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BMC Public Health
Socio-economic inequalities innon-use
ofmodern contraceptives amongyoung
andnon-young married women inIndia
Shobhit Srivastava1 , Parimala Mohanty2, T. Muhammad1* and Manish Kumar1
Abstract
Background It is documented that married women do not utilize contraceptive methods, because of the fear of
adverse effects, no or seldom sexual interaction; perception that they should not use contraception during breast-
feeding, postpartum amenorrhea, or dissatisfaction with a specific method of contraception. The current study aimed
to examine the socio-economic inequalities associated with the non-use of modern contraceptive methods among
young (15-24 years) and non-young (25-49 years) married women and the contributing factors in those inequalities.
Methods The present study utilized the cross-sectional data from the fourth round of the National Family Health
Survey (NFHS-4) with a sample of 499,627 women who were currently married. The modern methods of family plan-
ning include sterilization, injectables, intrauterine devices (IUDs/PPIUDs), contraceptive pills, implants, the standard
days method, condoms, diaphragm, foam/jelly, the lactational amenorrhea method, and emergency contraception.
Multivariable logistic regression analysis was used to estimate the odds of non-use of modern contraceptive methods
according to different age groups after controlling for various confounding factors. Additionally, concentration curve
and Wagstaff decomposition method were used in the study.
Results The prevalence of non-use of modern contraceptive use was higher among women from young category
(79.0%) than non-young category (45.8%). The difference in prevalence was significant (33.2%; p < 0.001). Women from
non-young age group had 39% significantly lower odds of non-use of modern contraceptive use than women from
young age group (15–24 years) [AOR: 0.23; CI: 0.23, 0.23]. The value of concentration quintile was -0.022 for young and
-0.058 for non-young age groups which also confirms that the non-use of modern contraceptives was more concen-
trated among women from poor socio-economic group and the inequality is higher among non-young women com-
pared to young women. About 87.8 and 55.5% of the socio-economic inequality was explained by wealth quintile
for modern contraceptive use in young and non-young women. A higher percent contribution of educational status
(56.8%) in socio-economic inequality in non-use of modern contraceptive use was observed in non-young women
compared to only -6.4% in young women. Further, the exposure to mass media was a major contributor to socio-
economic inequality in young (35.8%) and non-young (43.2%) women.
Conclusion Adverse socioeconomic and cultural factors like low levels of education, no exposure to mass media, lack
of or limited knowledge about family planning, poor household wealth status, religion, and ethnicity remain impedi-
ments to the use of modern contraceptives. Thus, the current findings provide evidence to promote and enhance the
use of modern contraceptives by reducing socioeconomic inequality.
*Correspondence:
T. Muhammad
muhammad.iips@gmail.com
Full list of author information is available at the end of the article
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Page 2 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
Keywords Modern contraceptives, Socioeconomic inequality, Young and non-young women, India
Background
e use of contraceptives is intricately linkedto permit-
ting people for making potential choices regarding their
reproductive life and childbirth preference [1]. Modern
contraceptive has long been recognized as one of the piv-
otal cost-effective strategies for boosting socio-economic
growth through education, gender equality, human
rights, and reduction of sexually transmitted diseases and
poverty [2, 3]. Despite the rising popularity of contracep-
tive and the desire for family planning, in the year 2019
globally, only an estimated 8crores of young and non-
young women from 15 to 49years used modern contra-
ceptives leaving 27 crores with an unmet need [4]. In the
low- and middle-income countries more than 20 crores
of women wanting to prevent pregnancy do not use con-
traceptives contributing to 84 percent of unintended
pregnancies [5]. Unmet family planning needs are high-
est among women under the age of 20 and lowest among
women 35 and older throughout the world [6].
India has created conducive policies implementations
for the use of contraceptive [7]. Back in the year 1952,
India was the first country to implement a family plan-
ning program, and priotised family planning as an inte-
gral part of many national plans and reproductive and
child health programs [8]. To increase the use of family
planning services in the country, many initiatives have
been used over time, including a coercive target strategy,
contraceptive-specific incentives, and a family planning
camp approach [9]. It has been found, thatthe unmet
need for family planning has decreased over the past
25years, especially following the International Confer-
ence on Population and Development in Cairo (ICPD-
1994), from 20.3% in 1992–1993 to 12.9% in 2015–2016
[10]. e need for family planning met by modern meth-
ods increased from 58.6 to 71.8% during the period
of1990–2015, while the unmet need for modern meth-
ods declined from 25.4% in 1990 to 20.4% in 2015 [11].
Various determinants are likely to influence con-
traceptive use, ranging at different levels from, indi-
vidual-related factors, household-related factors,
community-related factors, system-related factors,
or the interplay of combinations of these factors [12].
