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Addressing unmet need and religious barrier towards the use of family planning method among Muslim women in India

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Purpose – The purpose of this paper is to find out the prevalence and determinants of unmet need with a special focus on religious barrier towards the use of contraception among Muslim women in India. The study also addresses their future intention to use family planning method. Design/methodology/approach – Data from the latest round of District Level Household and Facility Survey (DLHS-3) in India is used. A multi-stage stratified probability proportion to size sampling design was adopted. The present analysis is based on 70,016 currently married Muslim women across the country. Findings – The prevalence of total unmet need is the highest in Bihar (48.5 per cent), which is two times higher than the national level (27.6 per cent). About 9 per cent Muslim women in India do not use contraception due to religious opposition. There is considerable gap in the future intention to use family planning method between Muslim (9.2 per cent) and non-Muslim (19.6 per cent) women particularly for limiting birth. The logistic regression analysis shows non-Muslim women are significantly more likely (OR=1.540, p<0.001) to have the intention to use family planning method in the future than Muslim women. Research limitations/implications – Men are not included to explore the differences in the perception of men and women towards family planning. Interventions targeting men and aiming at overcoming cultural barriers to using family planning method are equally imperative. Couple's knowledge, attitude and perception towards acceptance of family planning methods need to be addressed simultaneously by interviewing the couples separately. Practical implications – Public-private collaboration to promote family planning programme and providing services in the high prevalence (unmet need) states is required. Support from the religious leaders to overcome the cultural barriers towards the use of family planning is also needed. Originality/value – This is the first ever effort to address the existing unmet need for family planning among Muslim women in India, which is an important determinant of high fertility among Muslim women.
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Addressing unmet need and religious
barrier towards the use of family planning
method among Muslim women in India
Shraboni Patra and Rakesh Kumar Singh
Shraboni Patra and
Rakesh Kumar Singh are
Senior Research Scholars,
both are based at International
Institute for Population
Sciences, Mumbai, India.
Abstract
Purpose – The purpose of this paper is to find out the prevalence and determinants of unmet need with a
special focus on religious barrier towards the use of contraception among Muslim women in India. The study
also addresses their future intention to use family planning method.
Design/methodology/approach – Data from the latest round of District Level Household and Facility
Survey (DLHS-3) in India is used. A multi-stage stratified probability proportion to size sampling design was
adopted. The present analysis is based on 70,016 currently married Muslim women across the country.
Findings – The prevalence of total unmet need is the highest in Bihar (48.5 per cent), which is two times
higher than the national level (27.6 per cent). About 9 per cent Muslim women in India do not use
contraception due to religious opposition. There is considerable gap in the future intention to use family
planning method between Muslim (9.2 per cent) and non-Muslim (19.6 per cent) women particularly
for limiting birth. The logistic regression analysis shows non-Muslim women are significantly more likely
(OR ¼1.540, po0.001) to have the intention to use family planning method in the future than
Muslim women.
Research limitations/implications – Men are not included to explore the differences in the perception of
men and women towards family planning. Interventions targeting men and aiming at overcoming cultural
barriers to using family planning method are equally imperative. Couple’s knowledge, attitude and
perception towards acceptance of family planning methods need to be addressed simultaneously by
interviewing the couples separately.
Practical implications – Public-private collaboration to promote family planning programme and providing
services in the high prevalence (unmet need) states is required. Support from the religious leaders to
overcome the cultural barriers towards the use of family planning is also needed.
Originality/value – This is the first ever effort to address the existing unmet need for family planning among
Muslim women in India, which is an important determinant of high fertility among Muslim women.
Keywords Ethnicity, Contraception, DLHS-3, Family planning, Muslims, Religious belief,
Religious opposition, Unmet need
Paper type Research paper
Introduction
In many developing countries, millions of women in their childbearing age do not use any
contraception (World Health Organisation, 2013). Their desire to postpone or limit their birth
sometimes remains unfulfilled which indicates their failure to take a timely decision to prevent
and avoid unwanted pregnancy (Malwenna et al., 2012). Here, the concept of unmet need for
family planning has its relevance. Women, unable to delay their childbirth or wish to limit their
childbearing, are considered to have an unmet need for family planning (Thiagarajan and
Adhikari, 1995). The unmet need for family planning method may lead to unintended
pregnancies, which may result in several risks for women, their families, and societies
(Rajkumari et al., 2013). In other words, unmet need for family planning refers to the difference
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VOL.8NO.12015,pp.22-35,CEmerald Group Publishing Limited, ISSN 2056-4902DOI 10.1108/IJHRH-06-2014-0010
between expressed fertility goals and contraceptive practice (Laya, 2012). Most of the married
women in developing countries want to use contraceptive methods, but are unable to
use. The responsible factors are lack of knowledge about family planning; husband’s
non-cooperation in making decision and choice related to contraception; fear of side effects;
in-affordability for and inaccessibility of family planning services; religious prohibition; deficiency
and incompetence of family planning workers and limited supply (Bruce, 1990; Iyer, 2002).
Barriers to using of family planning services can be extended beyond the factors operating on
individual and household levels, to include social and cultural characteristics and lack of
infrastructure in providing health care services (Stephenson and Hennink, 2004). The low status
of Indian women and a very strong preference for male children are the two fore-most patriarchal
constraints towards the use of family planning method in India (Tayyaba and Khairkar, 2011).
In northern India, couples usually wish to have more children. They are more reluctant to accept
any contraceptive method for several reasons like they are uncertain about their child survival,
they expect more earning hands, their religious belief and their fear of ruining their “vansh”
(i.e. progeny) (Gaur et al., 2007). Even, sometimes it is observed that Indian couples who are
using family planning methods, consider it as a need for the government, rather than as it is for
their personal benefit (Tayyaba and Khairkar, 2011).
