Regional Health Forum

Regional Health Forum WHO South-East Asia Region Volume 8 Number 1, 2004

Women’s Health

Changing Family Planning Scenario in India#

By K.G. Santhya, PhD*

Introduction

Over the decades, contraceptive use has been increasing in India. At the same time, there is a substantial unmet need for contraception. The contraceptive scenario is also characterized by the predominance of non-reversible methods, limited use of male/couple-dependent methods, substantial levels of discontinuation, negligible use of contraceptives among both married and unmarried adolescents and wide regional variations.

Contraceptive Scenario

Nationally, nearly one half of currently married women (48%) were using some method of contraception in 1998-1999.⁽¹⁾ Contraceptive prevalence varied widely among states, from less than 30% in Bihar, Meghalaya and Uttar Pradesh to more than 60% in Delhi, Haryana, Himachal Pradesh, Kerala, Punjab, Maharashtra and West Bengal. Data for the 1990s, as reflected in the National Family Health Survey (NFHS)- 1 and 2, indicate that current contraceptive use increased by 18% nationally.⁽¹⁾ There has been an overall increase in contraceptive use in almost all states, except Goa, Jammu and Kashmir, and Meghalaya over the same period.

Method mix

Since the nineteen sixties, the family welfare programme has in theory adopted a ‘cafeteria approach’ whereby clients are provided with a choice of contraceptive methods. However, it is well documented that, until recently, the programme emphasis remained skewed towards promoting non-reversible methods, particularly female sterilization. Nationally, sterilization (female and male, but primarily female sterilization) accounts for 84% of current contraceptive prevalence due to modern methods and 75% of overall contraceptive prevalence. ⁽¹⁾ Although reported by a negligible minority, sterilization was the most common method used even among married adolescents, and a review of data on contraceptive behaviour of adolescents in Asian countries shows that India is the only country where such a pattern prevails.⁽²⁾ The predominance of sterilization is observed in almost all states; more than 90% of modern contraceptive method users are sterilized in all the southern states and Bihar; the situation is most skewed in Andhra Pradesh, where 97% of all modern method users are sterilized. Exceptions include Delhi, Punjab and a few north-eastern states where fewer than three in five users of modern methods are sterilized.

Officially-sponsored spacing methods (oral contraceptive pills, intra-uterine device [IUD] and condoms) account for 14% of current contraceptive use. The use of traditional contraceptive methods is reportedly low, accounting for 10% of current contraceptive use in the country.

Direct evidence on the use of male methods is scarce as men have been excluded from most of the national surveys, and small-scale studies exploring the contra-ceptive behaviour of men are limited. Nationally, data based on the responses of currently married women show that one in ten currently married ‘couples’ were using male/ couple-dependent contraceptive methods (condoms, vasectomy, withdrawal and periodic abstinence) in 1998-1999, which translates into 21% of the total current contraceptive prevalence. ⁽¹⁾ The data also show that the use of male/couple-dependent methods was as low as 2% of currently married couples in Bihar, Mizoram and Karnataka, and as high as 23%-28% of currently married couples in Delhi, Punjab and West Bengal.

Specific data on the use of modern male methods show that only a small minority of currently married couples were using such methods (condoms: 3% and vasectomy: 2%). Condom use was typically low in almost all the states, except Delhi and Punjab, where 18% and 14% respectively of currently married couples were using condoms. Nationally, over the nineties, the extent of use of male/couple-dependent methods remained the same. At the state level, all the southern states recorded a decline in the proportion of currently married couples using male/couple-dependent methods during the nineties (a decline ranging from 21% to 46%). Among the four major northern states, while Madhya Pradesh and Bihar recorded a decline, the proportion of couples using male methods increased in Rajasthan and Uttar Pradesh.

Contraceptive discontinuation and switching

As contraceptive use increases and becomes a more established behaviour, prevalence is no longer a sufficient marker of programme success.⁽³⁾ Contraceptive continuation may become more important than acceptance in increasing contraceptive prevalence.⁽⁴⁾