Individual factors include education level, partner vio-
lence, fertility preferences, and media exposure [12, 13];
household factors include, spousal communications on
family planning, and autonomy [14, 15]; community-
related factors include caste, religion, place of residence
and cultural norms pertaining to family planning [16,
17]. ere are cross-country as well as within-country
disparities, with lower levels of contraceptive use
among poorer, illiterate, rural, and younger women
[18]. Further these disparities are most pronounced
in southern region of Asia, including India [19]. Stud-
ies show that in the Indian society many factors like
urban vs rural residence, socioeconomic factors like
household wealth and media exposure are likely to
influencecontraceptiveuse [11, 18, 20]. Multiple pieces
of research in India have extensively focused on the
trend of contraceptive use, differentials, and its predic-
tors [11, 21]. However, the level of economic inequality
in the use of modern contraceptives and its relationship
remain unknown [22]. To understand health dispari-
ties, it is suggested to include aggregate measures of
socioeconomic status [23].
Evidence suggests that youth faces high sexual and
reproductive health risks and their age group is an
important social determinant of health [7, 24]. A study
comparing contraceptive use in adolescent girls (ages
15–19 years) and adult women (ages 20–34) in 103
low- and middle-income countries between 2000 and
2017 found that adolescent girls continue to fall behind
adult women in contraceptive use [25]. Another study
between 1992–93 and 2015–16, found the usage of
modern contraception among married adolescents
grew from 4 to 10%, however being uneducated, resid-
ing in rural areas, backward classes, poorest wealth
quintile, women with no child, and ones with no mass
media exposure were shown to have low uptake of
modern contraceptives [26]. roughout the literature,
inequality of these economic and socio-cultural factors
had an influence on the use of modern contraceptives.
We found relatively scarce work as most of the previ-
ous studies from India only looked at the overall fam-
ily planning services, levels and trends in contraceptive
prevalence and predictors of contraceptives use [7, 11,
20, 26]. erefore, to our knowledge, ours is one among
the few studies from India to report various factors
that determinethe non-use of modern contraceptives
and their associated inequalities among young and
non-young women. Generating more clear evidence
will have significant policy consequences for achieving
SDG 3.7, which targets universal access to family plan-
ning services and promote healthy lives and well-being
[27]. us, this study aimed to examine the factors con-
tributing to the socio-economic inequalities associated
with non-use of modern contraceptive methods among
young and non-young married women in India. Based
on the above literature, a conceptual framework has
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Page 3 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
been developed and summarised in Fig.1. Our study’s
conclusions may also have significant policy implica-
tions for those stakeholders and decision-makers work-
ing to improve and promote modern contraceptives by
reducing the related socio-economic inequality among
young non-young women in India.
e study hypothesizes that.
H1: there is significant wealth-based inequality for
the non-use of modern contraceptives among young
and non-young married women in India.
H2: there is a higher concentration of non-use of
modern contraceptives among youth than non-
youth from higher socioeconomic status.
H3: low levels of wealth, low education working sta-
tus, exposure to mass media, wealth, social class, and
place of residence are positively associated with non-
use of modern contraceptives among young and non-
young married women in India.
Materials andmethods
Data
e present study utilized the cross-sectional data from
the fourth round of the National Family Health Survey
(NFHS-4) conducted during 2015–16. e NFHS-4 is a
large-scale cross-sectional, and nationally representa-
tive sample survey carried out under the stewardship of
the Ministry of Health and Family Welfare (MoHFW),
Government of India. NFHS-4 provides self-reported
information about demographic, socio-economic, mater-
nal, and child health outcomes, family planning, and
reproductive health. In NFHS-4, a multistage stratified
random sampling method was adopted for the collec-
tion of data. It adopted three-stage sampling in urban
area and two-stage sampling design in the rural area. In
urban areas, in first stage, wards were selected with Prob-
ability proportional to size (PPS) sampling. In the next
stage, one census enumeration block (CEB) was selected
randomly from each sampled ward. In the final stage,
household were selected from each selected CEB. In rural
areas, villages referred as Primary Sampling Units (PSUs)
were selected in the first stage, followed by the selection
of the households in the selected villages using system-
atic random sampling. Details of the sample size, design,
and sample weights in NFHS-4 were published elsewhere
[10]. NFHS-4 surveyed a total of 699,686 women aged
15–49 in 601,509 households, with a response rate of 97
percent.
Final sample size
e effective sample size for the present study was
499,627 women who were currently married. Moreo-
ver, the number of women who were currently married
and aged 15–24years (young)was 94,034 and the num-
ber of women who were currently married and aged
25–49years (non-young)were 405,593.
