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Background: Large scale public investment in family welfare programme has made female sterilization a free service in public health centers in India. Besides, it also provides financial compensation to acceptors. Despite these interventions, the use of contraception from private health centers has increased over time, across states and socioeconomic groups in India. Though many studies have examined trends, patterns, and determinants of female sterilization services, studies on out-of-pocket payment (OOP) and compensations on sterilisation are limited in India. This paper examines the trends and variations in out-of-pocket payment (OOP) and compensations associated with female sterilization in India. Methods: Data from the National Family Health Survey-4, 2015-16 was used for the analyses. A composite variable based on compensation received and amount paid by users was computed and categorized into four distinct groups. Multivariate analyses were used to understand the significant predictors of OOP of female sterilization. Results: Public health centers continued to be the major providers of female sterilization services; nearly 77.8% had availed themselves of free sterilization and 61.6% had received compensation for female sterilization. About two-fifths of the women in the economically well-off state like Kerala and one-third of the women in a poor state like Bihar had paid but did not receive any compensation for female sterilization. The OOP on female sterilization varies from 70 to 79% across India. The OOP on female sterilization was significantly higher among the educated and women belonging to the higher wealth quintile linking OOP to ability to pay for better quality of care. Conclusion: Public sector investment in family planning is required to provide free or subsidized provision of family welfare services, especially to women from a poor household. Improving the quality of female sterilization services in public health centers and rationalizing the compensation may extend the reach of family planning services in India.

Fertility in West Bengal is one of the lowest in India, and this relies heavily on the use of traditional methods of contraception. Social scientists and demographers have pointed to the historical role of the diffusion process of adhering to a small family size. The Total Fertility Rate (TFR) in Kolkata district, the state capital, is the lowest in the country, and has been a centre of low fertility historically. However, stark differences in rural–urban fertility rates have existed over the last few decades in West Bengal, but these have now started to narrow. This study aimed to capture the macro-level rural–urban differences in fertility levels and preferences in the West Bengal, and understand how socioeconomic factors affect these. Data were drawn from the Census of India (2011) and NFHS-4 (2015–16). Using census data and the Reverse-Surviving Method, the TFR of West Bengal was estimated to be 1.9, varying between 2.1 and 1.7 in rural and urban areas. The rural–urban gap in the district-level fertility rates was prominent, specifically in districts with higher levels of fertility. Kolkata, Hugli and North Twenty-Four Parganas had the lowest-low fertility (TFR = <1.5). Fewer than half of women with only one living child wanted further children, and this was somewhat higher in rural areas. Around 40% of women had achieved their desired number of children. However, a substantial proportion (43.1%) had a lower number of children than desired, varying between 45.9% and 41.7% in urban and rural areas, respectively. Contraception use, female education and age at marriage, along with the other socioeconomic factors, had a greater influence on rural fertility rates than on urban counterparts in the districts of West Bengal. Further research should be directed at understanding the contemporary fertility decline as well as the gap between ideal and desired number of children, specifically in those districts with very low fertility rates.

SummaryThe desire for children could be considered a reliable predictor of subsequent fertility. At the same time, the sex composition of surviving children, along with other demographic and socioeconomic factors, may affect a couple's fertility desire and, therefore, their subsequent fertility. This study examined the impact of the sex composition of living children and a couple's agreement on fertility desire on their subsequent fertility in India using data came from two rounds of nationally representative surveys: the India Human Development Survey (IHDS)-I (2004-05) and IHDS-II (2011-12). To understand which factors affect the chances of an additional pregnancy or childbirth, a random effects logistic regression model was applied to the panel data. It was found that the fertility desires of both marital partners were important in determining the chances of subsequent fertility. About 35% of the couples wanting to limit children had undergone pregnancy or childbirth, while 76% of the couples wanting more children had conceived or given birth to children. In the case of discordance between the spouses, subsequent fertility was found to remain intermediate between those agreeing to continue childbirth and those wanting to limit it. The findings also affirmed that child sex preference, specifically son preference, still persists in Indian society. More than 80% of the couples with only daughters in IHDS-I mutually wanted to have additional children, whereas in families that only had sons, the chance of a subsequent pregnancy was inversely associated with the number of sons. Strong patriarchal settings, combined with cultural and socioeconomic factors, affect the persistence of sex preference in India. Programmes aimed at increasing family planning use need to address son preference and should include components that promote the value of girl children.

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