Introduction

India is the second most populous country in the world and houses nearly a fifth of the world’s population. According to its National Population Policy, India has set itself the goal of achieving population stabilization by 2045 [1]. While various policy and program interventions have been made from time to time to address sexual and reproductive health care needs, evidence on the key drivers of average family size, including the relative importance of these drivers, and how they vary across population subgroups, may further inform policies and programs. This paper examines key drivers of fertility for India, using the most recent available survey data, the National Family Health Survey (NFHS-4), conducted in 2015–16 [2]. It focuses on the four proximate determinants that can explain about 96% of reduction in fertility from the potential biological maximum—marriage, contraceptive use, induced abortion and the duration of postpartum infecundability [3]. The relative importance of these factors as determinants of family size were assessed by applying the proximate determinants model of fertility, developed in the 1950s [4], and operationalized and improved over the past four decades [5–8].

This work builds on a recent report [9] that looked at trends in the role of the proximate determinants among all women of reproductive age by state over the period 1998–2016, using three rounds of the National Family Health Surveys and covering the whole country and the largest 18 states. An important finding of that study is that while increased use of contraception was a major factor underlying the decline in family size between 1998/99 and 2005/06, it was replaced by two key factors that explained the further decline in fertility between 2005/06 and 2015/16: marriage and abortion. The contribution of postpartum infecundability gradually declined over this period. That study was only able to incorporate abortion at the national level given the data available at the time.

This study expands on previous studies in several important areas: We cover all 29 states in the country, with analyses of the NFHS-4, conducted in 2015–2016 and for the first time using a large enough sample size to provide estimates for all 29 states; we also for the first time provide estimates of the impact of the four key determinants for key demographic and socioeconomic population subgroups, namely age, place of residence, education, household wealth status and caste. In addition, we incorporate abortion into the model at all levels, national, for each state and for population subgroups—drawing on a recent study that provides estimates for the same time period as the NFHS-4, and that provides the basis for developing state and subgroup estimates (Singh et. al. 2018). Finally, we introduced two modifications to the model that were important in the Indian context: hysterectomy for non-contraceptive reasons is practiced at a notable level (reported by 4% of married women 15–49 in 2015–16), and this factor is incorporated into the estimate of the impact of postpartum infecundability and into the estimate of the impact of contraception, through its overlap with contraceptive use.

The objective of this paper is to provide comprehensive and detailed estimates of the four principal determinants of fertility level—nationally, by state and for key demographic and social-economic population subgroups—using the most recent data available, and with adjustments to the model to take the context of India into account. The goal is to inform policies and programs that address gaps in access to sexual and reproductive health (SRH) services at the national, state and subgroup level, through providing evidence on the role of the key determinants of fertility level across states and population groups.

It is important to analyze differences across states and population subgroups in India because of the wide variation across the country in terms of access to education, wealth differentials and social disenfranchisement (captured by ‘caste’), all factors that influence sexual and reproductive behaviors including childbearing. For example, in 2015–16 the Total Fertility Rate (TFR) varied from 1.17 in Sikkim to 3.41 in Bihar; the mortality rate for children varied from 7 deaths per 1000 children under five in Kerala to a rate of 78 in Uttar Pradesh; and use of modern contraceptive methods varied from 13 percent in Manipur to 69 percent in Andhra Pradesh [2]. As of 2015–16, 19 states had attained below replacement level fertility (TFR < 2.1) while six states in the central, east, and north-eastern parts of the country reported TFRs of 2.5 or higher. Furthermore, differentials in these measures by population characteristics are also considerably large (e.g., nationally, the TFR among women with no literacy was 3.06 versus 1.71 among women with 12 or more years of schooling), although these differentials are beginning to narrow in many states.

