Jahanvi
Background
India’s family planning programme, one of the oldest in the world, has seen considerable evolution. Yet, national progress masks deep regional inequalities. The National Family Health Survey (NFHS-5) shows that while the national contraceptive prevalence rate (CPR) has reached 67%, Bihar lags at 51.4%, with rural areas reporting even lower usage of modern spacing methods.
National vs Bihar Family Planning Statistics (NFHS-5)
Table 1: Analysis of NFHS Family Planning
| Indicator | India (NFHS-5) | Bihar (NFHS-5) |
| Any modern contraceptive use | 66.7% | 51.4% |
| Female sterilization (most common method) | 37.9% | 25.8% |
| Use of pills or injectables (spacing methods) | 8.9% | 2.1% |
| Unmet need for family planning | 9.4% | 13.3% |
Despite state and national programmes offering free services, rural women’s experiences often reflect deep social, economic, and infrastructural barriers.
This research topic emerged from my own experiences on the ground during my tenure as a Gandhi Fellow in Bihar, where I worked closely with the State Health Society and District Health officials. In community meetings and informal conversations, I witnessed how family planning decisions were shaped not only by service availability but by silence, fear, and patriarchal norms. These encounters made me realize that beyond data points lie unheard stories. This study is an effort to center those voices and to bridge the disconnect between reproductive rights as policy ideals and their lived realities in rural India.
Introduction
Despite decades of public health initiatives, access to family planning services in rural India remains uneven and fraught with systemic barriers. In the Hajipur Block of Bihar’s Vaishali district, this issue is not merely administrative—it is deeply personal and structural. Drawing on qualitative data from 30 women across six panchayats, this research investigates the intersectional realities shaping contraceptive access in rural India. This study transcends numerical metrics to explore the socio-cultural, economic, and institutional impediments that women face in exercising reproductive autonomy.
Fieldwork in Hajipur: Listening Beyond the Data
To move beyond aggregate data, I conducted qualitative fieldwork in six panchayats of Hajipur Block, Vaishali. Through 30 semi-structured interviews, I explored women’s lived realities around family planning. The aim was not just to gather opinions, but to understand how policy meets practice in rural homes and health centers.
Figure 1Interview with Pregnant Women in Dhobghatti Panchaya
Methodology
The research employed a qualitative action-research framework grounded in ethnographic methods. Semi-structured interviews were conducted with 30 women between the ages of 18 and 45. The interviews were held across six villages—Dhobghatti, Bishunpur, and four others—through Anganwadi centers and during Village Health Sanitation and Nutrition Days (VHSNDs).
Key Qualitative Insights from the Field
1. Knowledge Gaps and Misinformation
Many women had only heard of sterilization or copper-T. Pills and injectables were viewed with fear—some believed they caused infertility or weakness.
“I heard pills cause weakness—I can’t afford to lose strength; I have to work in the fields.”
2. Patriarchy in Decision-Making
Contraceptive decisions were often influenced—or dictated—by husbands and mothers-in-law. Several women used methods in secret.
“My mother-in-law threw away the contraceptives the ASHA gave me.”
3. Son Preference
Pressure to have male children often led to repeated pregnancies, even when women expressed a desire to stop.
“I have two daughters—I must try once more for a boy.”
4. Hidden Economic Costs
Despite free government supplies, women reported high indirect costs—travel, lost wages, and unofficial payments.
“I can’t afford to miss work just to get an injection that might be out of stock.”
5. Health System Gaps
PHCs were understaffed, lacked privacy, or were frequently out of stock—forcing women to walk long distances with no results.
“I walked 8 km and was told there were no injections available.”
Figure 2: Barriers to Family Planning Services
Frequency of Barriers Identified in Interviews
Below is a visualization showing the relative frequency with which each thematic barrier was identified during interviews.
