Not one method, not one woman: How India can redefine its family planning programme for a new generation

Every year, World Population Day arrives with a ritual anxiety about numbers: how many of us there are, how many more are coming, and whether that is good news or bad. This year, the United Nations Population Fund has chosen a theme that quietly overturns the usual script. It asks how we might empower young people “to create the families they want in a fair and hopeful world.” That single sentence contains almost everything that India’s family planning conversation has been missing: an acknowledgement that people still want families, that wanting them is legitimate, and that the barriers standing in their way are as much economic and emotional as they are medical.

I have spent two and a half decades in public health with a focus on women’s health, reading and assimilating survey data trying to make sense of what it means for an individual seeking care and the health system. I have learned that the clinical and the human aspects keep getting separated in policy discourse. In a commentary in BJOG with my colleague Ranee Thakar, we argued that reproductive autonomy cannot be reduced to a single metric of contraceptive coverage; it has to include the right to become a parent as much as the right not to. That argument feels more urgent with every new round of survey data, and the most recent one, the sixth National Family Health Survey, gives us a very specific reason why.

A paradox hiding in the numbers

The National Family Health Survey has tracked India’s fertility transition since the early 1990s, and the two most recent rounds, NFHS-5 (2019-21) and the newly released NFHS-6 (2023-24), together tell a story that should rejuvenate energy in anyone who has anything to do with family planning. Family planning impacts everyone, whether you are a policy maker or a teacher, a gig worker or a frontline health worker. The job of providing family planning is even more nuanced today. On the surface, the headline indicator tells a tale of success and achievement. Overall contraceptive use, counting both modern and traditional methods, rose from 66.7 per cent to 69.1 per cent of currently married women. India’s total fertility rate has held steady at 2.0 children per woman, comfortably below the replacement threshold of 2.1. Unmet need for family planning fell further, from 9.4 per cent to 8.5 per cent. Read quickly, this is a success story, and the government’s own release framed it that way, crediting programmes such as Mission Parivar Vikas for the improvement.

Deeper insights into the data highlight what has worked well and chart the path for areas to focus to strengthen and expand access. The proportion of married women using a modern method of contraception, the pill, condom, intrauterine device, injectables, implants or sterilisation, actually fell from 56.4 per cent to 52.7 per cent. The gap was filled almost entirely by a sharp rise in traditional methods, principally the rhythm method and withdrawal, which climbed from 10.3 per cent to 16.4 per cent. Female sterilisation, long the backbone of India’s programme, dipped only marginally, from 37.9 to 36.5 per cent, while male sterilisation remains statistically negligible at 0.5 per cent.

This is not simply a service-delivery data point but has much deeper roots in women’s choice and agency. Couples are choosing to plan their families, in growing numbers, but a rising share of them are doing so with methods that carry a substantially higher failure rate and that offer no protection against sexually transmitted infections. This is a nudge for policymakers, as well as healthcare providers in the public and private sectors, that there is a need for deeper understanding and investment in how these choices are being made. It is evidence that the design for offering family planning needs to be redefined to meet people where they are, and that unmet need, which is already an imperfect measure, is masking a quieter transition which requires rethinking access to information and services with a focus on quality, and trust.

Evolution process

India was the first country in the world to introduce a national family planning programme in 1952. It rightly positions family planning as a critical element of economic development while also recognising the health and welfare benefits of birth spacing and smaller families for women and children. As the country expanded its public health infrastructure during the 1960s and 1970s, the programme increasingly relied on community-based outreach. Auxiliary Nurse Midwives (ANMs) became a critical link between health facilities and households, particularly in rural areas where transport networks, roads and health systems were still evolving. They also become the unit source for data and insights, which are critical for any programme to run. While their role extended beyond service delivery to building trust, providing counseling, supporting maternal and child health, and bringing information and contraceptive services closer to communities, the assessment of impact was based on number of users, and not what the client needs and gets.

Over subsequent decades, India's approach evolved from a demographic and target-oriented framework towards a rights-based, client-centred model that emphasises informed choice, voluntarism, quality of care, and a broader reproductive health agenda. The introduction of the Community Needs Assessment Approach in the mid-1990s and the integration of family planning within the Reproductive and Child Health framework marked important milestones in this transition, shifting the focus from population goals to enabling individuals and couples to make informed decisions about the number, timing and spacing of their children according to their own aspirations and needs.

NFHS-5 highlighted that sterilisation, overwhelmingly female, accounted for roughly two-thirds of all modern contraceptive use nationally, a concentration in a single, permanent, largely irreversible method. While sterilisation is the method of choice for many women, this was a reminder for the need to expand choice and make a wider range of contraceptives available for women to choose from.