There has been substantial progress in access to contraceptive services in India since 1952, when India became one of the first countries in the world to initiate a state-sponsored family planning program, [10, 11]. The program was estimated to have averted 168 million births by the year 1996 [12]. In recent times, use of modern contraceptives has risen from 37 percent during 1992–93 [13] to 48 percent during 2015–16 [2]. However, there are several individual, social, and systemic barriers that Indian couples encounter when accessing and using family planning services; in addition, health concerns, side effects and other method-related reasons are also important barriers to use of modern contraception. Two useful summary indicators of barriers to using modern contraception are unmet need for modern contraceptive methods—the proportion of women who are fecund, do not want a child soon but are not using a modern method—and the proportion of total demand satisfied by modern methods. In 2015–16, 19% of married women aged 15 to 49 had an unmet need for modern methods of contraception nationally, ranging from 5% in Andhra Pradesh to 41% in Manipur [2]. Over 8 out of 10 women (80.6%) had their contraceptive demand satisfied by modern methods in India, lowest in Manipur (24%) and highest in Andhra Pradesh (94%). Unmet need was particularly high among married women aged 15–24 (27 percent), those with lower parity (24 percent among those with zero or one child), and poor women (23 percent among the lowest wealth quintile). A recent study in six states found that roughly half of pregnancies in 2015 were unintended, and about two-thirds of these unintended pregnancies ended in induced abortion [14].

India legalized abortion under broad criteria in 1971 [15] and in 2002, an amendment to the 1971 Act was passed, approving medication abortion (MA) [16]. A further amendment was passed in 2021, expanding access to later term abortions and improving access for many vulnerable subgroups, including unmarried women. Nevertheless, access to and utilization of safe and legal abortion services is still limited. While three-fourths of the Indian population live in rural areas, abortion services are rarely available at rural health facilities because physicians are not available to staff them [17–19] and other health professionals are not approved to provide abortion. Available safe abortion services are underutilized due to numerous individual and community-level factors, such as lack of awareness of the legality of abortion, limited understanding of the implications of unsafe abortion and lack of information on availability of safe providers and methods [20]. Representative estimates of abortion incidence are available for six states and at the national level for 2015, coinciding with the timing of data collection for the NFHS-4. The national abortion rate was 47 per 1000 women ages 15–49, and the abortion rate ranged widely among the six states from 37 for Tamil Nadu to a rate of 70 in Assam [14]. The study also permits approximate estimates for all states based on the average rates for six major regions [14].

The age at marriage for women in India increased over the last decade–the sharpest ever increase in the country’s history. The proportion of women marrying before 18 among women age 20–24 declined between 2005–06 and 2015–16 by 20 percentage points nationally–about 2 percentage points per year [2, 21]. Wide state-level variations were observed in early marriage: the proportions of women aged 18–29 years who married before age 18 were highest in Bihar and West Bengal (42% and 44% respectively) and lowest (9%-10%) in four states (Himachal Pradesh, Jammu & Kashmir, Kerala and Punjab) [2]. The median duration of postpartum insusceptibility (the average number of months women are either amenorrheic or abstaining from intercourse after giving birth) has been on the decline too–from 8.1 months in 2005–06 to 6.6 months in 2015–16 [2, 21]. NFHS 2015–16 data showed that median postpartum insusceptibility varied widely by place of residence (5.9 for urban residents versus 7.0 for women living in rural areas), education (5.8 among those having 12 years or more of schooling versus 7.6 among those who did not go to school) and wealth (5.1 among women from the highest wealth quintile versus 8.2 among women from the lowest wealth quintile) [2].

Materials and methods

Results

We present results at the national level and for each of the 29 states. Union Territories are included in national estimates, but results are not presented for them separately because of small sample size. Data are presented grouping the 29 states by major region to assess the extent to which the patterns in the contribution of the four determinants are region-specific, given similarities in sociocultural contexts within regions. We also analyzed patterns with states grouped according to level of the TFR (S5 Table), but no specific patterns emerged with respect to proportionate contribution of the determinants, possibly because by 2015–16 the TFR ranged narrowly across states. In assessing the extent to which state estimates are different from national estimates we deem a difference as significant if a determinant’s proportionate contribution to fertility reduction is more than five percentage points different from the contribution of that determinant for comparable subgroups at the national level, or by comparison with other subgroups with similar socio-economic characteristics within states. This approach was chosen under the assumption that if the four determinants contribute equally to the reduction in TF (i.e., 25 percent each) then a 5 percentage points change in any determinant’s contribution, i.e. (5/25*100) is equal to 20 percent, which can be considered as a significant change in the proportionate contribution.