India is slowly but steadily moving towards the goal of the replacement level of fertility by
decreasing its birth rate and increasing contraceptive prevalence rate (Rustagi et al., 2010).
However, despite an increase in the awareness and the use of family planning method, unmet
need for contraception is still prevalent in India (NFHS-1, International Institute for Population
Sciences, 1992-1993; NFHS-2, International Institute for Population Sciences , 1998-1999;
NFHS-3, International Institute for Population Sciences, 2005-2006). Unmet need is an
important indicator for national family planning programmes since it shows how well the county
is achieving its key target of meeting population’s requirement for family planning (Cleland et al.,
2006). Meeting the unmet need of family planning is also one of the key objectives of “National
Population Policy” of the Government of India (National Population Policy, 2000).
However, evidences from different surveys indicate that unmet need for family planning is higher
in rural areas than in urban areas, and it is largely varied among different socio-cultural groups
(NFHS-2, International Institute for Population Sciences, 1998-1999). The reasons perhaps, a
substantial minority group of women has an unmet need for family planning, and thus the study
of their unmet need is important for both social welfare and on demographic grounds (Laya,
2012). Researchers often ignore to investigate the issues related to health and services in a
population of a small community, which can be particular ethnic or religious groups (Stephenson
and Hennink, 2004). But, religion is one of the significant factors responsible for determining
personal and social behaviour of the individual within the family. In most of the societies, religion
has immense socio-cultural, economic and political significance in determining fertility (Gaur
et al., 2007; Ade and Patil, 2014). Studies have revealed that, to an individual, religious faith and
belief is a strong predictor of taking a decision on contraception use, especially on sterilization
(Stephenson, 2006; Bernhart and Uddin, 1990). Hence, it plays a significant role in approving or
encouraging the acceptance of or confrontation to using family planning (Iyer, 2002).
There are different opinions persistent regarding fertility, family planning and contraception use in
Islam. Few are contradictory to each other. Some argue; Islam is open to acceptability of
family planning method, whereas the “Quran” mentions children as the “decoration of life”, and it
forbids infanticide. It is explained such a way that Islam does not allow contraception (Mishra,
2004). According to Jeffery and Jeffery (1997), high fertility among Indian Muslims is due to their
weak socio-economic conditions rather than religious determinism. Though, many other
researchers found that the religious factor can explain well high birth rates among Muslims
(Sharma, 2012). A recent study (Jeffery et al., 2008) has showed how variation in a religious view
causes differentials in the use of contraception between Muslim and Hindu women.
In India, according to latest census data (Census, 2001) available on religion, Muslims (followers
of Islam) constitute 13.4 per cent of the total population. Muslim population of India is the third
largest population in the world, after Indonesia and Pakistan (Pew Center’s Forum of Religious
and Public Life, 2009). Since historical era, Muslim community has been consistently showing
higher population growth than any other religious groups. The share of Muslim population was
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increased from 20 per cent in 1881 to 24 per cent in 1941, while for Hindu, it was declined from
75 per cent to near about 70 per cent. Fertility is one of the three demographic processes that
affect the size of the Muslim population. Neither mortality nor migration is found important in
contributing to the increase of Muslim population in India (Mistry, 1999; Balasubramanian,
1984). There is a dearth of literature in Indian context to address high fertility in association
with low contraceptive prevalence rate (CPR) and high prevalence of unmet need particularly
among Muslim women.
Hence, the use of family planning methods by Muslim women who are likely to experience
particular barriers to using of family planning services require considerable attention of the
researchers, policy makers and planners. Therefore, the questions like, why CPR is low among
Muslim women in India; why there is a higher rate of unmet need among currently married
Muslim women; do the women from religious minority have any future intention to use family
planning method, etc., also need substantial focus and elaborate discussion. With this
backdrop, in the present study an attempt has been made to focus on the unmet need for
planning method among Muslims in India.
Therefore, the main objectives of the present study are: first, to investigate the state wise
prevalence of total unmet need for family planning, unmet need for spacing and unmet need for
limiting among Indian Muslim women (15-49 years); second, to study the factors influencing
unmet need for family planning and to explore the barriers towards the use of contraception
among Muslim women; and third, to find out the factors influencing their intention to use offamily
planning method in the future.
Methods
Data
In the present study, the latest round of District Level Household and Facility Survey (DLHS-3,
International Institute for Population Sciences, 2007-2008), data has been used which is one of
the largest ever demographic and health survey carried out in India covering all the districts.
Sampling
A multi-stage stratified systematic sampling design was adopted in DLHS-3. In each district, 50
primary sampling units (PSUs), which were census villages in rural areas and wards in urban
areas, were selected in the first stage by systematic probability proportional to size sampling.
DLHS-3 used the sampling frame for the Census of India, 2001. The PSUs were allocated to
rural and urban areas of the each district proportional to the actual rural-urban population ratio,
and within the rural-urban domains. The PSUs were further distributed proportionately to the
different sub-strata of combinations of household size, percentage of scheduled caste (SC) or
scheduled tribe (ST) population and levels of female literacy. In rural areas, in the second stage of
sampling, households were drawn from the selected villages (PSUs) after house listing. Whereas
in urban areas the second stage of sampling was the selection of Census Enumeration Blocks
followed by selection of households in the third stage of sampling. Circular systematic sampling
was adopted to select the households. In addition, 10 per cent over-sampling of the households
was made to minimize the non-response (DLHS-3, International Institute for Population
Sciences, 2007-2008).
