Use of traditional contraceptive methods in India & its socio-demographic determinants

Abstract

Background & objectives:

The high use of traditional contraceptive methods may have health repercussions on both partners. High failure rate, lack of protection from sexually transmitted diseases are some of the examples of these repercussions. The aim of this study was to understand the level, trends, pattern, volume and socio-demographic determinants of using traditional contraceptive methods in the Indian context.

Methods:

Percentages, per cent distribution, cross-tabulation and multinomial logistic regression analyses were carried out. The data from the three rounds of National Family Health Survey (NFHS) were used. The unit level District Level Household Survey (2007-2008) were mainly used to carry out the analysis in this paper. Marriage rates for States and Union Territories (UTs) were projected for the period of 2001-2011 to estimate the volume of traditional contraceptive users. These rates are required to get the number of eligible couples as on 2011 in the respective State/UT.

Results:

The latest round of the District Level Household Survey (2007-2008) revealed that 6.7 per cent currently married women were using traditional contraceptive methods in India. More than half of the currently married women (56%) have ever used these methods. In terms of socio-demographic determinants, the odds ratios of using these methods were significantly higher for women aged 35 years and above, rural, Hindu, other than Scheduled Castes/Tribes (SCs/STs), secondary and above educated, non-poor, having two plus living children, and at least one surviving son in most of the States as well as at the national level. The northeastern region showed higher odds ratios (5 times) of women using traditional contraceptive methods than the southern region.

Interpretation & conclusions:

A large number of currently married women have ever used the traditional contraceptive methods in India. On the basis of the findings from this study, the total size of those women who were using traditional methods and those who were having unmet need, and are required to use modern spacing methods of family planning in achieving the reproductive goals, is around 53 million. Women from a set of specific socio-demographic backgrounds are more likely to use these methods. A regional pattern has also emerged in use of tradition contraceptive methods in India.

The family planning scenario in India is dominated by the use of sterilization, but in many States, the traditional methods for birth spacing are preferred over the modern methods1. The family planning (FP) programme in India has always promoted the use of modern methods as evident from the high use of sterilization2. The average prevalence for traditional contraceptive is 6.7 per cent, which is not so high, but the variation across States hints that nearly a quarter of the currently married non-pregnant women aged 15-49 yr in Assam, West Bengal, and Manipur use traditional contraceptive methods2. However, if one converts these percentages into absolute number, it exceeds the 13 million mark at the national level. It is a huge number in view of managing health and other reproductive concerns of women. These methods are mostly considered less effective2, though it has been argued that traditional contraceptives have been equally effective if used with dedication and proper knowledge3. In the literature, traditional contraceptive methods have a high failure rate resulting into unplanned pregnancies, unsafe abortions, and maternal morbidities and mortality. It not only poses psychological, sexual disorder and dissatisfaction, but also makes men and women more susceptible to sexually transmitted infections4,5.

Not much information is available on the use of traditional family planning methods even though these methods, especially coitus interrupts, along with abortion played a major role in Europe's fertility transition6. The effective use of the rhythm method requires knowledge about the ovulation period, which can be acquired from medical professionals. Nevertheless, health providers had not been found propagating traditional methods unlike the modern methods7,8,9.

In the nineties a new variant of the rhythm method−the natural family planning method has gained importance and researches were carried out to identify the fertile and infertile periods in the cycle10. Data from countries like Turkey, Sri Lanka, and Italy suggest that high use of traditional contraceptive methods and achievement in fertility decline have been a simultaneous process11,12,13. This scenario is also evident in the States of West Bengal and Kerala where traditional method use is high in a low fertility setting, but at the same time traditional method use is also high in high fertility States like Uttar Pradesh and Assam14. In fact, the three rounds of the National Family Health Survey showed an increasing trend in the use of these methods at the national level15,16,17 (from 4.3% in 1992-93 to 7.8% in 2005-06). In 2005-2006, 4.6 per cent of couples were using the rhythm method, 1.8 per cent withdrawal and 0.3 per cent folkloric methods17.