Impact of proximate determinants at the national level

At the national level, the values of the indices and the percent contribution of the four determinants show that marriage makes the largest relative contribution to the TFR: It has the smallest index (0.59) and accounts for 36% of the reduction from Total Fecundity (TF) (Table 1). Contraception and induced abortion have similar indices (0.7 and 0.71) and each contributes almost one-fourth of the reduction from TF; postpartum infecundability has the largest index (0.78) and makes the smallest contribution (16%) to fertility reduction from TF.

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Table 1. Estimates of the indices of the four key proximate determinants on fertility, actual TFR, estimated TFR, residual, and estimates of percent contribution of each proximate determinant to fertility reduction: National and by state, India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.t001

Application of the model that includes the four key proximate determinants results in a difference of 0.30 births at the national level between the actual TFR (2.18) and the predicted TFR (2.48): this is a very good fit, given that the average residual or gap was 0.7 births in a study that applied the model to 36 countries [6]. The model produces residuals varying across the 29 states from low levels (-.13 to .08 births) in 10 states to relatively high levels (0.81 to 0.93 births) in four states, all in the South. The regression line between actual and predicted state level TFR has a moderate fit (R² = 49%) (Fig 1). Nationally, and in all states (Table 1), and for most of the socioeconomic subgroups (Tables 3–6), the estimated or predicted TFR is larger than the actual TFR, an expected pattern given that there are other unmeasured factors that may influence fertility levels, apart from the four measured factors [4].

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Fig 1. A moderate positive correlation is observed between actual and estimated total fertility rates, India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.g001

Impact of proximate determinants across age groups: National level

Estimates of the proximate determinants show that the relative role of marriage at the national level declined with age, leveling out between age groups 30–34 and 45–49 (Table 2 and Fig 2). The contribution of marriage as a proximate determinant was highest among younger women as expected, accounting for 84 percent of fertility reduction for the age group 15–19 and 42 percent for women age 20–24. This is consistent with the substantial rise in the age at marriage among women since 2000 and low contraceptive use among younger women. The effect of contraception rose sharply with age up to age 25–34 before declining slowly at older ages (Table 2 and Fig 2).

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Fig 2. Contraception and abortion are the leading fertility inhibiting factors among women above age 25, India, 2015–16.

https://doi.org/10.1371/journal.pone.0263532.g002

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Table 2. Estimates of the percent contribution of four key proximate determinants to fertility reduction by age-group, actual ASFR and number of women: India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.t002

Contraceptive use was the dominant determinant among women ages 25–49, accounting for 42 percent or more of fertility reduction. Induced abortion’s impact on fertility increased with age, and it had the second largest effect on fertility reduction across all age groups: It was second to marriage (and somewhat larger than contraception) at ages 15–24, and second to contraception at ages 25–49 (Table 2 and Fig 2). At the national level, the impact of postpartum infecundability rose sharply from ages 15–19 (5 percent) to 20–24 (20 percent) after which it steadily declined (Table 2 and Fig 2). The highest contributions (20–21 percent) were observed in the main childbearing age range (20–29). In sum, while marriage exhibited the most dominant role in reducing fertility in adolescence and in early adulthood, contraceptive use assumed the most important role from the middle through the end of the reproductive age-range, with abortion making the next largest contribution, from ages 25–29 onwards (Fig 2).

