BASELINE SURVEY REPORT

AGRA CITY

March, 2011

Chapter 1 INTRODUCTION
1.1 BACKGROUND Family planning (FP) is essential to achieving the Millennium Development Goals (Cleland et al., 2006; Potts and Fotso, 2007; Allen, 2007)1. While FP programs had considerable impact on increasing voluntary FP use and reducing fertility in many parts of the world in the 1970s-1990s, they have received less attention at the global level in recent years even as contraceptive use remains low in much of Sub Saharan Africa (SSA) and parts of South Asia despite high levels of unmet need (Cleland et al., 2006). The Bill and Melinda Gates Foundation (BMGF, also referred to as the Foundation) Reproductive Health (RH) Strategy aims to reduce maternal and infant mortality and unintended pregnancy in the developing world by increasing access to high-quality, voluntary FP services. The RH Strategy will be implemented at the country level through the Urban RH Initiative (also referred to as the Initiative). The Initiative aims to increase modern contraceptive use in selected urban areas of four countries in SSA and South Asia, namely India, Kenya, Nigeria and Senegal. In India, this Initiative has begun in select cities of Uttar Pradesh. Key elements of the Initiative include 1) integrating high-quality FP services with maternal and newborn health services especially post-abortion, post-partum, and antenatal care, and in HIV/AIDS services; 2) improving the overall quality of FP services, particularly in high-volume settings; 3) increasing access to FP services for the urban poor through public-private partnerships and other private sector approaches; and 4) creating sustained demand for FP services among the urban poor. By reaching urban women with greatest need, this comprehensive strategy is expected to increase contraceptive use among women in urban and peri-urban areas and potentially diffuse to rural areas to which urban women are linked (Cleland, 2001; Lindstrom and MunozFranco, 2005)2.
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Cleland, J., Bernstein, S., Ezeh, A., Faundes, A., Glasier, A., Innis, J. (2006). Family planning: The unfinished agenda. Lancet, 368: 181027. Potts, M., Fotso, J.C. (2007). Population growth and the Millennium Development Goals. Lancet, 360:3545. Allen, R. (2007). The role of family planning in poverty reduction. Obstetrics & Gynecology, 110(5):9991002. 2 Cleland, J. (2001). Potatoes and pills: An overview of innovation-diffusion contributions to explanations of fertility decline. In J. Casterline, ed. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington D.C.: National Academies Press. Lindstrom, D.P., Munoz-Franco, E. (2005). Migration and the diffusion of modern contraceptive knowledge and use in rural Guatemala. Studies in Family Planning, 36(4):277-288.

1.2

NEED FOR THE BASELINE SURVEY

The Measurement, Learning & Evaluation (MLE) Project will evaluate the impact and effectiveness of Urban Reproductive Health Initiative using rigorous impact evaluation methods. The MLE will address the evaluation gap for urban FP initiatives by: 1) Explicitly examining intra-urban differences in program impacts through comparison of slum and non-slum populations and of the wealthy and poor; 2) Using a strong program framework to examine steps along the causal pathway and assessing the plausibility of program effects on outcomes; 3) Using a longitudinal design to ensure the highest possible standard of evidence with minimal disruption to program implementation; and 4) Developing study tools and methods that permit generalization beyond the particular intervention areas and countries under study In short, the MLE project will use innovative methods to evaluate the impact of the Initiative on modern contraceptive use in diverse urban populations.
In India, six cities - Agra, Allahabad, Aligarh, Gorakhpur, Moradabad, and Varanasi from Uttar Pradesh are included in this study. The first four cities, Agra, Aligarh, Allahabad, and Gorakhpur are serving as the initial intervention cities while the remaining two cities, Moradabad and Varanasi, are serving as delayed intervention cities. It has a longitudinal design with baseline,

midline and end line surveys at 2 year intervals. In order to establish the baseline indicators against which the future impact of the project will be assessed, a baseline survey has been carried out at the initial stage of the project. 1.3 THE PROJECT SETTING - UTTAR PRADESH AND THE FOCUS CITIES FOR THE BASELINE

The state of Uttar Pradesh (UP) has a population of approximately 166.2 million, which accounts for nearly 16 percent of Indias total population (2001 Census). Around 21 percent of the population (34 million) is living in urban areas and urban areas are growing faster than rural areas. It is estimated that by 2016, almost 30 percent 3 of the population would be urban. Further, thirty-one percent, or 11 million people, are estimated to be living in poverty in urban Uttar Pradesh, which is the largest number of urban poor in a single state (Agarwal et al., 2006)4. Demographically, UP is one of the least advanced states of the country. When comparing health indicators in UP to national averages, UP is often much worse off; total fertility rate (TFR) of 3.8 as compared to the country average of 2.7 (NFHS-3)5; birth rate of 30.1

National Institute of Urban Affairs, 2000. UrbanStatistics Handbook. New Delhi : National Institute of Urban Affairs. 4 Agarwal S., Kaushik S., Srivasatav A. (2006). State of Urban Health in Uttar Pradesh, Urban Health Resource Centre, Ministry of Health and Family Welfare, Government of India. 5 National Family Health Survey-3 (2005-06). Ministry of Health and Family Welfare, Government of India

as against the national average of 23.5 (SRS 2007)6; infant mortality rate (SRS 2007) of 71 as compared to the nationwide 57. Though the urban average for these indicators suggests that urban dwellers are better off than their rural counterparts, urban averages often fail to elucidate differences that exist within the urban population, namely the inequalities between the urban poor and non-poor. NFHS-3 indicates large disparity between the urban poor and urban non-poor. With low contraceptive use (poor - 36 percent, non-poor - 56.5 percent) and high unmet need (poor 19, non-poor 6.7 percent), the urban poor of UP have high TFR (3.9) compared to non-poor (2.3). In Uttar Pradesh six cities were selected for carrying out the baseline survey including Agra, Aligarh, Allahabad, Gorakhpur, Moradabad and Varanasi. A brief profile of each of the six cities is given below. Agra City7 Agra city, one of the major cities of Uttar Pradesh, is located in the southwest corner of UP. Agra is best known as the home of the Taj Mahal, and as an important tourist destination, transport hub and commercial centre. The total population of the Agra urban agglomeration is 1,331,339; whereas the city population is about 1,275,000. The decennial growth rate of Agra city (1991-2001) is 40.7%, which is twice the national decennial growth rate of 21.3%. As an indication of the overcrowded conditions in Agra, the population density is 897 persons per square km. As per the 1991 census, the sex ratio of the city is 846 females per 1000 males (Indian average is 933). Eighty-two percent of the local population is of the Hindu religion, 15% are Muslims, 1% Jains and the remaining 2% are Sikhs, Christians and Others. The overall literacy rate is high at 70% and the work participation rate is at 27%. Caste wise majority is of Scheduled Caste (SC) population, which is 21.5% of the total. The population of 0-6 years constitutes 13.53% of the total and the sex ratio in this age group is around 900. The vulnerability assessment of the city conducted by various agencies estimates that over 50% of residents live in slums and squatter settlements. However, official figures reported during the 1991 census indicate that only 9.67% of residents are considered as slum population. Estimates of the total number of slums ranges from 215 official slums (DUDA), 386 slums (OXFAM), to 393 slums (215 registered and 178 unrecognized) (EHP). Health services in Agra are provided from a variety of sources including the public sector (Department of Medical, Health and Family Welfare (DoMHFW) the Agra Municipal Corporation), the private sector (hospitals, nursing homes, and clinics), as well as a few charitable hospitals that provide subsidized health services to the poor. Additionally, there are Central Government health facilities, which include Railways hospitals, ESI and Cantonment hospitals and dispensaries. Primary health care in the city is provided
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Simple Registration System (2007). Registrar General of India, Government of India. 7 www.uhi-india.org - Agra City Profile

through 20 first tier centres including 15 D-Type health centres located in various parts of the city. As per the recent District Level Household and Facility Survey (DLHS-3) 2007 2008, only 28.8% of currently married women are using a modern method of contraception. The DLHS-3 estimates the unmet Family Planning need in Agra at 33.7%, which consists of an 11.1% unmet need for spacing methods and 32.4% unmet need for limiting methods. The percentage of birth of order 3 and above is quite high at 44.9%. The slum women perceive pregnancy as a natural process associated with risks, which every woman undergoes in her life. EHP reports state that most deliveries are conducted at home by untrained dais, family members and relatives. A few women call a hospital nurse for conducting delivery at home. Data for urban low SLI, Reanalysis of NFHS II, EHP (2004) shows a similar picture, i.e. 85.3% of the deliveries take place at home, and of all deliveries only 26.2% are either attended by trained health professional at home or at a health facility. Aligarh City8 Aligarh is located at 27.30 N latitude and 79.40 E longitude in the western part of U.P. The total population of the city is 669,000 (53% males and 47% females) with literacy rate of 63.9% (Census 2001). It is estimated that 69.10% of the urban population is below the poverty line. According to the District Urban Development Authority in Aligarh there are around 128 registered slums with a total population of 380,776. As per EHP report 52.4% of the population reside in slums. Over a period of more than a decade some of the slums have become developed colonies. Additionally, some of the new unregistered colonies have mushroomed Health services in Agra are provided by the Public sector, including the Department of Medical, Health and Family Welfare, and by the Private sector (hospitals, nursing homes, and clinics). In addition, as per the list compiled by UNICEF, there are approximately 587 non-registered private providers catering to a large slum population of the city. Primary health care in the city is provided through 11 urban health posts and seven health & family welfare subcentres, located in various parts of the city. In Aligarh there are three Governmentrun secondary/ tertiary level hospitals. These three hospitals cater to the secondary care needs of the entire district. Apart from J.N Medical College, which is under the Central Government, the other health facilities are under the State Health Department. As per the recent District Level Household and Facility Survey (DLHS-3) 2007 2008, only 28.4% of currently married women are using a modern method of contraception. The DLHS-3 estimates the unmet Family Planning need in Aligarh is at 40.7%, comprised of 12.1% unmet need for spacing methods and 28.6% unmet need for limiting methods. The Ministry of Health and Family Welfare, Family Planning Division has
8

www.uhi-india.org - Aligarh City Profile

recognized Aligarh as a high priority district for family planning programs in Uttar Pradesh. According to family planning statistics shared by the Chief Medical Officer, the uptake of family planning methods is very low in Aligarh as compared to other districts in Uttar Pradesh. Allahabad City9 Allahabad is among the largest cities of Uttar Pradesh in terms of population and area. The geographical area of Allahabad is about 62 sq km. Its spatial extension falls at 25 28 N latitude and 8154 E longitude. Census data classifies Allahabad city as the 32nd most populous city in India with the population of 975,000. The city has a relatively poor sex ratio at 807 females per 1000 males, with the number of males being 539,772 and females 435,621. Approximately 10% of the total population falls between 0-6 years. The literacy rate was recorded at 81%, which is slightly better than many other cities of U.P. About 12.4% of the total population belongs to the Scheduled Caste (SC) category. The city registered a population growth of about 23% during the last decade. According to the 2001 Census, the average population density is 16,559 persons per sq. km. Allahabad has 185 slums spread all over the city. The total population living in slums is 318,000, which is about 30% of the entire city population. It is estimated that one-third of the slum population can be categorized in the urban poor category. Health services in Allahabad city are mainly provided by the Public sector, including the Department of Medical, Health and Family Welfare, and the Private sector (hospitals, nursing homes, and clinics). In addition, charitable hospitals provide subsidized health services to the poor. Additionally, there are Central Government health facilities, which include Railways hospital, ESI hospital/dispensaries and Cantonment hospitals/dispensaries. Primary health care is provided by first tier centres including 12 urban health posts, 3 urban Family Welfare Centers, and 30 dispensaries Though public health infrastructure is fairly extensive, the private sector is an important player in the city. There are 1421 health practitioners, 272 Maternity /Nursing Homes, 6 Certified Abortion Providers and 10 Certified NSV/DMPA Providers. Various indigenous systems of medicine health facilities such as Ayurvedic, Unani and Homoeopathic are also available. Allahabad city also has many charitable health care providers offering services. Gorakhpur City10 Gorakhpur occupies the north eastern corner of the state of Uttar Pradesh, and is located between Latitude 26 13 N and 27 29' N and Longitude 83 05' E and 83 56 E. It has a population of 622,701 (males - 53% and females - 47%). Gorakhpur has an average literacy rate of 78%, which is more than the state average (64.8%). About 13% of the population is under six years of age. The sex ratio of the city is an alarming 888 females per 1,000 males. In terms of religious composition, the majority of the population (70%) is Hindu, followed by Muslim (21%). Approximately 12% population belongs to the SC category.
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www.uhi-india.org - Allahabad City Profile www.uhi-india.org - Gorakhpur City Profile

Being a major transit point and a relatively developed among cities of eastern U.P., Gorakhpur attracts a large number of people from neighboring districts. One third of the city population is living in slums. Health services in Gorakhpur are provided by the Public sector (Department of Medical, Health and Family Welfare) and the Private sector (hospitals, nursing homes, and clinics). In addition, a couple of charitable hospitals provide subsidized health services to the poor. Central Government health facilities, which include Railways hospitals, ESI hospital and dispensaries and Cantonment hospitals and dispensaries, also provide health care services. Primary health care is provided by 21 First Tier centres. City has flourishing private health sector. According to information available at the CMO Office, there are over 400 private doctors and 87 nursing homes / maternity homes in the city. Moradabad City11 Moradabad city is situated in western U.P. between 2821 to 2816 Latitude North and 78 4 to 79 Longitude East. The total population of Moradabad city (Municipal Corporation) in year 2001 stood at 641,538 persons, of which 340,314 were males and 301,269 were females. The decennial growth rate (1991-2001) of 44.5% was more than double the national growth rate of 21.3%. The overall sex ratio was 885 females per thousand males, which is quite low when compared with the state average of 898. It has a literacy rate of 51.5%. Eleven percent of the city population resides in slum. Moradabad has both public and private health services, including health centres by religious and charitable institutions. There are several government as well as private hospitals and nursing homes, besides individual private practitioners. At the first tier, the city has 13 urban health posts. In addition there are 5 urban RCH health posts, focusing on reproductive and child healthcare services. There are two Governmentrun secondary / tertiary level hospitals, including one exclusively for women. There are 40 Maternity /Nursing Homes, 40 Abortion/NSV Providers and 34 DMPA providers. Varanasi City12 Varanasi is a major religious, cultural and educational centre of India and it lies between the 25o 15N to 25o 22 N latitudes and 82o 57E to 83o 01E longitudes. The total population of Varanasi urban agglomeration is 1.2 million; whereas the city population is about 1.09 million. The decennial growth rate of the city (1991-2001) is 17.6%.Its sex ratio is 891 females per 1000 males. The literacy rate of the city is 77.1%. Varanasi has 227 slums spread all over the city, both on government and private lands. Total population in slums is about 457,613, which is about 38% of the total population. Slum locations are spread all over the city but major concentrations can be found in the old city area near the ghats, areas near small scale industries as well as in the Rajghat area.
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www.uhi-india.org Moradabad City Profile www.uhi-india.org - Varanasi City Profile

Public sector health services in Varanasi include facilities of the state Department of Medical, Health and Family Welfare and Varanasi Municipal Corporation, besides Central Government, ESI, railway and Cantonment facilities. There are 21 Urban Health Posts, 19 District / Joint Hospital, 6 ESI Dispensaries, 1 Medical College , 1 One Medical Care Unit, 2 Railway Hospitals and I Defence Hospital. In Private sector there are 83 Maternity /Nursing Homes, 21 Private Health Posts/Clinics, 4 Abortion Clinics, 1077 Registered Providers and 56 NSV/DMPA Providers. In addition, there are few charitable hospitals, which provide subsidized health services to the poor. 4.0 OBJECTIVES OF THE MLE BASELINE SURVEY The major objective of the study is to collect baseline information at the household level and at health facilities that will be used to evaluate the impact of the Initiative on modern contraceptive use in diverse population groups. The baseline survey is a part of the longitudinal study and the same cohort of the currently married women ages 15-49 years and the facilities covered in the baseline survey will also be contacted for the mid-term and endline surveys at an interval of two and four years respectively.

Chapter 2 Methodology
A key objective of the MLE project is to undertake a rigorous impact evaluation of the URHI country programs. Specifically, the MLE project will evaluate the success of both demand-side URHI interventions (those that increase the desire for family planning services) and supply-side URHI interventions (those that increase the quality of and access to family planning services). The MLE project evaluation comprises three design elements that allow researchers to measure programmatic impact across cities, over time, and among the urban poor and non-poor. 2.1 Three Evaluation Design Elements Impact across Cities. The MLE project will take advantage of the delayed implementation of programmatic activities in some cities to develop a quasi-experimental study design. In each country, the MLE project will evaluate four URHI-targeted cities that will receive immediate interventions and two cities that will receive URHI interventions during the third or fourth year of the project. This latter group of cities with delayed URHI interventions will serve as comparison cities. An assessment of these cities with the original set of intervention cities will add variation that will provide more precise measures of program impact. Impact over Time. The MLE project will use a combination of repeated cross-sectional data (surveying a new representative sample of respondents at multiple points in time) and longitudinal data (surveying the same respondents at multiple points in time) in a hybrid study design. This hybrid approach maximizes the strengths of both types of data; rigorous cross-sectional surveys provide the attitudes and behaviors of a representative sample of the cities population at a given point in time, while longitudinal data measure the causal impact of program components on outcomes of interest. The project will also collect longitudinal data from a sample of health and family planning facilities that provide services to women and men service delivery points (SDPs) and examine access to and quality of family planning services at these facilities over the study period. Impact among the Urban Poor. To identify the impact of URHI interventions among the urban poor, the MLE project will structure the sampling of respondents to identify programmatic outcomes among both slum and non-slum populations. 2.2 Survey Components The project will use a quasi-experimental design in which data collection will be carried out in four intervention and two comparison cities (that is, cities where the introduction of the interventions will be delayed). Two types of data will be collected in all cities: individual-level data; and service delivery point data.

Individual Surveys. The MLE project carried out confidential surveys with women in all 6 cities, while with men in four intervention cities. Women of age 15-49 years and men of age 18-54 years provided their basic demographic characteristics (such as age, ethnicity, family structure, and migration practices), their experience with family planning methods, their awareness of family planning messages, and their fertility desires. In addition, respondents discussed their current health care experiences, including how they pay for health care and when and where they seek care for themselves and their children. At baseline, the contact information of women was also collected, so as to locate them at mid-term and endline surveys. This will permit an examination of how fertility desires and family planning behaviors change over time with increasing program activities and exposure. To ensure that the urban poor are fully represented in this study, Geographic Information System (GIS) data was utilized to map the location of urban slums and non-slum areas onto maps of the study cities using country-specific definitions of what constitutes a slum. As the residents of urban slums are predominantly poor, this geographic data served as an approximate measure of where poor populations live. From the GIS data, researchers designed sampling frames that captured both urban poor and non-poor populations, and systematically selected members from both groups as survey respondents from these geographically-determined sampling frames. SDP Surveys. The data from a wide range of public and private SDPs has been collected under the MLE project. Facility audits and provider interviews were conducted at these facilities. In addition, exit interviews with female clients using family planning and maternal and child health client services were conducted at high volume public and private health facilities. Since several contraceptive methods are available at pharmacies and retail outlets, facility audits were conducted.

2.3 Sample design and implementation The study has involved a multi-stage sampling design. In this section the sample size determination for Agra as well as the sample implementation procedures have been discussed. 2.3.1 Sample size determination The overall target sample size for Agra was 3,000 completed interviews with eligible women (currently married women 15-49). In order to attain this, a sample of approximately 3,840 households was selected. Similarly for men, the overall target sample size was 1,500 completed interviews with eligible men (currently married men 18-54). In order to attain this, a sample of approximately 2,250 households was selected. For both the womens and mens sample, the sample size was equally divided between slum and non-slum populations to get adequate sample for urban poor.

2.3.2 Sampling Techniques Household Survey: Using the GIS map, sampling frame for slum and non-slum were developed and 64 primary sampling units (PSUs) were selected from each domain. Then, a mapping and household listing operation was carried out in each of the selected PSUs, which provided the necessary frame for selecting households. The household mapping and listing operation involved preparing up-to-date notional and layout sketch maps assigning numbers to structures, recording addresses of these structures, identifying residential structures and listing the names of heads of all the households in residential structures in each of the selected PSU. The work was carried out by seven teams, each comprising one lister and one mapper, under the supervision of three field supervisors, and one field executive. The teams were trained from 27-30 January, 2010 in Lucknow. The mapping and household listing operation was carried out from 27 February-16 May, 2010. On average, 30 households for the womens survey and 20 households for the mens survey were selected in each of the PSU. All the selected households were visited during the main survey, and no replacement was made if a selected household was absent during data collection. In the selected household, all eligible women/men were interviewed. SDP Survey: In the SDP survey, all public health facilities, high volume private health facilities and select non-high volume private facilities, pharmacies and retail outlets were covered. For each PSU, most preferred13 private facility/provider and pharmacy were selected from the list of facilities which women reported visiting for family planning or maternal and child health services during the individual survey. At each of the selected SDP, a geographic information system (GIS) point was recorded using a geographic positioning system (GPS) device. 2.3.3 Achieved Sample Sizes Table 2.1 and 2.2 gives the sample size achieved in the household and SDP surveys Table 2.1 Sample results for Household survey in Agra Household Survey Household for women survey Women Household for men survey Men Achieved Number 3575 3007 2244 1673 Achieved Percent 94.56 92.89 89.04 83.60

Table 2.2 Sample results for SDP survey in Agra

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Preferred facility/provider A facility/provider mentioned maximum by women in a PSU.