Table 2: Summary of Interview Findings
Role of ASHAs: Enablers at the Frontlines
Accredited Social Health Activists (ASHAs) emerged as pivotal actors in navigating these constraints. Their proximity to communities allowed for trust-building and continuity of care. However, gaps in training, inconsistent incentive structures, and lack of support for engaging male stakeholders limited their effectiveness. Notably, where ASHAs were well-trained and supplied, women reported increased confidence and awareness.
Acts of Resistance: Quiet Empowerment
Beyond structural constraints, the research surfaced powerful examples of resistance. Women reported hiding contraceptive pills in painkiller wrappers, negotiating with husbands using financial logic, and collaborating covertly with sisters-in-law. These acts underscore not victimhood, but resilience and adaptive agency—an underrecognized form of empowerment in public health discourse.
Policy Implications and Recommendations
This study suggests that enhancing access to family planning must move beyond supply chains and infrastructure. It requires socio-cultural transformation supported by multi-level interventions:
- Inclusive Awareness Campaigns: Target men and mothers-in-law to shift household decision dynamics.
- Enhanced ASHA Capacities: Invest in comprehensive training on spacing methods and community counseling.
- Strengthened Infrastructure: Ensure consistent stock availability, privacy, and respectful treatment in PHCs.
- Economic Support Measures: Introduce transport vouchers and address opportunity costs.
- Community Dialogues: Facilitate open discussions to challenge son preference and health-related misinformation.
Conclusion
From Delhi, the policy may look like distribution targets. But in Vaishali, it looks like a woman walking miles to get an injection that isn’t there, a young mother whispering her needs to an ASHA, or a daughter-in-law hiding pills from family control.
These voices must shape the next generation of reproductive health interventions. Access alone is not enough. Dignity, privacy, and informed choice are what we must build towards.
References
- National Family Health Survey (NFHS-5), 2019–21. Ministry of Health and Family Welfare, Government of India.
https://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf - Ram, F., Mohanty, S. K., & Singh, A. (2012). Family Planning in India: A Need for a Paradigm Shift. Demography India, 41(1–2), 175–186.
- Scott, K., George, A. S., & Ved, R. R. (2019). Taking stock of 10 years of published research on the ASHA programme: examining India’s national community health worker programme from a health systems perspective. Health Research Policy and Systems, 17(1), 29.
https://doi.org/10.1186/s12961-019-0427-0 - Jain, A. K., & Hardee, K. (2018). Revising the FP Quality of Care Framework in the Context of Rights-Based Family Planning. Studies in Family Planning, 49(2), 171–179.
https://doi.org/10.1111/sifp.12052 - Government of Bihar (2021). State Health Society Bihar: Annual Report.
http://statehealthsocietybihar.org - Guttmacher Institute (2020). Adding It Up: Investing in Contraception and Maternal and Newborn Health in India.
https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-india
About the Contributor
Jahanvi is a Program Lead for the Centre of Excellence (CoE) for Learning & Design at Piramal Foundation’s Digital Bharat Collaborative Project. This initiative leverages digital technologies to strengthen health systems across India and foster Distributed Governance for systemic change.
Previously, as a Gandhi Fellow in Vaishali, Bihar, Jahanvi worked closely with the State Health Society of Bihar and the District Health Society, supporting capacity-building, ensuring compliance with the Ayushman Bharat Digital Mission, and implementing programs under the National Health Mission (NHM).
She holds an M.A. in Development Studies and is deeply committed to advancing social impact through public health, livelihoods, and development-focused initiatives. With a strong interest in impact consulting, she strives to contribute to scalable, sustainable transformation across India’s development ecosystem.
Acknowledgements
This article written as part of the Public Policy Qualitative Participatory Action Research Fieldwork Fellowship- Cohort 5.0, conducted by IMPRI, New Delhi, would not have been possible without the constant encouragement of Prof. Vibhuti Patel [Chair & Course Director], Session Speakers, and the Convenors and Coordinating team at IMPRI.
Disclaimer: All views expressed in the article belong solely to the author and not necessarily to the organisation.
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