Impact of proximate determinants among sociodemographic subgroups: National level

The overall national pattern of relative contributions among all women ages 15–49—marriage having the largest contribution (36 percent), followed by abortion and contraception (about 24 percent each), and with postpartum infecundability having the lowest contribution (16 percent)—is found among most socioeconomic subgroups at the national level (Tables 3–6 and Fig 3; in addition, the indices for the four determinants by state and subgroup are presented in S4 Table). However, marriage had a greater impact (43 percent) and postpartum infecundability had a lower impact (9 percent) among urban women compared to rural women and compared to the national pattern. Similarly, among women with 5–9 years of schooling, the relative contribution of the four determinants were very similar to the national pattern. However, the other two education subgroups differed substantially from the national pattern: (a) among the least educated women, marriage and abortion had smaller impacts (25 and 18 percent, respectively); and contraception and postpartum infecundability had greater impacts (33 and 25 percent, respectively); (b) among the highest educated group, this pattern was reversed. The lower two wealth groups were similar to the national pattern in relative importance of the four determinants, with small variations. However, among women with the highest wealth status, marriage was more important and postpartum infecundability was less important than average. The three caste/tribe subgroups were similar to the national pattern in terms of the relative contributions of the four proximate determinants, with small variations. Notably, only in the case of the lowest wealth status group was the predicted TFR found to be less than the actual TFR.

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Fig 3. Fertility inhibiting effect of marriage increases, while that of postpartum infecundability decreases with improvements in sociodemographic status, India, 2015–16.

https://doi.org/10.1371/journal.pone.0263532.g003

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Table 3. Estimates of the percent contribution of four key proximate determinants to fertility reduction, actual TFR, estimated TFR and residual by residence: National and by state, India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.t003

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Table 4. Estimates of the percent contribution of four key proximate determinants to fertility reduction, actual TFR, estimated TFR and residual by education: National and by state, India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.t004

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Table 5. Estimates of the percent contribution of four key proximate determinants to fertility reduction, actual TFR, estimated TFR and residual by wealth status: National and by state, India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.t005

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Table 6. Estimates of the percent contribution of four key proximate determinants to fertility reduction, actual TFR, estimated TFR and residual by caste: National and by state, India 2015–16.

https://doi.org/10.1371/journal.pone.0263532.t006

Discussion

This article analyses differences in the contribution of four key determinants—marriage, contraceptive use, induced abortion and postpartum infecundability—to average family size nationally, across states and among population subgroups in India. Building on earlier research [9], the current study focuses on the NFHS-4 (conducted in 2015–16) and incorporates abortion as a determinant at all levels of the analysis, using estimates of abortion incidence available for 2015, consistent with the timing of data from the NFHS-4 [14]. The earlier study was only able to incorporate abortion at the national level, given data available at that time. Additionally, the current study provides estimates of the four determinants for population subgroups according to key characteristics of women—place of residence, age, educational attainment, household wealth status, and caste—providing a means of assessing differences and potential inequities among population subgroups. The current study covers all 29 states, possible because the NFHS-4 had a much larger sample size than prior rounds of the NFHS.

The model is highly predictive of the actual level of fertility: At the national level, the difference is only 0.3 birth, compared to larger differences generally found (0.7 births and more) [6]. In addition, the regression coefficient between predicted and actual age-specific fertility rates is very high nationally and within each region (R² of 0.8 and higher). The results show that the four key proximate determinants predict the actual Total Fertility Rate very well, nationally and for most states and population subgroups. The remaining gaps between the predicted and the actual TFRs nationally are most likely due to unmeasured factors that influence fertility and underestimation of the impact of one or more of the four determinants included in the model.