The data have been collected from seven, 20, 320 households from 34 states and union
territories of India (excluding Nagaland). From these households, six, 43, 944 ever married
women aged 15-49 years were interviewed. The present analysis is based on 70,016 currently
married Muslim women across the country (DLHS-3, International Institute for Population
Sciences, 2007-2008).
Variables
All the variables used in the analysis are divided into two broad categories: i.e. predictor variables
and outcome variables.
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Predictor variables: the important predictor variables are re-coded for the purpose of analysis
and for effective comparison with the results. These variables are: Age group of women (15-19,
20-24, 25-29, 30-34, 35-39, 40-44 and 45-49 years); Place of residence (rural, urban); Age at
consummation (below 18 and 18 and above years); Marital duration (less than two, two to four
and five and above years); Parity (below two, two to four and five and above); Use of any family
planning method i.e. CPR (yes and no); Education level of women and their husbands separately
in terms of completed years of schooling (i.e. no education, less than five, five to ten and above
ten years); Media exposure (includes responses for any information or messages related to
family planning received by women from any media sources, and the categories are yes and no);
Religion (Muslim and non-Muslims, where non-Muslim includes Hindu, Christian, Sikh,
Buddhist, Jain, Tribal, other, none); Caste (SC, ST, Other Backward Caste and Others include
Brahmin and others) and Wealth quintile (lowest, second, middle, fourth and highest for poorest,
poor, middle, rich and richest, respectively).
Outcome variables: in DLHS-3, unmet need for spacing includes proportion of currently married
women who did not attain menopause or did not go under hysterectomy or were not currently
pregnant, who wanted more children after two years or later, and who were not using any family
planning method. Women, sure about when to have the next child and not using any spacing
method, were also considered to have an unmet need for spacing. Unmet need for limiting
includes all currently married women who did not attain menopause, did not go under
hysterectomy, were not currently pregnant and did not want any more children, but also were
not currently using any family planning method. Total unmet need is the summation of unmet
need for limiting and unmet need for spacing.
However, other outcome variables used in the present study are also re-coded purposively. They
are: Reasons for not using any family planning method (categories are fertility-related, method-
related, opposition to use, religious opposition, lack of knowledge and others) and future
intention to use family planning method (yes and no).
Statistical analyses
In the present study, bivariate and multivariate analyses are used. Significance level of the
bivariate association has been shown by Pearson’s w
2
test, whereas binomial logistic regression
analysis shows the significance level of multivariate association.
Binary logistic regression model is used to assess the effects of religion along with the other
socio-economic characteristics on women’s intention to use family planning method in the
future. Logistic regression analysis is commonly used when the independent variables
include both numerical and nominal measures, and the outcome variables (dependent
variables) are binary or dichotomous. Advantage of logistic regression analysis is that it requires no
assumption on the distribution of the independent variables, and the regression coefficient can be
interpreted in terms of odds ratio (OR). Logistic regression model is commonly estimated by
maximum likelihood function. For dependent variables, the logistic model takes following
general form:
Logit p¼b0þb1x1þb2x2þb3x3þ..................bkxkþek
Logp=1p¼b0þb1x1þb2x2þb3x3þ...............bkxkþek
where b
0
are intercepts and b
1
,b
2
,b
3
,yb
k
represents the coefficients of each of the predictor
variables in the model while e
k
is an error term. The natural logarithms of odds of the outcomes
are represented by e
k
. In the present study, the logistic regression model is applied to analyze the
effect of selected socio-economic factors on intention of Muslim women to use family planning
method in the future. Therefore, binary logistic regression is used to estimate the adjusted
effect of background characteristics (independent variables) on women’s intention to use family
planning methods in the future (dependent variable).
All the statistical analyses in the present study are performed by using statistical package SPSS,
version 18.
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Findings
Unmet need for family planning methods among currently married Muslim women
In India, about 28 per cent Muslim women had an unmet need for family planning method,
whereas about 9 and 19 per cent women had an unmet need for spacing and an unmet need for
limiting, respectively. The study has shown unmet need for spacing, unmet need for limiting and
total unmet need (i.e. unmet need for spacing and limiting both) among currently married Muslim
women is noticeably higher than the national level, and also higher than it is among the other
religious community (Figure 1).
Prevalence of unmet need for family planning is considerably higher in 20-24 year’s age groups
(30.5 per cent) than in other age groups of currently married Muslim women. Unmet need for
family planning is also found higher among women residing in rural areas (30.3 per cent) than
among urban women. Total unmet need is also high among uneducated (32.4 per cent) women,
among women who consummated her marriage at below 18 years (28.6 per cent), among
women in two to four year’s marital union (30.2 per cent), among women with parity five and
above (35.5 per cent) and among those who belong to the poorest section (38.1 per cent) of the
society (Table I).
The study has shown that among Muslim women, unmet need for spacing decreases
and unmet need for limiting increases with the successive age groups, and with an increase in
the duration of marriage. Unmet need for limiting is the highest (33.5 per cent) among
women with parity five and more. Unmet need for both spacing (8.5 per cent) and limiting
(17.9 per cent) birth are considerably lower among women who received any family
planning messages from media and any other sources than those who did not receive any
information.
State-wise CPR and prevalence of unmet need for family planning methods among currently
married Muslim women
The present study shows that CPR (for any method) among currently married Muslim women is
43.2 per cent in India. CPR is the highest in Tripura (65.3 per cent), followed by West Bengal
(63.1 per cent), Andhra Pradesh (60.1 per cent) and Punjab (59.8 per cent) (Figure 2).