In India, as the vast majority (66%) of ever-users are sterilized, only a small proportion of ever-users have the option of discontinuing its use. Nationally, data from NFHS-2 show that one in ten currently married women who have ever used a contraceptive method (which translates into 29% of ever-users of reversible methods) had discontinued its use at the time of the survey. The data also show that younger women (15–24-year-olds) were more likely to discontinue using contraceptives compared to older women. Younger women were also more likely to mention the desire for a child and less likely to mention side-effects as their main reason for discontinuation. However, younger women were no more likely than older women to discontinue contraceptive use due to method failure or difficulty in accessing a suitable method. Notably, contraceptive discontinuation was comparatively higher in the northern and north-eastern states, particularly the latter, than in the southern states. Moreover, women who discontinued using contra-ceptives in the northern and north-eastern states more frequently reported difficulty in accessing a method or inconvenience in using a method as reasons for disconti-nuation, compared with women in the southern states. ⁽¹⁾ Studies show higher discontinuation levels for oral contraceptive pills and condoms than IUDs.^(5-6) The tendency to discontinue contraceptive use seems to be more common in rural areas than in urban areas.⁽⁷⁾

Information on patterns of contraceptive switching is limited.  An analysis of data on future use of contraceptives available from NFHS-2 sheds light on the intended pattern of switching among current discontinuers and indicates that one third intend to use another method within 12 months from the time of the survey, another one third intend to use a method some time later, and the rest do not intend to use any method at all. While nearly one half (46%) of the potential contraceptive switchers plan to use female sterilization, one fifth plan to switch to pills, one tenth to condoms and another one tenth to natural family planning. Among discontinuers who intend to switch to a method within 12 months, the choice tends to be more in favour of reversible methods (48% for modern reversible methods, 10% for natural family planning methods and 33% for non-reversible methods). A prospective follow-up study of IUD users in Gujarat shows that approximately one third of those who discontinued contraceptive use after 12-18 months did not switch to any other method, one in ten switched to female sterilization, one in twenty to natural methods, 3% to oral pills and 3% to condoms.⁽⁵⁾

Unmet need for contraception

Despite improved availability and access to contraceptive services, a substantial propor-tion of pregnancies (21% of all pregnancies that resulted in live births nationally) were unplanned (mistimed or unwanted).⁽¹⁾ It is estimated that if all unwanted births could be eliminated, the total fertility rate would drop to the replacement level of fertility. Moreover, several studies report that the desire to limit family size and to space the next birth are the main reasons mentioned by the majority of abortion seekers,⁽⁸⁾ clearly highlighting that there is a substantial unmet need for contraception among women in India.

The NFHS-2 reports that 16% of currently married women have an unmet contraceptive need, which translates into one fourth of women who wish to space or limit births.¹ Based on the current population of 1 027 million, this implies that approximately 40 million married women have an unmet need.⁽⁹⁾ While the needs of the vast majority of women who wish to stop childbearing are being satisfied, the needs of women who wish to delay or space childbearing remain largely unsatisfied. For example, it is estimated that the needs of 86% of women who wish to stop childbearing are addressed by the existing services, compared to the needs of 30% of women who wish to delay their next pregnancy.

Young women are more likely to have an unmet need for contraception. According to NFHS-2 data, 25% of young women, compared to 17% of women aged 25-34 years and 7% of women above 35 years, had an unmet need for contraception. ⁽¹⁾ When translated in terms of young women who wished to space or limit births, this implies that the existing service delivery system was addressing the contraceptive needs of only 44% of young women. Among women who have not given birth, the contraceptive needs of only 25% of women are satisfied. ⁽¹⁾ In addition to the strong programmatic emphasis on sterilization until recently, this may be partly due to the neglect of young women by the programme that perceives a contraceptive need among young people only after they have completed their family formation. Evidence is emerging, however, that young couples, despite community norms that favour a first child soon after marriage, would prefer delaying the first birth until they have spent more time together getting to know each other better.⁽¹⁰⁾

There are pronounced regional differences in the proportion of women with an unmet need for contraception. The NFHS-2 shows that the level of unmet need is higher in northern and north-eastern states than in southern states − 19% vs. 11%. There are substantial differences in the unmet need within each region as well. In southern states, for example, 8% of married women in Andhra Pradesh had an unmet need for contraception, compared to 17% in Goa. Similarly, the level of unmet need in northern states ranged from 7% in Punjab to 25% in Bihar and Uttar Pradesh, and in the north-eastern states from 16% in Mizoram to 36% in Meghalaya. ⁽¹⁾

The proportion of women with an unmet need declined by 19% during the six years between NFHS-1 and NFHS-2; the decline was more pronounced in the case of unmet need for spacing (by 25%) than for limiting (12%) (see Figure 1).

