Leaving no one behind: can the Family Planning Estimation Tool help?
Authors: Anita Raj, Lotus McDougal
Journal: The Lancet Global Health (2017)

International research suggests that meeting 90% of unmet need for contraception, by averting short birth spacing, unintended pregnancy, and high fertility, could reduce poor maternal and child health outcomes and prevent 22% of maternal deaths, 22% of stillbirths, and 8% of child deaths, globally.1Black RE Levin C Walker N et al.Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition.Lancet. 2016; 388: 2811-2824Summary Full Text Full Text PDF PubMed Scopus (131) Google Scholar Modelling projections of unmet need for contraception in subpopulations can help countries better target efforts to improve contraceptive use. At present, models are limited to national projections, but in The Lancet Global Health, Jin Rou New and colleagues2New JR, Cahill N, Stover J, Gupta YP, Alkema L. Rates and trends in contraceptive prevalence, unmet need and demand for family planning for 29 states and union territories in India: a subnational analysis with the Family Planning Estimation Tool. Lancet Glob Health; 5: e350–58.Google Scholar present a new Family Planning Estimation Tool (FPET) that supports subnational geographic analysis of key family planning metrics (contraceptive prevalence, unmet need for family planning, and demand for family planning satisfied with modern methods). Such an approach improves precision in understanding contraceptive use and is in keeping with the Sustainable Development Goals' (SDGs') global agenda of “leaving no one behind”.3United Nations Economic and Social CouncilReport of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators. United Nations, New York2016Google Scholar New and colleagues apply FPET to India for state-level projections of these key metrics from 1990 to 2030; the findings show substantial heterogeneity within India but also reveal trajectories that suggest a need for greater focus on states such as Goa, which has a low fertility rate4Pachauri S Priority strategies for India's family planning programme.Indian J Med Res. 2014; 140: S137-S146PubMed Google Scholar but one of the largest projected gaps in the country for family planning demand satisfied with modern methods by 2030,2New JR, Cahill N, Stover J, Gupta YP, Alkema L. Rates and trends in contraceptive prevalence, unmet need and demand for family planning for 29 states and union territories in India: a subnational analysis with the Family Planning Estimation Tool. Lancet Glob Health; 5: e350–58.Google Scholar and Uttar Pradesh, which has shown significant improvement in modern contraceptive use since 1990 but is projected to require an additional 9 million new users to meet the authors' specified target of 75% demand satisfied with modern methods.2New JR, Cahill N, Stover J, Gupta YP, Alkema L. Rates and trends in contraceptive prevalence, unmet need and demand for family planning for 29 states and union territories in India: a subnational analysis with the Family Planning Estimation Tool. Lancet Glob Health; 5: e350–58.Google Scholar FPET is a valuable tool to support monitoring of SDG 3·7, which calls for universal access to family planning by 2030,3United Nations Economic and Social CouncilReport of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators. United Nations, New York2016Google Scholar albeit with a focus on demand and utilisation rather than access. Nonetheless, subnational geographic projections must be considered in light of some data limitations. Unmarried women are not included, and even among married women, disaggregation by key equity indicators affecting contraceptive use, such as age, wealth, ethnicity, and rural residence,5IIPSNational Family Health Survey (NFHS-3), 2005–06: India: Volume I. International Institute for Population Sciences and Macro International, Mumbai2007Google Scholar as well as related gender empowerment indicators such as mobility and decision-making control,6James-Hawkins L Peters C VanderEnde K Bardin L Yount KM Women's agency and its relationship to current contraceptive use in lower- and middle-income countries: a systematic review of the literature.Glob Public Health. 