There are often two possible scenarios when the traditional contraceptive methods are the last resort for the couples in reproductive age groups. One, when couples use these methods to avoid pregnancy without compromising on sexual pleasure and health outcomes. Therefore, it can be tagged as voluntary use of these methods. The other scenario is when couples are forced to use these methods, i.e. involuntary use of these methods. In both these scenarios, couples and mostly women bear the brunt of not using modern methods, in terms of unintended pregnancy and other associated consequences including reproductive tract infections and sexually transmitted diseases.

This study is an attempt to understand the level, trends, patterns and volume of traditional method usage and its determinants in the selected States. The reasons for not preferring/using modern methods among traditional method users are also highlighted.

Material & Methods

The data from all the three rounds of the National Family Health Survey (NFHS)15,16,17 and the third round of the District Level Household Survey (DLHS), 2007-20081 were used for this study. These cross-sectional surveys provide information at individual and household level. All the ethical protocols including individual consents were obtained before seeking response to a set of questions on use of contraceptives. Individual and household level background characteristics have been used to show differentials in the use of traditional contraceptive methods. The individual level data analysis was carried out by using DLHS (2007-2008)2. In overall, 6,43,944 ever-married women aged 15-49 yr from 7,20,320 randomly selected households were interviewed on various reproductive and child health issues. The study protocol approval was obtained from the Institutional Review Board of International Institute for Population Sciences, Mumbai, before collecting information in the survey. Individual level consent was also obtained prior to the start of face-to-face interview with women. The number of eligible couples was estimated for 2011 by projecting the marriage rates available in the Family Welfare Year Book published by the Ministry of Health and Family Welfare for different years18.

Prevalence rate, per cent distribution, bi-variate and tri-variate analyses were carried out to capture the differentials by socio-demographic background characteristics. Also, a multinomial regression analysis19 was conducted using DLHS (2007-2008)2 data in the context of high prevalence States (Assam, Delhi, Gujarat, Jammu & Kashmir, Kerala, Odisha, Uttar Pradesh, and West Bengal) to find the adjusted odds ratios of using traditional contraceptive methods. In this model, the dependent variable has three categories - using traditional method, using modern method, and not using any method. Independent variables are age of women, residence, religion, caste, wealth status, living number of children, and having at least one son. The national level model includes one additional variable ‘region’ other than the above independent variables taken at the State level. All the Indian States and Union Territories (UTs) were divided into six regions as per the geographic location. In this study, the term ‘traditional methods’ means traditional contraceptive/family planning methods, ‘modern methods’ means modern contraceptive/family planning methods, and ‘spacing methods’ means spacing contraceptive/family planning methods. ‘Limiting/permanent methods’ in this paper means limiting/permanent modern methods of family planning (i.e. male/female sterilization).

Results

Levels, trends and distribution of traditional contraceptive methods: The level of overall use of contraceptive methods was increased from 41 to 55 per cent between 1992 and 2008 (Fig. 1). Taking into consideration the NFHS estimates of contraceptive prevalence rate, use of traditional methods was increased by 1.8 times as compared to 1.3 times for modern methods during 1992-2006. In terms of percentage contribution, the use of traditional methods was increased from 11 to 13 per cent during 1992-2008. The State-wise estimates of the use of traditional methods and contribution of traditional method use in the overall use of spacing methods are given in Table I. The level of use varied over a wide range in the country, from 0.2 per cent in Andhra Pradesh to 26.8 per cent in Tripura. Fifteen States showed the level of utilization above the national level of 6.7 per cent. The use was more common in the northern and the eastern regions. The share of using these methods crossed 40 per cent of the overall use of spacing methods in 14 States/UTs. In some cases, it stood more than 50 per cent of the overall spacing method use (Manipur-65%; Lakshadweep-63%; Kerala-59%; Bihar-56%; Uttar Pradesh-54%; Tripura-52%; West Bengal-51%).

Fig. 1.

Level of use of modern and tradition methods in India, 1992-2008. Source: Generated from unit level data.

Table I.