Barriers to Meeting Contraceptive Needs

The family planning programme has been successful in improving contraceptive accep-tance and reducing fertility rates but its achievements have been modest. While contextual and structural factors (high levels of illiteracy, poor access to sources of knowledge, poverty, gender and non-gender-based disparities) are partly responsible, the direction, emphasis and strategies followed hitherto in the family welfare programme have contributed largely to the limited success of the programme.

Limited knowledge

As is known, the small family norm is widely accepted (the mean ideal family size reported by young people currently is 2.5 children) and general awareness of contraception is universal (99% of currently married women in the reproductive age group were aware of a contraceptive method). However, awareness of reversible (modern or natural) methods is relatively limited among both women and men.  Nationally, for example, only 71% of currently married women were aware of con-doms. ⁽¹⁾ In some major states including Andhra Pradesh, Karnataka, Madhya Pradesh and Orissa, fewer than three in five currently married women were aware of condoms. Awareness of specific reversible methods that are suitable for young women was even more limited among young women compared to other women. For example, only three fifths of married adolescents were aware of condoms, compared to nearly three fourths of women between 20-34 years.⁽¹¹⁾ Small-scale studies show that a substantial proportion of unmarried boys and girls also lack contraceptive knowledge.^(12-13)

Inadequate knowledge of contraceptive methods, and incomplete or erroneous information about where to obtain methods and how to use them are the main reasons for not accepting family planning.^(14-16) Studies assessing correct, adequate and timely knowledge suggest that only a small proportion have complete knowledge of various contraceptive methods. ^(17-19)

In many cases, men and women who were otherwise aware of contraceptive methods did not have timely knowledge. Studies show that if these couples had such knowledge during the initial years of their married life, they might have delayed the first pregnancy.^{(10, 14, 20)}

Limited male involvement

Within the patriarchal set-up in India, women have relatively little power. The critical role of the husband has been noted in several studies on decision-making related to the use of contraception, especially during the early years of marriage.^{(10, 21-24, 25-26)}  Most couples do not discuss with each other when to have their first child, birth spacing or contra-ception.^{(1, 27-28)}  Nationally, for example, fewer than one in five currently married women reported discussing family planning with their husbands.⁽¹⁾ Studies also show that most men approve of contraception only after having a second or third child, ⁽²⁸⁾ and that husbands’ approval of a particular method is critical.⁽²⁹⁾

Though the need for promoting shared responsibility and the active involvement of men to improve reproductive health for all has been acknowledged, men’s roles have not been properly defined in government programmes. There have been some programme efforts to promote the use of male methods such as vasectomy and condoms, and initiatives to re-popularise vasectomy, including information, education and communication (IEC) campaigns and training of surgeons in ‘no-scalpel’ vasectomy have been launched in several states.⁽³⁰⁾ Though these efforts have proved to be successful in some districts in Andhra Pradesh, a similar change has not occurred in most other states.⁽³¹⁾

Male health workers could play an important role in promoting male involvement in reproductive and child health. However, two thirds of primary health centres in India do not have a male health worker.⁽³²⁾ Moreover, the Reproductive and Child Health Programme document offers no clear guidelines on the role of male workers.⁽³³⁾  The experience in Karnataka shows that male workers who traditionally focused on malaria and tuberculosis screening and follow-up, view reproductive and child health as the domain of the female worker.⁽³⁴⁾

Limited informed choice

The public sector essentially provides five contraceptive methods − two forms of tubectomy (laproscopy and minilap), vasec-tomy (including ‘no-scalpel’ vasectomy), IUDs (Copper T200), oral pills (combined) and condoms. Efforts to broaden the basket of choices have been under way, including clinical trials to assess the safety and efficacy of available methods such as estrogen-progestogen combination injectables, vaginal rings and long-acting IUDs, and the development of new methods of male and female fertility regulation.⁽³⁵⁾ As part of expanding contraceptive choice, the govern-ment has introduced emergency contra-ceptive pills in the Reproductive and Child Health programme.⁽³⁶⁾ However, most women and men, particularly those who rely on the public sector (76% of current users of modern methods rely on the public sector)⁽¹⁾,do not have access to a wide choice of contraceptives. Methods that are perceived as less effective including pessaries, spermi-cides, diaphragms, or are controversial including injectables and implants, are either dropped from the public programme, or are not introduced or are given low priority by health workers. The recently-introduced emergency contraceptive pills are currently available through medical officers only at the district and sub-district level.⁽³⁷⁾