Measures
Dependent variable
e dependent variable in this study was "modern con-
traceptive use". Two questions were used to determine
the women utilizing modern contraceptive methods: (1)
Are you currently doing something or using any method
to delay or avoid getting pregnant? If yes: (2) Which
method, are you using? e modern methods of family
planning include sterilization, injectables, intrauterine
devices (IUDs/PPIUDs), contraceptive pills, implants,
the standard days method, condoms, diaphragm, foam/
jelly, the lactational amenorrhea method, and emergency
Fig. 1 Conceptual framework of the study
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Page 4 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
contraception. Women utilizing the modern contracep-
tive methods were coded as ’1’, otherwise ’0’.
Explanatory variables
Various explanatory characteristics related to women,
husbands, and households were included in the analy-
sis. Women’s characteristics include age at first sex (no
sex, < 18 years, ≥ 18 years), educational status (not edu-
cated, primary, secondary, higher), working status (cur-
rently working, currently not working), exposure to mass
media (no, yes), heard family planning on radio last few
months (no, yes), heard family planning on television
last few months (no, yes), heard family planning in news-
paper/magazine last few months (no, yes). Husband’s
characteristics include educational status (not educated,
secondary, primary, higher), working status (currently not
working, currently working). Household characteristics
consist of wealth index (poorest, poorer, middle, richer,
richest), religion (Hindu, Muslim, others), caste (Sched-
uled Caste, Scheduled Tribe, Other Backward Class, oth-
ers), place of residence (urban, rural), regions (north,
central, east, northeast, west, south).
e variable of wealth index was created using the
information given in the survey. Households were given
scores based on the number and kinds of consumer
goods they own, ranging from a television to a bicycle or
car, and housing characteristics such as source of drink-
ing water, toilet facilities, and flooring materials. ese
scores are derived using principal component analysis.
National wealth quintiles are compiled by assigning the
household score to each usual (de jure) household mem-
ber, ranking each person in the household population by
their score, and then dividing the distribution into five
equal categories, each with 20% of the population.
Statistical analysis
Descriptive analysis was utilized to report the general
characteristics of the sample. Proportion tests were uti-
lized to assess the significant difference in the preva-
lence of non-use modern contraceptive methods among
women in young (15–24years) and non-young age (25–
49 years) groups according to different characteristics.
Since our dependent variable, non-use of modern con-
traceptive methods, is binary, logistic regression analy-
sis was used to estimate the odds of non-use of modern
contraceptive methods according to different age groups
after controlling for various confounding factors.
e concentration index quantifies the degree of
socio-economic inequality in the given outcome vari-
able [28]. Due to the binary nature of the dependent vari-
able, we used the corrected concentration index (CCI)
that is a rescaled concentration index which ensures the
variability of the index within the range of -1 and 1 [29].
e CCI of the variable is given by:
where n is the sample size,
µ
is the mean non-use of the
modern contraception,
a
and
b
are the maximum and
minimum levels of non-use of modern contraception
(i.e., 0 and 1), and
ri
=
i
−
0.5/n
is the fractional rank of
the individual
i
in the socio-economic status, with
i=1
for the poorest and
i=n
for the richest. e negative
(positive) index value implies the pro-poor (pro-rich)
inequality in the non-use of modern contraceptive meth-
ods. e values are provided for Generalized CCI. As a
sensitivity check, we estimated and report CCI using
other two approaches of Erreygers normalized CCI and
Wagstaff normalized CCI.
Decomposition ofCCI
To determine the contribution of various determinants to
socio-economic inequality, CCI was decomposed using
the Wagstaff-type decomposition methodology [30]. e
Wagstaff-type decomposition technique decomposes
Generalized CCI. e equation of the linear relationship
of the continuous outcome variable and its k predictors is
given as:
where
yi
is the outcome variable,
xk
is the set of pre-
dictors, and
ε
is the error term that follows the normal
distribution
ei
∼
N(0, σ2)
. e overall CCI can be rep-
resented as the linear combination of
CCIk
of the deter-
minants and the ratio of the generalized concentration
index (GC) of the error term to the mean outcome vari-
able as follows [30]:
where
CI
denotes the overall concentration index,
µ
is
the mean of
y
,
xk
is the mean of
xk
,
Ck
is the normalized
concentration index for
xk
(defined exactly like CCI),
β
k
x
k
µ
is the elasticity of outcome variable with the explanatory
variables, and
GCε
is the generalized CCI for
εi
(resid-
ual component).Eq.(3) suggests that the concentration
index consists of explained and residual (unexplained)
components. Since outcome variable is not continuous,
we have approximated decomposition analysis by using
marginal effects on the logit model. A linear approxima-
tion of the non-linear estimation can be represented as:
(1)
CCI
=
1
n
n
i=1
(a
−
b)
(a
−
µ)(µ
−
b)
(2ri−1)
(2)
yi=α+
k
βkxki +ε
i
(3)
CI
=
βk
µ
xk
CCIk+
GCε
µ
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Srivastavaetal. BMC Public Health (2023) 23:797
where
βm
k
is the marginal effects (
dy
dx
) of each x;
µi
signi-
fies the error term generated by the linear approximation.
e concentration index for the outcome variable (y) (in
our case, use of modern contraceptive methods) is given
as:
Results
Table 1 provides the socio-demographic characteristics
of the study participants. A proportion of 40.5 and 40.6%
of young and non-young respectively had sex before the
age of 18years. About 17.7 and 36.7% of women were not
educated in the young and non-young category, respec-
tively. A proportion 11.2 and 26.2% of women were
working in young and non-young category, respectively.