2016; (published online Oct 1.)http://dx.doi.org/10.1080/17441692.2016.1239270PubMed Google Scholar is not available. Finally, and perhaps most importantly, FPET does not provide a breakdown by type of contraception. New and colleagues note that “the best-performing states or union territories are in the central region of India and the worst performing are in the northeast”. However, central states such as Andhra Pradesh, Maharashta, and Karnataka are also characterised by high rates of female sterilisation (reported by 49–68% of women of childbearing age in these states); less than 3% of women report use of the contraceptive pill, intrauterine device, or injectable contraceptives in these same states.7IIPSNFHS-4 Fact Sheets for Key Indicators Based on Final Data. National Institute of Health and Family Welfare, Mumbai2017Google Scholar States in the northeast, such as Manipur, Meghalaya, Assam, and Tripura, have some of the lowest proportions of female sterilisation in the country, ranging from 3% to 14%, but also report some of the highest prevalences of pill use (12–26%).7IIPSNFHS-4 Fact Sheets for Key Indicators Based on Final Data. National Institute of Health and Family Welfare, Mumbai2017Google Scholar These data reveal important state-level variations by type of contraceptive (spacing vs limiting). Variations in contraceptive type may further change with India's expansion in access to intrauterine devices and injectables,8FP20202016 FP2020 Annual Commitment Update Questionnaire Response: India.http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/09/FP2020_2016_Annual_Commitment_Update_Questionnaire-India_DLC.pdfDate: 2016Google Scholar and simultaneous curbing of female sterilisation camps because of deaths and a subsequent Supreme Court ruling against their continuation for a period of 3 years.9Mohanty S Bhalla N Indian activists welcome top court ban on ‘sterilization camps’ after women's deaths. Reuters.http://news.trust.org/item/20160916170351-mbik6/Date: September 16, 2016Google Scholar Despite these caveats and limitations, FPET is a key resource for Ministries of Health to monitor progress and to prioritise and advocate for states, and possibly in a future iteration, for more vulnerable subpopulations based on both social and gender inequities and with consideration of contraceptives by type. The ability to look at key metrics such as demand for family planning satisfied with modern methods broken down by geography and age and decision-making power, as well as contraceptive type, for example, will more concretely highlight subgroups that are in need of more direct programmatic and policy support to improve their health services and outcomes. This more nuanced modelling approach could enable tools such as FPET to have a broader, more effective reach, and to provide even more meaningful information to programme managers, policy makers, and funders. Whether with FPET or any modelling tool, benefits are best obtained in conjunction with other data to verify and interpret findings, as all tools are subject to assumptions that can change or may not consistently hold true across populations. Finally, efforts to model subgroup-specific family planning projections, and to leave no one behind to achieve ambitious and even aspirational targets such as those set in the SDGs, must guard against compromising choice and reproductive autonomy for women, particularly those who are most socially vulnerable. Certainly, India's progress on family planning has been impeded by over-reliance on a single method (female sterilisation5IIPSNational Family Health Survey (NFHS-3), 2005–06: India: Volume I. International Institute for Population Sciences and Macro International, Mumbai2007Google Scholar, 7IIPSNFHS-4 Fact Sheets for Key Indicators Based on Final Data. National Institute of Health and Family Welfare, Mumbai2017Google Scholar), with government sterilisation targets implicated in poor quality care and female mortality.9Mohanty S Bhalla N Indian activists welcome top court ban on ‘sterilization camps’ after women's deaths. Reuters.http://news.trust.org/item/20160916170351-mbik6/Date: September 16, 2016Google Scholar With the advent of promising modelling tools like FPET and a SDG agenda focused on disaggregated indicator tracking, care must be taken that choice and rights are not compromised on a course of meeting targets for all. We declare no competing interests Levels and trends in contraceptive prevalence, unmet need, and demand for family planning for 29 states and union territories in India: a modelling study using the Family Planning Estimation ToolThe demand for family planning among the states and union territories in India is highly diverse. Greatest attention is needed in Uttar Pradesh, Manipur, and Meghalaya to meet UN targets. The analysis can be generalised to other countries as well as other subpopulations. Full-Text PDF Open Access