Not only is access to a wider choice of methods limited, but providers also often do not assist women and men to exercise their right to contraceptive choice by offering them complete and accurate information on the variety of methods available. Nationally, for example, only 15% of users of modern contraceptive methods who were motivated by a health worker from the public or private sector were informed of at least one alternative method.⁽¹⁾ Private and nongovern-mental organization (NGO) health workers were more likely to inform clients of alternative methods than were public sector health workers (28% vs. 19%).⁽¹⁾ Several small-scale studies report that most providers have a distinct bias towards sterilization and only a minority of clients are informed of reversible methods.^(38-48)

In spite of evidence that pre-acceptance counselling improves contraceptive continua-tion ^(49-50),counselling of clients on how the method works, what the expected side-effects are and how to manage the side-effects is typically lacking or limited in the family welfare programme. Nationally, data from NFHS-2 indicate that only 22% of users of any modern method were informed of its possible side-effects at the time of accepting the method.¹ Similarly, data from the Reproductive and Child Health Survey report that only one third of sterilization users (35%), less than one half of IUD users (46%) and less than one fourth of pill users (23%) were informed of side-effects before accepting the method.⁽⁵¹⁾

Research on users’ perspectives/client acceptability of methods is limited, but available evidence suggests that many of these methods are acceptable to women in rural and urban areas.^(52-53) Evidence is emerging that if provided with detailed information on all available contraceptive methods, women do make an informed choice overriding the provider’s bias. For example, in a study where potential clients were provided with detailed information on various methods such as IUDs, oral pills, condoms, sterilization and Norplant, the majority (80%) opted for reversible methods, irrespective of their literacy status, and only 17% accepted sterilization.⁽⁵⁴⁾

Limited access and availability of services

Over the decades, there has been considerable expansion and strengthening of the health care infrastructure, and family welfare services are now an integral part of services provided by primary, secondary and tertiary care institutions across the country. Currently, approximately 137 271 sub-centres (1/4 579 population) and 22 975 primary health centres (1/27 364 population) in the rural areas, and 871 health posts and 1 083 family welfare centres in urban areas provide family planning services at the grass-roots level.³¹ Access to contraceptive methods has increased significantly, and only a negligible minority of women (4% as per NFHS-2 data) ⁽¹⁾ perceive availability, accessibility or cost as major impediments to using contraception. Yet, in practice, access to and availability of services are significant issues of concern.

Where workers are available, they are generally poorly trained and have little knowledge of the methods they are to provide. ^{(25, 55)}  A facility survey observes that only 16% of primary health centres have physicians trained in conducting sterilization, and only two thirds have at least one paramedical staff trained in IUD insertion.³² While female health workers in many studies reported that they had received training in IUD insertion, the majority did not feel confident about actually inserting an IUD in field-settings or showed little awareness of the precautions to be taken.⁴⁸ The Repro-ductive and Child Health Programme has laid greater emphasis on skill upgradation and gender sensitization training, and a nationwide reproductive and child health training programme has been launched to upgrade the skills of health providers and managers to deliver the package of repro-ductive and child health services. A mid-term review of the reproductive and child health training programme has noted that the training focuses more on the technical aspects of service delivery and gives little importance to areas such as client needs and quality of services.⁽⁵⁶⁾

Health and family planning workers are required to regularly visit households in their assigned areas to provide information related to health and family planning, counsel and motivate women to adopt appropriate health and family planning practices, and deliver other related services. However, data from NFHS-2 indicate that only 13% of women had received a home visit from a health and family planning worker during the 12 months preceding the survey and only 11% of women who were visited at home reported that they received family planning services. Women without any children were least likely to receive a home visit.⁽¹⁾. State-level data show that less than 2% of women in many states including Arunachal Pradesh, Delhi, Haryana, Jammu and Kashmir, Nagaland and Punjab received a home visit from a health and family planning worker in the 12 months preceding the survey. In only four states − Gujarat, Maharashtra, Mizoram and Tamil Nadu − did at least 25% of women receive such visits. Several small-scale studies also reveal significant shortcomings in the frequency and regularity of outreach services, the time devoted by workers to such activities and the length of time spent with clients.⁽⁵⁵⁾ Additionally, outreach services were reported to be almost non-existent in remote and tribal areas.⁽⁴³⁾ Moreover, health workers at the community level were often looked upon with distrust, and identified as interested only in recruiting ‘cases’ for family planning.^(25-26)  The introduction of the Target-free Approach/ Community Needs Assessment Approach, however, has reportedly enabled front-line health workers to gain a more positive image in their communities.^{(34, 57-58)}