Unmet need for spacing among currently married Muslim women is the highest in Bihar (15.1
per cent), followed by Jharkhand (14.5 per cent), Haryana (13.9 per cent), Kerala (12.5 per cent)
and Uttar Pradesh (12.3 per cent). Besides, unmet need for limiting is also found high in
Figure 1 Unmet need for family planning method among currently married women by
religions, India, 2007-2008
7.2 8.8 7
13.2
18.8
12.5
20.4
27.6
19.4
0
5
10
15
20
25
30
India Muslim Non Muslims
Percentage of currently
married women
Unmet Need For Spacin
g
Unmet Need For Limitin
g
Total unmet need
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Bihar (33.4 per cent), followed by Meghalaya (27.9 per cent), Uttar Pradesh (27.8 per cent),
Jharkhand (27.1 per cent) and Uttarakhand (27.0 per cent).
The prevalence of total unmet need is the highest in Bihar (48.5 per cent), which is almost double
of the national level (27.6 per cent), followed by Jharkhand (40.9 per cent), Uttar Pradesh (38.7
per cent), and Uttarakhand (31.7 per cent). Conversely, total unmet need is the lowest in
Mizoram (8.7 per cent) followed by West Bengal (15 per cent).
Table I Percentage of currently married Muslim women aged 15-49 years by unmet need
for family planning services according to selected background characteristics,
India, 2007-2008
Unmet need
Characteristics For spacing For limiting Total w
2
Women (n)
India 8.8 18.8 27.6 70,016
Residence 372.788***
Rural 10.0 20.3 30.3 48,253
Urban 7.3 16.8 24.1 21,763
Age group (years) 362.052***
15-19 24.1 2.1 26.3 4,632
20-24 21.4 9.1 30.5 13,169
25-29 10.9 18.0 28.9 14,400
30-34 4.4 23.1 27.5 12,768
35-39 1.5 27.1 28.6 11,162
40-44 0.5 26.5 27.0 8,274
45-49 0.1 17.9 18.1 5,611
Age at consummation of marriage (years) 36.874***
Below18 7.3 21.3 28.6 33,313
18 and above 10.1 16.7 26.8 36,701
Marital duration (years) 36.056***
Less than 2 24.4 1.6 26.0 8,219
2-4 22.9 7.3 30.2 5,402
5 and above 5.2 22.4 27.6 56,395
Parity 1,076.815***
Below 2 18.8 2.3 21.2 16,494
2-4 7.7 18.8 26.5 34,477
5 and above 1.9 33.5 35.5 19,045
Women’s education (in completed years) 845.91***
Uneducated 8.0 24.4 32.4 36,578
Less than 5 7.5 16.0 23.5 6,581
5-9 9.6 13.5 23.1 18,244
10 and above 11.1 11.4 22.5 8,613
Husband’s education (in completed years)
a
465.544***
Uneducated 8.4 24.3 32.8 22,400
Less than 5 7.4 18.4 25.8 7,484
5-9 9.3 16.6 25.9 23,426
10 and above 9.1 15.1 24.2 15,978
Media exposure
b
420.901***
Yes 8.5 17.9 26.5 60,022
No 11.2 25.2 36.4 9,394
Caste/tribe 369.788***
SC/ST 9.5 17.9 27.4 5,499
OBC 10.4 20.4 30.8 31,708
Others 7.1 17.3 24.4 32,809
Wealth quintile 1,002.982***
Poorest 11.1 27.0 38.1 8,591
Poor 10.2 23.6 33.8 12,522
Middle 9.0 19.5 28.5 14,757
Rich 8.1 16.6 24.6 17,402
Richest 7.9 14.9 22.8 16,734
Notes:
a
Excludes missing cases;
b
information related to family planning received from different media and
other sources. ***Significant at po0.001
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Reasons for not using contraception among Muslim women in India
The present study has found that a considerable percentage of Muslim women (about 34 per
cent) did not use contraception due to fertility-related issues like respondents not having sex,
having infrequent sex, attained menopause, were sub-fecund/in-fecund, were postpartum
amenorrheic or currently breast-feeding. About 10 per cent respondents did not use contraception
due to method related issues like undergone hysterectomy, fear of side effects, lack of access,
high cost, difficult/inconvenient to use, interferes with the body, do not like existing method,
afraid of sterilization, etc. Around 11 per cent women did not use contraception because of the
opposition against the use of contraception (either respondent herself or her husband and others
opposed). Due to the lack of knowledge or improper knowledge about particular method and its
source, 2.1 per cent women could not use contraception. Besides, about 38 per cent Muslim
women did not use contraception due to other reasons, such as, their husbands were living away,
or they think it is up to the God, or they have their health concerns (Table II).
Surprisingly, about 9 per cent Muslim women did not use contraception due to religious
opposition. Religious opposition against the use of contraception is found higher among older
women (10.3, 10.7 and 10.1 per cent among 35-39, 40-44 and 45-49 year’s aged women,
respectively); among women who are in a marital union for five or more years (9.4 per cent),
among women with parity five or more (11.6 per cent), among uneducated women (9.9 per
cent), among women from SC and ST communities, and among women belonging to the
poorest section of the society.