Proactive efforts have been made in this direction. Mission Parivar Vikas introduced the injectable contraceptive Antara and the non-hormonal pill Chhaya into the public system in 2017, aiming to build what policymakers like to call a “basket of choices.” In 2023, the basket expanded again with the introduction of the single-rod subdermal contraceptive implant, alongside a subcutaneous version of Antara, rolled out in a phased manner across ten states. The rationale behind this is backed by global evidence that every additional method added to a programme tends to increase overall modern contraceptive use because people find something that suits their bodies, their unique needs, matches their schedules, and allays their fears.

Every new method introduction requires meticulous planning and rigour in training and capacity building, strengthening supply chains and client education. The national programme is doing that exceptionally well leveraging technical expertise from experts. Uptake has also been increasing including women coming back to facilities for repeat doses which is reinforcement of the fact that there is a need for long-acting reversible contraceptives. This has to be linked back to the early insights we have from NFHS-6 which highlight a unique story.

A map of different choices

Look at NFHS-6 state by state, and a more hopeful question opens up. Female sterilisation accounts for close to seventy per cent of contraceptive use in Andhra Pradesh and under eight per cent in Meghalaya and Assam, a tenfold spread within one national programme. In Uttar Pradesh, Odisha, Tripura, Jharkhand, Punjab and Jammu & Kashmir, modern method use dipped even as overall contraceptive use kept climbing; couples there are stepping toward traditional methods, not away from family planning, a message worth listening to. In Himachal Pradesh, Maharashtra, Madhya Pradesh, Tamil Nadu, Telangana and Karnataka, modern method use kept rising. Infrastructure investments in the health system by these states has played a role.

Indian women are making thousands of locally specific decisions, shaped by what their health workers counsel, what their community trusts, and what has become habit over decades. This is one of the most valuable research opportunities in India’s family planning efforts. Contraceptive choice does not start at the health facility. It starts at home, with whether a woman has a voice in her own household to act on what she actually wants. And that is not some fixed, unchangeable fact about a culture or a state. It can be studied, understood, and changed with sustained effort. The opportunity is to study what already works in one part of India, or even the same state in many cases, and adapt it for another.

Who decides?

Contraceptive decisions in India are rarely made by one person alone. NFHS only asks women already using a method whether they felt they decided to use it, capturing too little about the household negotiation before a woman ever reaches a health worker. Studies find that when husband and wife report deciding jointly, contraceptive use rises sharply. In many households, particularly joint families, a mother-in-law or elder family member, the household's patriarch, carries real influence over whether, when, and how a couple plans their family. This is the actual unit of decision-making any programme has to work with, matched with sustained efforts to shift social norms.

Consent and choice matter more here than legal language suggests. A woman can be counted as a “user” of a method while having had very little say in choosing it, whether because a health worker offered only one option or an elder family member expressed a preference she could not contest. Seen this way, women navigating patriarchal structures are rarely powerless; they are strategic, working within their household's rules to secure the best outcome available. That reframes the question: not why women choose badly, but what would make it easier for her to be heard at home. Recent Indian research on women’s relative resources and contraceptive decision-making makes a related point: access to a method is not the same as the agency to choose it. India has made real strides on expanding the method mix. Focus now needs to be on supporting informed choice.

Vasectomy is the most underused lever here. NFHS-6 shows it accounts for a fraction of modern contraceptive use, even though it is simpler and safer than sterilisation; condoms already move readily through private channels, an opportunity to strengthen rather than a gap to close. The government's Vasectomy Fortnight and rising compensation are the right instruments; what is needed now is sustained investment. Male engagement also means sharing the load that falls on women, from tracking cycles to appointments, and counselling husbands as partners, not gatekeepers.

Self-care is one of the most underused tools for closing this agency gap. WHO's guidelines on self-care for sexual and reproductive health recommend self-injection of DMPA-SC, the subcutaneous contraceptive now part of India's own method mix, as safe and a genuine expansion of a woman's control over her method without a health facility visit. India has introduced DMPA-SC; supporting women’s journey to self-inject, as other countries have begun to do, is the logical next step.

Reproductive autonomy, also includes the choice not to continue a pregnancy. This is safeguarded by one of the oldest abortion laws, the Medical Termination of Pregnancy Act, 1971. Recent amendments have further strengthened access. Emergency contraception deserves the same recognition: India's oral EC pill market has grown at roughly 12 per cent a year for a decade, and the 2024 inclusion of the single-dose regimen in the National List of Essential Medicines, alongside WHO's confirmation that ECPs are safe for all women, marks a real widening of choice. Self-care, abortion access and emergency contraception rest on the same principle of supporting a woman's ability to act on her own decision, at the moment she makes it.