The Reproductive and Child Health programme recommends that women who do not deliver in institutions should receive three postpartum visits during which they are to be provided with advice on family plan-ning. Data from NFHS-2 show not only that postpartum check-ups are almost non-existent but also that family planning is given the lowest priority among the various compo-nents of postpartum care.⁽¹⁾ Nationally, fewer than one in five non-institutional births were followed by a postpartum check-up. Among those who received a postpartum check-up, only 27% of mothers received advice on family planning, compared to 43% receiving advice on breastfeeding and 46% receiving advice on baby care. Adolescent mothers and women delivering for the first time were less likely than older women to receive advice on family planning. Notably, mothers received advice on family planning during postpartum check-ups for only 14% of first births, although these women are more likely to need advice on birth spacing and contraception. Clearly health workers and other providers tend to overlook adolescent and young women until they are further advanced in their reproductive careers.

Stock-outs and erratic supplies of reversible contraceptives make it unrealistic to expect providers to offer clients a choice of methods. A survey reported that only 56%-61% of primary health centres had some stocks of condoms, IUDs and oral pills on the day of the survey. The situation was worse in states like Bihar, Orissa and Uttar Pradesh where fewer than one fifth of primary health centres had some stocks of these methods.⁽³²⁾

Many new initiatives, the restructuring of existing measures, particularly those under-taken by NGOs, and some experiments with public-private partnerships have been successful in improving access to and availa-bility of contraceptive and other reproductive health services. The social marketing and social franchising of selected reproductive health services by Janani, a registered society in Bihar,⁽⁵⁹⁾ and the experience of the Innovations in Family Planning Services project in Uttar Pradesh ⁾⁶⁰⁾ are examples of such success. 

Poor quality of services

It is now widely acknowledged that the quality of family planning services is generally poor. Little consideration is given to interpersonal interactions.^{(14,44,61-64)} Service providers tend to be insensitive and disregard women’s need for privacy. Pre-acceptance counselling or check-ups are limited, and little attention is paid to post-acceptance follow-up services. Nationally, for example, data from NFHS-2 showed that three in four sterilization users and two in five users of other modern methods received follow-up services.⁽¹⁾ The data also showed that although the quality of family planning services was far from satisfactory in all states, the quality of services was poorer in states such as Arunachal Pradesh, Orissa, Uttar Pradesh and West Bengal. 

Changing the Policy and Programme Environment

The Family Planning programme in India, launched in 1951, has evolved through a number of stages and has changed its direction, emphasis and strategies. The 1990s particularly witnessed dramatic changes in the family welfare policy and programme. With the 72^nd and 73^rd Constitutional amendments and the passing of the Panchayati Raj and Nagar Palika Acts in 1992, the Family Planning programme was legally brought into the domain of panchayati raj institutions. In 1996, the target-oriented approach was replaced with the target-free approach, where health workers’ case-load would be determined by needs identified at the community level rather than set at the central or state level. In 1997, in order to direct the programme more towards clients’ needs, the target-free approach was recast as the community needs assessment approach, and decentralized participatory planning was brought in place. In the same year, the Reproductive and Child Health programme was launched. The Reproductive and Child Health programme espouses the principles of client satisfaction and high quality in delivering comprehensive and integrated health services.

The National Population policy, adopted in February 2000, further legitimised the shift towards incorporating quality of care within public sector services. The National Popula-tion policy provides a policy framework for achieving the twin objectives of population stabilization and promoting reproductive health within the wider context of sustainable development. The immediate objective of the policy is to address the unmet need for contraception and to provide integrated service delivery for basic reproductive and child health care. In the medium term, the policy seeks to achieve the goal of bringing the total fertility rates to replacement level by 2010 through vigorous implementation of inter-sectoral operational strategies.⁽⁶⁵⁾ The National Population policy affirms the government’s commitment to the provision of quality services, information and counselling, and expanding contraceptive method choices in order to enable people to make voluntary and informed choices.