Percentage (prevalence rate) of currently married women using traditional contraceptive methods and their contribution in overall use of spacing methods in States/Union Territories of India, 2007-2008

Estimation of size of traditional method users and requirement of total demand of modern spacing family planning methods in India and its States/UTs: Table II shows the total numbers of eligible couples estimated by using the projected marriage rate as on 2011 and multiplied by the population enumerated in the census 2011 (column 1). Figures in column (2) were estimated by multiplying the number of eligible couples and the percentage of couples using traditional contraceptive methods. Figures in column (3) were obtained by multiplying the number of eligible couples and the percentage of couples (who were having unmet need for modern spacing methods plus who were using any traditional method). Thus, column (3) provides an idea about the additional (in addition to those who were already using modern spacing methods) number of couples who can be potential users of modern spacing contraceptive methods by States/UTs. Figures in column (4) were obtained by summing column (3) and the number of couples currently using modern spacing methods. Column (4) gives the total demand for modern spacing methods, provided all the current traditional methods users are assumed to use modern spacing methods to achieve their reproductive goals. Accordingly, we came up with the estimate of around 196 million eligible couples at the national level. Of these, around 13 million couples were using traditional methods. Nearly 27 million of couples were found to be having unmet need for spacing methods of family planning at the national level. Estimates in column (4) show that almost 53 million couples need spacing methods of family planning in a situation where no one uses traditional method and the couples in unmet need for spacing method start using the modern methods. Thus, the total estimated demand for modern spacing methods of family planning is around 9.8 million for Uttar Pradesh followed by 5.7 million for West Bengal and 3.4 million for Bihar.

Table II.

Estimated total numbers (×10³) of eligible couples, couples currently using traditional methods, additional no. of couples need modern spacing methods, and total no. of couples needing modern spacing methods in States/UTs, 2011

Further analysis suggested that importance of traditional methods among its users did not reduce much even for future course of time. At the national level, less than one-fifth of traditional method users (19.1%) expressed that they had intention to use a modern contraception method (Table III). It means that if this proportion is multiplied to the total of column (2) in Table II (i.e. total no. of current user of traditional method), then 10.6 million couples would intent to use traditional methods in future. However, among most of those who intended to use modern methods at any time in future, majority (68.3%) would resort to female sterilization followed by spacing methods (20.5%). Thus, only 1.7 million (i.e. 19.1%×68.3%×13.1354 million) out of 13.1 million total traditional method users intended to use female sterilization in future. The number of traditional method users who intended to use male sterilization comes only around 30,106. Finally, even if the estimates of Table II (in view of estimates in Table III about future intention) are refined, the total number of those needing modern spacing method would not go below the 50 million mark. One can always follow the same mechanism to understand how the future intention of traditional method users would affect State-wise estimate in column (4) in Table II.

Table III.

Percentage of traditional method users who intended to use any modern method of family planning in future, and type of FP methods by State, DLHS (2007-08)

Utilization of traditional contraceptive methods by socio-demographic backgrounds: Fig. 2 shows the level of use of modern spacing, and traditional contraceptive methods, and unmet need for overall spacing methods by the reproductive age groups. The use of traditional methods increases from 5 to 8 per cent from the age group 15-19 to 30-34. A large proportion of women aged below 30 yr had unmet need for spacing contraceptive methods. Specifically, 26 per cent of currently married women aged 20-24 yr were found to be in unmet need for spacing methods. Beyond age 30 yr, the level of unmet need for spacing methods was found to be negligible. It was surprising that the level of unmet need got equated to the total traditional and modern spacing methods use in the age groups 20-24 and 25-29 yr. Thereafter, the age group 40-44 yr showed the similar pattern. Almost four per cent (which may be huge in absolute number of women) continued to use traditional methods even in the terminal age group of the reproductive span Fig. 3.

Fig. 2.

Level of traditional, modern spacing family planning methods use, and unmet need for them, India, 2007-08. Source: Ref. 20. Unit level data.

Fig. 3.

Reasons for current traditional methods users not using medern methods, DLHS (2007-08).

Table IV shows the level of ever use of traditional methods in India. It provides levels by socio-demographic background of ever-married women. It indicates that almost 16 and nine per cent of currently married women have ever used rhythm method and withdrawal method, respectively. Around 56 per cent of women ever used any modern contraceptive methods in India. Age differentials suggest that married women in the age bracket of 30 to 44 yr are more in use of traditional methods (17%) as compared to women below aged 30 yr. It is interesting to see that around 15 per cent of women below 20 yr have ever used one of the traditional methods. A higher percentage of women from urban areas, Muslim religion, other castes, high school and above educated, and from the highest quintile household ever used the rhythm method than their counterparts in the respective groups. The ever use of this method was less common among schedule tribes community (10.9 %). The bi-variate analysis showed that the ever use of traditional methods increased with the level of women's education, and wealth index.