SDP Survey No of health facilities HV Public HV Private Other public Other private Total

Achieved Number 2 14 20 91 127

No of providers Doctor Nurse Midwife Ayush Traditional Birth Attendant Lady Health Visitor/Public Health Nurse/District Public Health Nurse Other* 104 96 14 36 9 29 6

Total 294 No of pharmacies 104 RMP 12 Retail outlets 23 Exit interviews 683 * Other includes Health educators/social workers, administrators, and others 2.4 Survey Questionnaires MLE Baseline survey used three types of questionnaires for the household survey: Household Questionnaire, the Womens Questionnaire, and the Mens Questionnaire. The questionnaires were in Hindi. Household survey The Household Questionnaire listed all usual residents in each sample household plus any visitors who stayed in the household the night before interview. For each listed person the basic information was collected on age, sex, marital status to the head of household head, education and occupation. The information was also collected on household assets and environmental circumstances. The Womens Questionnaire collected information from currently married women age 15-49 who were usual residents of the sample household or visitors who stayed in the sample household the night before the interview. The questionnaire collected the information on background characteristics, reproductive behavior, quality of care, knowledge and use of contraception, source of family planning, antenatal care and postpartum care, breastfeeding and health reproductive health, and gender violence. The Mens Questionnaire collected information from currently married men age 18-54 who were usual residents of the sample household or visitors who stayed in the sample

household the night before the interview. The questionnaire collected the information on background characteristics, reproductive behavior, quality of care, knowledge and use of contraception, source of family planning, antenatal care and postpartum care, reproductive health, and gender violence. Service Delivery Point Survey: The baseline data was collected from the selected service delivery points (SDP). The SDPs survey included public and private health care facilities, pharmacies and retail outlets which provide family planning services or method(s). At health care facilities a facility audit, provider interviews and exit interviews with women were conducted. The interviews were also conducted at pharmacies and retail outlets which provide family planning services or method(s). The questionnaires were bilingual, with questions in both English and Hindi. Facility audit: A manager at each public and private service delivery point included in the survey (including health care facilities, pharmacies, and retail outlets) was interviewed to obtain general information about the site including the number of family planning clients, quality of services, types of services provided, types of providers, prescription requirements, and whether each family planning method offered is in stock. Exit interviews: At high volume service delivery points that provide family planning (FP) and maternal, newborn and child health (MNCH) services, exit interviews with women ages 18 and older visiting the facility for family planning, child health and postpartum care. All women receiving the targeted type of services were eligible for participation in the exit interviews. Provider interviews: Provider interviews were conducted in both public and private FP and MNCH facilities. The same facilities used for the exit interviews were used for conducting provider interviews. A sample of providers was selected from the facility list of all providers offering FP and/or MNCH services at the selected service delivery points. Various types of providers were selected, including physicians, nurses, auxiliary staff, and auxiliary nurse midwives. Two providers from each type of larger service delivery points were selected for interviews.

2.6 Recruitment, Training, and Fieldwork Field staff for the main survey were trained by senior professionals of the FactIndepth in Lucknow. The training consisted of classroom training, demonstration and practice interviews, as well as actual field practice and additional training for field editors and supervisors. The class room training included instructions on interviewing techniques and survey field procedures, a detailed review of each item in the questionnaires, and instruction and mock interviews between participants. Special guest lectures on family planning and on reproductive and child health were also arranged. Seven interviewing teams conducted the main fieldwork in Agra, each team consisting of one field supervisor, one female field editor, three female interviewers and two male interviewers. The fieldwork was carried out between 17 April and 04 June 2010. The

coordinators and senior staff of the FactIndepth carried out monitoring and supervision of the data collection. ICRW also appointed one consultant to help with monitoring throughout the training and fieldwork period in order to ensure that correct survey procedures were followed and data quality was maintained. From time to time, ICRW staff visited the field sites to monitor the data collection operation. 2.7 Data Entry and Processing Completed questionnaires for MLE baseline survey in Agra were sent to the office of the FactIndepth, Lucknow, for data processing, which consisted of office editing, coding, data entry, and machine editing. CSPro data entry software was provided by UNC. Data entry was done in Lucknow by 8 data entry operators under the supervision of a staff member of the FactIndepth. The data entry operators and supervisor were trained by senior staff of UNC. The data entry and editing operations were completed between 19 May 2010 and 20 July 2010.

Chapter 3 Household Profile

This Chapter presents the profile of the households covered in the survey in the city of Agra. In the present survey information was collected about all the usual residents as well as the visitors who had stayed in the selected households the night before the household interview. The survey also collected information on key household characteristics, such as type of house, availability of electricity, sources of drinking water, type of toilets used, and the main source of drinking water. 3.1 Household Population by Age and Sex A total of 19,781individuals including the usual residents and visitors who had stayed there the night before the day of survey were enumerated in the 3,539 households interviewed in Agra. Table 3.1 shows the distribution of the household population in five year age groups by age and sex. Nearly one-third of the population (32%) is below 15 years of age and six percent is 60 years or above, with the remaining 62 percent in the age group of 15-59 years. The age distribution of the male and female population is similar to that observed for the total population. The sex ratio of the population surveyed in Agra is 903 females per 1,000 males. The sex ratio for the population in the age group of 0-6 years is only 844 females for 1000 males. Household Population by Age, Residence and Sex, India, 2007-08 Percentage D Table 3.1: Household Population by Age And Sex in Agra Age Male Female Total % Number % Number % Number 0-4 9.8 1014 9.6 900 1914 9.7 59 10.3 1069 9.7 913 1982 10.0 6 14 12.7 1316 12.7 1189 2505 12.7 15-19 13.4 1396 12.6 1180 2576 13.0 20-24 10.9 1131 10.9 1022 2153 10.9 25-29 7.9 824 8.0 753 1577 8.0 30-34 6.1 637 6.4 601 1238 6.3 35-39 5.6 580 6.7 627 1207 6.1 40-44 5.2 542 5.5 517 1059 5.4 45-49 4.9 508 3.9 370 878 4.4 50-54 3.6 371 3.8 361 732 3.7 55-59 3.2 333 3.8 358 691 3.5 60-64 2.7 278 2.5 233 511 2.6 65-69 1.5 157 1.5 144 301 1.5 70-74 1.2 120 1.1 104 224 1.1 75-79 0.6 58 0.5 51 109 0.6 80+ 0.6 62 0.7 62 124 0.6 Total 100.0 10396 100.0 9385 19781 100.0 Sex ratio for 0 6 years age group - 844

3.2 Housing Characteristics The MLE baseline survey collected information on several household characteristics that are related to the living conditions of the people. The data on household characteristics was based on questions answered by the respondents of the Household Questionnaire as well as the interviewers observation of the type of housing. In this Section, household access to water and sanitation facilities are discussed first, followed by a discussion of other household characteristics including type of housing and fuel used for cooking. Table 3.2 presents the percentage distribution of households by source of drinking water. Most of the households in Agra (97%) reported using an improved source of drinking water, which included water piped into the dwelling, yard or plot, water available from a public tap or standpipe, a tube well or borehole and bottled water. Among the improved sources of drinking water, public hand pump was reported by 27 percent of the households followed by tube well/borehole (21%) and bottled water (20%). With respect to the use of sanitation facilities, Table 3.2 shows that only 58 percent of households have a modern toilet facility, which empties into a sewer/pit/septic tank. Owning a pour/flush toilet that does not empty into a sewer/pit/septic tank was mentioned by twenty three percent of the households, while 17 percent of the households had no toilet facility and defecated in the open. Data on the type of cooking fuel shows that a majority of the households (72%) were primarily using LPG, while 17 and eight percent of the households were using wood and dung respectively. Table 3.2 also gives information about the type of house, availability of a separate kitchen in the household and availability of electricity. Among the households covered in the survey, 89 percent lived in pucca houses and 10 percent lived in semi-pucca houses. Less than one percent of the households lived in kuchha houses. Fifty eight percent of the households had a separate room for cooking. Electricity was available in 96 percent of the households. Table 3.2: Housing Characteristics of the Households Surveyed in Agra Characteristics % Main source of drinking water Piped water into dwelling 6.7 Piped water into yard/plot 8.7 Piped water to public tap/standpipe 4.2 Hand pump inside dwelling 9.2 Public hand pump 26.7 Tube well/borehole 21.1 Dug unprotected well 0.2 Tanker truck 1.2 Cart with small tank 0.1 Bottled water 19.9 Other 1.9 Total 100.0 Toilet facility Septic tank/modern toilet 58.0 Pour/flush toilet that does not empty to 22.7

Number 237 309 150 326 944 746 6 44 5 704 67 3538 2053 803

Table 3.2: Housing Characteristics of the Households Surveyed in Agra Characteristics % sewer/pit/septic tank Water sealed/slab latrine 1.8 Pit latrine without slab 0.1 No facility/bush/field 17.2 Other 0.1 Total 100.0 Type of Cooking fuel Electricity 0.5 LPG/natural gas 71.8 Biogas 0.1 Kerosene 1.2 Coal/lignite 0.6 Charcoal 0.0 Wood 16.9 Straw/shrub/grass 0.3 Dung 8.4 Other 0.1 Total 100.0 Type of house Kachcha 0.9 Semi Pucca 9.8 Pucca 89.3 Total 100.0 Separate room for kitchen Households with separate kitchen 58.0 Households without separate kitchen 42.0 Total 100.0 Availability of electricity Households with Electricity 96.4 Households without Electricity 3.6 Total 100.0 3.3 Possession of BPL Cards and Ration Cards

Number 64 5 607 7 3539 18 2541 2 43 21 1 598 9 296 5 3537 32 347 3158 3537 2053 1486 3539 3413 126 3539

The baseline survey collected information on the availability of Below Poverty Line (BPL) Cards and ration cards for all the households covered in the survey. As Table 3.3 shows, BPL cards were available in only two percent of the households while ration cards were available in around two-thirds of the households.

Table 3.3 : Possession of BPL Card and Ration Card in Agra Possession Percentage BPL Card Households with BPL Card 1.9 Households without BPL card 98.1 Total 100.0 Ration Card Households with Ration Card 66.9 Households without Ration Card 33.1 Total 100.0

Number 67 3472 3539 2366 1173 3539

3.4 Coverage under Health Insurance Schemes All the households covered in the survey were asked whether any member in the household was covered under any health insurance scheme. Table 3.4 shows that only in four percent of the households was any member covered under some health insurance scheme. Table 3.4 Coverage of Household Members Under Health Insurance Schemes in Agra Health Insurance Coverage Percentage Number HH member covered by health scheme 4.4 156 Households without health scheme coverage 94.9 3361 Dont Know 0.6 23 Total 100.0 3540

Chapter 4 Profile of Respondents

The information on age, educational status, religion, caste, number of live births, work status was collected from all currently married men and women covered in the survey. Information on household assets was collected through the household questionnaire to construct the household wealth index, which serves as a proxy indicator of the household economic well being of the women and men covered in the survey. This Chapter presents the socio-economic and demographic profile of the women and men covered in the survey in Agra. Table 4.1 provides information on age, education, religion, caste, wealth index, number of live births, employment in the last one year, type of payment received, education of the spouse, type of payment received by the spouse and duration of residence in the current location. The age distribution of the women shows that nearly two-fifths belonged to the age group of 20 - 29 years and around one-fourth were in the age group of 40- 49 years. About four percent of the women were in the age group of 15-19 years. The education status of the women presented in Table 4.1 shows that approximately 38 percent of the women surveyed in Agra had no education. Twenty six percent of women had completed 12 or more classes, while 12 percent had completed 10 or 11 classes. The majority of women (86%) covered in the survey were Hindus, while 13 percent were Muslims. The caste wise distribution shows that the surveyed women in Agra were mostly from the three caste groups,-Other Backward Classes (32%), Scheduled Castes (30%), and others, which is a general caste category (37%). One of the background characteristics used throughout this report is an index of the economic status of households called the wealth index. It is an indicator of the level of wealth that is consistent with expenditure and income measures. The wealth index has been constructed using household asset data. Table 4.1 presents the distribution of women by five wealth quintiles. Approximately 21 percent of the women surveyed in Agra were in the highest two wealth quintiles, while 18-20 percent were in the other three quintiles. As regards the number of live births, half of the women hadthree or more live births, while 42 percent had one to two live births (Table 4.1). Nine percent of the women had no live birth.

Table 4.1: Background Characteristics of Currently Married Women from Agra Number of Women Characteristic: Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Missing Religion Hindu Muslim Other/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Other Dont know Missing Wealth Index Lowest Second Middle Fourth Highest Number of live births 0 1 Percentage of Women* 3.5 17.2 21.6 18.0 16.3 14.5 9.0 38.0 3.1 9.6 11.1 12.1 26.1 0.1 85.8 12.8 1.4 30.4 0.4 32.2 36.8 0.0 0.1 18.0 19.5 19.9 21.1 21.5 8.5 16.7 Weighted (N=3007) 106 516 649 542 489 436 269 1144 92 287 334 363 784 3 2580 386 41 915 13 967 1107 1 4 540 588 599 635 646 256 501 Unweighted (N=3007) 108 503 627 543 520 443 263 1279 92 309 353 329 642 3 2462 514 31 982 13 1030 978 1 3 602 619 621 571 594 273 440

Table 4.1: Background Characteristics of Currently Married Women from Agra 2 25.0 752 682 3 18.7 561 568 4 12.7 382 418 5 8.4 254 271 6+ 10.0 302 355 *Percentages are weighted

In the survey, all the women were asked about their employment status in the last one year. In response to the query, only one-tenth of the women affirmed that they were employed in the last one year and almost all of them (98%) were paid in cash. With regard to the education of the spouses of the women covered in the survey, around one-fifth of the women reported that their spouses had no education, while 36 percent reported that their spouses had completed 12 or more classes Further, 97 percent of the women reported that their spouses receive payment in cash for their employment. Data on the duration of residence in the current location indicated that 38 percent of the women had stayed there for 10 years or more. However, a substantial proportion (20%) has stayed at the current location for two years or less (Table 4.1).

Table 4.1: Background Characteristics of Currently Married Women from Agra cont. Number of Women Characteristic: Employment in the last year Did not work in the last year Worked in the last year Type of payment (among employed) Cash only Cash and kind In kind only Not paid Spouses education level No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Percentage of Women* 90.0 10.0 Weighted (N=3007) 2706 302 (n= 301) 296 4 0 1 580 77 317 408 497 1091 Unweighted (N=3007) 2714 293 (n=293) 286 5 0 2 697 85 371 427 492 904

98.2 1.3 0.0 0.5 19.3 2.6 10.5 13.6 16.5 36.3

Table 4.1: Background Characteristics of Currently Married Women from Agra cont. Dont know Missing Spouses form of payment for work in the last year Cash only Cash and kind In kind only Not paid Not working/unemployed Missing Duration of residence in current location < 1 year 1-2 years 3-4 years 5-6 years 7-8 years 9-10 years >10 years Visitor Always Missing *Percentages are weighted Table 4.2 presents the background characteristics of the currently married men surveyed in Agra. The age distribution of the men shows 43 percent were in the age group of 18 34 years and 40 percent were in the age group of 40 - 54 years. Nearly half of the men surveyed had completed at least 10 classes whereas 15 percent had no education. As regards religion, 87 percent were Hindus and 12 percent were Muslims. Thirty-two and 30 percent of the men belonged to the OBCs and SCs respectively. Nearly two-fifths were from the other caste groups. Data on wealth quintiles indicates that 20 percent of the men surveyed in Agra belonged to the highest wealth quintile and 18 percent to the lowest wealth quintile. Nineteen, 21 and 23 percent of the men were from the second, middle and fourth wealth quintiles respectively. Nearly one-third of the men had four or more live births and 39 percent had one to two live births and 10 percent of the men had no live births. 7.5 12.6 11.2 10.8 6.8 8.1 37.7 4.5 0.6 0.3 226 379 337 323 204 242 1133 136 19 8 201 354 321 291 205 237 1255 114 22 7 96.6 0.3 0.1 0.0 2.8 0.1 2905 10 4 0 85 3 2915 10 2 0 78 2 1.1 0.2 32 6 25 6

Table 4.2: Background Characteristics of Currently Married Men from Agra Number of Men Characteristic: Age 18-24 25-29 30-34 35-39 40-44 45-49 50-54 Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Missing Religion Hindu Muslim Other/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Other Missing Wealth Index** Lowest Second Middle Fourth Highest Number of live births 0 1 2 3 Percentage of Men* 9.7 16.7 16.1 17.7 15.9 15.1 8.9 15.1 6.7 11.8 17.6 17.7 30.7 0.6 87.0 12.3 0.8 29.5 0.5 31.9 38.0 0.0 17.6 19.1 20.8 22.9 19.7 9.8 15.4 23.8 18.1 Weighted (N= 1682) 164 280 270 298 268 253 150 253 112 198 295 298 516 10 1462 206 13 497 9 537 639 1 295 321 349 386 331 165 259 400 305 Unweighted (N= 1682) 146 281 282 312 281 241 139 298 128 218 311 280 436 11 1400 270 12 571 12 570 528 1 324 347 338 380 293 173 230 374 295

4 56 7+ *Percentages are weighted

13.0 14.4 5.5

218 242 93

247 260 103

Only three percent of the men covered in the survey reported that they had not worked in the last one year. Among the men who were employed in the last one year, 66 percent worked for someone else and 27 percent were self employed. Almost all the men who worked in the last one year said that they were paid in cash for their services. Only seven percent of the men reported that their wives were employed for cash. In response to the question on who decides how his earnings are used, 77 percent reported that they take the decision jointly with their wives. Only 16 percent reported that they decide independently about the use of their earnings. On the age at marriage, around one-fourth of the men reported that they got married before the age of 20 years, while 70 percent got married between 20 - 29 years.
Table 4.2: Background Characteristics of Currently Married Men from Agra, cont. Number of Men Weighted Unweighted Characteristic: Percentage of Men* (N=1682) (N=1682) Employment status in the last year Did not work in the last year 2.8 47 45 Worked in the last year 97.2 1635 1637 For whom do you work (among employed) (n= 1635) (n= 1637) Self-employed 26.7 437 410 For family member 6.9 112 126 For someone else 66.3 1083 1100 Missing 0.2 2 1 Type of payment (among employed) (n= 1635) (n= 1637) Cash only 99.2 1622 1620 Cash and kind 0.8 13 16 In kind only 0.0 0 1 Not paid 0.0 0 0 Age at marriage <15 1.3 22 27 15-19 23.8 401 382 20-24 48.9 822 834 25-29 21.5 362 361 30-34 4.0 67 66 35+ 0.5 8 12 Wife employed for cash Yes 6.9 116 109 No 93.1 1566 1572 Don't know 0.0 0 1 Who decides how your earnings are used? (n= 1635) (n= 1637) Respondent 16.4 269 289 Wife 0.9 14 18 Respondent and wife 76.9 1257 1242 Other 5.7 94 87 Missing 0.1 1 1 *Percentages are weighted

Chapter V Marriage, Fertility and Fertility Preferences

Information relating to marital experiences, fertility and fertility preferences was collected from currently married women (15-49 years) and currently married men (18-54 years) in the survey. This Chapter presents the findings relating to age at first marriage, age at first cohabitation, fertility level, fertility preferences, age at first birth, the ideal number of children and planning status of pregnancies. 5.1 Marital Experiences

The age at marriage among males and females, as well as the age at first cohabitation has direct bearing on several social and demographic outcomes. In this context, the information on age at first marriage and age at first cohabitation was ascertained from all the men and women covered in the survey. Table 5.1 presents age at first marriage and age at first cohabitation as reported by the currently married women. One-third of the women reported that they had been married by the age of 17 years i.e. before the legal minimum marriage age of 18 years, while44 percent of the women had been married between the ages of 18-20 years. Thus, by the age of 20 years, 77 percent of the women were married. A small proportion of women (5 %) got married at the age of 25 years or later. As regards the age at first cohabitation, 30 percent of the women reported that they had started living with their husbands before the age of 18 years. In the case of 46 percent of the women, the age at first cohabitation was between the ages of 18- 20 years. The age at first cohabitation exceeded 25 years in only five percent of the women. Table 5.1 also shows the co-residence with the husband in the last six months of the women covered in the survey. Almost all the women (98 %) contacted for the interviews were reportedly living together with the husband during the last six months.