Figure 2 Percentage of currently married Muslim women with unmet needs in Indian states,
2007-2008
17
23
24
29
29
42
43
44
45
47
47
48
51
51
52
53
55
55
56
57
57
57
58
58
59
60
60
63
65
15
14
14
1
11
9
9
6
6
8
9
5
11
7
12
8
5
5
5
3
6
6
3
7
6
3
4
5
3
33
27
24
28
27
17
19
26
19
21
15
19
10
17
10
13
10
11
20
13
13
11
13
2
11
12
6
10
12
70 60 50 40 30 20 10 0 10 20 30 40 50
Bihar
Jharkhand
Haryana
Meghalaya
Uttar Pradesh
Goa
India
Uttarakhand
Assam
Tamil Nadu
Rajasthan
Chhattisgarh
Karnataka
Jammu & Kashmir
Kerala
Orissa
Arunachal Pradesh
Manipur
Sikkim
Delhi
Madhya Pradesh
Maharashtra
Himachal Pradesh
Mizoram
Gujarat
Punjab
Andhra Pradesh
West Bengal
Tripura
Percentage
CPR Unmet need for spacin
g
Unmet need for limitin
g
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Intention for the use of family planning method in the future
The intention for the use of contraception (for both spacing and limiting their child-birth) in the
future is largely varied between non-Muslim and Muslim women. About 6.7 per cent currently
married Muslim women, with unmet need for family planning method, intend to use spacing
method in the future. Whereas, 9.2 per cent women intend to use limiting method in the
future (Figure 3).
Table II Percentage distribution (weighted) of currently married Muslim women aged 15-49 years having unmet need for
family planning methods by reasons for not using any contraceptive according to selected background
characteristics, India, 2007-2008
Reasons for not using contraception
Characteristics Fertility related Method related Opposition to use Religious opposition Lack of knowledge Others
a
Total Total women
India 34.0 5.9 11.1 9.2 2.1 37.7 100.0 28,038
Residence
Rural 33.5 5.5 11.3 9.5 2.7 37.5 100.0 16,941
Urban 34.9 6.5 10.7 8.8 1.1 38.0 100.0 11,097
Age group (years)
15-19 47.7 4.5 13.1 3.4 0.0 31.3 100.0 176
20-24 44.9 4.0 10.9 6.5 2.8 30.9 100.0 2,247
25-29 39.4 5.4 12.1 6.7 1.9 34.5 100.0 4,916
30-34 28.1 6.3 11.9 9.7 2.6 41.4 100.0 5,728
35-39 25.8 6.5 12.7 10.3 2.3 42.4 100.0 6,141
40-44 32.5 6.1 9.6 10.7 2.0 39.1 100.0 5,297
45-49 45.1 5.8 7.8 10.1 0.9 30.3 100.0 3,532
Age at consummation of marriage (years)
Below 18 33.0 6.1 11.0 9.6 2.3 38.0 100.0 14,461
18 and above 35.2 5.7 11.2 8.8 1.9 37.2 100.0 13,576
Marital duration (years)
Less than 2 48.4 3.2 10.1 5.2 0.4 32.7 100.0 249
2-4 50.7 4.6 10.7 5.7 0.9 27.4 100.0 758
5 and above 33.4 6.0 11.1 9.4 2.1 38.0 100.0 27,031
Parity
Below 2 30.2 5.9 12.2 7.1 1.2 43.4 100.0 884
2-4 33.4 6.4 11.5 6.9 1.8 40.0 100.0 13,481
5 and above 34.9 5.4 10.6 11.6 2.4 35.1 100.0 13,672
Women’s education (in completed years)
Uneducated 34.8 5.4 11.0 9.9 2.6 36.3 100.0 18,077
Less than 5 37.5 6.0 10.9 8.7 2.4 34.5 100.0 2,193
5-9 31.2 7.3 11.3 8.4 1.2 40.6 100.0 5,432
10 and above 31.1 6.3 11.4 6.5 0.3 44.4 100.0 2,335
Husband’s education (in completed years)
b
Uneducated 35.2 5.4 11.6 9.5 2.7 35.6 100.0 11,042
less than 5 37.3 4.8 12.6 9.4 2.8 33.1 100.0 2,812
5-9 33.7 6.5 10.1 9.2 1.8 38.7 100.0 8,331
10 and above 30.5 6.7 11.0 8.6 0.9 42.3 100.0 5,598
Media exposure
c
Yes 34.8 5.9 10.6 9.4 1.4 37.9 100.0 23,578
No 29.8 5.8 13.9 8.5 6.0 36.0 100.0 4,460
Caste/tribe
SC/ST 31.1 4.3 8.5 14.4 3.3 38.4 100.0 2,101
OBC 30.4 6.3 9.3 10.9 1.9 41.2 100.0 13,990
Others 38.8 5.7 13.6 6.4 2.1 33.4 100.0 11,947
Wealth quintile
Poorest 33.3 4.4 12.8 10.5 4.4 34.6 100.0 3,906
Poor 34.4 5.1 12.4 10.2 3.2 34.7 100.0 5,254
Middle 35.6 6.9 10.6 9.1 2.1 35.7 100.0 5,727
Rich 35.8 6.0 10.4 7.9 1.1 38.8 100.0 6,513
Richest 31.0 6.5 10.2 9.2 0.8 42.3 100.0 6,637
Notes:
a
Others include who said husband away, up to god, health concerns, other, do not know and missing cases;
b
excludes missing cases;
c
information related to family planning received from different media and other sources
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Multivariate analysis for use of family planning method in future
Table III has shown that, non-Muslim women are significantly more likely (OR ¼1.540, po0.001)
to intend to use family planning method in the future than Muslim women. It is also evident that,
intention to use of family planning method in the future is reduced significantly with the
succeeding age groups of women. Women aged 30-39 years and 40-49 years are found less
likely (OR ¼0.300 and 0.043, po0.001) to intend to use family planning method in the future
compared to women in young age groups (15-19 years).
Women with parity two to four, significantly two times more likely (OR ¼2.840, po0.001) and
women with parity five and above are four times (OR ¼4.310, po0.001) more likely to intend for
the use of family planning method in the future than women with parity below two. Women’s high
level of education (for ten and above years of completed education, OR ¼1.292, po0.001) and
exposure to media (OR ¼1.798, po0.001) play a significant role in motivating them towards
the use of family planning method in the future.