Table IV.

Percentage of currently married women ever used rhythm, withdrawal and any modern method, India, DLHS, 2007-08.

Results from multivariate regression analysis: Table V provides adjusted odds ratios of using traditional contraceptive methods against no method use. The States chosen for the analysis were those where the use of traditional methods was found to be relatively higher. Results indicated that odds ratios for using traditional methods against not using any method were significantly lower among women below aged 25 yr in Uttar Pradesh, West Bengal and Odisha and at the national level. On the other hand, women in the age group 25-35 have high odds of using traditional methods in Jammu & Kashmir, NCT Delhi, Uttar Pradesh, Assam and West Bengal. In case of NCT Delhi and West Bengal, women aged 25-35 yr were 36 and 32 per cent more likely to use traditional methods against non users as compared to the reference group of women aged 35 yr and above (Table V).

Table V.

Odds ratios from the multinomial models of traditional method use against no method for Selected states and India, DLHS 2007-08.

Rural women in Uttar Pradesh, Odisha and India as a whole were significantly less likely to use traditional methods than their urban counterparts. Hindu women were significantly more likely to use traditional methods (23%) as compared to women from other religions. However, likelihood of Hindu women using the traditional methods was much higher in Uttar Pradesh (49%), West Bengal (43%), Jammu & Kashmir and Gujarat (around 30% each), and Kerala (24%). Caste seems to play significant role in use of traditional contraceptives in Jammu & Kashmir, Odisha, Gujarat, and at all India level. In these three States, SCs/STs women had significantly lower adjusted odds ratios (minimum by 22%) for using traditional methods than the other women. But, at the national level, scheduled tribes using traditional methods of family planning had shown significant lowest odds ratios (about 45%) followed by OBCs (28 % lower odds) compared to women in ‘Others’ category.

Women who possessed 10 and above years of schooling had a higher chance of using traditional methods than those women who were less educated. Another important variable wealth did not appear significant in Jammu & Kashmir, NCT Delhi, Assam, and Kerala. Adjusted odds ratios show that it was most significant in case of Gujarat, where non-poor women were more likely to use traditional methods as compared to poor (around 35%). Non-poor women had significantly higher odds (by 22%) in using traditional methods as compared to poor women at the national level (Table V). Number of living children was found significant in all the populations chosen in the analysis. Women who had less than two living children were significantly less likely to use the traditional methods than those who had two or more living children (31% lower odds for one living child and 83% lower odds for nulliparous women at the national level). In the context of son-preference, having a son in Assam and Kerala has not influenced the use of traditional methods of family planning. On the contrary, all the other selected populations provided evidence of son-preference in use of traditional methods. At all India level, women who had no son had 27 per cent lower odds of using these methods as compared to those who had at least one son. In case of NCT Delhi, Uttar Pradesh, Odisha and Jammu & Kashmir, odds ratios significantly ranged between 35-39 per cent at the lower side of using these methods among those who had no son than those who had at least one son.

To understand the regional variation in the use of traditional contraceptive methods, a region variable, by keeping State in appropriate geographical location, is created and placed in the model at the national level. Results suggest that currently married women who belong to the northeastern region were almost five times more likely to use traditional methods of family planning as compared to those belonging to the southern region. Women from the eastern region were also almost 2.4 times more likely to use these methods than their southern counterparts. Compared to other regions, women from the western region were found to be closer (still 1.7 times more) to women from the southern region in terms of odds for using traditional methods (Table V).

