International Journal of Community Medicine and Public Health

Habib A et al. Int J Community Med Public Health. 2025 Mar;12(3):1549-1556

[Link] pISSN 2394-6032 | eISSN 2394-6040

DOI: [Link]
Review Article

A comparative study of National Family Health Survey-4 and National

Family Health Survey-5 on quality of family planning services and
unmet need for family planning indicators in Assam
Ashfia Habib*, Sthapana Sharma, Aamir Saeed, Achyut C. Baishya, Jutika Ojah

Department of Community Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India

Received: 24 December 2024

Revised: 17 February 2025
Accepted: 18 February 2025

*Correspondence:
Dr. Ashfia Habib,
E-mail: ashfiahabib40475@[Link]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Family planning is an important component of health, welfare, family stability as well as the social and economic
progress of a community. The purpose of this study is to assess the shifts in the quality of family planning services and
unmet needs in Assam based on National Family Health Survey (NFHS) rounds 4 and 5. The study is based on both
NFHS-4 (2015-2016) and NFHS-5 (2019-2021) data and compares the major indicators; unmet need for family
planning and quality of family planning services. Data disaggregated to district level were considered including total
unmet need, demand for spacing, and the communication between health workers and female non-users regarding
contraceptives. The current study shows that the overall total unmet need for family planning has declined in most of
the districts in Assam when compared. However, when comparing districts large disparities have been found for certain
districts demonstrating higher levels of unmet need. Contrary to this, the study established that the quality of family
planning services measured by health worker’s interaction with non-users had increased in most districts but was still
inadequate in the state. It is clear from the analysis that there has been significant improvement in family planning
services, however; there are challenges concerning the use and availability of family planning services. Interventions
proposed are strengthening interventions for certain groups, improving access, and increasing cultural competence.

Keywords: Unmet need, Health workers, Reproductive health, National Family Health Survey

INTRODUCTION Ensuring universal coverage and access to sexual and

reproductive health services will be important to meeting
Family planning services influence maternal and child the stakeholders' needs under the 2030 agenda for
health, population, and development. In 2021, out of the sustainable development premise of 'leaving no one
1.9 billion women of childbearing age or 15-49 years, 1.1 behind'.3 The most appropriate source for health corridors
billion needed family planning services.1 Employment of and related demographic frequencies, such as family
contraception is encouraged due to the risks posed by planning services and unmet requirements, is India's
pregnancy; many of these risks impact the lives of women National Family Health Survey (NFHS). The program's
and girls. It has been seen that if children are born within aim has shifted from providing vertical family planning
two years of the elder sibling, they die within sixty percent services to providing efficient and integrated reproductive
of the total death rate of newborns; if children are born health services at both the individual and systemic levels.4
within two to three years of the elder, they die within ten 1952 India established the world's first National Program
percent of the total death rate of infants and rest ninety for Family Planning. Over time, the project has developed
percent of the total infant death rate is of those children in terms of policy and program implementation, and it is
who are born after three years of the elder sibling dies. 2 currently being repositioned to not only accomplish

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 Habib A et al. Int J Community Med Public Health. 2025 Mar;12(3):1549-1556