Where larger differences are found between predicted and actual TFRs, unmeasured factors that explain them can be identified. For example, the likely reason for the higher-than-average residuals in the South is the higher prevalence of primary and secondary infertility, which is well documented [26–29]. When the five southern states (Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Karnataka) are removed, R² increases from 49% to 72%. Another example is the case of two states (Meghalaya and Mizoram), where marriage has a larger than average impact (43% and 52% respectively compared to the national average of 36%, S2 Table): The factor contributing to this result is marriage customs. In both states, the prevalence of single mothers, forced marriage, polygamy, and separate living arrangements of husbands and wives in certain tribes mean that the index of marriage will not fully capture the effects of marriage on fertility [30–32]. A third example is the impact of migration resulting in separation of spouses, therefore reducing the risk of pregnancy within marriage [33]. Our results show a pattern of larger residuals for less educated compared to more educated women: the prevalence of male migration as unskilled and semi-skilled laborers among lower income, less educated families [34] may contribute to this pattern since it is likely to be associated with greater prevalence of prolonged abstinence among less educated women. The prevalent pattern of a decline in the contribution of contraception as education rises is unexpected, given that the opposite pattern (increase in contraceptive use with rising education) is common in other countries [35]. However, factors that may contribute to a different pattern in India are need for effective reversible methods to space births—more common among younger women and therefore among the better educated—and the relatively narrow availability of such methods [36]; there is also some evidence of a preference among more educated women for traditional contraceptive methods and their ability to effectively use these methods [37, 38].

These results suggest that overall, India is moving towards homogeneity in the relative contribution of the four proximate determinants of fertility, as differences in the level of fertility across states and across subgroups within states narrow. Apart from educational subgroups, there are no systematic differences among socio-demographic subgroups at the national or state level, from the national pattern of the contribution of the four determinants. In addition, the contribution of the four factors were similar to the national pattern, across groupings of states by region and level of current fertility (S5 Table).

The results also show that, despite some variations, all four proximate factors are important determinants of the current level of fertility. The steady increase in the average age at first marriage [39–41] reflects broad social changes, including increasing proportions living in cities, rising educational attainment, social policies that encourage families to postpone marriage of their girl children until at least age 18, and changing values that support women being in the workforce and having an increased role in decision-making within the family. These changes are likely to be accompanied by a rise in women’s status and increased ability to implement their fertility preferences. These same broad societal trends lead to an increased preference for smaller families and for controlling the spacing of births, which in turn is likely to result in an increased demand for contraception and abortion, strengthening the contribution of these two proximate determinants among states and population groups that are more urban, more highly educated and economically better off. The results show that women in all states and across all age and socioeconomic subgroups are relying on both contraception and abortion as means of fertility control, even though the relative importance of these two factors differs somewhat across groups and states. The reasons for similarities and differences across subgroups and states are likely to be wide-ranging and include accessibility and affordability of these two SRH services, as well as women’s knowledge, perceptions, and preferences. The former group of reasons is likely to be more important for poor, less educated, rural, and lower caste women (groups for which contraception plays a smaller than average role), and the latter type of reasons appear to be relevant for some of the more advantaged population subgroups (for example abortion often has a larger contribution than contraception for these groups).

The finding that the contribution of abortion is often close to (and occasionally larger) than that of contraception in explaining current fertility levels supports other research documenting barriers that women face in obtaining good quality contraceptive services [36, 42]. A high proportion of contraceptive users rely on private sector providers–one third of sterilization users and 56% of users of other modern methods [43]. Given that private sector providers charge for services, and are concentrated in urban areas, this may also be a barrier for low income and rural women. It is also possible that, lacking acceptable effective short-term contraceptive methods, some women may prefer to use abortion as their means of spacing births or controlling family size—and the results suggest that this is likely the case for younger women. However, the fact that among women of higher wealth status, contraception has a smaller role than abortion in several states and an equal role in many other states suggests that in addition, poor quality of contraceptive services is also likely to be an important factor.

Having a choice of methods with good quality counselling and information is far from universal in India. In fact, less than one-third of clients reported receiving information about key factors affecting method choice and only half of these clients were told about the side effects of the method they chose [44]. Poor quality of services is likely connected with high levels of discontinuation of method use: About 10–20% of women who started using the pill, IUD and injectables in the five years before interview, that is, about 25%-50% of all who discontinued use [2] stopped within 12 months because of method related reasons such as concerns about health and side-effects, wanting a more effective method and other method-related reasons (including lack of access, distance, cost and inconvenience of using the method). The clinical quality of contraceptive care is also lacking: A study in Uttar Pradesh (public and private facilities) and Bihar (public facilities) found that only 62% of facilities that offered sterilization services followed all required components of infection prevention and provider adherence to infection prevention practices occurred in only 68% of female sterilization procedures [45].