Table 5.1: Marital experience of currently married women Percentage distribution of currently married women by age at first marriage and age at cohabitation , Agra , MLE-2010 Number of Women Background Characteristic: Age at marriage <15 15-17 18-20 21-24 25-29 30-34 35+ Age at first cohabitation Percentage of Women* 6.7 26.3 43.8 18.0 5.0 0.1 0.0 Weighted (N=3007) 201 792 1317 541 150 4 1 Unweighted (N=3007) 214 788 1366 504 129 5 1

<15 15-17 18-20 21-24 25-29 30+ Don't know *Percentages are weighted

3.9 26.3 45.9 18.5 5.1 0.2 0.2

116 790 1380 556 153 6 7

127 809 1412 518 131 6 4

Table 5.2 presents the age at first marriage of the women by their background characteristics. The analysis of age at first marriage by age of the women shows that there has been a steady rise in the age at first marriage, which is reflected by the general trend of declining marriages before the age of 15 years, from the oldest to the youngest age groups. A particularly notable decline is seen in the age at first marriage by the age of 15 years and the ages of 15-17 years in the three age groups of 20-24 years, 25-29 years and 30-34 years. The age at first marriage has strong positive association with the womens education. There is a sharp increase in the age at first marriage with the increase in the womens education level. For example, the mean age at first marriage increases from 17 years for the women with no education to 21 years for the women with 12 or more years of education. The proportion of women who got married before the age of 15 years and between the ages of 15-17 years declines sharply with the increase in the womens education. There was not much variation in the mean age at marriage by the religion and caste of the women. The womens wealth is also strongly associated with their age at first marriage. The mean age at first marriage is much higher for the women coming from the highest and the fourth wealth quintiles compared to those coming from the lowest and the second wealth quintiles (Table 5.2).

Table 5.2: Marital experience by background characteristics of currently married women Percentage distribution of currently married women by age at first marriage, Agra , MLE-2010

Background Characteristics Age in Years 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete

Age at first marriage <15 6.3 3.7 3.1 5.4 10.7 10.3 10.9 11.8 7.9 9.1 3.2 3.7 15 - 17 49.8 21.8 21.4 24.1 31.8 26.3 32.3 38.7 41.7 33.4 26.9 23.5 18 - 20 43.9 58.2 43.3 41.4 36.1 41.5 40.0 44.0 38.3 47.8 52.2 51.4 21 - 24 0.0 16.3 23.9 20.1 17.8 15.5 14.1 4.6 9.2 7.6 14.4 17.8 25 - 29 0.0 0.0 8.3 8.5 3.2 6.3 2.7 0.7 2.9 2.1 3.3 3.6 30 - 34 0.0 0.0 0.0 0.4 0.4 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Mean 17.1 18.5 19.5 19.3 18.2 18.5 18.1 17.2 17.7 17.8 18.5 18.9

Table 5.2: Marital experience by background characteristics of currently married women Percentage distribution of currently married women by age at first marriage, Agra , MLE-2010

12 or more classes complete Religion Hindu Muslim Others/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Others Dont know Wealth Lowest Second Middle Fourth Highest Total

0.9 6.9 6.3 0.0 9.6 7.3 7.8 3.4 0.0 8.6 9.8 8.9 5.0 1.8 6.7

4.9 26.8 25.6 4.0 32.8 21.5 29.8 17.9 0.0 40.9 31.1 28.1 20.4 14.1 26.3

35.8 43.4 48.4 28.4 43.4 63.8 44.8 43.0 100.0 42.8 48.3 44.3 46.3 37.7 43.8

43.9 18.2 14.2 40.4 11.0 7.3 14.7 26.9 0.0 4.8 8.7 15.2 22.1 36.1 18.0

14.0 4.6 5.5 27.2 3.0 0.0 2.8 8.7 0.0 2.9 2.0 3.5 6.1 9.8 5.0

0.5 0.2 0.0 0.0 0.3 0.0 0.0 0.2 0.0 0.0 0.1 0.0 0.1 0.5 0.1

21.4 18.7 18.6 22.1 18.0 17.4 18.2 19.8 20.0 17.5 17.8 18.2 19.3 20.5 18.7

The N's are slightly smaller due to missing data for some characteristics

The age at first cohabitation by the womens background characteristics is presented in Table 5.3. As observed in the age at first marriage of the women, the proportion of women reporting first cohabitation by the age of 17 years also declines from the oldest age group of 45 -49 years to the younger age group of 20-24 years. The above findings indicate an increase in the age at first cohabitation over the years. Like the age at first marriage the age at first cohabitation also has a strong positive association with the education and the wealth index of the women. The variations in the mean age at first cohabitation of the women by education, wealth index, religion and caste are more or less similar to that observed for the womens age at first marriage.

Table 5.3: Age at cohabitation of currently married women Percentage distribution of currently married women by age at cohabitation - Agra , MLE-2010

Background Characteristics Current Age 15 19 20 24 25 29 30 34 35 39 40 44 45 49 Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Religion Hindu Muslim Others/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Others Dont know Wealth Lowest Second Middle Fourth Highest Total

Age in years <15 6.7 2.0 2.3 4.1 4.6 4.7 6.6 5.8 3.3 7.9 3.1 2.3 0.6 3.9 4.1 0.0 5.0 0.0 4.8 2.1 0.0 3.4 6.6 4.4 3.3 1.6 3.8 15 - 17 44.8 21.1 21.5 23.1 34.0 27.7 29.8 39.0 43.2 33.4 24.3 22.5 5.3 26.5 27.0 3.9 33.2 3.7 29.9 17.3 0.0 40.2 30.5 29.1 20.8 13.3 26.2 18-20 48.5 59.8 43.1 42.0 39.4 44.8 45.7 48.5 38.9 48.0 54.5 51.9 35.7 45.7 48.6 27.7 46.7 73.7 46.4 44.3 100.0 46.3 50.9 47.1 47.2 38.4 45.8 21 - 24 0.0 17.1 24.5 21.3 17.8 16.0 14.7 5.5 11.6 8.3 14.2 19.4 43.7 18.9 14.1 39.4 11.7 22.6 15.5 27.0 0.0 6.4 9.4 15.9 22.1 36.1 18.6 25 - 29 0.0 0.0 8.6 9.0 3.3 6.4 3.1 1.0 2.9 2.3 3.3 3.9 14.2 4.8 6.0 26.5 3.1 0.0 3.0 9.0 0.0 3.5 2.0 3.5 6.4 10.1 5.2 30+ 0.0 0.0 0.0 0.5 0.8 0.4 0.1 0.2 0.0 0.1 0.5 0.0 0.6 0.3 0.3 2.4 0.3 0.0 0.4 0.2 0.0 0.2 0.5 0.1 0.3 0.5 0.3 Mean 17.1 18.6 19.6 19.5 18.5 18.8 18.5 17.7 17.9 17.9 18.7 19.0 21.4 18.9 18.8 22.1 18.3 18.8 18.5 19.9 20.0 17.9 18.1 18.5 19.4 20.5 18.9 Total N 106 514 649 542 489 436 269 1,144 92 287 331 363 784 2,577 386 41 915 13 967 1,105 1 540 585 599 635 645 3,004

* The N's are slightly smaller due to missing data for some characteristics

5.2

Fertility Levels

Table 5.4 presents the age-specific fertility rates (ASFR) and total fertility rates (TFR) for the women covered in Agra. As the Table shows, the TFR is 3.8 births per woman in Agra. The women belonging to the poorest wealth quintile have reported the highest TFR (4.8) and for the other wealth quintiles it varies between 2.9 to 3.3. The data on ASFR shows that the peak child bearing age is 20-24 years where the ASFR is 278.2 births per 1000 currently married woman. There is also a considerable amount of early childbearing at the age of 15-19 years (221.3 births per 1000 currently married woman). After the age of 39 years fertility is quite low.

Table 5.4: Current marital fertility Age-specific and Total Marital Fertility Rates - Agra , MLE-2010

Age-specific fertility rates per 1000 women 15 -19 20-24 25-29 30-34 35-39 40-44 45-49 Total Fertility Rate by Wealth Poorest Poor Middle Rich Richest Total Fertility Rate

221.31 278.21 151.70 72.52 32.95 3.50 0.00 4.79 2.93 3.50 3.23 3.33 3.80

In order to assess the fertility levels in the past, data on the number of children ever born (CEB) was collected from all the women covered in the survey. Table 5.5 presents the number of children ever born to currently married women in the age group of 15-49 years by their background characteristics. The mean number of children ever born to women covered in Agra is 2.9. Over one-third of the women in the age group of 15-19 years had at least one child, which indicates that early childbearing is still common among the women. The mean number of children ever born is highest for the women in the two oldest age groups of 45-49 years (4.3) and 40-44 years (4.2). Among the women in the age group of 45-49years, 35 percent reported three to four children and 43 percent reported five or more children. The above findings suggest high fertility among the women in the past. The number of children ever borne by the women is strongly influenced by their education and wealth index. The mean number of children ever born declines sharply with an increase in the womens education and wealth index. The proportion of women having one or two children increases steadily with the increase in the education and wealth index of the women. The analysis

by religion of the women shows that the mean number of children ever born is higher for Muslim women compared to women from other religions. Analysis by shows that the number of children ever born is lower for women belonging to other/general castes than those belonging to SCs, STs and OBCs.

Table 5.5 : Children ever born by background characteristics of women Percentage distribution of currently married women by number of children ever born - Agra , MLE-2010

Background Characteristics: Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Wealth Index Lowest Second Middle Fourth Highest Religion Hindu Muslim Other Caste Scheduled caste Scheduled tribe Other backward class Others Dont know Total

Number of children ever born 0 1 2 3 4

65.4 19.0 9.8 2.5 1.5 0.8 0.3 5.7 2.5 10.8 11.7 8.5 11.2 7.6 8.6 9.3 7.5 9.5 8.7 8.2 0.5 9.3 7.6 7.3 8.9 0.0 8.5 29.2 38.8 24.2 11.5 6.3 3.5 1.6 10.0 16.9 16.7 19.4 20.2 23.7 13.1 14.5 14.5 21.6 18.9 16.7 16.1 18.6 14.3 26.4 17.0 18.1 0.0 16.7 5.3 29.8 28.8 32.5 19.6 18.3 19.8 15.2 13.0 19.2 24.5 31.9 39.9 17.0 19.5 22.0 27.1 37.3 26.0 16.8 38.3 16.5 25.3 21.9 34.7 0.0 25.0 0.0 9.7 20.4 18.8 25.0 22.7 20.4 14.8 30.1 20.0 21.7 19.4 20.6 16.6 13.8 19.9 21.0 21.5 19.2 13.7 33.2 16.0 3.5 19.2 20.6 0.0 18.7 0.0 2.4 11.1 18.8 17.0 16.8 14.4 17.4 16.4 17.0 14.0 11.8 3.7 16.6 15.3 15.2 10.0 7.3 12.6 14.0 9.3 15.4 12.0 13.5 9.8 100.0 12.7

5
0.0 0.2 4.1 8.4 13.7 15.6 16.9 15.3 6.4 7.1 5.8 7.6 0.7 11.2 13.7 8.0 7.2 2.9 8.1 11.7 0.0 12.4 3.5 9.3 4.5 0.0 8.4

6+
0.0 0.0 1.6 7.4 16.9 22.2 26.7 21.6 14.7 9.3 2.9 0.7 0.3 17.9 14.5 11.2 5.7 2.6 8.8 19.5 0.0 16.1 21.5 11.8 3.3 0.0 10.0

Mean
0.4 1.4 2.2 3.0 3.7 4.2 4.3 3.8 3.3 2.8 2.4 2.3 1.9 3.5 3.3 3.0 2.5 2.2 2.8 3.5 2.3 3.3 3.3 3.0 2.4 4.0 2.9

Total N
106 516 649 542 489 436 269 1,144 92 287 334 363 784 540 588 599 635 646 2,580 386 41 915 13 967 1,107 1 3,007

* The N's are slightly smaller due to missing data for some characteristics

Table 5.6 shows the percentage of women who are currently pregnant and the mean number of children ever born to women in the age group of 40-49 years. Among all the women covered in Agra, seven percent were currently pregnant at the time of survey. The percentage of such women was higher among the SCs, Muslims and in the poorest wealth quintiles. The percentage of women currently pregnant was lower for the women having 12 or more years of education.

The mean number of children ever born to women age 40-49 years is 4.2. The mean number of children ever born declines gradually with the increase in the education and wealth. The mean number of children ever born is much higher for Muslim women (5.65) compared to Hindus (4.1). It is also higher among the women belonging to SCs (5.2) and OBCs (4.7) as compared to other castes (3.2).
Table 5. 6: Currently pregnant and children ever born to women aged 40 49 years Percentage of currently married women age 15-49 who are currently pregnant and mean number of children ever born to women age 40-49 by background characteristics, Agra, MLE-2010

Background Characteristic: Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Religion Hindu Muslim Other/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Other Missing Wealth Index Lowest Second Middle Fourth Highest Total

Percentage of Currently Pregnant 7.4 9.2 10.2 9.6 7.6 4.1 7.1 7.9 0.0 10.1 7.6 7.6 4.3 0.0 10.7 8.3 9.4 3.7 4.2 7.1

Mean number of children ever born to women 4049 5.35 4.74 4.50 3.56 3.11 2.58 4.09 5.65 2.53 5.23 7.74 4.70 3.22 1.43 5.48 5.16 4.74 3.84 3.18 4.23

* The N's are slightly smaller due to missing data for some characteristics

Table 5.7 presents the percentage of women who gave birth by specified exact ages, the percentage of women who have never given birth, and the median age at first birth by the age of the women. The median age at first birth is 21 years for the women in the age group of 20-49 years as well as those in the age group of 25-49 years. The median age at first birth is almost constant in all the five-year age groups starting from 25-29 years. In the city of Agra, 11 percent of women aged 20-49 years had given birth by the age of 18 years. Thirty four percent of women

aged 20-49 years gave birth by the age of 20 years and 61 percent gave birth by the age of 22 years. By the age of 25 years, 81 percent of the women aged 20-49 years had given birth.
Table 5.7. Age at first birth Percentage of currently married women who gave birth by exact age and who never gave birth and median age at first birth -Agra , MLE-2010

Percentage who gave birth by exact age Current Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 20-49 Age 25-49 15 0.0 0.5 0.2 0.4 1.0 1.0 1.3 0.6 0.7 18 na 12.1 8.2 11.6 14.2 11.0 7.8 10.9 10.7 20 na 40.7 29.0 32.9 38.7 32.6 27.8 33.9 32.4 22 na na 57.1 59.0 64.4 62.2 58.5 60.9 60.1 25 na na 78.5 77.3 85.5 84.8 82.6 81.2 81.2

Percentage who have never given birth 65.4 19.0 9.8 2.5 2.3 0.8 0.5 6.6 3.9

Number of women 106 516 649 542 489 436 269 2901 2385

Median age at first birth nc nc 21.3 21.2 20.7 21.2 21.3 21.0 21.2

na - not applicable nc - not calculated because less than 50% of women had a birth before reaching the beginning of the age group All the women and women in the survey were asked about the desire for a child or another child and the timing. The information on the desire for another child helps program managers and policy makers draw interventions and strengthen strategies of family planning and other health services. It also helps understand prevailing fertility norms. Table 5.8 provides information regarding the desire for a child or another child among the women by their background characteristics. The survey shows that 28 percent of the women expressed their desire to have another child; 13 percent said within the next two years and 15 percent said two years or later. Forty three percent of women said they did not want any more children. Among all the women, 22 percent were sterilized and seven percent were declared infecund. Analysis by background characteristics indicates that the desire for more children declines sharply with the increase in the number of living children. Ninety five percent of women with no living children said they want a child, compared with only 18 percent of women with two living children and seven percent of women with three living children. A similar relation is observed with the age of the women. However, no consistent pattern emerged while analyzing the desire for children by education, wealth index, religion and caste of the women (Table 5.8).

Table 5.8: Fertility preferences among women Percentage of currently married women age 15- 49 years by desire for children according to other background characteristics, Agra, MLE-2010 Background Fertility Preferences Characteristics: Wants Wants in Wants Does Steriliz Declared D/K Total now (+ 2 yrs) but dont not ed infecund N (< 2 yrs) know want when Age 42.2 50.9 1.5 5.4 0.0 0.0 0.0 106 15-19 22.9 42.6 0.2 31.3 2.2 0.0 0.8 516 20-24 21.4 19.1 0.1 50.6 8.2 0.2 0.5 649 25-29 10.1 7.5 0.1 56.1 23.6 2.6 0.1 542 30-34 3.1 1.2 0.0 53.4 35.1 7.2 0.0 489 35-39 1.5 0.0 0.0 40.4 41.1 17.0 0.0 436 40-44 0.9 0.0 0.0 25.0 43.7 30.4 0.0 269 45-49 Education 9.5 10.8 0.0 43.0 28.3 8.0 0.4 1144 No education 14.5 5.1 0.0 37.9 37.3 5.2 0.0 92 <5 classes complete 13.2 17.4 0.7 39.4 21.0 8.2 0.0 287 5-7 classes complete 15.2 18.4 0.3 41.2 19.5 5.5 0.0 334 8-9 classes complete 13.3 18.0 0.1 41.0 20.1 7.3 0.2 363 10-11 classes complete 15.5 17.8 0.0 47.7 13.3 5.4 0.3 784 12 or more classes complete 0.0 0.0 0.0 100.0 0.0 0.0 0.0 3 Missing Wealth Index 14.0 12.4 0.1 43.9 24.1 4.7 0.8 540 Lowest 12.5 17.5 0.1 43.0 20.4 6.4 0.2 588 Second 11.8 15.6 0.3 43.1 23.2 6.0 0.0 599 Middle 12.7 12.9 0.0 45.3 20.0 9.1 0.1 635 Fourth 12.5 15.3 0.1 41.6 22.5 7.9 0.2 646 Highest Religion 12.6 14.6 0.1 42.6 23.1 6.8 0.2 2580 Hindu 14.3 17.2 0.2 47.0 13.6 7.1 0.6 386 Muslim 3.2 0.0 0.0 59.5 30.6 6.7 0.0 41 Other Caste 12.5 15.2 0.2 41.5 25.1 5.3 0.3 915 Scheduled caste 33.7 3.8 0.0 57.0 5.4 0.0 0.0 13 Scheduled tribe 13.4 15.8 0.1 43.9 19.4 7.1 0.4 967 Other backward class 11.9 13.8 0.1 44.2 21.8 8.1 0.1 1107 Other 0.0 0.0 0.0 100.0 0.0 0.0 0.0 1 Donnt know 0.0 0.0 0.0 61.6 38.4 0.0 0.0 4 Missing No. of live births 63.1 31.5 0.2 0.5 0.0 4.7 0.0 256 0 26.4 49.7 0.6 18.1 0.4 4.7 0.3 501 1 7.2 10.9 0.0 65.1 11.8 4.4 0.6 752 2 2.5 3.9 0.0 52.5 35.6 5.5 0.0 561 3 2.9 1.5 0.0 46.0 40.9 8.4 0.4 382 4 2.7 0.8 0.0 46.2 35.9 14.1 0.3 254 5 0.2 0.8 0.0 44.9 41.0 13.0 0.2 302 6+ Total 12.7 14.8 0.1 43.4 22.0 6.9 0.3 3007 * The N's are slightly smaller due to missing data for some characteristics

As presented in Table 5.9, 28 percent of the men reported that they would like to have another child (10 %within 2 years, 17 % after 2 years, and 1 %were undecided). As observed in the

women, the desire for additional children declines rapidly with the increase in the number of living children. Eighty nine percent of men with no living children said they want to have a child, compared with 22 percent of men with two living children and 10 percent of men with three living children.