Almost 79% of women in both young and non-young cat-
egory had mass media exposure. Only 16.7 and 18.1% of
women from young and non-young categories reported
that they heard about family planning on radio. Similarly,
a proportion of 56.9 and 58.4% of women reported that
they heard about family planning on television. Also, a
(4)
y
i=α
m
+
k
β
m
kxki +µ
i
(5)
CI
=
k(
β
k
x
k
µ
)Ck+GCε/
µ
Table 1 Sample characteristics of the study population, 2015–16
Background
characteristics Youth (15–24years) Non-youth
(25–49years)
Sample Percentage Sample Percentage
Women characteristics
Age at rst sex
No sex 2,487 2.6 21,909 5.4
< 18 years 38,116 40.5 164,711 40.6
≥ 18 years 53,431 56.8 218,972 54.0
Educational status
Not educated 16,651 17.7 148,803 36.7
Primary 55,213 58.7 156,862 38.7
Secondary 12,353 13.1 59,058 14.6
Higher 9,817 10.4 40,870 10.1
Working status (last 12months)
Currently working 1,776 11.2 18,579 26.2
Currently not
working 14,037 88.8 52,419 73.8
Exposure to mass media
No 19,775 21.0 84,642 20.9
Yes 74,259 79.0 320,951 79.1
Heard family planning on radio last few months
No 78,345 83.3 332,250 81.9
Yes 15,689 16.7 73,343 18.1
Heard family planning on television last few months
No 40,499 43.1 168,918 41.7
Yes 53,535 56.9 236,675 58.4
Heard family planning in newspaper/magazine last few months
No 61,848 65.8 268,006 66.1
Yes 32,186 34.2 137,587 33.9
Husband characteristics
Educational status
Not educated 1,879 11.9 14,294 20.1
Primary 9,468 59.9 35,600 50.1
Secondary 2,041 12.9 10,982 15.5
Higher 2,425 15.3 10,123 14.3
Working status (last 12months)
Currently not
working 861 5.4 2,739 3.9
Currently working 14,952 94.6 68,259 96.1
Household characteristics
Wealth Index
Poorest 19,512 20.8 71,147 17.5
Poorer 22,416 23.8 76,037 18.8
Middle 21,383 22.7 80,825 19.9
Richer 18,532 19.7 86,524 21.3
Richest 12,191 13.0 91,060 22.5
Religion
Hindu 75,807 80.6 331,116 81.6
Muslim 14,468 15.4 51,226 12.6
Others 3,759 4.0 23,252 5.7
Table 1 (continued)
Background
characteristics Youth (15–24years) Non-youth
(25–49years)
Sample Percentage Sample Percentage
Caste
Scheduled Caste 20,760 22.1 80,407 19.8
Scheduled Tribe 10,064 10.7 35,513 8.8
Other Backward
Class 40,845 43.4 177,256 43.7
Others 22,365 23.8 112,417 27.7
Place of residence
Urban 24,374 25.9 142,799 35.2
Rural 69,660 74.1 262,794 64.8
Regions
North 11,658 12.4 55,422 13.7
Central 22,007 23.4 90,686 22.4
East 26,389 28.1 88,898 21.9
North East 3,261 3.5 13,673 3.4
West 12,892 13.7 59,152 14.6
South 17,827 19.0 97,762 24.1
Total 94,034 100.0 405,593 100.0
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Srivastavaetal. BMC Public Health (2023) 23:797
Table 2 Percentage of non-use of modern contraceptive methods among currently married women by background characteristics in
India, 2015–16
Background characteristics Youth (15–24years) Non-youth (25–49years) Dierences p-value
Percentage Percentage Percentage
Women characteristics
Age at rst sex
No sex 72.7 47.7 25.0 < 0.001
< 18 years 73.7 40.7 33.0 < 0.001
≥ 18 years 83.1 49.5 33.6 < 0.001
Educational status
Not educated 83.9 47.2 36.8 < 0.001
Primary 77.5 44.3 33.2 < 0.001
Secondary 76.9 40.8 36.1 < 0.001
Higher 81.6 54.1 27.5 < 0.001
Working status (last 12months)
Currently working 72.4 37.2 35.2 < 0.001
Currently not working 79.0 47.8 31.2 < 0.001
Exposure to mass media
No 86.3 58.4 28.0 < 0.001
Yes 77.0 42.5 34.5 < 0.001
Heard family planning on radio last few months
No 78.7 45.6 33.1 < 0.001
Yes 80.7 47.1 33.6 < 0.001
Heard family planning on television last few months
No 82.4 51.3 31.2 < 0.001
Yes 76.4 41.9 34.5 < 0.001
Heard family planning in newspaper/magazine last few months
No 79.8 46.2 33.6 < 0.001
Yes 77.4 45.0 32.4 < 0.001
Husband characteristics
Educational status
Not educated 81.1 45.6 35.6 < 0.001
Primary 78.2 44.7 33.5 < 0.001
Secondary 73.4 39.6 33.8 < 0.001
Higher 80.4 51.0 29.4 < 0.001
Working status (last 12months)
Currently not working 81.8 50.0 31.9 < 0.001
Currently working 78.1 44.8 33.3 < 0.001
Household characteristics
Wealth Index
Poorest 84.6 57.7 26.9 < 0.001
Poorer 79.5 46.5 33.0 < 0.001
Middle 77.7 42.1 35.6 < 0.001
Richer 75.9 42.0 33.9 < 0.001
Richest 75.8 42.9 33.0 < 0.001
Religion
Hindu 79.3 44.5 34.8 < 0.001
Muslim 79.2 57.1 22.1 < 0.001
Others 71.9 40.2 31.6 < 0.001
Caste
Scheduled Caste 77.6 43.7 34.0 < 0.001
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Srivastavaetal. BMC Public Health (2023) 23:797