Discussion
Unmet need for family planning is a crucial input to programme vigilance and its success. This
indicator is obtained to understand the potential demand for family planning services among Indian
Muslim women. The present study has shown that in India, the CPR among currently married
Muslim women is 43.2 per cent, which is quite lower than the national level (55 per cent). Lower CPR
among Muslims indicates a higher need for family planning methods. Besides, it is also found that
unmet need for family planning is considerably high among women belonging to socio-economically
disadvantaged section. Predominantly, unmet need is found high among those women who
are uneducated and are not exposed to any family planning messages from any sources.
From the findings of the present study, it is also evident that in India, huge variation in the CPR
and difference in the prevalence of unmet need among Muslim women exists at the state level.
The reason behind the variation perhaps due to women’s social status (within the community),
decision-making power regarding use of contraception and access to family planning services
differ across the state boundary (Gaur et al., 2007; Ram, 2009; Sharma and Pasha, 2012).
In orthodox Islamic society, religious and cultural norms related to contraceptive use have a
significant influence on use of family planning services, irrespective of individual’s choice of
method and place of residence (Stephenson and Hennink, 2004). A study (Ram, 2009) had
shown that the prevalence of sterilization (limiting method) is significantly lower among currently
married young Muslim women than among women from other religions which also validate the
findings of the present study. Moreover, among Muslims, the prevalence of use of a traditional
family planning method is higher than other methods which indicate potential demand for the
modern contraception (Sharma and Pasha, 2012).
Figure 3 Percentage of currently married who have future intention to use family
planning method by religion, India, 2007-2008
6.7
9.2
4.1
19.6
Spacing Limiting
Percentage of women
Muslim Non Muslims
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The situation is found worse in states like Bihar, Jharkhand, Uttar Pradesh and Haryana, where
low CPR and high prevalence of unmet need among Muslims persists. Women in most of the
Muslim societies have less access to consistent means of contraception (Hassan, 2014). Within
the Muslim community, the interpretation of the “Quran’s” position on use of family planning
method is open to extensive variations (Obermeyer, 1993; Underwood, 2000). The ambiguity in
the interpretation of the “Quran” on family planning indicates that attitudes of Muslims towards
family planning are often shaped by local consensus (Amin et al., 1997; Stephenson and
Hennink, 2004). On the other hand, according to Hassan (2014), family planning itself should be
Table III Results of logistic regression analysis showing significance of the association
among future intention to use FP method and selected background
characteristics, India, 2007-2008
Future intention to use FP method
Characteristics Expb95% CIs of Expb
Religion
Muslims
a
1.0
Non-Muslims 1.540*** (1.464-1.621)
Residence
Rural
a
1.0
Urban 0.920** (0.875-0.967)
Age group (years)
15-29
a
1.0
30-39 0.300*** (0.289-0.312)
40-49 0.043*** (0.041-0.046)
Age at consummation of marriage (years)
Below18
a
1.0
18 and above 1.214*** (1.171-1.258)
Marital duration
Less than 2
a
1.0
2-4 0.866* (0.755-0.994)
5 and above 0.572*** (0.504-0.650)
Parity
Below 2
a
1.0
2-4 2.840*** (2.577-3.051)
5 and above 4.310*** (3.930-4.728)
Women’s education (in completed years)
Uneducated
a
1.0
Less than 5 1.026 (0.961-1.097)
5-9 1.120*** (1.069-1.174)
10 and above 1.292*** (1.207-1.382)
Husband’s education (in completed years)
Uneducated
a
1.0
Less than 5 1.005 (0.942-1.073)
5-9 years 1.067** (1.019-1.117)
10 and above 1.070* (1.013-1.130)
Media exposure
No
a
1.0
Yes 1.798*** (1.702-1.901 )
Caste/tribe
SC/ST
a
1.0
OBC 1.132*** (1.089-1.177)
Others 1.125*** (1.072-1.181)
Wealth quintile
Poorest
a
1.0
Poor 0.951* (0.906-0.998)
Middle 0.863*** (0.818-0.910)
Rich 0.850*** (0.801-0.902)
Richest 0.659*** (0.612-0.709)
Notes:
a
Reference category of different characteristics. Significant at ***po0.001; **po0.01; *po0.05
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perceived as a fundamental human right, especially for the disadvantaged Muslim women.
There are some justifiable reasons under Islam towards family planning that have increased CPR
in many Muslim dominated countries (above 90 per cent Muslim population). Muslims may use
contraception to evade health risks of women from repeated pregnancies, pregnancy at an early
age and short birth intervals; to avoid transmission of diseases from parents to their children; to
allow for the education, proper rearing and religious training of offspring, which are more feasible
with fewer children; to circumvent economic hardships of caring for a larger family and many
more (Roudi-Fahimi, 2004). For example, in Iran 74 per cent (highest among Muslim countries)
currently married women use contraception and therefore the country has become successful in
narrowing the gap between rural and urban areas in respect of use of modern contraception.
Usually, unmet need for family planning among women decreases with improvement in their
educational status and decision-making power, and increase in their awareness on family
planning services (Obermeyer, 1993; Laya, 2012). The existing value systems of “purdah” and
“izzat” in Islamic society, which drive the partition between sexes and detention of women to
family, reduces women’s mobility and access to services (Stephenson and Hennink, 2004). The
present study has found that unmet need for family planning is negatively associated with
women’s education level. Highly educated women are more intended to use family planning
method in the future than women with low education. Apart from the educational status of
women and their partners, there are some other factors which are associated with use of family
planning methods. Such important determinants are socio-economic status, place of residence,
access to media and other sources of information, knowledge of family planning methods,
support to family planning methods by women, their partners and other family members, current
age of users, age at consummation, marital duration, parity, wealth equity, religious beliefs and
ethnic affiliations (Addai, 1999; Mekonnen and Worku, 2011). Therefore, it is important for all to
understand the fact that contraception helps families to achieve tranquillity by having children
when they desire them and when they are ready to have them (Roudi-Fahimi, 2004).