Table 5.9: Fertility preferences among men Percentage of currently married men age 18- 54 years by desire for children according to no. of live births, Agra , MLE-2010 Number of living children (in percentage) 0 1 2 3 4 5-6 7+ Total Desire for children Wants another soon (<2 years) Wants another later (2+ years) Wants another, undecided when Want no more Wife or husband sterilized or infecund Don't Know/Missing Number of Men 49.1 38.5 1.3 6.8 4.4 0.0 165 19.4 49.2 3.0 23.6 2.4 2.4 259 MEN 5.9 15.3 0.6 60.2 15.2 2.7 400 3.0 7.1 0.0 58.7 29.0 2.2 305 2.2 2.7 0.2 45.2 46.8 2.9 218 0.8 1.8 0.0 50.5 46.1 0.8 242 1.2 0.4 0.0 71.8 23.7 3.0 93 10.2 16.9 0.8 46.3 23.7 2.1 1682

Each woman who had given birth since 2007 as well as the women who were pregnant at the time of the survey were asked whether the pregnancy was wanted at that time (planned), wanted at a later time (mistimed), or not wanted at all. Table 5.10 shows the percentage distribution of births since 2007 and current pregnancies according to fertility planning status by birth order and the mothers age at birth. Nineteen percent of all pregnancies that resulted in live births since 2007 (including current pregnancies) were unplanned (that is, unwanted at the time the woman became pregnant), nine percent were wanted later and 10 percent were not wanted at all. The proportion of births that were not wanted at all increases sharply by birth order of children. Table 5.10. Fertility planning status among women
Percentage distribution of last birth since 2007 by birth order and mother's age at birth among currently married women*, Agra , MLE-2010

Planning status of birth (in percentage) Birth order/mother's age at birth Birth Order 1 2 3 4+ Mother's age at birth** <20 20-24 Wanted then 95.3 85.5 82.2 51.9 71.4 84.0 Wanted later 4.1 13.4 6.5 10.2 8.9 8.2 Wanted no more 0.0 0.5 10.9 35.3 17.4 7.3 Missing 0.6 0.6 0.3 2.6 2.3 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of births 321 367 205 253 198 663

25-29 30-34 35-39 40-49 Total

79.8 68.1 74.4 0.0 80.2

11.5 5.2 12.1 0.0 8.9

8.3 21.4 13.5 100.0 9.9

0.4 5.4 0.0 0.0 1.0

100.0 100.0 100.0 100.0 100.0

232 42 8 1 1146

*including current pregnancies as last birth if currently pregnant **for current pregnancy, used mother's current age; some women had missing data on age at birth

Table 5.11 shows the planning status of the last birth since 2007 by birth order and father's age at birth among men. As reported by the men, 13 percent of births since 2007/current pregnancies of the spouse were not wanted at the time the wife became pregnant, six percent wanted the child later, while seven percent did not want the child at all.
Table 5.11. Fertility planning status among men Percentage distribution of last birth since 2007 by birth order and father's age at birth among currently married men *, Agra, MLE-2010

Planning status of birth (in percentage) Birth order/Father's age at birth Birth Order 1 2 3 4 5-6 7+ Father's age at birth <25 25-29 30-34 35-39 40+ Total Wanted then 96.6 86.6 78.7 89.8 64.7 94.1 86.2 92.2 87.3 91.0 68.8 Wanted later 2.8 12.2 5.7 6.2 4.0 0.0 6.8 4.4 5.3 0.0 20.5 Wanted no more 0.7 1.2 15.6 4.0 31.3 5.9 7.0 3.4 7.4 9.0 10.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of births 157 118 80 35 35 17 111 148 97 49 37 442

87.5 6.1 6.4 100.0 *including current pregnancies as last birth if spouse is currently pregnant

5.3

Perception on Ideal Number of Children

Table 5.12 presents information on the ideal number of children for women. Overall, three-fifths of the women perceived that two children was the ideal number of children. Around one-fifth thought three was the ideal number and 11 percent considered four children the ideal number. The proportion of women reporting one or two as the ideal number of children declines with the increase in the number of living children. The proportion of women reporting the ideal number of children as three or more increases with the increase in the number of living children. Among

women with four children, 74 percent perceived fewer than four children as ideal. Similarly, among women with five living children, 95 percent perceived less than five children as ideal. These findings indicate a huge mismatch in the ideal and actual number of children and also indicate the potential for program intervention.

Table 5.12. Ideal number of children Percent distribution of ideal number of children among currently married women of age 15 49 years by number of living children-Agra, MLE-2010 Ideal Number of living children (in percentage) number of 0 1 2 3 4 5 6+ Total children 0 1.5 0.5 2.1 2.7 1.1 4.3 9.3 2.7 1 5.1 8.7 1.0 1.4 0.3 0.0 0.0 2.4 2 3 4 5 6+ Other Dont know Missing Number of Women 80.7 6.4 2.7 0.0 0.0 2.9 0.6 0.2 256 77.6 10.8 2.2 0.1 0.0 0.3 0.0 0.0 501 83.0 11.1 1.9 0.0 0.0 0.8 0.0 0.0 752 53.3 36.8 4.6 0.1 0.0 1.1 0.0 0.0 561 45.1 27.8 23.3 0.5 0.0 1.9 0.0 0.0 382 30.5 33.9 25.9 1.4 0.3 3.3 0.2 0.2 254 16.3 26.0 34.8 4.0 0.8 7.6 1.3 0.0 302 60.4 21.0 10.6 0.6 0.1 2.0 0.2 0.0 3007

Fifty three percent of men perceived two children as the ideal number of children (Table 5.13), 23 percent perceived three children as ideal and 11 percent considered four to be ideal. The analysis of the ideal number of children by number of living children for the men exhibits a similar pattern as observed in the case of the women.
Table 5.13. Ideal number of children Percent distribution of ideal number of children among currently married men of age 18 54 years by number of living children-Agra, MLE-2010 Ideal Number of living children (in percentage) number of 0 1 2 3 4 5-6 7+ Total children 0 3.1 0.3 3.1 4.0 5.1 14.4 13.3 5.3 1 2 3 4 5 7.3 76.5 8.6 4.5 0.0 12.5 75.1 9.6 1.6 0.0 3.1 73.9 15.6 3.2 0.1 0.0 48.1 40.5 5.7 0.3 0.3 34.4 25.9 27.3 4.3 2.9 218 0.1 12.8 37.1 22.9 5.9 6.8 242 0.0 16.2 22.2 34.1 2.0 12.3 93 3.4 52.6 23.3 11.2 1.6 2.7 1682

6+/other* 0.0 0.9 1.1 1.4 Number of 165 259 400 305 Men *Other includes infrequent responses, such as God/other

Table 5.14 presents information on the ideal birth interval as perceived by men and women. Eight percent of the women and 71 percent of the men consider a birth interval of at least three years as ideal. Against 17 percent of women, 27 percent of the men considered two years as the ideal birth interval.

Table 5.14. Birth intervals Percent distribution of ideal birth intervals among currently married women and men -Agra , MLE-2010

Ideal birth interval 1 year 2 years 3 years 4 years 5 years 6+ years Total

% of women 2.8 17.3 44.2 16.4 18.6 0.6 100

% of men 2.3 26.6 47.6 9.3 13.4 0.8 100.0

Chapter VI Family Planning

This Chapter presents information on various aspects of family planning collected from women and men. The issues covered in this Chapter include knowledge and use of various contraceptive methods, sources of first knowledge, discussions and decision making regarding contraception, future intention of using contraception and willingness to pay for contraceptive methods. This Chapter also includes data about the mens knowledge and the sources of first learning about contraceptive methods.

6.1 KNOWLEDGE OF CONTRACEPTIVE METHODS The study participants were questioned about their knowledge of various methods of family planning, which included female and male sterilization, the pill, IUDs, injectables, implants, male condoms, female condoms, diaphragms, foam or jelly, the lactational amenorrhea method (LAM), emergency contraception and two traditional methods (rhythm and withdrawal). In addition, a provision was made in the questionnaire to record any other methods named by the respondents. Information on knowledge of contraception was collected in two ways. First, the respondents were asked to spontaneously mention all the methods that they had heard of. For methods not mentioned spontaneously, the interviewer described the method and probed to see whether the respondent recognized it. The information about the womens knowledge of different contraceptive methods according to their background characteristics has been presented in Table 6.1. Knowledge about any family planning method among women is nearly universal. Ninety one percent of women spontaneously mentioned at least one method of family planning. Overall, 95 - 100 percent of women were aware of female sterilization, male sterilization, the pill, IUDs, condoms/Nirodh and injectables. Nearly three-fourths of the women knew about emergency contraceptives. However, knowledge about the female condom is quite limited (only 9%). Twenty nine percent of women were aware of other modern methods, such as implants, diaphragms and foam or jelly. Although less than one fifth of the women spontaneously mentioned the rhythm method (20 %) and withdrawal (13 %), 94 and 83 percent reported these methods respectively on probing. Almost all of the men reported at least one contraceptive method spontaneously or after probing. Similar to women, the knowledge of the two terminal methods (female and male sterilization) and two of the most commonly promoted spacing methods (the pill, and condoms/Nirodh), is universal. Four-fifths of the men were aware of IUDs, while nearly two-thirds were aware of injectables. Awareness of emergency contraception and female condoms has been reported by 65 and 38 percent of the men respectively. Nearly three-fourths of the men reported knowledge of the two traditional methods (rhythm-73 % and withdrawal-70 %) (Table 6.1). When comparing knowledge of contraceptive methods by type of method, it appears that except for the female condom, women are more informed about various contraceptive methods than men.

Table 6.1 Knowledge of contraceptive methods Percentage of currently married women and men who know any contraceptive method by specific method, Agra, 2010
Women Spontaneous or probed knowledge Method Any method Modern methods Female sterilization Male sterilization Pill IUD Injectables Condom/Nirodh Female condom Emergency contraception Other modern method Traditional methods Rhythm Withdrawal 94.3 83.1 19.8 13.2 73.1 70.0 9.3 10.3 100.0 98.6 99.7 98.4 94.6 99.4 9.0 75.2 28.9 69.4 28.3 63.1 32.3 16.9 59.8 0.6 11.5 2.8 97.7 97.6 94.9 80.6 65.0 99.1 38.1 64.6 31.5 78.5 68.8 60.2 31.2 23.4 86.7 13.0 17.6 1.4 100.0 91.0 99.4 93.6 Spontaneous knowledge Spontaneous or probed knowledge Men Spontaneous knowledge

Table 6.2 presents data on womens knowledge about contraceptive methods according to their age and education. The data indicates that the womens awareness about female sterilization, male sterilization, pills, injectables, IUDs and male condoms does not vary by these background characteristics. The knowledge about newer methods such as emergency contraceptives and female condoms shows significant variation by education. As expected, women with 12 or more years of education (95 %) are more informed about emergency contraceptives as compared to women with no education (56 %). Among different age groups, women in the age group of 20-39 years are better informed about emergency contraceptives as compared to their younger and older counterparts.

Table 6.2 Knowledge of contraceptive methods among women Percentage of currently married women who know any contraceptive method by specific method, according to background characteristics, Agra, 2010
Female Sterilization Male Sterilization Pill IUD Injectables Condom / Nirodh Female Condom EC LAM Rhythm Withdrawal Others * AGE 15 - 19 99.1 98.1 99.7 90.4 85.9 99.0 8.4 66.3 19.0 79.1 20 - 24 100.0 97.8 100.0 97.2 93.8 99.7 8.7 76.1 25.9 90.2 25 - 29 99.9 98.6 99.9 98.7 96.4 99.4 11.5 79.8 27.5 94.6 30 - 34 100.0 98.7 99.5 98.9 95.8 99.7 8.4 81.4 29.1 97.1 35 - 39 100.0 98.8 100.0 99.6 95.9 99.9 9.0 75.9 29.8 95.4 40 - 44 100.0 98.7 99.8 99.2 93.2 98.6 9.0 66.5 29.0 96.6 45 - 49 100.0 98.9 98.7 98.1 92.4 98.8 5.6 65.6 29.9 96.0 EDUCATION No education 99.9 97.7 99.4 96.9 90.8 98.8 4.4 55.7 25.3 90.7 <5 classes complete 100.0 100.0 100.0 98.6 92.9 95.9 6.6 62.1 15.9 95.5 5-7 classes complete 100.0 98.7 99.8 98.8 95.4 99.8 4.9 75.2 35.2 95.7 8-9 classes complete 99.8 99.0 100.0 98.8 95.9 99.8 12.3 85.4 28.4 93.7 10-11 classes complete 100.0 98.8 99.9 98.7 94.8 100.0 12.3 88.2 25.4 96.8 12or more classes 100.0 99.3 100.0 100.0 99.2 100.0 14.8 94.7 31.7 98.0 complete * Dermal patch, Diaphragm and Spermicide / Foam are included in others; * The N's are slightly smaller due to missing data for some characteristics

64.1 78.7 84.1 85.5 83.9 85.6 85.9 76.8 80.8 85.4 83.4 83.6 91.1

0.0 1.0 3.1 2.5 2.8 2.0 0.1 1.0 0.4 0.7 2.2 3.6 3.5

6.2 SOURCE OF FIRST LEARNING ABOUT CONTRACEPTIVE METHODS The source of first knowledge about contraceptive methods among women has been presented in Table 6.3 by their age. As the Table shows, television (TV) (74 %) followed by partner/spouse (63 %) and family members/relatives (49 %) are the three commonly mentioned sources from where women first learned about contraceptive methods. Doctors emerged as the first source of information among 32 percent of the women. Health workers, newspapers/magazines and friends have been mentioned as the sources of first learning by 13 - 15 percent of the women. There is not much variation in the source of first learning by age, with the exception of women aged 15-19 years. The data on source of first learning about contraceptive methods among the men has been presented in Table 6.4. The two predominant sources from where the men first learned about contraceptive methods are television (76 %) and friends (64 %). Doctors and newspapers /magazines have been reported as the first source of information about contraception by 38 and 32 percent of the men respectively. Compared to women, a much lower proportion of men reported family members/relatives (11 %) and partner/spouse (17 %) as the first source of information about contraceptive methods. In general the source of first learning about contraceptive methods does not vary much by the age of the men.

Table 6.3 Source of first learning about contraceptive methods among women Percentage of currently married women who know any contraceptive method by source of first learning, MLE- Agra, 2010 Background Doctor Health Friend Partner/ Family Peer Radio TV Characteristics Workers* Spouse Members Educator /Relatives**

Newspaper/ Magazine

Poster

Other***

Dont know

Age
15-19 13.0 8.9 8.7 60.7 52.7 0.8 0.3 67.4 5.5 20-24 28.0 9.4 11.8 65.9 51.7 1.8 1.7 74.0 10.9 25-29 35.3 16.9 10.2 59.8 51.2 1.9 3.7 74.5 15.8 30-34 35.8 15.0 14.2 66.0 47.2 2.4 2.9 74.7 15.8 35-39 33.7 17.8 12.1 63.0 48.1 1.3 3.1 75.3 11.9 40-44 30.1 15.9 17.5 60.9 47.5 3.1 2.1 68.6 14.9 45-49 29.5 11.9 14.7 61.3 48.9 1.6 2.6 74.1 14.2 Total 31.8 14.6 12.9 62.8 49.3 2.0 2.7 73.5 13.7 * Includes ANM or Nurse, Comm Health worker/ASHA/USHA and AWW ** Includes Mother/M-in-Law, Father/F-in-Law, Sister/S-in-Law, Brother/B-in-Law and other relatives *** Includes RMP, Unqualified Medical Provide, Leaflet/Broucher, Billboards, Community events, Live drama/theatre, School and Health center 6.7 11.3 12.0 13.1 9.4 8.4 9.1 10.7 7.4 12.5 12.4 12.9 9.8 10.7 13.0 11.7 2.3 0.0 0.2 0.0 0.0 0.0 0.1 0.1

Table 6.4 Source of first learning about contraceptive methods among men Percentage of currently married men who know any contraceptive method by source of first learning, according to background characteristics, Agra, 2010 Background Characteristics: Doctor Health Friend Partner/ Family Peer Radio TV Newspaper/ Poster or Workers* Spouse Members Educator Magazines Nurse /Relatives** Age 18-24 39.7 3.0 67.4 20.4 12.4 5.3 10.8 72.5 34.6 15.4 25-29 33.6 3.3 65.9 22.0 9.0 6.2 16.1 75.2 27.1 11.6 30-34 38.8 3.3 70.6 20.3 12.8 3.9 14.2 79.3 36.1 11.8 35-39 34.8 4.0 65.2 13.9 9.7 6.8 16.3 76.0 28.8 9.4 40-44 41.7 6.0 59.2 18.5 12.1 6.1 15.9 77.4 30.7 9.7 45-49 38.5 2.7 65.2 10.2 9.8 3.6 18.0 74.7 32.6 10.3 50-54 40.0 2.9 51.5 9.3 7.8 11.0 18.0 72.4 38.3 12.0 Total 37.8 3.7 64.2 16.7 10.6 5.9 15.7 75.8 32.0 11.1 * Includes ANM or Nurse, Comm Health worker/ASHA/USHA and AWW ** Includes Mother/M-in-Law, Father/F-in-Law, Sister/S-in-Law, Brother/B-in-Law and other relatives *** Includes RMP, Unqualified Medical Provide, Leaflet/Brochure, Billboards, Community events, Live drama/theatre, School and Health center

Other***

Dont know

18.5 22.1 17.5 24.1 16.1 18.1 23.7 19.9

0.0 0.3 0.3 0.4 0.5 0.7 0.5 0.4

6.3 DISCUSSIONS AND DECISION MAKING ON FAMILY PLANNING The information relating to discussions with the spouse and others on family planning is presented in Table 6.5. The majority of women (89 %) said that they have discussed family planning with their spouse at some time. Among those women who have discussed family planning with their spouses, 86 percent mentioned that these discussions were usually initiated by both the spouse and herself. The other persons with whom the women primarily discuss family planning are female relatives (36 %), friends (27 %) and neighbors (25 %). Forty six percent of the women have never discussed family planning with any other person. Eighty six percent of the women said that they need the consent of their husband or family to use family planning. Most of the women (92 %) reported that the decisions to use various methods of family planning were taken jointly by the husband and the wife. Table 6.5 shows that most of the women (88 %) have discussed the number of children they would like to have with their spouse, and 38 percent of these women reported discussing this issue with the spouse in the last six months.
Table 6.5 Discussion and decision making around family planning Percentage of currently married women who discussed family planning and were involved in decision making, Agra, 2010
Behavior Ever discussed FP with spouse Yes No Who initiates discussion among those who discuss Self Spouse Both Who else have you ever discussed FP with** Female relatives Male relatives Friend Neighbor Others No one Do you need consent of your husband or family to use FP Yes No Not applicable/never used or wanted to use Dont know Who decides what type of method to use Mainly you Mainly husband Jointly Percentage (n=3007) 88.8 11.2 (n=2669) 6.1 7.9 86.0 (n=3007) 36.1 2.1 27.2 25.4 7.5 46.2 (n=3007) 85.6 4.1 10.1 0.2 (n=3007) 1.6 4.7 92.1

Table 6.5 Discussion and decision making around family planning Percentage of currently married women who discussed family planning and were involved in decision making, Agra, 2010
Other Missing Have you discussed the number of children you would like to have with your spouse Yes No How often have you discussed the subject in the last 6 months Not discussed in last 6 months Once or twice More than twice * number of respondents vary by question ** percentages do not sum to 100 because women can give multiple responses. 0.5 1.2

(n=3007) 87.9 12.1 (n=2643) 61.7 32.1 6.1

6.4 EVER USE OF CONTRACEPTIVE METHODS Contraception ever used, provides a measure of the cumulative experience of a population with family planning. All currently married women who reported having heard about any method or methods of family planning were asked whether they had ever used each method that they had heard about. Table 6.6 presents the percentage of these women who had ever used any family planning method by method and the age of the women. Almost three-fourths of currently married women have used a family planning method at some time in their lives. Women are much more likely to have used a modern method (60 %) than a traditional method (28 %). Condoms/Nirodh (32 %) followed by female sterilization (22 %) are the two most commonly used modern methods among currently married women. The pill and IUDs have been used by 12 and six percent of the women respectively. The rhythm method has been used by 26 percent of women, and 13 percent of women have used the withdrawal method. The use of any method and any modern method increases with the womans age up to the age of 35-39 years and decreases subsequently. At the ages of 35-39 years, 85 percent of the currently married women reported having used family planning and 70 percent reported using a modern method. The extent of ever having used female sterilization and IUDs increases with the increase in the womens age. The use of condoms/Nirodh as well as the pill reaches a peak in the age group of 30 - 34 years and thereafter the proportion of women reporting the use of these two methods declines. Compared to all the age groups, the use of the two natural methods is lowest for the youngest age group of 15-19 years.