population stabilization goals, but also to improve challenges in meeting clients’ reproductive health needs.
reproductive health and reduce maternal, newborn, and This analysis is particularly important, given India’s
child mortality and morbidity.5 Since its inception in 1992- engagement with the sustainable development goals
93, the NFHS, conducted by the International Institute of (SDGs), particularly SDG 3: good health and well-being
Population Sciences (IIPS) under the Ministry of Health and, SDG 5: gender equality.
and Family Welfare (MoHFW), has helped generate
accurate data on family health as well as modified health METHODS
indicators.6 According to the World Health Organization
(WHO), family planning is “the ability of individuals and We compared the summary data of NFHS-5 and NFHS-4
couples to anticipate and attain their desired number of with the state and district fact sheets of Assam published
children and the spacing and timing of their births. It is by the IIPS. In this study, we included two indicators
achieved through the use of contraceptive methods and the namely, Unmet need for family planning (currently
treatment of involuntary infertility” (the working married women aged 15-49 years) and quality of family
definition used by the WHO Department of Reproductive planning services. Furthermore, according to NFHS data,
Health and Research). Avian Donabedian defined quality two variables were included for calculating the unmet need
of care as “the application of medical science and for family planning (currently married women aged 15-49
technology in a manner that maximizes the benefits to years); total unmet need (%) and unmet need for spacing
health without correspondingly increasing the risk”.7 The (%). Two variables were evaluated when assessing the
Bruce-Jain paradigm focuses on the clinical provision of quality of family planning services; whether health
family planning and defines six factors of quality: personnel had ever talked to female non-users about family
provision of choice, client information and counselling, planning (%) and whether current users had ever been told
technical competence, effective interpersonal interactions, about the side effects of their current method (%). Data
continuity of care, and suitable constellation of services.8 from both NFHS-4 and NFHS-5 were used to prepare maps
Women with unmet needs are those who are fecund and and figures.
sexually active but do not use contraception and report not
wanting to have any more children or delaying the next RESULTS
child. The concept of unmet need refers to the discrepancy
between women's reproductive objectives and The differences regarding total unmet needs (%) in
contraception use.9 As per the NFHS 5 (2019-2021) India different districts of Assam have been shown here. The
factsheet, 23.9% of health workers talked to female non- total unmet need (%) in India as per NFHS-5 was 9.4% and
users about family planning, and 62.4% of current users in NFHS-4 was 12.9%. The definition of an unmet need
were told about the side effects of the current method for family planning as described in the NFHS refers to
(based on current users of female sterilization, fecund women who are not using contraception but who
IUD/PPIUD, injectables, and pills who started using that wish to postpone the next birth (spacing) or stop
method in the past 5 years); the total unmet need for family childbearing altogether (limiting). The NFHS-4 data was
planning (currently married women aged 15-49 years) was not documented for the districts such as Biswanath,
9.4%, and unmet need for spacing was 4.0%. 10 In the Charaideo, Hojai, Majuli, South Salmara, and West Karbi
context of Assam, only 21.4% of health workers talked to Anglong (Table 1).
female non-users about family planning, and 70.0% of
current users were told about the side effects of the current There is an overall decrease in the total unmet need for
method (which is higher than the national average); the family planning from NFHS-4 to NFHS-5 in most districts,
total unmet need for family planning (currently married indicating improved access to family planning services.
women aged 15-49 years) was 11.0% (higher than the Districts with significant improvement are Dhubri,
national average), and unmet need for spacing was 4.1% Lakhimpur, Dhemaji, Goalpara, and Dima Hasao. Districts
(somewhat similar).11 with increased total unmet needs are Darrang, Bongaigaon,
Nalbari, and Udalguri. Persistent discrepancies were
The study aims to examine and evaluate changes in two discovered when comparing districts, with Kamrup (R)
key aspects of family planning which include the ability of having the largest unmet demand (17.6%), and more than
the service delivery point to offer quality family planning three times the lowest (5.3%) in Biswanath (Figure 1).
services and the demand for such services in the
population. Attributes like accessibility of the services, There is an overall decrease in the unmet need for spacing
different opportunities to use various types of between NFHS-4 and NFHS-5 in most districts. The
contraceptives, counselling services, and general districts with the highest unmet need for spacing are
satisfaction with the family planning services can be put Kamrup (R), Cachar, and Udalguri. The districts with the
under this aspect. The unmet need aspect probably focuses lowest unmet need for spacing are Biswanath, South
on the extent of the population that desires to avoid or Salmara, and Morigaon. The variations in the districts may
space childbirth but does not use any contraception be due to the factors which were mentioned earlier (Figure
method. Comparative analysis of the NFHS-4 and NFHS- 2).
5 of Assam permits an understanding of the advancement
of family planning service uptake and the remaining

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 Habib A et al. Int J Community Med Public Health. 2025 Mar;12(3):1549-1556

Table 1: Showing the total unmet need in percentage for up to two years after an unwanted delivery with no
for all the districts of Assam. contraception.6,10,11