proportion of 34.2 and 33.9% of young and non-young
women heard about family planning through newspapers
and magazines.
Table2 represents the percentage of women not using
modern contraceptives by their background character-
istics. It was found that the prevalence of modern con-
traceptive use was higher among women from young
category (79.0%) than non-young category (45.8%). e
difference in prevalence was significant (33.2%; p < 0.001).
Table 3 reveals logistic regression estimates for non-
use of modern contraceptive use among women by their
background characteristics. e estimates presented are
adjusted estimates. It was found that age was significantly
associated with non-use of modern contraceptive among
women. at is women from non-young age group (25–
49 years) had 39% significantly lower odds of non-use
of modern contraceptive than women from young age
group (15–24 years) [AOR: 0.23; CI: 0.23, 0.23]. Addi-
tionally, education, exposure to mass media, knowledge
about family planning, household wealth status, religion
and ethnicity were the significant predictors of modern
contraceptive use among women.
Figures 2 and 3 present the concentration curves of
non-use of modern contraceptives for young and non-
young women, respectively.
Table 4 reveals that non-use of modern contra-
ceptive is concentrated among women from poor
socio-economic strata both in young and non-young
categories. The value of concentration quintile was
-0.022 for young and -0.058 for non-young age groups
which also confirms that the non-use of modern con-
traceptive use was more concentrated among women
from poor socio-economic group and the inequality is
higher among non-young women compared to young
women (difference: 0.036, p < 0.001).
Table5 represents the decomposition estimates for
non-use of modern contraceptive use among young
and non-young women. It was found that about 87.8
and 55.5% of the socio-economic inequality was
explained by wealth quintile for modern contraceptive
use in young and non-young women. A higher percent
contribution of educational status (56.8%) in socio-
economic inequality in non-use of modern contracep-
tive use was observed in non-young women compared
to only -6.4% in young women. Further, the exposure
to mass media was a major contributor to socio-eco-
nomic inequality in young (35.8%) and non-young
(43.2%) women. The knowledge about family planning
through television explained 26.9 and 30.8% of the ine-
quality in non-use of modern contraceptive use among
young and non-young women, respectively. Addition-
ally, region explained the observed inequality for non-
use of modern contraceptive use by about -14.2% in
young and 68.4% in non-young women.
Discussion
e study examined socioeconomic differences in the
use of modern contraceptive methods among young and
non-young adults in India using NFHS 4 data. A signifi-
cant contribution of this study is to reveal that the use of
modern contraceptives was more concentrated among
young women from the poor socioeconomic group in
the Indian context. Prevailing prior studies from low
and middle-income countries showed the prevalence
Dierence: %youth—%non-youth; p-value based on proportion test
Table 2 (continued)
Background characteristics Youth (15–24years) Non-youth (25–49years) Dierences p-value
Percentage Percentage Percentage
Scheduled Tribe 81.4 47.2 34.2 < 0.001
Other Backward Class 82.0 46.7 35.3 < 0.001
Others 73.6 45.6 28.1 < 0.001
Place of residence
Urban 75.9 44.0 31.9 < 0.001
Rural 80.1 46.8 33.3 < 0.001
Regions
North 76.3 37.9 38.4 < 0.001
Central 84.9 55.0 29.9 < 0.001
East 77.5 53.8 23.7 < 0.001
North East 71.8 63.4 8.4 < 0.001
West 77.4 36.8 40.6 < 0.001
South 78.2 37.6 40.6 < 0.001
79.0 45.8 33.2 < 0.001
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Page 8 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
of modern contraception among adolescent and young
women was lower than the prevalence among non-young
women [31–33]. In this milieu, our study provides strong
evidence of socioeconomic inequality among non-young
women compared to young women in non-use of mod-
ern contraceptives. is study found existing differences
in the non-usage of modern contraceptive methods
among the young category and non-young category. In
line with earlier research, our study reported that the
usage of modern contraception was significantly associ-
ated with age and [19] it decreases with age [31, 34, 35].