Our results show that abortion is an important means of fertility control in most states and subgroups. Abortion is legal under broad criteria in India, but access to safe services remains poor [14, 46, 47] and information provided to clients on MA use is generally inadequate [48, 49]. These findings reinforce the need for improvements in access to comprehensive abortion care.

The study has some data limitations that must be kept in mind. The analysis is for married women, which is a limitation in terms of population level conclusions, though the findings are relevant for the married women. It was not feasible to include unmarried women because survey data on sexual activity among unmarried women is likely to be highly underreported. Some studies have shown relatively low levels of sexual activity among unmarried young women [50]. While this suggests that the contribution of sexually active unmarried adolescents and young women to need for contraception and abortion may be relatively small in terms of magnitude, more studies and improved study designs are needed to better document the sexual and reproductive health and behaviours of this extremely vulnerable and at-risk group. Sample size limitations for some states (and for all Union Territories) and for many demographic and socio-economic subgroups meant that we were not able to present estimates for them. Preliminary analyses of NFHS-5 recently published for 22 states and union territories suggest that contraceptive use may be underestimated in a few states in the NFHS-4 survey. Six states show exceptionally steep increases between NFHS-4 (2015–16) and NFHS-5 (2019–20), suggesting that contraceptive use may be underreported in NFHS-4 (39); in addition, it is also possible that contraceptive use is over-reported in NFHS-5, or that both factors contributed to the observed difference.

Policy and program recommendations

Based on this study’s findings and their implications, we recommend a few critical strategies to improve access to contraceptive and safe abortion services in India. These will help couples in exercising and achieving their sexual reproductive health and rights as laid out India’s Sustainable Development Goals [51, 52].

• Improve public education on both contraception and abortion.

1. Expand the use of existing outreach and public education programs under the National Health Mission (NHM) to provide information on both contraceptive and safe abortion services. It is efficient, effective, and feasible to implement existing media campaigns about contraceptive and abortion more widely and build on them by developing additional materials. One such mass media campaign was initiated by the NHM in 2014 to disseminate information regarding the legality and availability of induced abortion at public and registered private sites. This and similar campaigns should be continued.
2. Broaden the sources providing education by including community level providers: Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwifes (ANMs) are often women’s first point of contact with the health system. They provide contraceptive counseling and some contraceptive services. In addition, although these providers do not perform abortions, they can expand the range of their services to facilitate the early determination of pregnancy, provide counseling on decision making regarding the pregnancy and provide guidance on abortion services including where to obtain safe abortion.

• Improve the availability, accessibility, and quality of contraceptive services.

1. Increase provision of accurate information on contraceptive methods for spacing and stopping, including relative effectiveness and common side effects of each method. This can be done through popular communication channels for all people of reproductive age and by targeting specific groups (such family planning clinic clients and postpartum and post abortion patients). It is also critical that comprehensive sexuality education is provided to both in school and out of school adolescents.
2. Ensure that users are provided with a choice of methods, both short-term and longer-term reversible methods as well as sterilization.
3. Improve the quality of contraceptive services. Recent data from the NFHS-5 (2019–21) survey shows that districts that shown improvements in quality of services gained most on modern method use. Giving appropriate and adequate information, providing follow-up care and treating clients well will go a long way to ensure adoption and continuation of all methods, specifically, newly introduced spacing methods (e.g., injectables and post-partum IUD).
4. Monitor and ensure that coercive practices are eliminated with particular attention to sterilization. Contraceptive coercion is still practiced. For example, some providers insist that women who fit certain characteristics (e.g., married with two children) must accept tubal ligation as a condition for providing her with an abortion. Also, evidence suggests that women were being sterilized without being told that the procedure means an end to their childbearing and many women still receive financial incentives for sterilization [53].

• Improve the availability, accessibility, and quality of abortion care.