Total unmet need (%) Bar diagram (stacked) for total unmet
District
NFHS 5 NFHS 4 need
Baksa 12.5 12.4 West Karbi Anglong
Barpeta 12.3 10.1 Tinsukia
Biswanath 5.3 N/A Sonitpur
Nalbari
Bongaigaon 16.1 9.9
Morigaon
Cachar 15.6 12.9 Lakhimpur
Charaideo 8.3 N/A Karimganj
Chirang 9.8 7.9 Kamrup (R)
Darrang 14.8 6.3 Jorhat
Dhemaji 7.1 17.9 Hailakandi
Dhubri 11.5 21.7 Goalpara
Dibrugarh
Dibrugarh 8.7 13.7
Dhemaji
Dima Hasao 9.7 18.4 Chirang
Goalpara 7.4 17.7 Cachar
Golaghat 10.9 16.3 Biswanath
Hailakandi 8.6 16.6 Baksa
Hojai 13.2 N/A 0 10 20 30 40
Jorhat 10.4 11.4 NFHS 5 NFHS 4
Kamrup (M) 8.8 17.8
Kamrup (R) 17.6 19.6 Figure 1: Showing the bar diagram (stacked) for total
Karbi Anglong 9.3 13.6 unmet needs in percentage for all the districts of
Karimganj 8.6 14.6 Assam. The labels (numbers) in black and white are
Kokrajhar 10.0 11.6 for NFHS-5 and NFHS-4 respectively.
Lakhimpur 9.8 20.1
Majuli 11.6 N/A Line chart for unmet need for spacing
Morigaon 6.5 14.1 10
Nagaon 12.3 16.0 9
Nalbari 13.2 7.0 8
Sivasagar 8.3 16.0 7
Sonitpur 5.8 8.6 6
South Salmara 8.0 N/A 5
4
Tinsukia 11.0 11.8
3
Udalguri 14.6 8.5
2
West Karbi Anglong 7.1 N/A
1
0
The differences in NFHS-4 and NFHS-5 regarding unmet
Baksa

Dibrugarh
Goalpara

Kamrup (R)
Karimganj

Morigaon
Nalbari
Biswanath
Cachar
Chirang

Hailakandi
Dhemaji

Jorhat

Lakhimpur

Sonitpur
Tinsukia
West Karbi Anglong

need for spacing (%) in the districts of Assam in terms of

unmet need for spacing (%) have been shown here. The
unmet need for spacing (%) in India as per NFHS-5 was
4.0% and in NFHS-4 was 5.7%. The below-mentioned
women are considered to have an unmet need for spacing
- women who are at risk of pregnancy, do not use NFHS 5 NFHS 4
contraception, do not want to become pregnant within the
next two years, or have not yet decided when they want to
become pregnant; pregnant with a mistimed pregnancy; Figure 2: Showing the line chart for the unmet need
and postpartum amenorrhea for up to two years after a for spacing in percentage for all the districts of Assam.
mistimed delivery and no contraceptive use.
Women who are classified as infecund have no unmet need
Women who are considered to have an unmet need for because they are not at risk of becoming pregnant. The
limiting: women who are at risk of pregnancy, do not use unmet need for family planning is the sum of the unmet
contraception and wish to have no more children; pregnant need for spacing plus the unmet need for limiting (Table
with an unplanned pregnancy; and postpartum amenorrhea 2).