is higher uptake among younger women has been
attributed to effective communication on family plan-
ning issues [36]. On the contrary, a study using NFHS
data reveals contraception use among married adoles-
cent females has been continuously low in comparison
to higher age groups [26]. Women from the non-young
category had significantly lower odds of modern contra-
ceptive use than women from the young category. Similar
to these findings a study from NFHS data shows that the
age group 20–24years has the highest rate of contracep-
tive use before first pregnancy, which decreases as one
gets older [37]. Earlier researches have depicted similar
findings [33, 38]. Apart from age, this study observed that
women’s educational level influences their usage of mod-
ern contraceptives. Higher educational levels and using
modern contraceptives are associated among young
adults [35, 36]. e non-young women had a higher per-
centage contribution of educational status (56.8%) in
socioeconomic inequality in modern contraception use
than young women (-6.4 percent). is same evidence
aligns with multiple studies where women’s education
level was found to be a substantial predictor multiple
studies (38-40). A cross-country study including India,
Bangladesh, Nepal, and Pakistan on contraceptive use
and inherent socioeconomic inequality showed illiter-
acy, poor economic status, and rural contributed nega-
tively to inequalities in contraceptive use [39]. Likewise,
another study including 11 low- and middle-income
countries shows inequalities in the prevalence of contra-
ceptive use were higher among poorer, older, and non-
educated women [40]. In addition, previous researches
also revealed that modern contraception use is linked to
education [41], exposure to mass media [20], knowledge
Table 3 Logistic regression estimates for non-use of modern
contraceptive methods among currently married women by
background characteristics in India, 2015–16
Background characteristics AOR
95% CI
Women characteristics
Age group
Youth (15–24 years) Ref
Non-youth (25–49 years) 0.23*(0.23,0.23)
Age at rst sex
No sex Ref
< 18 years 0.63*(0.62,0.65)
≥ 18 years 0.98(0.95,1)
Educational status
Not educated 0.55*(0.54,0.57)
Primary 0.66*(0.64,0.68)
Secondary 0.52*(0.51,0.54)
Higher Ref
Exposure to mass media
No 1.37*(1.34,1.39)
Yes Ref
Heard family planning on radio last few months
No 0.83*(0.81,0.84)
Yes Ref
Heard family planning on television last few months
No 1.37*(1.35,1.39)
Yes Ref
Heard family planning in newspaper/magazine last few months
No 0.98*(0.96,0.99)
Yes Ref
Household characteristics
Wealth Index
Poorest 1.37*(1.33,1.41)
Poorer 1.16*(1.14,1.19)
Middle 1.14*(1.11,1.16)
Richer 1.12*(1.1,1.15)
Richest Ref
Religion
Hindu Ref
Muslim 1.73*(1.7,1.76)
Others 1.13*(1.1,1.16)
Caste
Scheduled Caste 1.06*(1.03,1.08)
Scheduled Tribe 1.14*(1.11,1.16)
Other Backward Class 1.07*(1.05,1.09)
Others Ref
Place of residence
Urban Ref
Rural 0.99(0.97,1)
Regions
North Ref
Central 1.69*(1.65,1.72)
East 1.74*(1.71,1.78)
Table 3 (continued)
Ref Reference, CI Condence Interval; *if p < 0.05; AOR Adjusted Odds Ratio
Background characteristics AOR
95% CI
North East 2.59*(2.53,2.66)
West 1.06*(1.03,1.08)
South 1.07*(1.05,1.1)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
about family planning [7], household wealth status [42],
surviving son, religion, and ethnicity [43].
is study further reveals that modern contraceptive
use is concentrated among women from poor socioeco-
nomic strata both in young and non-young categories.