The strategies delineated in the new policies are currently under way with varying intensity and clarity in different parts of the country. It is too early to make definitive assessments about the impact of the new initiatives. However, early assessments suggest that although a decentralized, participative planning process through community needs assessment has begun, it requires considerable refinement to become effectively functional.⁽⁶⁶⁾ Uncertain of the consequences of the new approach, many states continue to impose targets, setting local goals based on the previous year’s centrally assigned targets ⁾⁶⁷⁾ Women’s involvement in the process of decentralized decision-making at the grass-roots has yet to be operationalized. In many states, the involvement of the community and other stakeholders, including panchayati raj institutions, in community needs assessment is reported to be minimal.^(31,68)

The Way Forward

Though the Family Planning programme has experienced significant growth and expansion over the past half century, pregnancies continue to be unplanned and the unmet need for contraception remains substantially high. Important sub-groups, such as ado-lescents, are neglected or underserved, the vast majority of contraceptive users are sterilized, contraceptive choice is conspi-cuous by its absence and quality of care is limited within the programme.

The 1990s witnessed a growing recognition of the challenges faced by the programme that led to the development of several new policy initiatives. The programme focus has shifted from vertical family plan-ning services towards the provision of comprehensive, integrated reproductive health care. Early assessment of the impact of the new policy and programme initiatives suggests some improvements in overall indicators such as contraceptive prevalence rates and the magnitude of unmet need for contraception. However, the underlying issues including limited contraceptive choice, poor quality of services, restricted access, gender inequalities and lack of male involvement continue to plague the programme. Mechanisms to address these issues remain elusive and the strategies outlined in policies to address these core issues remain poorly implemented.

Recommendations regarding the Programme

     An expanded reproductive health programme must address men both in terms of their own health needs and in terms of their shared responsibility as partners, husbands and fathers and should not be limited to promoting the use of male contraceptive methods. The role of male health workers who could play an active role in promoting male involvement also needs to be clearly defined. 

     The contraceptive needs of sexually active young people remain largely unmet. Young people, married as well as unmarried, need accurate, user-friendly information and services. Multiple entry points (edu-cation, work, sports, or other social activities) and settings (home, com-munity, workplace, school or clinic) must be used to enhance access to information and services.

     Provider bias continues to restrict the rights of women and men in exercising contraceptive choice. The providers need to be oriented about the clients’ rights to exercise choice. Additionally, a variety of providers, including traditional medical practi-tioners, should be trained and engaged to promote detailed infor-mation on various contraceptive methods.

     Given that women, especially young women, are powerless and voiceless in sexual and reproductive matters, multi-sectoral activities to enhance women’s status are much needed. Since reproductive decision-making is often beyond the control of young women and their husbands, engage-ing other gate-keepers including senior men and women in the family and influential people in the community is crucial.

     IEC efforts to enable clients to exercise informed contraceptive choice have been increased, but inadequate collaboration between the health sector, IEC units and other stakeholders is reportedly rendering these efforts ineffective. Hence, intersectoral coordination needs to be promoted vigorously.

     The involvement of the community in planning and monitoring remains minimal. Concerted efforts to promote community participation are needed.

     As reflected throughout in this review, there are substantial state-level variations in contraceptive prevalence, the method-mix com-monly used, the extent of unmet need, the level of awareness of reversible methods, and the quality of services. This clearly highlights the importance of state-specific interventions to improve family planning services.

Recommendations regarding Research

     Research on the attitude and practice of men regarding fertility regulation, and the factors inhibiting their role and participation in reproductive health could help improve and modify the delivery system. Research is also required to deter-mine men’s needs for services and information in specific communities. Operations research is required to assess how educational campaigns could be made effective to promote shared responsibilities. As methods of fertility regulation available to men are limited, priority should be given to developing male methods of family planning.

     Gaining a better understanding of how women and men make choices and negotiate trade-offs among methods could provide useful insights for policy-makers, programme managers as well as clients themselves. Future research should explore the con-text in which women and men exercise choice, including the power dynamics of relation-ships, and the interface between clients and the service system.

      Additional research is required to understand why women discontinue contraceptive use, and whether efforts to provide detailed infor-mation under the new programmes have improved contraceptive conti-nuation rates. Similarly, explorations into whether the new rhetoric on quality of care has been translated into reality and whether it has impacted contraceptive use dyna-mics are critically needed.

      Apart from data from Reproductive and Child Health-2 currently under way and a few small-scale studies, detailed and in-depth insights into the impact of new initiatives are scarce. Qualitative studies are needed to assess the perspectives of primary and secondary stakeholders regarding the changes in the programme.

Acknowledgements

I am grateful to Nicole Haberland, Shireen Jejeebhoy, Ardi Kaptiningsih, A.R. Nanda, Saroj Pachauri, T.K. Roy, Deepika Ganju, Asha Matta and anonymous reviewer for their valuable suggestions and comments. Support from the WHO South-East Asia Regional Office is acknowledged.

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