Table 6.6 Ever use of contraceptive methods Percentage of currently married women who ever used any contraceptive method by age, Agra, 2010
Age Any method Modern method Any modern method 18.2 39.0 57.8 70.7 69.5 68.9 64.9 59.7 Female sterilization Male sterilization Pill IUD Injectables Condom/ Nirodh Other modern method 0.4 3.4 3.3 3.8 1.2 0.6 0.5 2.3 Traditional method Any traditional method 14.3 25.9 30.2 26.2 29.6 31.6 31.9 28.4 Rhythm Withdra wal Number of women

15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total

32.5 59.0 75.4 83.5 85.0 84.2 82.7 76.0

0.0 2.2 8.2 23.6 35.1 40.8 43.5 21.9

0.0 0.0 0.0 0.0 0.0 0.3 0.2 0.1

4.7 7.8 11.7 14.8 13.3 11.3 11.9 11.5

0.0 2.5 3.7 7.0 8.2 8.1 9.9 5.9

0.0 1.6 2.7 1.8 2.0 0.4 0.0 1.5

14.4 27.5 39.6 42.1 30.6 25.4 18.5 31.7

14.3 23.8 27.5 23.5 27.7 29.7 30.9 26.3

7.8 13.4 13.3 11.6 14.1 11.7 10.7 12.5

106 516 649 542 489 436 269 3007

6.5 CURRENT USE OF CONTRACEPTIVE METHODS The current level of contraceptive use, i.e., the contraceptive prevalence rate (CPR), is defined as the percentage of currently married women aged 15-49 years who are currently using a contraceptive method or whose husbands are currently using a contraceptive method. It is one of the principal determinants of fertility. It is also an indicator of the success of family planning programs. This Section focuses on the levels and differentials in the current use of contraceptive methods in Agra. Current use of any contraceptive method, modern, traditional and method mix among currently married women is presented by background characteristics in Table 6.7. The contraceptive prevalence rate, of women using modern or traditional methods, in Agra is 63 percent, 48 percent are using modern methods and 15 percent are using traditional methods. Similar to the age pattern of ever having used contraception, the current use of modern methods also increases with age, peaks at 60 percent in the age group of 30-34 years and decreases thereafter. The current use of any modern method of family planning increases sharply with the increase in the wealth index of the women. Data on method mix indicates a high preference for female sterilization (22 %) followed by condoms (19 %). The use of IUDs, pills and injectables is limited. Only one to three percent women reported using these methods. The current use of male sterilization is almost negligible. The current use of female sterilization increases sharply with the increase in the age of women. The use of four modern spacing methods namely the pill, IUDs, condoms and injectables increases till the women reach the age of 25-29 years and starts declining thereafter. The current use of all the above four modern spacing methods reaches a peak in the age group of 25-29 years. In general, with increasing education and wealth of the women, the current use of female sterilization declines where as the use of all the four modern spacing methods (the pill, IUDs, condoms and injectables) increases steadily. The use of traditional methods is higher among women in the lowest wealth quintile and women with no education. Compared to Hindus (30 %), Muslim women (13.6 %) are less likely to use female sterilization. However, condom use is high among Muslims. Analysis by caste shows that the current use of female sterilization is higher among women belonging to the SCs. The variations in the current use of various spacing methods by caste do not show any consistent pattern. A higher proportion of women having three or more living children report the current use of female sterilization, whereas current use of spacing methods is higher among low parity women.

Table 6.7 Current use of contraceptive methods by background characteristics Percent distribution of currently married women by contraceptive methods currently used, according to background characteristics, Agra, 2010 Modern method Background Characteristic Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Education No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete Wealth Index Lowest Second Middle Fourth Highest 20.5 44.3 64.2 73.9 75.3 69.2 58.4 60.0 65.6 55.6 59.3 64.1 71.2 56.3 60.3 60.1 66.8 69.9 9.1 27.2 48.5 59.5 58.7 55.0 48.6 43.7 52.4 42.0 45.7 48.7 57.0 38.0 43.4 46.8 54.0 56.0 0.0 2.2 8.2 23.6 35.1 40.8 43.5 28.3 37.3 21.0 19.5 20.1 13.1 24.1 20.4 23.2 20.0 22.2 0.0 0.0 0.0 0.0 0.0 0.3 0.2 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.3 1.4 2.3 5.0 3.1 4.6 1.8 1.0 2.1 0.7 3.5 3.2 4.4 4.4 2.0 2.6 2.5 4.4 3.9 0.0 2.1 2.9 1.2 1.6 0.5 1.7 0.5 0.4 2.2 0.2 1.3 4.1 0.8 0.6 1.5 2.1 3.1 0.0 0.4 1.7 1.3 1.3 0.1 0.0 0.6 0.0 0.8 0.7 0.2 1.9 0.1 0.7 1.3 1.0 1.2 7.3 18.6 29.3 28.6 15.9 11.4 2.3 11.5 12.9 13.8 21.7 20.9 32.1 9.5 18.2 18.0 25.6 23.9 0.4 1.7 1.5 1.7 0.3 0.0 0.0 0.7 1.1 0.8 0.5 1.9 1.2 1.5 0.9 0.3 0.8 1.5 11.4 17.1 15.7 14.4 16.6 14.2 9.7 16.2 13.2 13.6 13.5 15.4 14.2 18.3 16.8 13.3 12.9 14.0 79.5 55.7 35.8 26.1 24.8 30.8 41.7 40.0 34.4 44.4 40.7 35.9 28.8 43.7 39.7 39.9 33.2 30.1 106 516 649 542 489 436 269 1144 92 287 334 363 784 540 588 599 635 646 Any method Any modern method Female sterilization Male sterilization Injectables Condom/ Nirodh Other modern method Any traditional method Nonusers Number of women

Pill

IUD

Table 6.7 Current use of contraceptive methods by background characteristics Percent distribution of currently married women by contraceptive methods currently used, according to background characteristics, Agra, 2010 Modern method Background Characteristic Religion Hindu Muslim Other/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Other Dont know Missing Number of live births 0 1 2 3 4 5 6+ Total 6.8 51.5 70.9 75.2 76.9 66.1 67.2 63.0 5.1 35.8 48.2 63.7 64.8 49.7 52.9 48.1 0.0 0.4 11.6 35.5 40.9 35.9 40.9 21.9 0.0 0.0 0.2 0.1 0.0 0.0 0.1 0.1 0.0 2.8 4.1 3.7 5.1 1.1 2.3 3.2 0.0 2.4 2.8 1.8 1.3 0.0 0.6 1.7 0.0 0.9 1.3 1.1 1.5 0.1 0.1 0.9 5.1 27.5 27.3 20.4 15.9 10.1 8.6 19.4 0.0 1.9 0.8 1.1 0.2 2.4 0.3 1.0 1.7 15.7 22.7 11.5 12.1 16.4 14.3 14.9 93.2 48.5 29.1 24.8 23.1 33.9 32.8 37.0 256 501 752 561 382 254 302 3007 60.8 36.8 59.8 67.7 100.0 89.0 45.6 33.3 46.7 51.4 100.0 38.4 25.0 5.4 19.4 21.7 0.0 38.4 0.0 0.0 0.0 0.1 0.0 0.0 3.1 0.0 3.6 2.9 0.0 0.0 0.8 8.2 1.6 2.3 0.0 0.0 0.0 0.0 1.5 1.1 0.0 0.0 15.8 19.6 19.4 22.3 100.0 0.0 0.8 0.0 1.2 1.0 0.0 0.0 15.2 3.5 13.1 16.3 0.0 50.6 39.2 63.2 40.2 32.3 0.0 11.0 915 13 967 1107 1 4 Any method 63.6 57.0 78.5 Any modern method 48.4 43.6 67.0 Female sterilization 23.0 13.6 30.6 Male sterilization 0.1 0.0 0.0 Injectables 0.9 0.9 0.0 Condom/ Nirodh 18.7 22.8 27.1 Other modern method 0.9 1.6 0.0 Any traditional method 15.2 13.4 11.5 Nonusers 36.4 43.0 21.5 Number of women 2580 386 41

Pill 3.2 2.9 5.7

IUD 1.6 1.8 3.7

6.6 SOURCE OF CURRENT CONTRACEPTIVE METHODS

The source of the current method used was ascertained from the women who reported current use of any modern method of family planning (Table 6.8). Fifty seven percent of women currently using female sterilization reportedly accepted the method in a government/public sector facility (govt./municipal hospital - 48 %, medical college hospitals 3 % and other public sector facilities 6 %). Two-fifths of the women accepted female sterilization in a private hospital/clinic and 11 % accepted it in a NGO/Trust hospital/clinic. Among the women currently using IUDs and injectables, the majority received the method from a private hospital/clinic (IUDs- 76 % and injectables - 87 %). Among the women currently using pills, 71 percent obtained it from a pharmacy/drugstore. Condoms were mostly procured from a pharmacy/drug store (71 %). Nearly one-fifth of the women reported that condoms were typically obtained by their husbands. Condoms, pills and IUDs were infrequently obtained from government/public sector facilities. Among all the current users of modern methods, 35 percent availed the method from a pharmacy/drug store, 28 percent obtained them from government/public sector facilities and 23 percent received the method at a private hospital/clinic. Overall, the procurement of modern methods by husbands has been reported by nine percent of the women.

Table 6.8 Source of modern contraceptive methods Percent distribution of women modern contraceptive users by most recent source of the methods, Agra, 2010 Female and Male sterilization 48.4 2.7 5.6 3.6 39.7 na na na 0.0 0.0

Source Govt/municipal hospital Medical college hospitals Other public sector facility NGO/Trust hospital/clinic Private hospital/clinic/doctor Pharmacy/drugstore Husband Other private source Other Don't know

Pill 3.9 0.4 3.5 0.0 6.3 70.6 7.8 0.8 0.0 6.8

IUD 11.3 2.1 4.7 0.9 75.9 1.1 0.0 0.0 3.9 0.0

Injectables 2.6 0.0 0.0 0.0 86.6 3.6 0.0 0.0 7.2 0.0

Condom/ Nirodh 1.3 0.0 0.9 0.0 0.2 71.4 21.1 0.8 1.2 3.0

All modern methods 23.7 1.3 3.4 1.7 23.3 34.7 9.3 0.4 0.5 1.7

6.7 REASON FOR DISCONTINUATION OF A FAMILY PLANNING METHOD The reason for the discontinuation of family planning methods was ascertained from all the women who had reported ever using any family planning method, but did not report the current use of the method (Table 6.9). The most commonly mentioned reasons for discontinuation of family planning methods are, wanted to get pregnant (48 %), method failed/got pregnant (18 %), created health problems (14 %) and created menstruation problems (9%). Five percent of the women had switched to other methods and four percent discontinued the method due to menopause. Other reasons for discontinuing a family planning method were mentioned infrequently, including that the method costs too much, suggesting that cost does not play a role in why women stop using contraception.

Table 6.9 Reasons to discontinue a contraceptive method Percent distribution of currently married women who are currently not using the same method as first time by reasons to discontinue the method used first time, Agra, 2010 Reasons Wanted to get pregnant Method failed/got pregnant Lack of sexual satisfaction Created menstruation problem Created health problem Inconvenient to use Costs too much Did not like method Husband does not approve Fear of side effects Menopause Switched method Others % of women 47.8 17.8 2.1 8.5 13.8 1.1 0.2 1.6 2.1 0.8 3.9 5.1 3.1

6.8 TIMING OF STERILIZATION The timing of sterilization by age of the women at the time of sterilization has been presented in Table 6.10. Eight percent of women reported that they did not know the year of sterilization. Among sterilized women, 18 percent underwent sterilization when they were 20-24 years old, 38 percent when they were aged 25-29 years and 25 percent when they were aged 30-34 years. Ninety two percent of sterilized women were sterilized before the age of 34 years.

Table 6.10 Timing of sterilization Percent distribution of sterilized women by her age at sterilization, according to the number of years since the sterilization, Agra, 2010 Age of woman at time of sterilization Total Years since 20 25 30 35 40 DK/CS sterilization < 20 24 29 34 39 44 /NR N % < 2 years 2.8 13.0 42.4 25.8 13.0 3.1 0.0 73 11.3 2 - 3 years 1.3 8.4 28.7 38.6 16.5 6.5 0.0 35 5.3 4 - 5 years 0.0 27.6 36.3 21.4 11.0 3.6 0.0 30 4.6 6 - 7 years 1.3 6.5 53.4 37.0 1.8 0.0 0.0 36 5.5 8 - 9 years 0.0 14.0 41.7 25.0 19.3 0.0 0.0 30 4.7 10+ years 1.8 22.4 41.7 26.7 7.4 0.0 0.0 397 60.9 DK/CS/NR 0.0 0.0 0.0 0.0 0.0 0.0 100.0 50 7.6 Total 1.5 17.8 38.3 25.4 8.4 0.9 7.6 652 100.0

6.9 REASONS FOR CURRENTLY NOT USING ANY FAMILY PLANNING METHOD Table 6.11 shows the reasons for not using any family planning method among the women who were currently not using any family planning method. The reasons more commonly mentioned for not currently using any family method among the non users are currently pregnant (19 %),

wants to get/trying to get pregnant (19 %), attained menopausal/hysterectomy (15 %) and health concerns (13 %) . Up to God, infrequent sex/no sex, wants as many children as possible, postpartum amenorrhea and fear of side effects were mentioned as other reasons for not using any family planning methods by six to 11 percent of the non users. Three to four percent of the women cited opposition to using family planning (either by the husband, family members or because of religious beliefs), currently breast feeding and cannot have children as some of the other reasons for not using family planning methods. Interestingly, a very small percentage (0.1 %) of women cited the lack of access as their reason for currently not using contraception.

Table 6.11 Reasons for not currently using contraception among women Percent distribution of currently married women age 15-49 who are not using contraception by reasons for non-use, Agra, 2010 Reason * Menopausal/hysterectomy Trying to get pregnant No sex/ infrequent sex Husband away Already pregnant Breastfeeding Wants as many children as possible Postpartum amenorrhea Has faced opposition to use Lacks knowledge Method-related reasons Lack of access/too far Costs too much Percentage 15.3 18.5 9.5 1.4 18.7 3.7 6.7 6.4 3.7 0.5 16.8 0.1 0.9

Others/ Don't know 12.2 *percentages do not sum to 100 because women could give multiple reasons

6.10 INTENTIONS TO USE CONTRACEPTION The women who were not using contraceptive methods at the time of the survey were asked about their intention to use contraceptives in the next 12 months. Table 6.12 shows the intention to use family planning methods among the non users within 12 months. Nearly one-fourth of the non users intend to use contraception, while 49 percent do not, and 28 percent were not sure about their intentions. The intention to use family planning in the next 12 months increases marginally with the increase in the womens age; it peaks in the age group of 25-29 years and declines thereafter. However, it does not vary much with education or wealth. The intention to use family planning is relatively lower among women belonging to other castes and Muslims. Analysis of intention with parity indicates that it increases with the increase in the number of live births up to four live births and declines thereafter.

Table 6.12 Future intention to use contraception Percent distribution of currently married women who are currently not using any contraceptive method by intention to use within 12 months, according to background characteristics, Agra, 2010 Whether intends to use within 12 months Total Characteristics Yes No Don't know N Age 27.5 40.8 31.7 84 15 - 19 28.2 33.7 38.1 288 20 - 24 30.5 44.2 25.3 234 25 - 29 22.0 54.9 23.1 130 30 - 34 12.6 63.4 24.0 87 35 - 39 3.9 86.5 9.6 67 40 - 44 4.0 92.8 3.2 33 45 - 49 Education 22.0 52.2 25.7 374 No education 9.5 60.4 30.1 27 <5 classes complete 21.6 45.7 32.7 107 5-7 classes complete 8-9 classes complete 10-11 classes complete 12+ classes complete Wealth Lowest Second Middle Fourth Highest Religion Hindu Muslim Others/None Caste/Tribe Scheduled caste Scheduled tribe Other backward class Other Number of live births 0 1 2 3 4 5 6+ Total
19.7 34.7 26.8 24.0 25.4 22.8 20.6 25.8 24.7 19.2 .0 24.4 5.6 28.3 18.3 21.1 26.3 25.7 25.6 27.6 10.8 22.8 23.7 50.6 35.9 47.8 48.2 43.6 46.2 52.6 55.9 47.9 51.2 96.6 44.6 18.1 48.3 54.7 41.0 41.8 57.5 52.1 46.7 56.1 65.2 48.7 29.7 29.4 25.3 27.8 31.0 30.9 26.8 18.2 27.3 29.6 3.4 31.0 76.3 23.4 27.0 37.9 31.9 16.8 22.4 25.7 33.1 11.9 27.5 120 104 190 213 200 207 158 145 776 141 6 314 8 324 276 226 224 188 109 59 56 61 923

*Total number does not include women who, in a previous question, reported having a hysterectomy, being menopausal, or being unable to have children

6.11 WILLINGNESS TO PAY FOR CONTRACEPTIVE METHODS The willingness to pay for family planning methods was ascertained from all the women who intended to use a family planning method within the next 12 months. Nearly one-fourth of all the women intending to use a family planning method within the next 12 months were willing to pay for them (Table 6.13). The willingness to pay for family planning methods increases with the age of the women, though it peaks in the age group of 25-29 years and thereafter declines. The women belonging to the highest wealth quintile and women having 10 or more years of schooling are more likely to express their willingness to pay for contraceptives. A higher proportion of Hindu women as compared to Muslim women have expressed willingness to pay for contraceptives.

Table 6.13 Willingness to pay for contraceptive method Percent distribution of currently married women who are currently not using any contraceptive method but intent to use within 12 months by willingness to pay, according to background characteristics, Agra, 2010
Willing to pay for FP Yes AGE 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 EDUCATION No education <5 classes complete 5-7 classes complete 8-9 classes complete 10-11 classes complete 12 or more classes complete WEALTH INDEX Lowest Second Middle Fourth Highest RELIGION Hindu Muslim Others/None CASTE/ TRIBE Scheduled caste Scheduled tribe Other backward class Others Total 27.5 28.2 30.5 22.0 12.6 3.9 4.0 47.9 61.8 61.1 71.6 58.6 69.4 24.0 25.4 22.8 20.6 25.8 24.7 19.2 0.0 57.2 100.0 54.2 70.4 23.7 No 40.8 33.7 44.2 54.9 63.4 86.5 92.8 8.7 0.0 18.7 0.0 6.5 1.4 48.2 43.6 46.2 52.6 55.9 47.9 51.2 96.6 7.1 0.0 9.2 0.0 48.7 Don't know 31.7 38.1 25.3 23.1 24.0 9.6 3.2 43.4 38.2 20.2 28.4 34.9 29.2 27.8 31.0 30.9 26.8 18.2 27.3 29.6 3.4 35.7 0.0 36.6 29.6 27.5 Total N 84 288 234 130 87 67 33 75 3 19 24 36 49 213 200 207 158 145 776 141 6 69 0 89 47 923

6.12 ATTITUDE TOWARDS CONDOMS AND HORMONAL METHODS Table 6.14 provides information regarding the womens attitude towards condoms and hormonal methods. Fifty four percent of women thought that if a condom is used correctly it protects against pregnancy most of the time and 24 percent said it is effective only sometimes. Over onefifth of the women were not aware about how well a condom protects against pregnancy. Eleven percent of the women said that condoms reduce sexual pleasure and six percent perceived the use of condoms as a sign of infidelity. Sixty nine percent of the women had not recommend condoms for family planning to their friends and relatives. Forty two and 32 percent of the women said that if a woman uses a hormonal method as instructed, it provides protection against pregnancy most of the time and sometimes respectively. The percentage of women who have ever recommended the use of pills, IUDs and injectables to their friends and relatives are 33, 28 and 25 percent respectively (Table 6.14).
Table 6.14 Attitude towards condoms and hormonal methods Percent distribution of currently married women according to their attitude towards condom and hormonal methods, Agra, 2010
Attitude If a condom is used correctly how well does it protect against pregnancy Most of the time Sometimes Not at all Dont know Do you think condom reduces sexual pleasure Yes No Dont know Do you think using a condom is a sign of infidelity Yes No Dont know Missing Have you recommended the condom for FP to friends and relatives Yes No Missing If a woman uses a hormonal method as instructed how well does it protect against pregnancy Most of the time Sometimes Not at all Percentage

(n= 2989) 54.2 23.8 0.8 21.2 (n= 2989) 11.0 59.0 30.0 (n= 2989) 5.9 63.7 30.2 0.2

(n= 2989) 30.6 69.0 0.4 (n= 3003) 41.8 32.2 2.1

Dont know Missing

23.9 0.1

Have you recommended the pill for FP to friends and relatives Yes No

(n=3003 ) 32.7 67.2

Have you recommended the IUD for FP to friends and relatives Yes No Missing

(n= 3003) 28.3 71.6 0.1

Have you recommended injectables for FP to friends and relatives Yes No Missing * number of respondents vary by question; * The N's are slightly

(n=3003 ) 24.7 75.0 0.3

smaller due to missing data for some characteristics

6.13 UNMET NEED FOR FAMILY PLANNING Unmet need is an important indicator representing the potential demand for family planning. The data on unmet needs for the city of Agra, presented in Table 6.15, indicates that five percent of the women have an unmet need for the spacing method, i.e., they want to delay the next birth, but are not using any contraception. An additional 11 percent women have an unmet need for the limiting method, i.e., they want to stop child bearing, but are not using any method to do so. Thus, despite various efforts to ensure supply, 16 percent women have an unmet need for family planning. Analysis by wealth indicates that poor women have a higher unmet need particularly for the limiting method. Women in the first two quintiles have 19 - 21 percent unmet needs for family planning. Even among the women from the richest quintile, the unmet need is 11 percent.