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Table 2: Showing the unmet need for spacing in NFHS-4 data but have significant values in NFHS-5,
percentage for all the districts of Assam. indicating fresh initiatives in these areas. Udalguri and
Jorhat have lower NFHS-5 percentages (14.6% and 14.4%,
Unmet need for spacing (%) respectively), indicating that these localities may require
District
NFHS 5 NFHS 4 more emphasis on family planning communication (Figure
Baksa 5.7 6.8 3).
Barpeta 3.9 4.7
Biswanath 1.4 N/A Table 3: Showing the percentage of health worker
Bongaigaon 5.1 4.5 who ever talked to female non-users about family
Cachar 6.9 8 planning for all the districts of Assam.
Charaideo 3.7 N/A
Health worker ever talked
Chirang 3.7 3.1 to female non-users about
Darrang 5.8 3.1 District
family planning (%)
Dhemaji 3.5 7.2 NFHS 5 NFHS 4
Dhubri 4.0 4.7 Baksa 24.8 22.8
Dibrugarh 4.8 6.6 Barpeta 18.4 11.8
Dima Hasao 2.6 5.8 Biswanath 29.9 N/A
Goalpara 2.2 8.3 Bongaigaon 23.4 17.5
Golaghat 4.7 6.6 Cachar 23.6 23.8
Hailakandi 4.2 4.4 Charaideo 22.0 N/A
Hojai 4.9 N/A Chirang 34.2 14.3
Jorhat 3.2 5.7 Darrang 18.0 12.9
Kamrup (M) 2.5 6.9 Dhemaji 28.2 19.5
Kamrup (R) 7.7 5.9 Dhubri 22.6 6.9
Karbi Anglong 2.4 6.6 Dibrugarh 28.9 15.1
Karimganj 4.2 7.5 Dima Hasao 18.3 10.8
Kokrajhar 3.7 5.3 Goalpara 19.3 17.8
Lakhimpur 4.5 9.2 Golaghat 25.3 26.4
Majuli 4.7 N/A Hailakandi 26.1 21.7
Morigaon 1.9 5.8 Hojai 21.7 N/A
Nagaon 3.1 6.2 Jorhat 14.4 18.0
Nalbari 4.8 1.8 Kamrup (M) 16.6 11.8
Sivasagar 3.2 6.0 Kamrup (R) 17.1 14.6
Sonitpur 2.0 3.9 Karbi Anglong 23.6 16.2
South Salmara 1.7 N/A Karimganj 31.0 26.1
Tinsukia 4.4 4.9 Kokrajhar 18.7 16.4
Udalguri 6.4 3.7 Lakhimpur 30.8 24.7
West Karbi Majuli 25.1 N/A
3.2 N/A
Anglong Morigaon 27.0 16.2
Nagaon 16.6 20.4
The differences regarding the percentage of health workers Nalbari 18.8 8.3
who ever talked to female non-users about family planning
Sivasagar 22.1 21.2
in NFHS-4 and NFHS-5 in the districts of Assam have
Sonitpur 20.5 13.8
been shown here. The percentage of health workers who
ever talked to female non-users about family planning as South Salmara 26.7 N/A
per NFHS-5 was 23.9% and as per NFHS-4 was 17.7% in Tinsukia 17.6 19.0
India (Table 3). Udalguri 14.6 20.9
West Karbi
23.0 N/A
From NFHS-4 to NFHS-5, most districts had an increase Anglong
in the percentage of health workers talking to non-users
about family planning, indicating improved outreach and The differences regarding the percentage of current users
efforts by healthcare providers to educate and raise ever told about the side effects of the current method in
knowledge about family planning. Chirang experienced a NFHS-4 and NFHS-5 in the districts of Assam have been
huge growth from 14.3% in NFHS-4 to 34.2% in NFHS-5. shown here. The percentage of current users ever told
Dhubri also improved significantly, going from 6.9% in about the side effects of the current method as per NFHS-
NFHS-4 to 22.6% in NFHS-5. Biswanath, Charaideo, 5 was 62.4% and as per NFHS-4 was 46.6% in India. The
Hojai, South Salmara, and West Karbi Anglong have no current method as per the NFHS is based on current users

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 Habib A et al. Int J Community Med Public Health. 2025 Mar;12(3):1549-1556

