J Obstet Gynaecol Can. 2008;30(2):129-137. doi:10.1016/S1701-2163(16)32736-0

29.

Iyer

. Religion and the Decision to Use Contraception in India. J Sci Study Relig. 2002;41:711-722. https://www-jstor-org-443.web.bisu.edu.cn/journal/jsciestudreli

30.

Forrest

. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynecol. 1994;170(5 Pt 2):1485-1489. doi:10.1016/S0002-9378(94)05008-8

31.

I. A . The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50(2):179-211.

32.

Family Planning Division . India’s vision FP. Ministry of Health and Family Welfare (MoHFW); 2014.

33.

Gulati

Chaurasia

ARSR

. Contraception in India: exploring met and unmet demand. World Health Popul. 2008;10(2).

34.

Pandey

Jejeebhoy

Acharya

Singh

SSM

. Effects of the PRACHAR Project’s Reproductive Health Training Programme for Adoles-Cents: Findings from a Longitudinal Study; 2016. Published online.