Table 6.15 Unmet need for family planning Percent distribution of currently married women with unmet need for family planning by wealth index, Agra, 2010 Unmet Need* Wealth Poorest Poor Middle Rich Richest Overall For spacing 4.6 7.4 5.5 4.2 3.3 5.0 For limiting 16.0 11.9 11.5 9.3 7.8 11.1 No unmet need 79.5 80.7 82.9 86.5 89.0 83.9 Total 100.0 100.0 100.0 100.0 100.0 100.0

*Unmet need for spacing includes pregnant women whose pregnancy was mistimed; and fecund women who are nonpregnant, who are not using any method of family planning, and say they want to wait 2 or more years for their next birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted; and fecund women who are non-pregnant, who are not using any method of family planning, and who want no more children. Excluded from the unmet need category are pregnant women who became pregnant while using a method (these women are in need of a better method of contraception).

Chapter VII Maternal and Child Health

This Chapter presents information on some of the key maternal and child health indicators such as place of birth/delivery, reasons for non-institutional births, immunization of the children and contact with the health personnel for maternal and child health services. 7.1 Place of Delivery The women were asked about the place of delivery for the youngest child born since 2007. Table 7.1 presents the place of delivery according to the womens background characteristics. Overall, 73 percent all the live births that had taken place since 2007 took place in some health institution, 57 percent in private hospitals/clinics and 16 percent at government health facilities. Over one-fourth (27%) of the deliveries took place at home. A higher percentage of women in the age group of 25-29 years (80 %) and 30-34 years (73%) reported institutional births. The proportion of home deliveries was considerably higher for women in the youngest age group of 15-19 years (46%) as well as the older age group of 40-44 years (47 %). The proportion of institutional births increases sharply with the increase in the womens education and wealth (Table 7.1). Women having 12 or more years of schooling and the women belonging to the highest wealth quintile are more likely to deliver at private hospitals/clinics. A higher proportion of Hindu women (75 %) than Muslims (63 %) reported deliveries at health institutions. Across caste categories, the proportion of institutional deliveries was higher among women from other castes as compared to women from the SCs and OBCs. The results presented for the other religious groups and Scheduled Tribes (STs) should be viewed with caution because of low cell frequencies. Table 7.1: Place of delivery Percentage Distribution of last live births by the currently married women of age 15 49 years, who have given birth in the past three years preceding the survey by place of delivery and percentage delivered in a place by background characteristics- Agra, MLE 2010
Background Characteristics Age 15-19 20-24 25-29 30-34 35-39 40-44 Education No education Public facility 15.2 16.5 13.2 18.3 14.5 35.3 17.8 NGO/Trust 0.0 0.8 0.3 0.6 1.8 0.0 0.5 Pvt facility 39.4 52.8 66.4 53.8 52.7 17.6 35.4 Any Facility 54.5 70.1 79.8 72.8 69.1 52.9 53.7 Home 45.5 29.9 20.2 27.2 30.9 47.1 46.0 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.3 Total* 33 381 372 169 55 17 387

<5 years complete 20.7 5-7 years completed 22.9 8-9 years complete 14.9 10-11 years complete 17.8 12+ complete 8.5 Wealth Index Lowest 18.5 Second 24.8 Middle 10.5 Fourth 10.3 Highest 11.6 Caste Scheduled Caste 20.1 Scheduled Tribe 0.0 Other backward class 15.6 None of the above 12.0 Religion Hindu 17.2 Muslim 8.7 Other 0.0 15.8 Total * 12 missing cases are excluded

0.0 0.0 0.0 0.0 1.5 0.0 0.0 1.1 1.0 0.6 0.6 0.0 0.0 0.9 0.5 1.2 0.0 0.6

34.5 46.7 65.8 69.0 85.4 28.1 42.2 68.4 76.8 84.1 47.6 12.5 55.5 68.7 57.1 53.4 100.0 56.9

55.2 69.5 80.7 86.8 95.4 46.6 67.0 80.0 88.1 96.3 68.3 12.5 71.0 81.6 74.8 63.4 100.0 73.2

44.8 30.5 19.3 13.2 4.6 53.4 33.0 20.0 11.9 3.7 31.7 87.5 28.7 18.4 25.2 36.0 0.0 26.7

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.6 0.0 0.1

29 105 114 129 260 249 230 190 194 164 328 8 366 326 858 161 8 1027

All the women who had delivered the child at home were asked to mention the reason for not delivering the child at a health institution. The responses presented in Table 7.2 show that the most commonly mentioned reasons for non-institutional deliveries are it is not necessary to give birth at the health facilities (37%), Did not have time to go to the health facility (28 %) and expensive institutional deliveries (25 %). Poor quality of services at the health facilities and did not trust the staff have been mentioned as reasons for non institutional deliveries by seven and four percent of the women respectively.

Table 7.2: Reasons for not delivering in a health facility Percentage of currently married women of age 15 49 years, who had their last live birth in the three years preceding the survey by reasons for not delivering the mist recent live birth in a health facility, Agra, MLE 2010
Costs too much Didnt have time Dont trust the staff Not necessary Poor quality services Other Reasons Base 25.4 28.4 4.4 36.6 6.9 44.6 288

7.2 Vaccination Coverage Table 7.3 presents the immunization status of the youngest child born since 2007. Among them, 86 percent received the Polio vaccine and 83 percent received BCG. DPT and measles vaccines were administered to 62 and 42 percent of the children respectively. One-tenth of the children had not received any vaccination. Ninety eight percent of all the women who reported administration of any vaccine to their youngest child said that the child was given at least one dose of polio drops .Among these children, 83 percent had received the first dose within the first two weeks of birth. Table 7.3: Vaccinations received by youngest child Percentage of children, who are most recent born in past three years preceding the survey to a currently married women of age 15 49 years, who received different vaccinations, at any time before the survey, Agra, MLE 2010
Vaccinations received 86.3 Polio 83.3 BCG 62.1 DPT Measles Others None Total N Ever received polio vaccine including the vaccine received in a Pulse Polio campaign Receipt of polio drops within the two weeks after birth Received in first two weeks Received later than 2 weeks Total N 41.6 0.3 10.2 1025 98.1 (N=871) 83.5 16.5 871

7.3 Contacts with Health Personnel Table 7.4 shows the contact the women have had with health workers and visits to doctors or health workers because of illness. Nineteen percent of the women reported contact with an Auxiliary Nurse Midwife (ANM) or Lady Health Visitor (LHV) in the last three months. Women had primarily visited a private hospital/clinic/doctor (87 %) in the last one year in case of their illness or their childrens illness. Only 11 percent of the women reported visiting a government health facility in case of sickness in the last one year. The most commonly mentioned reason for visiting a particular doctor/health personnel is proximity to home (61 %) followed closely by high quality of services offered by the health provider (56 %). Good reputation, provision of multiple services at the same facility and affordability of services have been mentioned as other reasons for visiting the facility by 14 to 19 percent of the women.

Table 7.4: Contact with Health Personnel Percent of currently married women of age 15 49 years who contacted or were contacted by any health personnel, type of facilities visited and reasons for visiting the health facilities by these women, Agra, MLE 2010
Contact Have you been contacted by a health worker in the last 3 months Yes No Don't know In the last year have you or your child been ill and visited a doctor or other health personnel Yes No Did not fall ill Don't Know What type of health facility did you visit Govt./municipal hospital Medical college hospitals Other public sector facility NGO/Trust hospital/clinic Private hospital/clinic/doctor Pharmacy/drugstore Other private source Don't Know Other Why did you visit this facility * Close to home Has a good reputation Provides multiple services It is affordable High quality services Other reasons 65.4 28.9 5.6 0.1 (n=1968) 9.3 0.9 0.4 0.3 86.6 2.0 0.0 0.1 0.3 60.7 15.4 14.3 19.0 55.6 23.0 18.6 81.1 0.3 Percentage

* Percentages do not sum to 100 because women can give multiple responses.

Chapter VIII Media

This Chapter presents the main sources of information on birth spacing among currently married women and men. The Chapter also discusses the exposure the women and men have had to radio and television (TV), as well as the type of information on family planning they received from these sources.
8.1 Sources of Information on Birth Spacing Table 8.1 presents the main sources of information about birth spacing among the currently married women and men. Television is citied as the main source of information on birth spacing for both women and men (women 91% and men 88 % respectively).This is followed by friends/relatives/neighbors (66% and 77% among women and men respectively). Newspapers are a major source of information for 55 percent of the men and 29 percent of the women. Compared to 62 percent of the men, only 12 percent of women mentioned other health sources (other than government and private hospital staff) as their main source of information on birth spacing. The women (63 percent) are more likely than the men (19 %) to report their spouse as the main source of information on birth spacing. A small proportion of women have reported radio, government health staff and private health staff as their main sources of information on birth spacing. Table 8.1. Source of information on birth spacing Percentage distribution of women and men by main source of information for birth spacing - Agra, MLE 2010
Exposure What are your main sources of information for birth spacing * Radio TV Newspapers Other media sources Govt. hospital staff Pvt. hospital staff Other health sources Community sources Spouse Friends/relatives/neighbors Other interpersonal sources Other Percentage of Women (n=3007) 4.5 91.0 28.9 18.5 14.9 14.5 12.2 1.8 62.9 65.9 26.4 0.2 Percentage of Men (n= 1673) 16.0 87.8 55.2 20.9 16.7 16.0 61.6 22.5 18.8 77.3 4.9 0.1

None/Don't know 0.2 0.7 * percentages do not sum to 100 because multiple responses could be given

8.2 Exposure to Information on Family Planning Through Radio and TV An attempt has been made in the present study to assess the exposure of women and men to radio and television and the different types of family planning information that they received through these sources in the last three months. As Table 8.2 shows, only nine percent of the men and four percent of the women listen to the radio. Seventy four percent of the women and 63 percent of the men listening to the radio reported receiving some family planning information on the radio in the last three months. Among the women reporting exposure to family planning messages on the radio, information about condoms was the most mentioned (67 %) topic. The other methods on which a sizeable proportion of the women received information through the radio are emergency contraceptives (42 %), pills (39 %) and IUDs (31 %). Receiving information through the radio on female sterilization, spacing between births, limiting family size and delaying first birth has been reported by 13 to 20 percent of the women. Among the men receiving any family planning information on the radio in the last three months preceding the survey, 86 percent had reportedly heard about condoms and 58 percent about emergency contraceptives. Receiving information through the radio on pills, female sterilization, male sterilization and injectables has been mentioned by 25 to 39 percent of the men. Compared to women, a lower proportion of the men received information on spacing between births, limiting family size and delaying first birth (711%). The vast majority of women and men (over 90 %) have been exposed to television (Table 8.2). Seventy nine percent of the women and 65 percent of the men watching television have seen some family planning related information on television in the last three months preceding the survey. Women had primarily seen information related to condoms (74 %) and emergency contraceptives (59%) on television. Thirty eight percent of the women had seen information related to pills on television and 19 to 27 percent had been exposed to information on IUDs, spacing between births and limiting family size. The men had mostly received family planning information through television on condoms (86 %), pills (57 %) and emergency contraceptives (52 %).

Table 8.2: Exposure to family planning on radio and television Percent distribution of recent exposure to FP in the media among currently married women of age 15- 49 years and currently married men of age 18 54 years- Agra, MLE 2010
Women Do you listen to the radio Yes No Have you heard any family planning information on the radio in the past three months Yes (n=3007) 3.5 96.6 (n=104) 74.1 Men (n= 1682) 8.6 91.4 (n= 145) 63.3

No What information have you heard * Pills IUD Condom Injectables Emergency contraceptives Female sterilization Male sterilization Standard days method (sdm) Mtp/abortion Age at marriage Delaying first birth Spacing between births Limiting family size Do you watch television Yes No Have you seen any family planning related information on the TV in the past three months Yes No What information have you seen * Pills IUD Condom Injectables Emergency contraceptives Female sterilization Male sterilization Standard days method (SDM) MTP/abortion Age at marriage Delaying first birth Spacing between births Limiting family size

26.0 (n=77) 38.8 31.3 67.4 6.4 41.6 16.0 1.6 3.7 0.0 5.1 13.1 20.2 16.8 (n=3007) 90.4 9.6 (n=2419) 79.4 20.6 (n=2157) 37.7 18.8 73.9 8.3 58.9 11.7 1.9 0.4 1.0 7.6 10.7 26.9 22.4

36.7 (n= 92) 38.7 7.7 86.2 24.8 57.8 37.0 35.2 2.2 0.0 4.0 5.1 9.4 9.4 (n=1682) 91.1 8.9 (n= 1533) 64.8 35.2 (n= 994) 57.1 6.7 86.3 4.6 51.6 16.0 14.6 0.6 0.1 9.5 7.3 11.0 11.2

* percentages do not sum to 100 because multiple responses could be given

Chapter IX Gender
The present Chapter deals with the issues relating to womens participation in decision making, opinions regarding the mobility of the women, the perceptions of women and men regarding the justification for domestic violence and spousal control, spousal communication and gender attitudes among men. 9.1 Decision Making Table 9.1 shows womens participation in decision making regarding the use of their cash earnings as well as their husbands earnings. Eighty nine percent of the women earning cash reported that the decision regarding the use of their earnings was jointly taken by the wife and the husband. Seventeen percent of the women reported that they took the decision themselves. As for the decision making regarding the use of the husbands cash earnings, 71 percent of the women reported that this decision was taken jointly, 13 percent said that this decision was taken mainly by the husband and 15 percent said that someone other than the husband decided how the husbands income was to be used. Half of the women said that they had some money of their own that they alone could decide how to use it. Table 9.1. Decision making regarding the womens and mens cash earnings in Agra Decisions Percent N Who decides how the money she earns will be used Respondent 5.9 24 Husband 0.8 4 Respondent & husband 91.2 246 Other 2.1 7 Who decides how the money that husband earns will be used Respondent 1.3 39 Husband 12.2 386 Respondent & husband 70.6 2109 Other 14.8 395 Do you have any money of your own that you alone can decide how to use Yes 50.9 1439 No 49.2 1524 Table 9.2 provides information about the participation of women in decision making for four different types of decisions, including buying food for the week, their own health care, their childrens health care and visiting their natal homes. Joint decision making was most common for all the four decisions described above. Only four to seven percent of the women themselves took the decisions on the above issues. Table 9.2 : Womens participation in decision making on certain key issues

Decisions Buying food for the week Mainly you Mainly husband Jointly Others About health care for yourself Mainly you Mainly husband Jointly Others About health care for your children Mainly you Mainly husband Jointly Others NA About visits to your natal home Mainly you Mainly husband Jointly Others NA

Percent 5.2 17.4 56.6 20.9 7.2 15.2 66.7 11.0 7.5 10.0 68.0 8.3 6.2 3.9 15.0 68.9 12.1 0.2

N 179 460 1765 601 222 472 1997 313 242 312 2023 225 203 151 565 1963 319 7

Table 9.3 shows the mens perspectives on womens participation in household decision making on matters relating to the wifes health care, the childrens health care, making major household purchases, making purchases for daily needs and the wifes visit to her family or relatives. Fifty one to 71 percent of the men said that the decision regarding the above four issues was jointly taken with the wife. A small proportion of the men felt that these decisions should be mainly taken by the wife. Twenty two to 37 percent of the men said that the decision regarding their wifes health care, major household purchases, purchases for daily needs and visits to the wifes family or relatives should mainly be taken by themselves. Table 9.3: Mens perspecitives on womens participation in decision making on certain key issues Decisions Mainly Mainly Jointly Others NA you wife About health care for your wife 37.0 4.2 54.1 4.8 About health care for your children 12.4 7.6 71.3 3.1 5.6 Making major household 23.5 3.6 64.3 8.6 purchases Making purchases for daily needs 21.9 20.4 50.8 6.9 Deciding about visits to the wifes 23.8 5.9 64.6 5.7 family or relatives Total N 1680

9.2 Women and Mobility

The women were asked if they were allowed to go alone, with the child, only with another adult or not allowed to go at all to different places like the health center, friends or relatives houses, to the market and religious events. As Table 9.4 shows, only seven and 15 percent of the women are allowed to go alone to visit the health center/clinic for their checkups or in the case of their childrens illness respectively. Thirty five and 32 percent of the women said that they could go alone to a friend or relatives house located within a 5-10 minute walk and located in another neighborhood or place respectively. As regards visiting the market, 35 percent said that they were allowed to go alone to the market if it was located in the same neighborhood or area, whereas 24 percent said that could go alone to the market, which is located in a different neighborhood or area. Similarly, 19 and 10 percent of the women respectively said that they were allowed to attend a religious event in the same neighborhood or area and a religious event in another neighborhood or area alone. In a majority of the cases it was required that the women be accompanied by another adult to different places especially when the place was located in another neighborhood or place.

Table 9.4: Mobility of the Women in Agra Places Alone

With child

Only with another adult 86.6 64.8 39.5 39.7 38.6 46.2 50.1 53.6 3004

Not at all

Health centre or clinic for yourself for a check up like when you are pregnant Health centre or clinic for yourself if you are sick Friends or relatives house within a 5-10 minute walk Friends or relatives house in another neighborhood or place To the market in the same neighborhood or area To the market in a different neighborhood or area To a religious event in the same neighborhood or area To a religious event in another neighborhood or area Total N

6.6 14.8 34.9 31.5 35.0 24.3 19.3 9.7

4.8 19.8 25.2 27.9 22.6 21.4 16.8 10.3

1.9 0.6 0.5 1.0 3.9 8.1 13.9 26.5

9.3 Justifications for Domestic Violence The women were asked whether, in their opinion, a husband is justified in hitting or beating his wife in the following seven situations: if she goes out without telling him, if she neglects the house or children, if she argues with him, if she refuses to have sex with him, if she does not cook food properly, if he suspects her of being unfaithful, and if she shows disrespect for her in-laws. Agreement with any of the reasons justifying wife beating indicates a low level of womens empowerment, since it implies an acceptance of mens exercise of power over women.

Table 9.5 shows the percentages of women who agree with the different reasons for hitting or beating the wife. Except for the reasons for hitting or beating a woman for suspecting her of being unfaithful (41%), five to 21 percent of the women agreed with the other reasons for beating the wife.

9.5 Attitude of the women towards hitting or beating the wife Issues Percent If she goes out without telling him 10.1 If she neglects the house or the children 4.7 If she argues with him 17.8 If she refuses to have sex with him 5.4 If she doesnt cook the food properly 9.8 If he suspects her of being unfaithful 40.8 If she shows disrespect for her in-laws 20.8

The men respondents were asked as to whether they thought that a wife was justified in refusing to have sex with her husband when she knows her husband has a sexually transmitted disease, when she knows her husband has sex with other women, when she is tired or not in the mood and when the husband refuses to use contraception. As Table 9.6 shows, 69 - 79 percent of the men agree with the first three reasons that they were asked about and 62 percent agree with the fourth reason (refusing to have sex if the husband refuses to use contraception). Table 9.6 Attitude of the men towards refusing sexual intercourse with husband Whether wife should refuse sexual intercourse with husband if She knows her husband has a sexually transmitted She knows her husband has sex with other women She is tired or not in the mood Her husband refuses to use contraception Total N Yes 79.3 76.4 69.3 62.3 No 18.5 20.4 27.6 32.6 1680 Dont know 2.3 3.2 3.1 5.2

The currently married men were also asked; Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to: 1) Get angry and reprimand her, 2) Refuse to give her money or other means of financial support, 3) Use force and have sex with her even if she doesnt want to and 4) Go and have sex with another woman. The responses of the currently married men on the above queries are presented in Table 9.7. Over one-fifth of the men said that if the wife refuses to have sexual intercourse with the husband, the husband has the right to get angry and reprimand her. Seven to 11 percent of the men agreed that if the woman refuses to have sex with her husband when he wants her to, the husband has the right to refuse to give her money or other means of financial support (11 %) and use force and have sex with her even if she doesnt want to (8 %) and have sex with another woman (7 %).

Table 9.7 Attitude of the men towards rights of the men when the women refuses to have sex with the husband Rights of the men to Yes No Dont know Get angry and reprimand her 22.3 75.9 1.8 Refuse to give her money or other means of 10.8 85.3 3.9 financial support Use force and have sex with her even if she 7.8 88.5 3.7 doesnt want to Go and have sex with another woman 6.5 89.9 3.6 Total N 1680 9.4 Spousal Control The study participants, including both women and men, were asked whether a husband should prohibit his wife from doing certain things such as working outside the home, receiving visits from people, visiting her friends, visiting her family and using contraceptives. As Table 9.8 shows, over one-third of the women perceived that a husband should prohibit the wife from working outside the home and 22 percent were in favor of the husband prohibiting the wife from receiving visits from people. Four to nine percent of the women felt that a husband should prohibit his wife from visiting her friends, visiting her family and using contraceptives. Compared to women, a considerably higher proportion of the men (75 %) think that a husband should prohibit his wife from working outside the home (Table 9.8). Further, the men are much more likely to be in favor of prohibiting the wife from receiving visits from people (59 %). A higher proportion of men than the women also think that a husband should prohibit his wife from visiting her friends (30 %), visiting her family (15 %) and using contraceptives (19 %).