Conclusions and recommendations
According to Mohammed Ali Albar (1989), faculty of Medicine of King Abdulaziz University,
“Islam encourages limitless procreation within wedlock; nevertheless, it does not ban the use
of temporary means of contraception. The use of permanent means of contraception is not
allowed unless pregnancy would pose a threat to the health or life of the expectant mother.
Similarly, abortion is not allowed unless the life or health of the pregnant woman is at real risk”
(pp. 79). Hence, proper and meaningful interpretation of the “Quran” can diminish the barrier to
the use of family planning among Muslim women. In a study (Iyer, 2002), author showed that
Muslim priests exercise more influence over their communities than the Hindu priests. Therefore,
co-operation from local religious leaders will help in promoting family planning and limiting family
size across the states, whereas, in a long run it is by educating women. The enhancement in the
status of Muslim women at state level can be attained by acknowledging their right to education
and by providing them equal economic opportunities (Mistry, 1999). Other Muslim countries,
such as Bangladesh, Egypt, Indonesia, Iran, and Tunisia, have already obtained the endorsement
from religious scholars contributing towards the success of their family planning programmes
(Mir and Shaikh, 2013). Likewise in India, an attempt to seek the support of religious scholars
in explicitly approving use of contraception, as well as public-private collaboration to promote
family planning programme among Indian Muslims will certainly be a revolutionary family planning
movement.
Moreover, spread of awareness and increase in reproductive health knowledge among Muslim
women are the utmost important to diminish religious barriers hindering acceptance of family
planning methods. Unmet need for contraception among Muslims should be given priority
to achieve low-fertility rate and a reduction in future population growth. Again, the fear of side
effects of IUDs needs to be overcome by supportive behavior of health personnel. The use of
emergency contraception also plays an important role in preventing unplanned pregnancies
(Ade and Patil, 2014), and it does not require partner’s consent (Rajkumari et al., 2013).
Hence, message on benefit of the use of modern contraception over the use of traditional
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contraception, use of emergency contraception and injectable is also needed to be spread
across the country.
In India, Muslim is the largest minority group, and to meet their unmet need of family planning
substantial resources will be required for supplying free contraceptive at government health
centres, for the training of service providers, for intensifying the service delivery, and for
improving the logistics management system. Increase in the effort to offer reproductive health
services among Muslims should be encouraged by state authority. Hence, governments can
play an important role in removing social and cultural barriers through educational system and
with the help of media (Roudi-Fahimi, 2004).
Limitations and scope for future work
Limitations of the study are worth mentioning. In the present study, men are not included to
explore the differences in perception of men and women towards family planning. Along with
women’s choice and decision regarding family planning issues, partner’s choice, decision and
involvement in the utilization of family planning and their perception towards use of contraception
are equally important (Mekonnen and Worku, 2011; Patra and Singh, 2014). A study (Lata et al.,
2012) has shown husbands disapproval, lack of awareness and fear of side effects are common
reasons behind high prevalence of unmet need for family planning among the respondents.
Hence, there is scope for research to find outattitudes of Muslim’s men and women towards family
planning. Interventions targeting men and aiming at overcome the cultural barriers to using family
planning method are equally imperative (Stephenson and Hennink, 2004). Individual beliefs held
by men and women about whether their religion recommends or bans contraceptive use can be
fundamental to demographic decisions (Iyer, 2002). Therefore, couple’s knowledge, attitude and
perception towards acceptance of family planning methods need to be addressed simultaneously
by interviewing the couples separately. Again, exploratory research on internal conflict between
couples and spousal violence over the choice and acceptance of family planning method,
particularly among Muslims, are also obligatory.
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pp. 75-86, available at: www.msh.org/resources/factors-associated-with-unmet-need-of-family-planning-
andits-impact-on-population-growth
Corresponding author
Shraboni Patra can be contacted at: shrageo@gmail.com
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... From the personal domain, knowledge about family planning methods and available health services was discussed as a factor influencing women's SRH [19-21, 25, 26, 28, 30, 32, 33, 35, 39, 43-45, 47-53, 68, 70, 77, 79, 80, 83, 86, 87, 89, 90]. Insufficient knowledge about contraception and lack of basic reproductive knowledge was reported as one of the main barriers to contraception use among Muslim women [20,26,29,31,39,41,46,83,90,91]. Some women are unaware of services available for them [69,74,75,78,87], particularly unmarried women [74,75,78]. ...
... An increase in women's age was associated with increased contraceptive use [21,25,27,29,34,38,40,42]. Women in their late 20s and 30s were more likely to use contraception than younger age groups (15-25 years). Parity was significantly associated with women's contraceptive use [21,24,33,36,37,[40][41][42][43][44], with contraceptive use increasing with a rising number of children [24,33,36,37,[40][41][42][43]. One study conducted in Thailand showed opposing findings, with smaller numbers of children associated with more contraceptive use. ...
... An increase in women's age was associated with increased contraceptive use [21,25,27,29,34,38,40,42]. Women in their late 20s and 30s were more likely to use contraception than younger age groups (15-25 years). Parity was significantly associated with women's contraceptive use [21,24,33,36,37,[40][41][42][43][44], with contraceptive use increasing with a rising number of children [24,33,36,37,[40][41][42][43]. One study conducted in Thailand showed opposing findings, with smaller numbers of children associated with more contraceptive use. ...