of female sterilization, IUD/PPIUD, injectables, and pills 47.2% – all of them significantly lower than the average,
who started using that method in the past 5 years (Table 4). proving that the choice of family planning service needs a
quality boost. These can be caused by various factors
Bar chart (stacked) for health workers including more trained health workers and health
who ever talked to female non-users promotion, enhanced physical health infrastructure, health
about family planning policies and programs and health systems enhancement,
West Karbi Anglong and cultural and economic factors (Figure 4).
Tinsukia
Sonitpur Table 4: Showing the percentage of current users ever
Nalbari told about the side effects of the current method for all
Morigaon the districts of Assam.
Lakhimpur
Karimganj
Current users ever told
Kamrup (R)
about side effects of the
Jorhat District
Hailakandi current method (%)
Goalpara NFHS 5 NFHS 4
Dibrugarh Baksa 76.2 78.4
Dhemaji Barpeta 55.1 48.2
Chirang Biswanath 73.5 N/A
Cachar
Bongaigaon 65.1 60.4
Biswanath
Baksa Cachar 82.2 78.5
0 10 20 30 40 50 60
Charaideo 69.5 N/A
NFHS 5 NFHS 4 Chirang 75.3 38.9
Darrang 51.2 51.7
Figure 3: Showing the bar chart (stacked) depicting Dhemaji 67 44.8
the percentage of health workers who ever talked to Dhubri 76.7 19.9
female non-users about family planning for all the Dibrugarh 76.5 71.3
districts of Assam. Dima Hasao 66.6 37.9
Goalpara 68.1 53.5
Column chart (stacked) for current users Golaghat 63.3 66.4
ever told about the side effects Hailakandi 94.7 77.4
200
180
Hojai 73.5 N/A
160 Jorhat 62.6 68.0
140 Kamrup (M) 50.3 47.9
120 Kamrup (R) 58.9 52.1
100
80 Karbi Anglong 74.6 62.1
60 Karimganj 84.5 65
40 Kokrajhar 51.3 50
20 Lakhimpur 80.3 70.9
0
Majuli 85.6 N/A
Kamrup (R)
Baksa

Dibrugarh
Goalpara

Karimganj
Biswanath

Chirang

Nalbari
Cachar

Hailakandi

Morigaon
Dhemaji

Jorhat

Lakhimpur

Sonitpur
Tinsukia
West Karbi Anglong

Morigaon 66.4 40.4

Nagaon 73.7 61.0
Nalbari 60.6 32.2
Sivasagar 80.1 56.0
Sonitpur 72 56.8
NFHS 5 NFHS 4
South Salmara 71.8 N/A
Tinsukia 72.2 51
Figure 4: Showing the column chart (stacked) for the Udalguri 47.2 52.1
percentage of current users ever told about the side West Karbi
80.5 N/A
effects of the current method for all the districts of Anglong
Assam.
DISCUSSION
Hailakandi (94.7%), Karimganj (84.5%), and Majuli
(85.6%): These districts have high percentages of NFHS-5 Unmet need for family planning
and are well facilitated in inter and intra-personal
communication regarding family planning. That is why The reduction of the total unmet need for family planning
Kamrup (M) has 50.3%, Kamrup (R) 58.9%, and Udalguri in most of the districts of Assam over NFHS-4 and NFHS-

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5 is appreciable which indicates that the female population family planning concerns with non-users; and cultural
has proper access to family planning services which is vital barriers: some people may be sensitive to family planning
in improving their maternal and child health as well as in topics, particularly non-users.
attaining our set targets in population regulation.
Women with the greatest level of education had larger
However, the prosecution of inequalities in the districts has unmet needs than women in other educational attainment
been contentious. Thus, Kamrup Rural has a much higher categories, it must be noted that the unmet need for spacing
unmet need, almost 3 times Biswanath, which shows great grew with education level, but the unmet need for limiting
disparities in the need for and the uptake of family planning remained relatively constant.12 This shows that women
services. This disparity could be due to a variety of factors, with greater education are more interested in spacing rather
including than limiting; nonetheless, limiting procedures are more
widespread in India, particularly female sterilization. 13
Population mobility and changes in other demographic
indicators that affect fertility include a high number of The National Family Planning Program has undertaken
migrants, or refugee-like populations, with different family several projects, including Mission Parivar Vikas, which
planning needs, and cultural practices, together with the was started in 2016 to enhance access to contraception and
increase of women of childbearing age. family planning services in seven states with high total
fertility rates.14
Accessibility to healthcare facilities
Implications
Some families because of geographical barriers won’t be
able to access family planning. Progress towards SDGs

Challenges faced by the health systems such as logistic As a result of the overall decreasing trend in unmet demand
issues regarding contraceptive supply chain, and a short for family planning, Assam is on track to meet SDGs 3 and
supply of qualified health staff. 5, which are good health and well-being and gender
equality, respectively. However, it should be highlighted
Culture and religion can play their part in people being that the districts' performance remains lopsided, implying
reluctant to use modern forms of contraception. that this advancement does not apply uniformly.

Family planning implementation and outreach initiatives Maternal and child health
vary per district.
Increased access to family planning services will improve
The COVID-19 outbreak may have hindered the maternal and child health by allowing women to space
availability to family planning services. their pregnancies and avoid difficulties during pregnancy.