Table 9.8 Perception of women and men regarding prohibition by the husbands in doing certain things by the wife Things for prohibition % of women % of men Working outside the home 35.7 74.9 Having visits from people 21.8 58.5 Visiting your friends 9.3 30.1 Visiting your family 7.0 14.7 Using contraceptives 4.4 19.1 Total N 2999 1680

9.5 Spousal Communication All the currently married women were asked about the extent of spousal communication on things that happen at home, events in the community, events that happen at work and money matters. The womens responses on the extent of spousal communications have been presented in Table 9.9. Among the women, 50 - 54 percent reported that they often spoke with the husbands on matters relating to things that happened at home,

events that happened at work and on money matters and another 19 - 25 percent reported that they only communicated with the husband on these matters some times. Nineteen to 30 percent said that the husband talked on these issues all the times. Half the women say that the husband speaks to them about events in the community only some times and 13 percent mention no spousal communication on this issue.

Table 9.9: Extent of Spousal Communication Issues on which the All the time husband talk to the wife Things that happen at 21.5 home Events in the community 11.6 Events that happen at work 18.8 Money matters 29.7 Total N

Often 53.8 25.5 53.8 50.0

Sometimes 23.8 50.2 24.5 18.8 3002

Never 0.9 12.6 2.9 1.6

9.6: Gender Attitudes In order to assess the gender attitudes, a number of statements were read out to each of the currently married man covered in the survey one by one and thereafter the respondent was asked to mention whether they agree or partially agree or do not agree with the statement. The analysis of their responses has been presented in Table 9.10. The majority of the men (61-82 %) agreed with the statements such as Changing diapers, giving the kids a bath, and feeding the kids are the mothers responsibility, A man should have the final word about decisions in his home A couple should decide together if they want to have children, In my opinion, a woman can suggest using condoms just like a man can, If a man gets a woman pregnant, the child is the responsibility of both , A man and a woman should decide together what type of contraceptive to use and It is important that a father is present in the lives of his children, even if he is no longer with the mother. A majority of the men either did not agree or partially agreed with the statements You dont talk about sex, you just do it and I would be outraged if my wife asked me to use a condom respectively. It is not encouraging to note that over half of the men either agreed or partially agreed with the statement that It is a womans responsibility to avoid getting pregnant and A woman should tolerate violence in order to keep her family together.

Table 9.10: Gender Attitudes among Men in Agra Decisions Agree You dont talk about sex, you just do it Women who carry condoms on them are easy Changing diapers, giving the kids a bath, and feeding the kids are the mothers responsibility It is a womans responsibility to avoid getting pregnant A man should have the final word about decisions in his home A woman should tolerate violence in order to keep her family together I would be outraged if my wife asked me to use a condom A couple should decide together if they want to have children In my opinion, a woman can suggest using condoms just like a man can If a man gets a woman pregnant, the child is the responsibility of both It is important that a father is present in the lives of his children, even if he is no longer with the mother A man and a woman should decide together what type of contraceptive to use Total N 32.7 43.1 75.6

Partially agree 27.7 18.7 10.0

Do not agree 39.4 38.0 14.3

Missing .1 .2 .1

39.6 61.4 39.2 29.9 82.2 75.1 77.7 60.1

14.6 22.1 18.9 25.6 14.3 17.0 15.6 20.4

45.6 16.4 41.6 44.2 3.4 7.7 6.4 19.5

.2 .1 .3 .3 .1 3 .3 .1

80.2

14.3

5.2

.3

1680

Chapter X SERVICE DELIVERY POINTS The Service Delivery Points (SDP) survey in Agra included all public health facilities, all high volume private sector health facilities, and a sample of other private sector health facilities that were preferred by the women covered in the individual survey. Additionally, the SDP survey covered a sample of pharmacies and retail outlets located in the Public Sector Undertakings (PSUs) covered in the study. The details of the SDPs included in the survey and the procedure followed for the selection of the SDPs have been described in Chapter 2. The survey of SDPs involved facility audits, exit interviews and provider interviews at the public and private sector health facilities located in Agra. In addition to the above, a facility audit was also undertaken at pharmacies and retail outlets selected for the study. The findings of the facility audit, exit interviews and provider interviews are presented in this Chapter.

10.1

AVAILABILITY OF SERVICES AND INFRASTRUCTURE

Table 10.1 shows the types of services provided at the health facilities covered in the survey. The majority of the health facilities covered in the survey provide family planning and counseling services (97 %), counseling on initiating breastfeeding after pregnancy (60 %) and ante-natal care services (55 %). The services on maternal care/delivery, post-abortion care, post natal care, child immunization and child growth monitoring are offered at 35-48 percent of the facilities. Only 20 percent of the facilities offer services for the detection and treatment of Sexually Transmitted Infections (STIs). All of the high volume public and high volume private health facilities provide services on antenatal care, counseling on initiating breastfeeding after pregnancy, and family planning and counseling services. More than 97 percent of other public and other private health facilities provide family planning and counseling services. A higher proportion of the other public health facilities (95 %) than the other private health facilities (32 %) provide services on child immunization. A higher proportion (39 %) of the other private health facilities provides maternal care and delivery services as compared to other public health facilities (15 %). Only 10 and 18 percent of the other public and other private health facilities respectively provide services for the detection and treatment of STIs.

Table 10.1. Percent of facilities providing services by type of service in Agra High Volume Public
50.0

Type of Service Maternal Care/Delivery services Post-abortion care

High Volume Private

92.9

Other Public
15.0

Other Private
38.5

Total

40.9 34.7 55.1 48.0

50.0

85.7

20.0

29.7

Ante-natal care

100.0

100.0

90.0

39.6

Post natal care

100.0

92.9

70.0

35.2

Counseling on initiating breastfeeding after pregnancy

100.0

100.0

73.7

49.5

59.5

Child immunization

100.0

64.3

95.0

31.9

46.5 38.6 19.7 97.6 127

Child growth monitoring Detection and treatment of STIs Family planning and counseling services

50.0

42.9

50.0

35.2

50.0

42.9

10.0

17.6

100.0

100.0

100.0

96.7

Total number of facilities*

14

20

91

* The N's are slightly smaller due to missing data for some services

Table 10.2 provides information on the health facilities with specific services by type of facility in Agra. Seventy-nine percent of both the high volume private and the other private health facilities open seven days in a week. However, only 50 percent of the high volume public and 10 percent of the other public health facilities have reported that they open seven days in a week. Among the facilities that provide family planning services, 28 percent of high volume private and none of the high volume public health facilities have standard operating procedures. Twenty-one percent of the high volume private health facilities are registered with an institution or program that provides/discounts family

planning methods. However, none of the public sector facilities are registered with an institution or program that provides/discounts family planning methods. Eight-five percent of the other public health facilities are registered with an institution or program whereas six percent of the other private health facilities are registered with an institution or program that provides/discounts family planning methods. Further, while none of the high volume public sector facilities accept vouchers for family planning services, 14 percent of the high volume private sector facilities accept vouchers for family planning services. Against 83 percent of the high volume private health facilities, none of the high volume public health facilities are willing to participate in a voucher program for family planning methods. Fifty-seven percent and 53 percent of the other private and other public health facilities respectively are willing to participate in a voucher program.

Table 10.2. Percent of facilities with specific services by type of facility in Agra High High Volume Volume Public Private
50.0 78.6

Indicator Percent of facilities open 7 days/week Of facilities that provide FP services, the percent of facilities with standard operating procedures* Percent of facilities registered with an institution or program that provides/discounts FP methods Of facilities that provide FP services, the percent of facilities that accept vouchers for FP services* Of facilities that provide FP services and are not participating in a voucher program, percent of facilities that would be willing to participate in a voucher program for FP methods*

Other Public
10.0

Other Private
78.7

Total

67.2

0.0

28.6

10.0

2.3

6.5

0.0

21.4

85.0

5.5

19.7

0.0

14.3

5.0

0.0

2.4

0.0

83.3

52.6

56.8

57.9

Total number of facilities**

14

20

91

127

*Number of facilities slightly smaller than full sample when services not provided; **The N's are slightly smaller due to missing data for some services

Table 10.3 shows the health facilities that offer sterilization, IUDs, injections and implants with specific conditions by type of facility in Agra. Fifty two to 76 percent of the public sector facilities offering sterilization, IUDs, injections and implants have reported that they have running water supply, availability of sterile disposable gloves, availability of sharps container, availability of an examination light and privacy for pelvic examination/IUD insertion and 81 percent have facilities with a storage area for drugs and supplies. All high volume private facilities have mentioned supplies/facilities except storage. Among 14, only one facility reported that it doesnot have storage facility. Among, other private facilities, 80-87% have basic supplies/facilities.

Table 10.3. Percent of facilities that offer sterilization, IUD, injections and implants with specific conditions by type of facility in Agra* Public facilities**
52.4

Indicator Percent of facilities with running water supply Percent of facilities with storage area for drugs and supplies Percent of facilities with sterile disposable gloves always available Percent of facilities with a sharps container Percent of facilities that offer privacy for pelvic exam/IUD insertion Percent of facilities with an examination light

High Volume Private

100.0

Other Private
84.1

Total

78.5 87.3 77.2 82.3 77.2 82.3 79

81.0

92.9

88.6

57.1

100.0

79.6

57.1

100.0

88.6

57.1

100.0

79.6

76.2

100.0

79.6

Total number of facilities

21

14

44

*Includes only those facilities that provide these methods; **Two high volume public facilities included

Table 10.4 provides information on the availability of staff in the different categories of health facilities. Fifty percent of the high volume public health facilities and 35 percent of the other private facilities do not have a single doctor. The availability of two or more

doctors has been reported in 86 percent of the high volume private, five percent of the public and 31 percent of the other private health facilities. Ninety-six percent of the high volume public, 93 percent of the high volume private, and 57 percent of the other private health facilities do not have a single Ayush doctor. As compared to 43 percent of the other private facilities, five percent and seven percent of the high volume public and high volume private have one or more Ayush doctor respectively. Eighty two percent of the high volume public facilities, 59 percent of the other private facilities and seven percent of the high volume private facilities do not have any nurse. Availability of five or more nurses has been reported in 29 percent of the high volume private facilities and in less than 10 percent of the public and other private facilities. Ninety seven percent of the other private health facilities, 86 percent of the private health facilities, and 77 percent of the high volume private facilities do not have any midwives. A traditional birth attendant (TBA) is available in 43 percent of the high volume private facilities and 27 percent and three percent of the public facilities and other private facilities respectively. The other staff, which includes the health educators/social workers and Lady Health Visitors/Public Health Nurse/District Public Health Nurse are available in 73 percent of the public facilities and 21 percent of the high volume private facilities. Table 10.4. Level and composition of facililty staff by type of facility in Agra Public facilities** High Volume Private Other Private

Staff composition Physicians/Doctors No doctors One doctor Two or more doctors Physicians/Doctors (Ayush) No doctors (Ayush) One or more doctors (Ayush) Nurses No nurses 1 - 2 nurses 3 - 4 nurses

50.0 45.5 4.6

0.0 14.3 85.7

35.2 34.1 30.8

95.5 4.6

92.9 7.1

57.1 42.9

81.8 9.1 4.6

7.1 28.6 35.7

59.3 20.9 9.9

5+ nurses Midwife No midwives 1+ midwives Traditional Birth Attendant No TBAs 1+ TBAs Other* None 1+ Total number of facilities***

4.6

28.6

9.9

77.3 22.7

85.7 14.3

96.7 3.3

72.7 27.3

57.1 42.9

96.7 3.3

27.3 72.7 22

78.6 21.4 14

94.5 5.5 91

*Other includes: health educators/social workers and Lady Health Visitors/Public Health Nurse/District Public Health Nurse; **Two high volume public facilities included; *** The N's are slightly smaller due to missing data for some types of providers

Table 10.5 provides information on the public facilities providing family planning methods and services by type of method. Most of the public health facilities provide IUDs, oral pills, and condoms (96% each). Female sterilization, male sterilization, and MTP services (9% each) are available in a few public health facilities. Emergency contraceptives and Progestin-only oral pill are provided at nine percent and five percent of the public facilities respectively. None of the public health facilities provide implants, dermal patches and female condoms and only two facilities offer the progestin-only oral pill. Of facilities providing these services, 50 percent facilities are open seven days in a week for female sterilization. The partners consent is required in all the facilities for male sterilization. Seventy percent of the facilities required the partners consent for IUDs, followed by oral pills (55%), emergency contraceptives, female sterilization, MTPs (50% each), and male condoms (40%). In general the public sector facilities require a prescription for providing different family planning methods. None of the public facilities providing injectables, progestin-only oral pills, and emergency contraceptives reported current availability of the method at the facility. IUDs was reported currently available in 95 percent of public facilities, followed by the combined oral pill and male condom (86% each). Of the methods that they have currently available, none of the public facilities reported stock-out in the last 30 days or in the last one year except for male condoms (11%), IUDs (10%), and combined oral pills (6%).

Table 10.6 shows private facilities providing family planning methods and services by type of method. Thirteen of the 14 high volume private facilities provide female sterilization. Twelve high volume private facilities provide MTP services and nine high volume facilities provide IUDs and injectables. Seven high volume facilities provide combined oral pills and male sterilization and six high volume private facilities provide emergency contraception and male condoms. None of the high volume private facilities provide implants, dermal patches and female condoms. Sixty-seven to 75 percent of the high volume facilities providing different methods of family planning have reported that they provide these services seven days a week, though all facilities provide the progestin-only pill seven days a week. Partners consent is required in all the facilities for male sterilization. Eighty nine percent of facilities require the partners consent for IUDs, followed by injectables (88%), female sterilization (85%), emergency contraceptives (50%), combined oral pill (43%), progestin-only oral pill (33%), and male condoms (17%). In general, the high volume private sector facilities require a prescription for providing different family planning methods. None of the high volume private facilities reported stock-out of the methods they have currently available in the last 30 days, though stock-outs of IUDs and injectables were reported in the last one year. Among the other private facilities, 48 percent and 44 percent of the facilities provide male condoms and emergency contraceptive pills respectively and 40 percent each provide both IUDs and the combined oral pill (Table 10.7). Twenty three to 31 percent of other private facilities provide injectables, progestin-only oral pill, female sterilization, and MTPs. All of the other private facilities are open seven days a week for female sterilization, male sterilization, and female condoms. Seventy eight to 88 percent of the other private facilities reportedly provide various family planning methods seven days a week. All the other private facilities providing implants, dermal patches, and female condoms, and nearly all providing female sterilization (96%) and MTP (94%) require the partners consent to provide the method Between 64 and 77 percent of facilities require the partners consent to provide IUDs, male sterilization, and injectables. Almost all the other private facilities require a prescription for providing different family planning methods. All other private facilities have at least one method currently available. Stock-out of the methods currently available at other private facilities were reported for IUDS, injectables, progestin-only pill and the combined oral pill in the last 30 days as well as in the last one year. Table 10.8 shows the percentage of pharmacies that provide various family planning services. Almost all the pharmacies (93 to 99%) contacted provide emergency contraceptives, combined oral pills, and male condoms, and 37 percent of the pharmacies

provide injectables. Progestin-only oral pills are provided at 24 percent of the pharmacies. A few pharmacies (1 %) provide female condoms. None of the pharmacies stock dermal patches or implants. All the pharmacies providing family planning methods report current availability of some method. Stock-outs of the methods currently available at pharmacies were reported for all methods with the exception of the female condoms in the last 30 days (1 to 12%), as well as in the last one year (2 to 12%). ,

Table 10.5 Percent of public facilities providing FP methods and services by type of method in Agra* Stock-out situation Percent of facilities Number that of provide facilities this service % (n) Method IUD Injectable Implant Combined oral pill Progestin-only oral pill Emergency contraceptive Dermal patch Male Condom Female Condom 22 22 22 22 22 22 22 22 22 95.5 (21) 4.6 (1) 0.0 (0) 95.5 (21) 4.6 (1) 9.1 (2) 0.0 (0) 95.5 (21) 0.0 (0) Of facilities providing the service, the percent of facilities that: Method is currently Require partners Requires a available Offer this % (n) consent to prescription service 7 receive to receive days/week the the method method 4.8 0.0 0.0 4.8 0.0 0.0 0.0 4.8 0.0 70.0 0.0 0.0 55.0 0.0 50.0 0.0 40.0 0.0 60.0 0.0 0.0 60.0 0.0 50.0 0.0 45.0 0.0 95.2 (20) 100.0 (1) 0.0 (0) 85.7 (18) 100.0 (1) 100.0 (2) 0.0 (0) 85.7 (18) 0.0 (0) Of facilities with method currently available, percent of facilities that: Stock-out in the last 30 days** 10.0 0.0 0.0 5.6 0.0 0.0 0.0 11.1 0.0 Stock-out in the last one year** 10.0 0.0 0.0 5.6 0.0 0.0 0.0 11.1 0.0

Male sterilization Female sterilization MTP

22 22 22

9.1 (2) 9.1 (2) 9.1 (2)

0.0 50.0 NA

100.0 50.0 50.0

NA 100.0 100.0

100.0 (2) 100.0 (2) 100.0 (2)

NA NA NA

NA NA NA

* High volume public facilities are included in this table; **Only among those with method currently available; small number with missing information on stock; NA - Not asked

Table 10.6 Percent of High Volume Private facilities providing FP methods and services by type of method in Agra Stock-out situation Percent of facilities Number that of provide facilities this service % (n) Method IUD Injectable Implant Combined oral pill 14 14 14 14 64.3 (9) 64.3 (9) 0.0 (0) 50.0 (7) Of facilities providing the service, the percent of facilities that: Method is currently Require partners Requires a available Offer this % (n) consent to prescription service 7 receive to receive days/week the the method method 66.7 75 0 71.4 88.9 87.5 0.0 42.9 88.9 87.5 0.0 71.4 77.8 (7) 66.7 (6) 0.0 (0) 71.4 (5) Of facilities with method currently available, percent of facilities that: Stock-out in the last 30 days** 0.0 0.0 0.0 0.0 Stock-out in the last one year** 14.3 16.7 0.0 0.0

Progestin-only oral pill Emergency contraceptive Dermal patch Male Condom Female Condom Male sterilization Female sterilization MTP

14 14 14 14 14 14 14 14

21.4 (3) 42.9 (6) 0.0 (0) 42.9 (6) 0.0 (0) 50.0 (7) 92.9 (13) 85.7 (12)

100 66.7 0 66.7 0 100 84.6 NA

33.3 50.0 0.0 16.7 0.0 85.7 83.3 81.8

66.7 66.7 0.0 50.0 0.0 NA 83.3 81.8

33.3 (1) 66.7 (4) 0.0 (0) 66.7 (4) 0.0 (0) 100.0 (7) 92.3 (12) 91.7 (11)

0.0 0.0 0.0 0.0 0.0 NA NA NA

0.0 0.0 0.0 0.0 0.0 NA NA NA

*Only among those with method currently available; small number with missing information on stock; NA - Not asked

Table 10.7. Percent of other private facilities providing FP methods and services by type of method in Agra Stock-out situation Percent of facilities Number that of provide facilities this service % (n) Method IUD Injectable Implant Combined oral pill Progestin-only oral pill Emergency contraceptive Dermal patch Male Condom Female Condom 91 91 91 91 91 91 91 91 91 39.6 (36) 30.8 (28) 1.1 (1) 39.6 (36) 30.8 (28) 44.0 (40) 1.1 (1) 48.4 (44) 1.1 (1) Of facilities providing the service, the percent of facilities that: Require partners Requires a Offer this consent to prescription service 7 receive to receive days/week the the method method 85.7 88.0 0.0 86.2 82.6 78.4 0.0 78.4 100.0 77.1 64.0 100.0 58.6 52.2 51.4 100.0 35.1 100.0 85.7 84.0 100.0 69.0 73.9 62.2 100.0 27.0 100.0 Method is currently available % (n) Of facilities with method currently available, percent of facilities that: Stock-out in the last 30 days* 6.1 4.6 0.0 4.0 5.0 0.0 0.0 0.0 0.0 Stock-out in the last one year* 6.1 4.6 0.0 4.0 5.0 0.0 0.0 0.0 0.0

91.7 (33) 78.6 (22) 100.0 (1) 69.4 (25) 71.4 (20) 65.0 (26) 100.0 (1) 54.6 (24) 0.0 (0)

Male sterilization Female sterilization MTP

91 91 91

5.5 (5) 26.4 (24) 23.1 (21)

100.0 100.0 NA

75.0 95.7 94.4

NA 82.6 88.9

80.0 (4) 91.7 (22) 81.0 (17)

NA NA NA

NA NA NA

*Only among those with method currently available; small number with missing information on stock; NA - Not asked

Table 10.8. Percent of pharmacies providing FP methods by type of method in Agra Percent of facilities that provide this method % (n) 96.2 (100) 24.0 (25) 93.3 (97) 0.0 (0) 99.0 (103) 1.0 (1) 36.5 (38) 0.0 (0) Of facilities providing the service, the percent of facilities where: Method is currently available % (n) 100.0 (100) 100.0 (25) 100.0 (97) 0.0 (0) 98.1 (101) 100.0 (1) 100.0 (38) 0.0 (0) Stock-out in the last 30 days* 4.0 (4) 12.0 (3) 1.0 (1) 0.0 (0) 2.0 (2) 0.0 (0) 2.6 (1) 0.0 (0) Stock-out in the last one year* 4.0 (4) 12.0 (3) 2.1 (2) 0.0 (0) 2.9 (3) 0.0 (0) 5.3 (2) 0.0 (0)

Number of pharmacies

Method Combined oral pill Progestin-only oral pill Emergency contraceptive Dermal patch Male Condom Female Condom Injectable Implant 104 104 104 104 104 104 104 104

*Only among those with method currently available; small number with missing information on stock; NA - Not asked

Table 10.9 shows the proportion of different categories of health facilities, which are currently providing some family planning method. All the high volume facilities (both public and private) and all the pharmacies currently provide some family planning method. Among the other public and other private facilities, 90 and 48 percent respectively currently provide some family planning method. All the high volume public facilities and 29 percent of the high volume private facilities are currently providing more than four modern methods. Among other private facilities and pharmacies 66 and 46 percent, respectively, provide more than four modern family planning methods. Among other public facilities and pharmacies, 78 and 53 percent respectively provide two to three modern methods. All of the high volume public, 86 percent of the high volume private, 52 percent of the other private, and six percent of the other public facilities are offering at least two long-acting and permanent methods.