Discontinuation rate and reasons for discontinuation of traditional and modern spacing methods of family planning: The National Health and Family Welfare Survey (2005-2006)18 provides information on discontinuation rate of each method. Almost 33 per cent couples discontinued using traditional methods (32 % rhythm and withdrawal 35%). Almost a quarter of the rhythm method users discontinued due to method failure, 44 per cent to become pregnant, and 30 per cent cited other reasons. In case of withdrawal users, one-fifth of the women discontinued due to method failure, 32 per cent because they wanted to become pregnant, and remaining around 46 per cent due to other reasons. On the contrary, in DLHS (2007-2008)1, method failure was the reason among only 13 per cent women of those who discontinued traditional methods. Almost 56 per cent women discontinued the traditional methods to become pregnant. The distribution of duration of current users of traditional methods showed that 43 per cent women were using these methods since the last three or more years. In response to the question “why you are not using any family planning method”, 26 per cent women who were using traditional methods gave the response that they were concerned about their health followed by 22 per cent of women who reported that modern methods had several side effects. In the country as a whole, self or family members’ opposition also added up to 23 per cent of those of traditional method users who did not want to use modern contraceptive methods. Nearly half of the traditional methods users (52%) had received some advice on modern methods. Inspite of it, only one-fifth of traditional methods users intended to use a modern method (70% of them preferred sterilization). These percentages vary a lot across socio-demographic and economic backgrounds of the respondents. In DLHS (2007-2008)1, only main reason was asked for not using modern contraceptive methods, however, there could be more than one reason operating as barriers in their use.

According to NFHS (2005-2006)18, the discontinuation rate for modern spacing family planning methods amounts to 42.3 per cent. Almost one fourth (24.6%) of them discontinued after facing method related side effects, and an equal proportion (25%) of them was accounted for desiring to become pregnant.

Discussion

The use of traditional family planning methods was as high as 18 per cent in West Bengal followed by Assam (17%), and it is also not less common at the national level (7%). These methods also known as natural methods contribute to around 35 per cent of overall use of spacing methods of family planning. Thus, in a scenario of high level of unmet need for spacing contraceptive methods (13%), the only option left especially to younger women is to adopt the natural methods to achieve their desired goals of fertility. Almost 13 million couples were using the traditional methods in 2011. To abolish the unmet need for modern spacing methods completely, the total number of couples to be served spacing modern methods is 53 million.

One can visualize from the differentials in use of traditional contraceptive methods by age that a sizeable number of women might have used these as the limiting method. Moreover, nearly one-fifth of them were using the traditional methods for more than six years without any discontinuation. As evident from the regression analysis, women aged 35 yr and above were more likely to use the traditional methods in some of the States.

This study shows that the myth that women from poor socio-economic milieu are more likely to use the traditional methods does not hold true. On the other hand, it is found that highly educated, urban, non-poor and other than SCs/STs women carry relatively higher odds to use traditional methods. The findings from the study by Basu21 also confirmed that the high level of use of traditional methods of birth control among educated women was not surprising in the framework of the sociology of the body. Another study22 also showed that one of the greatest factors supporting traditional contraception use among more educated and wealthier women was not the perceived ineffectiveness of modern methods but their wholesome side effects.

It was also evident from the multinomial regression analysis that these methods were consciously chosen in relation to the size of family because women who had two or more children or had at least one son had a higher likelihood to adopt these methods. These likelihoods are given against those who are not using any family planning method. Thus, group of potential users in the above categories i.e. women with two or more children with at least one son must have already adopted permanent methods like sterilization or other modern methods. One can use regional variable to interpret that socio-cultural learning, and environment also plays a role in high use of these natural methods. Women from other than the southern region were more prone to adopt these methods. Several studies have shown that southern States have implemented the official family planning programmes most effectively in the country23. Thus, the other argument may be given in favour of this finding is that these methods are the last resort23 to couples who want to regulate their family size and living in a highly contraceptive insecure environment.

This study gives several programmatic implications towards improving the existing family planning programmes. These programmes need to focus on health concerns and side effects faced by women after using modern contraceptive methods. The family planning programme managers also need to involve other family members who often make reproductive decisions with/without women's own consent. Further, only half of women traditional method users were advised on modern family planning methods on modern methods and only one-quarter of them were advised by health workers. Therefore, the quality of information that traditional methods users received may not be necessarily satisfactory. The interpersonal communication and technical competency need to be improved. Otherwise, it is highly probable that these women may also shift to traditional method use in the future.

There is also a need to introduce family life education among younger women and adolescents so that they acquire necessary skills before entering into the process of family building and reproduction. Moreover, prevailing myths and misconceptions regarding several reproductive functions, particularly about the timing of ovulation, must be cleared to younger women to avoid the risks of pregnancy while on the use of traditional methods. New contraceptive technologies and wider social market also need to be promoted to handle such large numbers and varieties of clients in the country.