The existing unmet requirements of women in districts Women's empowerment

such as Darrang, Bongaigaon, Nalbari, and Udalguri,
among others, are increasing. This may be due to the Family planning services empower women by allowing
following reasons: population dynamics which refers to them to make their own decisions about reproduction.
changes in a country's age structure and influx of migrants;
health system challenges including disruptions in the Population dynamics
supply chain for contraception and a shortage of skilled
human capital in the area; and the COVID-19 outbreak Improving family planning services will help regulate
may have negatively impacted family planning services in population increase, which has policy implications for
these countries. economic growth and development, as well as resource
management.
Quality of family planning services
Health system challenges
Health workers are increasingly discussing family
planning with female non-users, indicating increased These discrepancies identify possible areas of vulnerability
advocacy for education and awareness among women. in the district's health system that must be addressed.
However, the differences in this aspect indicate that the
quality of services provided to women in each district is Policy implications
not comparable to that of other districts in the state. The
fact that some districts have a drop in this statistic is Based on the findings, a new policy should be developed
problematic and could signal the following - resource that will address the needs of a specific district rather than
constraints: some districts may have limited health staff the entire state.
and budgets for health campaigns; health workers in some
districts may lack training on how to effectively handle

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CONCLUSION platforms. To guarantee that people are taught the correct

components of family planning, it is best to design and
It is reasonable to compare NFHS 4 and 5 data on the develop age-appropriate family planning and sex
quality of family planning services and unmet family education programs for school implementation.
planning needs in Assam. It holds the key to providing a Participation in some activities, such as hosting
serious understanding of the level of its progress in the community events and health fairs focused on family
domain of reproductive health, areas of concern that still planning, is also required. People will receive information
require attention, and strategic planning for equal access to on family planning via once-daily SMS messaging.
the best array of family planning services to people and
couples in Assam. Increased male involvement

Recommendations Expanding the campaign to encourage males to use family

planning services can also be taken into consideration.
Targeted interventions Creating male-friendly techniques to encourage males to
participate in family planning counseling at health
Conducting comprehensive needs assessments at the institutions can greatly contribute towards achieving the
district level is crucial for identifying barriers to family goal of family planning services. Teach male CHWs how
planning service utilization. A 'High-impact practice' plan to involve other male community members in topics
should be developed, which involves prioritizing effective related to family planning. Improve father-sensitive
practices and coordinating and adapting them to each prenatal and postnatal care, including family planning
district. Peer education initiatives can be organized in components. Increase the use of role models in the media
target communities to encourage members to use family to promote family planning plans among men.
planning services.
Policy and governance
Improve accessibility
Coordinating and improving present family planning
Mobile clinics can visit underserved communities to policies in light of current national and international norms
extend family planning approaches. E-health systems can and regulations. A steering committee should be formed at
be created to focus on family planning. the state level to oversee all family planning initiatives and
communicate with other departments. Introduce a
Cultural sensitivity performance-based bonus for districts that meet the
established family planning targets. Collaborate with
It is also important to enshrine the support of religious NGOs and private organizations to increase access to
leaders and community elders in the family planning family planning services.
promotional crusade. The other important
recommendations are to train the health workers on aspects Research and innovation
of communication and handling of the people and their
cultural beliefs. Sponsor studies to identify new contraception options for
usage in the country. Establish, test, and scale up
Strengthen health systems operational innovations such as social marketing for family
planning. Also, conduct an operational study to identify the
Creation of awareness by conducting meetings as well as difficulties that impede the flow of service delivery.
improving seminars and training for the health care Identify emerging trends in the use of artificial intelligence
personnel with regards to the family planning methods and and big data analytics to analyze unmet family planning
counseling interventions. Implementation of a concept of requirements.
sharing skills where there will be a pairing of skilled family
planning service providers with less skilled individuals in Funding: No funding sources
a facility. There is a possibility to develop a well-fixed Conflict of interest: None declared
supply chain concerning the supply of contraceptives Ethical approval: Not required
which would minimize the problem of stock out. This must
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International Journal of Community Medicine and Public Health | March 2025 | Vol 12 | Issue 3 Page 1556