Table 10.9. Percent of facilities currently offering modern methods by facility type in Agra Percent of facilities providing any FP method % (n) 100.0 (2) 100.0 (14) 90.0 (18) 48.4 (44) 100.0 (104) Percent of facilities currently offering: Only 1 modern method 0.0 0.0 11.1 15.9 1.0 2-3 modern methods 0.0 71.4 77.8 18.2 52.9 4+ modern methods 100.0 28.6 11.1 65.9 46.2 Percent of facilities offering 2+ long-acting and permanent methods* 100.0 85.7 5.6 52.3 NA

Facility type High Volume Public High Volume Private Other Public Other Private Pharmacies

* Long-acting and permanent methods includes male sterilization, female sterilization, and IUD

Table 10.10 shows that 60 percent of the providers at the high volume public 41 percent providers at the high volume private, other public (18 %) and other private (11 %) facilities have received pre-service training on family planning. A higher proportion of the providers at the public and private facilities than those at the other public and other private facilities had received in-service training on family planning. Sixty percent of the providers at the other public facilities and half of those at the high volume public facilities had received in-service training on family planning. None of the providers at the high volume public facilities are members of an institution or program that provides family planning methods at a discounted rate or free. However, 88 percent of providers from high volume private facilities are members of an institution or program that provides family planning methods at a discounted rate or free of charge.

Table 10.10. Provider training and participation in FP initiatives by facility type in Agra High Volume Public n = 10 60.0 40.0 50.0 50.0 n=5 20.0 80.0 n = 10 0.0 100.0 High Volume Private n = 46 41.3 58.7 26.1 73.9 n = 10 20.0 80.0 n = 45 24.4 75.6 Other Public n = 50 18.0 82.0 60.0 40.0 n = 30 23.3 76.7 n = 50 88.0 12.0 Other Private n = 188 11.2 88.8 27.1 72.9 n = 47 19.2 80.9 n = 186 6.5 93.6

Characteristic Received pre-service training on FP Yes No Received in-service training on FP Yes No Received in-service training on FP in the last year* Yes No Member of institution or program that provides FP methods at a discounted rate or free Yes No

*Only includes those providers who ever received in-service training

Table 10.11 shows the specific services provided by the pharmacies. Almost all the pharmacies stock socially marketed contraceptive products (99 %). Among the pharmacies not participating in a voucher program, 21 percent have shown willingness to participate in a voucher program for family planning methods. A few pharmacies are registered with an institution or program that provides family planning methods and materials at a discounted rate or free of charge (2 %) and accept/redeem vouchers for contraceptives (1 %).

Table 10.11. Percent of pharmacies with specific services in Agra

Of pharmacies that provide FP methods, percent Indicator Registered with an institution or program that provides FP methods and materials at a discounted rate or free Accept/redeem vouchers for contraceptives Of pharmacies not participating in a voucher program, percent that would be willing to participate in a voucher program for FP methods With socially marketed contraceptive products in stock Number of Pharmacies 1.9 1.0 21.4 99.0 104

Table 10.12 shows the type of services provided by the Registered Medical Providers (RMP) and retail outlets. Ninety two percent of the RMPs provide family planning counseling and 17 percent provide some family planning method. Eighty two percent of retail outlets provide some family planning method and 22 percent provide family planning counseling. Of the retail outlets who do not provide any family planning method (n=4), half of them are willing to provide a family planning method. None of the RMPs or the retail outlets accept/redeem vouchers for contraceptives.

Table 10.12. Percent of Registered Medical Providers and Retail Outlets with specific services in Agra Registered Medical Provider (RMP) 91.7 16.7 Retail outlets

Service Percent that provide FP counseling Percent that provide any FP method

21.7 82.6

Of those that do not provide any FP method, the percent that would be willing to provide FP

NA

50.0

Percent that accept/redeem vouchers for contraceptives Total Number of RMPs/Retail Outlets*

0.0 12

0.0 23

*Number of RMPs/retail outlets included is small as only those in the localities of the individual-level survey were identified and included

10.2

INTEGRATION OF FAMILY PLANNING WITH MATERNAL, NEWBORN AND CHILD HEALTH (MNCH) PROGRAMS

Table 10.13 shows information on the integration of family planning with MNCH programs across different types of health facilities. All of the high volume facilities (both public and private) and 95 percent of the other public and 75 percent of other private facilities offering MNCH services provide family planning information during MNCH visits. Therefore, none of the high volume facilities require a return visit for family planning information nor provide family planning referrals at MNCH visits. Additionally, none of the other public facilities and only six percent of the other private facilities require a return visit for family planning information at MNCH visits. However, nine percent and five percent of other private and other public facilities, respectively provide family planning referrals at MNCH visits. All of the public and private facilities offering postnatal services provide family planning information at postnatal visits, therefore none of them require a return visit for family planning information nor provide family planning referrals at postnatal visits. Similarly, all the public facilities offering post abortion services provide family planning information at post-abortion visits, and therefore none of them require a return visit for family planning nor provide family planning referrals at post-abortion visits. More than 90 percent of all private facilities provide family planning information at post-abortion visits, and the majority of the remaining private facilities therefore require a return visit for family planning information, as no private facilities report providing referrals for family planning at postabortion visits.

Table 10.13 Integration of FP with MNCH services at facility Percent distribution of facilities where family planning services are integrated with maternal and child health services, according to facility type, Allahabad, 2010 MNCH visits* Percent of facilities that require a return visit for FP at MNCH visits 0.0 0.0 0.0 5.9 Percent of facilities that provide FP referrals at MNCH visits 0.0 0.0 5.0 9.8 Postnatal visits* Percent of facilities that require a return visit for FP at postnatal visits 0.0 15.4 0.0 3.1 Percent of facilities that provide FP referrals at postnatal visits 0.0 0.0 0.0 0.0 Post-abortion visits* Percent of Percent of facilities facilities that that require a provide FP return information visit for at postFP at abortion postvisits abortion visits 100.0 91.7 100.0 92.3 0.0 8.3 0.0 3.9

Number of facilities offering child health services Facility type High Volume Public High Volume Private Other Public Other Private

Percent of facilities that provide FP information at MNCH visits

Number of facilities offering postnatal care

Percent of facilities that provide FP information at postnatal visits

Number of facilities offering postabortion care

Percent of facilities that provide FP referrals at postabortion visits 0.0 0.0 0.0 0.0

2 9 20 51

100.0 100.0 95.0 74.5

2 13 14 32

100.0 84.6 100.0 93.8

1 12 4 26

The providers offering antenatal care, postnatal care, post-abortion care, child health services and curative services at the health facilities were asked about whether they routinely provide family planning information to clients visiting for other services. Table 10.14 shows that 59 percent of the providers interviewed at different types of health facilities provide antenatal care services. Among them, 91 percent are routinely providing family planning advice to ANC clients. All the providers offering ANC services in other public facilities and 92 percent of those in the other private facilities routinely provide family planning to ANC clients. Overall 51 percent of all the providers provide post natal care/delivery services. Ninety percent of these providers routinely offer family planning information to delivery/ postnatal care clients. Nearly half of the providers provide post-abortion care and out of these providers 89 percent routinely provide family planning information to post-abortion clients. Nearly half of the providers offer child health services like immunization and growth monitoring. Among them 89 percent are routinely providing family planning information to child immunization/child growth monitoring clients. Fifty nine percent of the providers offer curative services. Eighty seven percent of providers providing curative services routinely offer family planning information to curative services clients. Table 10.15 shows that among all the women that participated in exit interviews at the public and private high volume facilities, 60 percent were MNCH clients. Among these MNCH clients, only three percent reported receiving any family planning related information during their visit to the facility. The Table further shows that among the MNCH clients, only a few (less than 1%) received either a prescription or a family planning method and two percent were currently using a family planning method. Ninety seven percent of the women did not receive any family planning services during their MNCH visits to the facilities. Among the women who did not receive any family planning service during their visit for MNCH services, 37 percent reported that they would have been interested in family planning if the provider had offered any family planning services.

Table 10.14. Percent of interviewed providers routinely providing family planning services to clients seeking other services by type of visit in Agra Antenatal care Postnatal care Post-abortion care Child Health Services Curative Services

Type of Facility High Volume Public High Volume Private Other Public Other Private Total*

Percent Percent Percent Percent of Percent of Percent Percent Percent of Percent of providers Percent of providers of of routinely of providers of providers Number of providers routinely providers providers providing of providers routinely providers routinely providers routinely providing offering offering FP to child providers offering providing offering providing immunioffering providing FP to postchild postnatal FP to FP to zation/child curative ANC FP to delivery/ abortion health care postservices curative growth % (n) ANC postnatal care services monitoring % (n) abortion % (n) services clients care % (n) % (n) clients clients clients clients
10 46 50 188 294 60.0 (6) 82.6 (38) 80.0 (40) 47.3 (89) 58.8 (173) 83.3 79.0 100.0 92.1 90.7 70.0 (7) 82.6 (38) 38.0 (19) 45.2 (85) 50.7 (149) 100.0 76.3 100.0 92.9 89.9 50.0 (5) 73.9 (34) 50.0 (25) 43.6 (82) 49.7 (146) 80.0 79.4 100.0 90.2 89.0 60.0 (6) 47.8 (22) 82.0 (41) 39.4 (74) 48.6 (143) 100.0 72.7 97.6 78.4 83.9 50.0 (5) 69.6 (32) 60.0 (30) 53.2 (100) 56.8 (167) 80.0 67.7 100.0 90.0 87.4

* The N's are slightly smaller due to missing data for some services

Table 10.15. Percent of women surveyed in exit interviews receiving MNCH services by whether they received FP information, referrals, or methods at high volume facilities in Agra Of clients at facility for MNCH visit, percent that received any FP information % (n) 0.0 (0) 3.7 (13) 3.2 (13) Of clients at facility for MNCH services, percent of clients that received: Did not receive anything % (n)
Of those that did not receive anything, if the provider had offered, percent that would have been interested in FP

Number of clients

Percent of clients at facility for MNCH services % (n)

Any Method

Referral

Prescription

Already using

Type of Facility High Volume Public High Volume Private Total*

80 603 683

65.0 (52) 59.0 (356) 59.7 (408)

0 0.6 0.5

0 0.3 0.3

0 0.8 0.7

0 2 1.7

100.0 (52) 96.4 (343) 96.8 (395)

48.9 34.8 36.6

* The N's are slightly smaller due to missing data for some services

10.3

QUALITY OF FAMILY PLANNING SERVICES

Table 10.16 shows the percentage of family planning clients and providers at high volume facilities who discussed topics related to contraception during counseling. At the high volume public facilities, almost all the clients using family planning as well as the clients not using or switching family planning at the time of the visit reported discussing the purpose of visits and identification of reproductive goals at the facility. The majority of both categories of clients reported discussions on different family planning methods, client's family planning preferences, possible side effects of the methods, and specific medical reasons to return and when to return for follow-up. All of the clients not using or switching family planning methods at the time of visit reported discussing the clients family planning preferences, selection of a method, how to use the method, and possible side effects of the method. Among the clients using family planning at time of visit, the majority also reported that the problems encountered with the current method were discussed and they were suggested some action(s) to resolve the problem. Among the providers contacted at the high volume public facilities, 78 percent reported discussing the possible side effects with the family planning clients and 67 percent reported discussions about the identification of reproductive goals as well as information given about different family planning methods. The discussions about the client's family planning preferences, selection of a method, possible side effects of the methods, and when to return for follow up were reported by 11 to 44 percent of the providers at the high volume private facilities. At the high volume private facilities, all of the clients reported that the reason for their visit was discussed at the facility. Similar to that observed in case of public high volume facilities, the majority of clients both using family planning as well as the clients not using or switching family planning methods at the time of the visit, reported discussions on identification of reproductive goals, different family planning methods, client's family planning preferences, possible side effects of the methods, specific medical reasons to return and when to return for follow-up at high volume private facilities. Further, the majority of the clients not using or switching family planning methods at the time of the visit reported discussions on the selection of a method and how to use a method. Among the clients using family planning at time of visit, almost all of the clients reported discussing the problems encountered with the current method and they were suggested some action(s) to resolve the problem. Among the providers contacted at the high volume private facilities, 67 percent reported discussing the different family planning methods with the family planning clients as well as how to select a method. Discussions about the identification of reproductive goals, the client's family planning preferences, selection of a method, use of the method, possible side effects of the methods was reported by 19 to 43 percent of the providers at the high volume private facilities.

Table 10.16. Percent of FP clients (from exit interviews) and providers (provider surveys) at high volume facilities who discuss(ed) topics related to contraception during counseling in Agra At High Volume Public facilities, the percent of clients/providers: Client: Using FP at time of visit Topics of discussion Reason for visit Identify reproductive goals Information about different FP methods About the client's FP preferences Help client to select a method Explain how to use this method Talk about possible side effects Explain specific medical reasons to return Tell client when to return for follow-up 100.0 100.0 100.0 94.1 NA NA 94.1 100.0 92.9 Client: Not using or switching FP at time of visit 100.0 81.8 90.9 100.0 100.0 100.0 100.0 93.3 93.3 At High Volume Private facilities, the percent of clients/providers: Client: Using FP at time of visit 100.0 93.7 98.2 97.3 NA NA 93.7 98.2 90.1 Client: Not using or switching FP at time of visit 100.0 97.1 99.3 98.5 98.2 98.2 98.8 97.5 93.3

Providers

Providers

NA 66.7 66.7 33.3 44.4 0.0 77.8 NA 11.1

NA 42.9 66.7 42.9 66.7 33.3 50.0 NA 19.1

Any problems had with current method Suggest any action(s) to resolve the problem Total number of clients/providers*

93.8 94.1 17

NA NA 11 (15)**

NA NA 9

99.1 100.0 111

NA NA 136 (162)**

NA NA 42

NA - Not Asked; Not all questions were asked to all clients and/or providers; * The N's are slightly smaller due to missing data for some topics; **Note, n in parentheses includes switchers; method switchers were only asked fewer questions including method selection, how to use the method, side effects, actions to resolve the problem and return for follow-up

Table 10.17 shows the clients level of satisfaction with the services at the high volume public and private facilities. Almost all of the clients reported that the waiting time at the high volume public and private facilities was reasonable. Almost all of the clients in both categories of high volume facilities reportedly felt overall satisfaction with their visit. Privacy during the examination was reported by a higher proportion of the clients at the high volume private (93 %) than the public (69%) facilities. Forty six and 36 percent of the clients at the high volume private and public facilities respectively believed that the information they shared with the provider would be kept confidential. Almost all of the clients at both categories of facilities reported that they felt comfortable asking questions during their visit.

Table 10.17. Client satisfaction with services by facility type in Agra Type of Facility* High Volume Public 100.0 (80) 68.75 (55) 95.0 (76) High Volume Private 98.8 (596) 93.4 (563) 98.0 (591)

Indicator Percent of clients reporting waiting time is reasonable Percent of clients reporting privacy during their exam Percent of clients who felt comfortable asking questions during their visit Percent that believe the information they shared with the provider will be kept confidential Percent of clients who reported overall satisfaction with their visit Total number of clients**

36.3 (29)

45.6 (275)

98.73 (78) 80

98.8 (596) 613

*Client exit interviews come from 2 high volume public facilities and 14 high volume private facilities; ** The N's are slightly smaller due to missing data for some services

Table 10.18 shows the availability of information, education and communication (IEC) material for family planning at different types of health facilities. All of the high volume public facilities reported availability of a family planning sign or poster. The high volume public facilities did not report having an IEC outreach program for family planning. Among high volume private facilities, 86 percent have a family planning sign or poster,

96

64 percent have brochures/ handouts, 36 percent have job aids, and 21 percent have an IEC outreach program for family planning. Only 14 percent of the high volume private facilities give health talks about family planning to community members. Among the other public facilities, 90 percent give health talks for community members, 70 percent have an IEC outreach program for family planning, and 45 percent have a family planning sign or poster. Only 10 percent of these facilities have brochures/ handouts and job aids. Availability of family planning signs or posters has been reported by 39 percent of the other private facilities. However, a few of these facilities (4 to 12%) have brochures/ handouts, job aids, give health talks for community members and have an IEC outreach program for family planning.

Table 10.18. Availability of information, education and communication materials for family planning by facility type in Agra Percent of facilities*
Number of facilities Facility type High Volume Public High Volume Private Other Public Other Private

IEC outreach program for FP 0.0 21.4 70.0 1.2

Brochures/ handouts

FP sign or poster

Job aids

Give health talks for community members 50.0 14.3 90.0 3.5

2 14 20 85

50.0 64.3 10.0 11.9

100.0 85.7 45.0 39.3

50.0 35.7 10.0 8.3

* Some data on IEC materials are missing; Those that respond "don't know" are recoded to "no" for relevant IEC items

Table 10.19 presents the number of family planning providers who provide different methods of family planning and the percentage of providers who restrict the clients' eligibility to use a method for reasons of parity, marital status or spouse's consent. The majority of doctors providing sterilization restrict clients' eligibility to use sterilization for reasons of parity, marital status, and spousal consent. Among the doctors providing injectables, 79, 76, and 57 percent consider marital status, spouses consent, and parity respectively to screen women. Similarly, most of the doctors, nurses and midwifes consider marital status and parity for IUD insertion.

97

Table 10.19. Number of family planning providers who provide each method and who restrict clients' eligibility to use a method for reasons of parity, marital status or spouse's consent, by method, according to type of provider in Agra Doctors Number that provide method 46 43 26 51 37 47 42 27 51 34 45 42 27 51 34 Percent that restrict Nurses Number that provide method 24 25 NA 31 NA 25 25 NA 33 NA 24 25 NA 33 NA Percent that restrict Midwife Number that provide method 8 8 NA 8 NA 8 8 NA 8 NA 8 8 NA 8 NA Percent that restrict

Barrier and method Parity Pill Condom Sterilization IUD Injection Marital status Pill Condom Sterilization IUD Injection Spouse's consent Pill Condom Sterilization IUD Injection

47.8 14.0 88.5 82.4 56.8 74.5 42.9 100.0 98.0 79.4 64.4 35.7 92.6 76.5 76.5

79.2 24.0 NA 93.6 NA 72.0 36.0 NA 84.9 NA 75.0 44.0 NA 93.9 NA

75.0 12.5 NA 87.5 NA 75.0 75.0 NA 100.0 NA 87.5 12.5 NA 95.5 NA

Table 10.20 shows the number of pharmacies who provide different methods of family planning and the percentage who restrict the clients' eligibility to use a method for reasons of parity, marital status or spouse's consent. As compared to providers at health facilities, overall, pharmacies have fewer restrictions for clients eligibility to use a method based on parity, marital status, or spousal consent.

98

Table 10.20. Number of pharmacies that provide each method and restrict clients' eligibility to use a method for reasons of parity, marital status or spouse's consent, by method in Agra Number of Percent that restrict pharmacies Barrier and method Parity 7.1 Pill 98 1.0 Condom 102 5.4 Injection 37 Marital status 15.2 Pill 99 2.9 Condom 102 15.8 Injection 38 Spouse's consent 10.1 Pill 99 4.9 Condom 102 7.9 Injection 38

99