e non-use was more common among women in the
highest wealth quintile, the probable reason might be
the fear of side effect or health concern [44, 45] among
wealthy women[46]. e estimates from this study
confirm the concentration quintile of modern contra-
ceptive use had higher inequality among non-young
women compared to young women. e reason may be,
in concurrence with Sedgh etal. [47], that non-young
women may have infrequent sex and are less likely to
Fig. 2 Concentration curve of non-use of modern contraceptive among young married women age 15–24 years
Fig. 3 Concentration curve of non-use of modern contraceptive among non-young married women age 25–49 years
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
become pregnant as a cause of non-use. Similar to these
findings, other possibilities are, work leading to geo-
graphic relocation [47], which can lead to couples living
apart may be the reason for non-use among non-young
category women. Additionally, some studies found that
participants cited "method-related" reasons for not
using contraceptives reflecting unhappiness with cur-
rent contraceptive techniques [46]. Other factors that
could explain why women in the highest wealth quin-
tile had a greater mean prevalence of non-use are that
non-young women refusing to use contraception may
be because of their spouse’s choice, other members
of their families or communities’ issues, or even their
religious beliefs [44, 48]. On the contrary,some stud-
ies showed richer women were more likely to use mod-
ern contraceptives than poorer women. is could be
owing to their social level, which includes access to
modern health care and education, influencing their
wealth [35, 49, 50]. e present study represents the
decomposition estimates of about 87.8 and 55.5% of the
socioeconomic inequality was explained by the wealth
quintile for modern contraceptive use in young and
non-young women. However, a study shows women in
the poorest wealth quintile had low demand for mod-
ern contraceptives and it varied greatly across states of
India [51]. Further, the wealth index, site of residence,
husband’s educational level, women’s educational level,
and mass media exposure were the key drivers of pro-
poor socioeconomic inequalities, according to decom-
position analysis data from another study [52].
When we look at the study participants half of the
women from the reproductive age group have heard
about family planning on television, around thirty per-
cent from newspaper/magazines, and less than twenty
percent from the radio. Alike in the Philippines and
Myanmar, a study found a robust link between media
exposure and family planning use among married and
cohabiting women [53]. Our finding is consistent with
a study conducted by Rana etal.[54]. Moreover, prior
studies suggest that media exposure significantly con-
tributed to the current use of modern contraceptives
[20, 55]. Studies from NFHS data suggest that expo-
sure to radio, television, and movies have a significant
favourable impact on current contraceptive use and
future contraception intentions [20]. Findings revealed
media exposure was a significant driver of socioeco-
nomic inequality in both young and non-young women
and suggest that mass media campaigns can help pro-
mote the use of modern contraceptives [56].
Furthermore, in this study, the region explained
roughly -14.2 percent of the observed difference in mod-
ern contraceptive use in young and 68.4 percent in non-
young women. Similarly, according to a study, specific
demographic areas reflecting undereducated, poor, with
few or no children, and without their partner’s sup-
port, and newlywed women noted inequality in the use
of modern contraception. For example, as commonly
noticed there is a provider restriction in the supply of
contraceptives for newlywed women in the state of Uttar
Pradesh [57]. Considering that, the challenge of reduc-
ing socioeconomic inequality among non-young women
compared to young women in non-use of modern con-
traceptives is much higher, and educational programs
should be created with an equitable perspective in order
to target these groups. erefore, findings from the study
have demonstrated substantial evidence on the factors
affecting the non-use of modern contraceptives like edu-
cation, exposure to mass media, knowledge about family
planning, household wealth status, religion, and ethnicity.
Limitations
ere were some limitations to this study. Given the
country’s broad social, cultural, and traditional views
and practices, the conclusions generated herein may
not be applicable to the entire population. e varied
group, migration, and intermarriage within, the find-
ings may not have produced definite information on
a single tribe or culture. Women self-reported their
usage of modern contraception, and the results could
be distorted by interviewer bias or social desirability
influencing the estimations. However, the presence
of a family member during the interview may influ-
ence responses in some situations, particularly among
young women and those from the conservative places.
Due to data constraints, it was not possible to evalu-
ate additional factors that affect the use of contracep-
tives, including family dynamics, social norms, and the
standard of family planning services. e NFHS survey
does not capture the duration of contact or the nature
of the conversation, a thorough evaluation of the qual-
ity of family planning conversations with healthcare
practitioners could not be conducted in this study role.