The introduction of Antara, Chhaya and now the implant is the clearest sign that the programme is intent on expanding contraceptive choices without focussing on one method. A newly married woman delaying her first pregnancy to finish her education; a mother of two seeking a permanent method, and a young girl seeking confidentiality, women in perimenopause, all need different things from the system, at every life stage. Meeting each of them where she is, rather than offering whichever method is easiest to deliver that month, is what a life-stage approach actually means in practice. These efforts also need to be coupled with better understanding of hormonal transitions starting from puberty to adulthood, pregnancy and in perimenopause and menopause. How well women understand these processes and how well they are equipped to manage them impacts their productivity, be it as a homemaker or as part of the workforce.

The economic and climate backdrop nobody asked to plan around

India's female labour force participation rate stood at roughly 32 per cent in 2024, still low by international comparison, and delayed marriage, education and urban costs have pushed the age of first childbirth later. Climate anxiety adds a new variable: a ten-country survey of ten thousand young people found four in five young Indian respondents frightened about the future, a higher share than the global sample. UNFPA's 2025 report adds a further layer: around 30 per cent of Indian adults say they have been unable to have the number of children they wanted, as much a family planning story as unwanted pregnancy is.

What a family-centred, life-stage approach actually requires

A family-centred, life-stage approach starts by naming the differences: an adolescent, a woman in her twenties, in her thirties, managing infertility, or nearing menopause has genuinely distinct needs.

NFHS-5 found unmet need for family planning among girls aged fifteen to nineteen at eighteen per cent, against just three per cent among women aged forty-five to forty-nine, the widest gap in the entire survey. Nearly seven per cent of girls in that age band, some 8.16 million young women, were already mothers or pregnant. Restrictive social norms and a near-absence of confidential services shape the rest of their lives. Meeting them now is one of the highest-return investments the country can make.

In the twenties, the need is dominated toward delaying first pregnancy and spacing, for women balancing careers, education and their own timeline. This is when the need for reversible contraceptives is high. By the thirties, the conversation moves toward achieving the desired family size, where consent and genuine choice matter most. Female sterilisation, while it remains disproportionately common by international standards, for many women it is the right choice. For others, as Indian clinical literature documents, it is a decision they would revisit had a reversible option been fully explained and available. Long-acting reversible contraceptives, including implants and hormonal IUDs, offered as an option among several, are the clearest way to close that gap.

Infertility, too, is a growing and under-addressed need. Secondary infertility affects more than one in four Indian women who have already had a child, linked to delayed marriage, thyroid disorders and lifestyle factors, and bringing these women inside the definition of “family planning” is a clear opportunity.

The opportunity in the private sector

India already has a large, private contraceptive market, an under-leveraged asset rather than a parallel system. Research using a total market approach finds a substantial share of India's contraceptive users already access methods privately, particularly in urban areas, while the public system carries the bulk of permanent methods and last-mile rural access.

A recent evaluation of a tech-enabled social franchising platform found it increased current use of temporary modern contraceptives by more than nine percentage points. The Federation of Obstetric and Gynaecological Societies of India has said its members would engage more actively through simpler, cost-effective, trust-based mechanisms. This complements the public system for the poorest, most remote households, while giving urban, digitally connected populations more private ways to choose.

Reframing the mission

This is an argument for strengthening contraceptive investment to serve India's diversity, not for stepping back now that fertility has reached replacement level. Contraception remains among the most cost-effective interventions in public health, and its benefits only grow from here.

What NFHS-6 makes impossible to ignore is the theory the programme now needs to wind down slowly. For decades, it achieved extraordinary results by organising around demographic targets and a small number of dominant methods, building infrastructure, workforce and trust. The next chapter asks something different: to treat every woman, from the adolescent to the woman in perimenopause, as a distinct person making a distinct decision inside a household whose dynamics matter as much as the clinic down the road. The state variation in this year's data is a map of where that flexibility already exists, and where it still needs to be built.

The tools already exist in national programme which is capable of expanding choice. States that have shown what sustained investment looks like, and a private sector ready to engage on fair terms could be the early adopters.

On this World Population Day, the honest, hopeful answer to how we support young people create the families they want, in a fair and hopeful world, is to keep girls and women at the centre of every decision this programme makes. India's family planning programme is well placed to build on its gains and carry that forward.

Medha Gandhi is the Founder and Executive Director of Counterpoint Impact Advisory.

 

This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.