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Context: An estimate of the determinants of contraceptive usage and the extent of unmet need for contraception is necessary to determine the maximum potential demand for family planning services to achieve the targeted Total fertility rate of 2.1 in our country. Aims: To assess the contraceptive uptake and its determinants and to estimate the unmet need of contraception. Materials and Methods: A cross-sectional study was conducted amongst 728 married women of an urban Muslim dominated community in the age group 15-45 years at Khetrigao, Imphal East, Manipur, during April-June 2012. A semi-structured proforma was used to collect the respondents' characteristics. Chi-square test and multiple logistic regression analysis were used to test for association. Results: Contraceptive prevalence was found to be 55.5%, but only 351 respondents were effectively protected and were using modern methods (Couple Protection Rate 48.2%). The total unmet need calculated was 23.9%. Fear of side effect (29.9%) was the major reason for not using family planning methods. Almost half of the respondents [345 (47.4%)] gave history of undergoing abortions. Multiple logistic regression analysis showed that having access to health facility [odds ratio (OR) 1.989, 95% confidence interval (CI) 1.083-3.665], husbands having a favourable attitude toward family planning (OR 3.224, 95% CI 1.268-8.199), women who had undergone an abortion (OR 2.471, 95% CI 1.707-3.576), and women who discuss with their husbands about using contraceptives (OR 3.069, 95% CI 1.696-5.551) were significantly more likely to be users of modern contraceptive methods. Conclusion: Education of women and increased accessibility to family planning services in this community will empower them to take decisions regarding adoption of contraception. Keywords: Contraception, Limiting, Spacing, Unmet need
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Substantial proportions of women from the Muslim minority community, who want to stop or delay childbearing, do not practice contraception. The choice of contraceptives available and the variable perception of risk involved with their use along with socio-religious barriers put most women in dilemma regarding adoption of a birth control method. A qualitative study using focus group discussions and in-depth interview of women having two or more children was conducted in an urban area of Central Delhi to explore the perception and attitude of women towards family planning and barriers to use currently available contraceptives. The findings reveal that majority of the women in the current study did not favour early age marriage and prefer smaller family size. However, attitude of husband and family was mostly considered to be unfavourable for the use of contraception and to limit the family size. Religious beliefs were the most commonly cited barrier to use contraceptives especially surgical sterilization. Other barriers include fear of side-effects about IUDs and prejudiced behaviour of health care providers. These women are in need of a contraceptive which they can use confidentially and is devoid of adverse effects. Education of women can help a lot in the long-term for improving women's reproductive health.
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Men’s perception, knowledge and attitude are very important in family planning issue. Men’s attitudes towards family planning influence their partner’s attitudes and eventual adoption of contraceptive method. Present study has addressed men’s attitudes towards the use and choice of contraception by women in India. The National Family Health Survey-3 (NFHS-3) data has been used. Bivariate and multivariate analyses are used. Findings show, 22% men in India think contraception is women's business, and men should not have to worry about it. 16% men believe, by using contraception, women may become promiscuous. According to 49% men, a lactating woman, can’t become pregnant. 66% men accept that male condom, if used correctly in most of the time, can protect unwanted pregnancy. Men with higher education level (OR=9.798, p<0.01), having media exposure (OR=2.688, p<0.01) and with knowledge of modern family planning (OR=2.688, p<0.01) are significantly more likely to agree that wife can ask her husband to use condom if he has STDs. Hence, men can support the choice and use of contraception made by their wives or partners, and can adopt any modern contraception method which can protect the couples from STDs. Awareness programs and family planning services should target men from disadvantaged background.
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Background: According to NFHS-2005, prevalence of female sterilization is lowest among Muslims (21 percent). Many women prefer not to use contraception and continue childbearing until they have at least one son. Proper use of family planning methods is the key to preventing unplanned pregnancies. This study aimed to assess the contraceptive practices and awareness about emergency contraception among 82 married Muslim women in the reproductive age group. Methods: A cross-sectional study was done in an urban slum area, Raichur where all the Muslim married women in the reproductive age group, attending OPD at UHC, during between August and September 2013 were interviewed using a pre-tested and pre-structured questionnaire. Privacy, anonymity and confidentiality were maintained throughout the process of this study. Results: Out of total 82 Muslim ever married women, majority of them were literate, 63 (76.8%). 50 (61.0%) of women had family size less than or equal to 5. 44 (53.7%) were married at 16-19 years of age and 8 (9.8%) women married between 12-15 years of age which is below legal age of marriage. Maximum total numbers of births were 3-4. Those who wanted male child had births between 5-6. Majority of women 34 (41.5%) had a birth interval of 1 year and 19.5% women had no birth interval. 32 (39.0%) women didn’t use any contraceptive till they completed family. 71 (86.5%) women were aware of all the methods of contraception. Majority of women 30 (36.6%) received information from doctors. Only 11 (13.4%) women were aware of Emergency Contraception. Conclusions: Despite 76.8% literacy and 86.5% of awareness of the various methods of contraception, contraceptive practices were low among women. 32 (39.0%) women didn’t use any contraceptive till they completed family. There is a gap between awareness and practice. Awareness of emergency contraception is quite low among women (13.4%). Emphasis has to be laid on delaying marriage and first pregnancy and education on planning and spacing children and reproductive contraceptive options, especially emergency contraception since all contraceptive methods can have potential failure; the use of emergency contraceptive of plays an important role in preventing unplanned pregnancies. There is a need to improve women's education about EC. The primary health care providers can play a major role in informing their patients about emergency contraception. Keywords: Contraceptive practices, Knowledge, Emergency contraception, Muslim women