By Dr Richa Kothari & Surabhi Singh
Picture a woman in her late twenties in a mid-sized Indian city. She banks on her phone, has health insurance, and googles medical information before visiting a clinic. She knows what an IUD is, has read about its side effects, and decides against it. Instead, she and her husband track her cycle. She is not rejecting family planning. She is exercising choice.
She is also part of a shift that India's family planning program has yet to reckon with. The latest National Family Health Survey shows modern contraceptive use among currently married women fell from 56.4% to 52.7?tween 2019-21 and 2023-24, while traditional methods rose from 10.3% to 16.4%—a 6.1%-point swing.
This comes even as internet use among women nearly doubled from 33.3% to 64.3%, bank account ownership increased from 78.6% to 89%, and household health insurance coverage rose from 41% to 60.2%. Every indicator of agency moved forward. One critical health indicator did not.
Yet the official press release highlighted a different statistic: overall contraceptive prevalence, which increased from 66.7% to 69.1%. That figure appears encouraging but combines modern and traditional methods, masking an important shift. Meanwhile, unmet need for family planning declined and India's total fertility rate remained at 2.0.
Some women are making informed, autonomous choices about their bodies; others are moving away from a system they no longer trust. Both trends are real and demand different policy responses. Collapsing them into a single headline number creates a policy blind spot.
Three things are pushing women away from the program, and the policy debate has taken none of them seriously enough.
The first is the long shadow of sterilization. Female sterilization still accounts for 36.5% of all contraceptive use in India, and the average age at which women undergo it has consistently been around mid-twenties (IIPS, NFHS-4 and 5). Male sterilization, safer in procedure and free of any hormonal burden, hovers around 0.3 to 0.5%, and this number has barely moved in two decades.
The body that bears the risk of pregnancy has also been designed, by this program, to carry the weight of preventing it. A woman who grew up watching this, and now reads about it online, does not easily walk back into that system. Trust, once lost, is difficult to rebuild.
The second is stigma. Seeking contraception in India still carries a social charge. “Are you married?” instead of “are you sexually active?” is not a neutral clinical question. It is, rather, a gatekeeping mechanism that signals who the system considers a legitimate patient and who it does not. For many women, a tracking app or a friend carries no judgement. The clinic does.
The third is a pattern, not an episode. Following earlier attempts to restrict emergency contraceptive pills, including the controversy surrounding Tamil Nadu's 2006 ban, the Drugs Consultative Committee in September 2023 again considered moving I-Pills behind a prescription wall. The committee ultimately held firm, but only after two years of regulatory uncertainty and enough public debate to shape perceptions. The final ruling retained OTC access but added a
warning: do not take this more than twice a month. The signal, in other words, was built into the label.
The health consequences are not about fertility rising. They are about method failure. A 2025 peer-reviewed study using NFHS-5 data found that self-managed abortion- where women bypass clinical care entirely- rose from 19% in 2014 to 45% in 2021, with the highest rates in regions where institutional trust is thinnest.
The women most at risk are not those without contraceptive intent-they are those whose chosen method let them down. If policymakers are serious about closing that gap, four things need to change.
First, delink ASHA incentives from sterilization referrals and reorient them toward method-neutral counselling, so that a woman’s first encounter with the program is not also a push toward permanence.
Second, mandate non-judgemental protocols in public health facilities. A woman seeking contraception should not be asked to justify her marital status before she can be helped. The clinical encounter should feel like healthcare, not a moral audit.
Third, resist the impulse to restrict emergency contraception access as a response to its overuse.
The answer to women relying on I-Pills too regularly is not a prescription barrier—it is addressing why the burden of contraceptive planning falls on her in the first place, and why her partner’s role in that conversation remains, like his sterilization rate, close to zero.
Fourth, include male family planning participation as a measurable indicator in the next NFHS cycle, and build ASHA outreach capacity for male partners alongside female counselling. The program has diagnosed this gender asymmetry for decades without ever prescribing a fix.
India's family planning program was built for a different era. The women it was designed to serve have moved on. The question is whether the program is ready to follow.
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[Dr Richa Kothari is Senior Economist and Surabhi Singh is Research Associate at Pahle India Foundation.]
Acknowledgement: The authors thank Dr Urvashi Prasad - Director, PAVANA and Senior Fellow, Pahle India Foundation, and former Director, NITI Aayog - for her guidance on the issues covered in this piece.
The views expressed are not necessarily those of The South Asian Times