1. Expand the capacity of public health facilities, especially at the primary health center level to provide medical methods of abortion, vacuum aspiration and postabortion care by increasing the number of trained staff and the availability of equipment and drugs. This would improve access to vulnerable groups including rural, poor, young and unmarried women, and other disadvantaged groups.
2. Strengthen existing campaigns to widely disseminate information regarding the legality and availability of induced abortion services at public and registered private sites. Information and instructions on appropriate use of medical abortion drugs (including correct regimen, what to expect and where to go in case of complications) by means of clearly worded text in appropriate languages and use of pictorials. Recognizing that most abortions take place outside facilities, helplines should be set up to assist women seeking medical abortion and helpline numbers should be prominently displayed on combi-packs and at pharmacies.
3. Ensure that abortion care is provided confidentially, that providers treat patients with respect and are non-judgmental in their attitude to clients seeking abortion care, as emphasized in the MTP Amendment Act, 2021.
4. Require that the curricula for training abortion providers at all levels include updated information about the country’s abortion laws (especially important in view of the passage of the MTP Amendment in 2021), and about women’s rights to obtain abortion and sexual and reproductive healthcare, more broadly.
5. Provide mechanisms for regular monitoring to ensure that health care providers and other facility staff do not impose unnecessary limitations on abortion provision. This is necessary to ensure implementation of the provision under the MTP Amendment of 2021 that allows unmarried women to obtain abortion.

• Improve policies regarding early marriage and breastfeeding.

1. Continue and improve on initiatives such as Dhanalakshmi Yojana (a conditional cash transfer program was that launched by the central government in 2008 to encourage parents to delay marriage of girls to 18 or older and to educate girls) and Sukanya Samridhi Yojana, a second program that was launched in 2015 with a similar goal. Such programs are important given their potential to reduce early marriage and thereby improve women’s decision-making regarding timing and number of children they will have.
2. Continue to implement an existing, important element in government maternal health services for postpartum women, that is, to support exclusive breastfeeding for six months after delivery.

• Conduct new studies to fill evidence gaps.

1. New and more comprehensive estimates of the incidence of abortion are needed, including estimates for each state. Independent and reliable estimates of abortion incidence, available at regular intervals, are needed to improve state governments’ ability to address gaps in and barriers to abortion-related services.
2. Both public and private service providers need to be sensitized about the importance of keeping records on services provided. Improved and comprehensively implemented data collection systems and training provided on how to collect these data correctly and confidentially is likely to improve ability to effectively assess and meet service needs.
3. Better quality data on unmarried women’s sexual and reproductive behaviors are also needed to effectively include the needs of young, unmarried women in effort to improve women’s sexual and reproductive health and rights.

Conclusion

Acknowledging that being free to decide how many children to have is a human right, it follows that access to sexual and reproductive health information and services is essential. Given that both contraception and abortion are important means in all states and across all population groups for managing fertility and avoiding unwanted pregnancy and births, supportive and non-coercive policies, adequate resources and mechanisms to monitor quality and access to these essential sexual and reproductive health services, must be improved. This study’s finding that abortion is an important means of fertility management for women and couples in all states and population subgroups, often as important as, and in some cases more important than contraception, further reinforces the importance of ensuring that women have good access to safe and legal abortion services that meet global standards of care.

The results increase our understanding of the determinants of variations in average family size across states and subpopulations and have implications for meeting the need for sexual and reproductive health services. Health policies and programs in India are generally set at the national level, and the findings of this analysis, that patterns of contributions of the key drivers of fertility are increasingly homogeneous across states and groups reinforces the value of national level policies and programs. At the same time, state governments are largely responsible for implementation, and having evidence on the determinants of family size for each state, and for population subgroups within states, is highly relevant, providing insights into where additional efforts may be needed to ensure that all women are obtaining essential sexual and reproductive health services. This analysis also highlights the need for further in-depth research to understand the specific barriers faced by some sub-groups, especially those that are more vulnerable and disadvantaged in terms of ability to access needed sexual and reproductive services.

Supporting information