Understanding drivers of family planning in rural northern India: An integrated mixed-methods approach

Background: Family planning is a key means to achieving many of the Sustainable Development Goals. Around the world, governments and partners have prioritized investments to increase access to and uptake of family planning methods. In Uttar Pradesh, India, the government and its partners have made significant efforts to increase awareness, supply, and access to modern contraceptives. Despite progress, uptake remains stubbornly low. This calls for systematic research into understanding the ‘why’—why people are or aren’t using modern methods, what drives their decisions, and who influences them. Methods: We use a mixed-methods approach, analyzing three existing quantitative data sets to identify trends and geographic variation, gaps and contextual factors associated with family planning uptake and collecting new qualitative data through in-depth immersion interviews, journey mapping, and decision games to understand systemic and individual-level barriers to family planning use, household decision making patterns and community level barriers. Results: We find that reasons for adoption of family planning are complex–while access and awareness are critical, they are not sufficient for increasing uptake of modern methods. Although awareness is necessary for uptake, we found a steep drop-off (59%) between high awareness of modern contraceptive methods and its intention to use, and an additional but smaller drop-off from intention to actual use (9%). While perceived access, age, education and other demographic variables partially predict modern contraceptive intention to use, the qualitative data shows that other behavioral drivers including household decision making dynamics, shame to obtain modern contraceptives, and high-risk perception around side-effects also contribute to low intention to use modern contraceptives. The data also reveals that strong norms and financial considerations by couples are the driving force behind the decision to use and when to use family planning methods. Conclusion: The finding stresses the need to shift focus towards building intention, in addition to ensuring access of trained staff, and commodities drugs and equipment, and building capacities of health care providers.