Oftentimes, the family planning programs focused on
population control aspect in India [58]. For this mat-
ter, accessibility to health centers plays a pivotal role
and limited access leads to non-use or discontinuation
of contraceptive methods [59]. However, due to huge
number of missing cases in the concerned variable in
Table 4 CCI for non-use of modern contraceptive methods
among the currently married women in India, 2015–16
CCI Concentration Index
Types of CCI Youth Non-youth Dierence p-value
Generalized CCI -0.022 -0.058 0.036 < 0.001
Erreygers normalized CCI -0.036 -0.053 0.017 < 0.001
Wagstaff normalized CCI -0.095 -0.067 -0.028 < 0.001
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
Table 5 Decomposition estimates for non-usage of modern contraceptive methods among currently married women in India, 2015–
16
Background characteristics Youth (15–24years) Non-youth (25–49years)
Elasticity CCI Absolute CCI % Contribution Elasticity CCI Absolute CCI %
Contribution
Women characteristics
Age at rst sex
No sex
< 18 years 0.001 -0.168 0.000 1.2 -0.042 -0.160 0.007 -26.4
≥ 18 years 0.062 0.120 0.007 -43.7 -42.6 -0.002 0.124 0.000 0.8 -25.6
Educational status
Not educated
Primary -0.010 0.088 -0.001 5.4 0.018 0.219 0.004 -15.8
Secondary -0.005 -0.229 0.001 -7.1 -0.002 -0.125 0.000 -1.2
Higher 0.002 0.523 0.001 -4.6 -6.4 0.015 0.651 0.010 -39.8 -56.8
Exposure to mass media
No
Yes -0.043 0.144 -0.006 35.8 35.8 -0.071 0.154 -0.011 43.2 43.2
Heard family planning on radio last few months
No
Yes 0.006 0.103 0.001 -3.5 -3.5 0.007 0.157 0.001 -4.2 -4.2
Heard family planning on television last few months
No
Yes -0.023 0.201 -0.005 26.9 26.9 -0.036 0.218 -0.008 30.8 30.8
Heard family planning in newspaper/magazine last few months
No
Yes 0.000 0.299 0.000 -0.7 0.006 0.375 0.002 -8.8 -8.8
Household characteristics
Wealth Index
Poorest
Poorer -0.007 -0.347 0.002 -13.8 -0.010 -0.462 0.005 -18.5
Middle -0.010 0.119 -0.001 6.8 -0.011 -0.075 0.001 -3.3
Richer -0.013 0.544 -0.007 41.7 -0.013 0.338 -0.004 17.6
Richest -0.010 0.870 -0.009 53.0 87.8 -0.019 0.776 -0.015 59.8 55.5
Religion
Hindu
Muslim 0.004 0.054 0.000 -1.2 0.015 0.001 0.000 0.0
Others -0.002 0.141 0.000 1.4 0.2 -0.001 0.248 0.000 0.8 0.7
Caste
Scheduled Caste
Scheduled Tribe 0.003 -0.364 -0.001 5.3 -0.001 -0.412 0.000 -0.8
Other Backward Class 0.016 0.058 0.001 -5.5 0.006 0.014 0.000 -0.3
Others -0.007 0.170 -0.001 6.8 6.6 -0.004 0.225 -0.001 3.4 2.2
Place of residence
Urban
Rural 0.011 -0.152 -0.002 10.0 10.0 -0.006 -0.232 0.001 -5.6 -5.6
Regions
North
Central 0.010 -0.091 -0.001 5.5 0.032 -0.161 -0.005 20.2
East -0.006 -0.319 0.002 -10.3 0.027 -0.338 -0.009 35.6
North East -0.002 -0.228 0.000 -2.5 0.007 -0.226 -0.002 6.4
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 12 of 14
Srivastavaetal. BMC Public Health (2023) 23:797
the dataset, the role of accessibility of health centers
could not be considered in this study. Lastly, cross-
sectional survey data can only reveal an association
between the outcomes and explanatory variables, not
necessarily a causative relationship which needs to be
investigated in future research with advanced methods.
Future studies based on the latest data of NFHS-5 need
to be conducted that focus on more number of factors
associated with socioeconomic inequalities in non-use
of modern contraceptives among young and non-young
married women in India.
Conclusion
e current findings provide evidence to promote and
enhance the use of modern contraceptives by reducing
socioeconomic inequality, which is more effective than
traditional contraceptives for both young and non–
young women. For policy purpose, it is vital to explore
a realistic and long-term solution to wealth-based ine-
qualities in reproductive health utilization. In order to
dispel misunderstandings about the non-use of modern
contraceptives, it is critical to work on awareness as
well as to provide a variety of contraceptive choices to
fit each woman.
Acknowledgements
Authors acknowledge the inputs, including the conceptual framework, from
Ms. Nilanjana Gupta who helped improve the manuscript during the revisions.
Authors’ contributions
Conceived and designed the research paper: SS and TM; analysed the data:
SS; Contributed agents/materials/analysis tools: TM, MK and PM; Wrote the
manuscript: PM, MK and TM; Refined the manuscript: SS and TM. All authors
read and approved the final manuscript.
Funding
No funding was received for the study.
Availability of data and materials
The study utilizes secondary source of data which is freely available in public
domain through dhsprogram.com.
Declarations
Ethics approval and consent to participate
Not applicable. All methods were carried out in accordance with relevant
guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 International Institute for Population Sciences, Mumbai, Maharashtra 400088,
India. 2 Institute of Medical Sciences & Sum Hospital, Siksha “O” Anusandhan
Deemed to Be University, Bhubaneswar, Odisha, India.
Received: 18 May 2022 Accepted: 13 April 2023
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