The Government of India has taken significant steps toward improving national, regional and village-level sexual and reproductive health, including making substantial progress on key maternal and newborn health indicators. Yet many women continue to have an unmet need for modern contraception and receive substandard pregnancy-related care.

Adding It Up is a project meant to guide investments in the essential sexual and reproductive health services required to ensure that people can decide whether and when to have children, experience safe pregnancy and delivery, have healthy newborns, and have a safe and healthy sexual life. The estimates presented here, which pertain to women of reproductive age (15–49) in India in 2019, demonstrate the need for, benefits of and costs associated with fully investing in contraceptive services, pregnancy-related and newborn health care, and treatment for the four major curable STIs (chlamydia, gonorrhea, syphilis and trichomoniasis).

Need for contraceptive services

• As of 2019, about half (52%) of India’s 353 million women of reproductive age want to avoid pregnancy. Of these 183 million women, 49 million (27%) do not use a modern contraceptive method and are thus considered to have an unmet need for modern contraception.
• An estimated 47 million pregnancies occur each year in India, and 45% of them are unintended (meaning that they have occurred too soon or are not wanted at all). Women with an unmet need for modern contraception account for nearly nine out of every 10 unintended pregnancies.
• Approximately 134 million women in India use modern contraceptives. The majority of them (77%) rely on female sterilization, and relatively few use reversible methods: Eleven percent rely on the male condom, 8% on the pill and 3% on long-acting reversible methods. Only 1% of women rely on their male partner’s vasectomy.
• Fewer than half of current contraceptive users (47%) receive information on their method’s possible side effects, and only 39% receive information on what to do if they experience them.¹

Need for pregnancy-related, newborn and STI care

• India has made substantial progress on key maternal and newborn health indicators. Largely dbecause of programs such as the Janani Suraksha Yojana scheme, the proportion of deliveries at a health facility doubled, growing from 41% in 20062 to 82% in 2016.¹
• However, gaps in coverage remain. For example, 51% of women with a live birth—12 million in total—make fewer than the recommended minimum of four antenatal care visits.
• Additionally, although 82% of women giving birth deliver at a health facility, many women do not receive high-quality maternity care:
  • Forty percent of women with a live birth do not receive a postnatal checkup within 24 hours of delivery.
  • Thirty-seven percent of those delivering at a health facility do not stay at the facility for at least 48 hours after delivery, despite national recommendations that they do so.³
  • Half of women who experience medical complications related to pregnancy or delivery do not receive treatment.
• The proportions of women making the recommended number of antenatal care visits, delivering at a health facility and receiving a postnatal checkup are lowest among those from the poorest households.
• Further, 31% of newborns who experience major complications do not receive the health care they need.
• An estimated 14 million women of reproductive age in India do not receive needed treatment for one of the four major curable STIs.

Impact

• Providing women with the full spectrum of contraceptive options, counseling and complete information allows them to make informed choices and decreases the numbers of unintended pregnancies, unsafe abortions and maternal deaths.
• If all women in India wanting to avoid a pregnancy were using modern contraceptives, the annual number of unintended pregnancies would decrease by 77%, resulting in 16 million fewer unintended pregnancies and 10 million fewer unsafe abortions every year.
• Each year, 27,000 women die from pregnancy-related causes. The majority of these deaths are preventable, including 3,000 per year that are related to complications of unsafe abortion.
• If all women in India wanting to avoid pregnancy were using modern contraceptives and all abortions were conducted safely, deaths related to abortion would decline by 98%.
• Providing all women wanting to avoid pregnancy with modern contraceptive services and all pregnant women and their newborns with adequate health care would together reduce annual maternal deaths by 14,000 (or 52%) and newborn deaths by 403,000 (74%).

Costs

• As of 2019, the annual cost of providing current levels of contraceptive care, pregnancy-related and newborn health care, and treatment for the four major curable STIs for women in India is estimated at US$5.0 billion (₹364 billion)^*

• Fully meeting the recommended health care needs of all pregnant women and their newborns would cost US$7.9 billion (₹582 billion) per year.
• Yet that cost could be reduced to US$6.3 billion (₹460 billion) by investing an additional US$398 million (₹29.1 billion) in contraceptive care to meet the needs of all women wanting to avoid pregnancy.
• In other words, every additional dollar spent on contraceptive services above the current level would save $4.17 (₹306) in the cost of pregnancy-related and newborn health care.
• Fully meeting all needs for contraception, pregnancy-related and newborn health care, and treatment for the major curable STIs would cost US$7.4 billion (₹542 billion) annually, or US$5.41 (₹397) per capita per year.

Recommendations

• Although the Government of India has made important strides in sexual and reproductive health, additional funds must be committed toward providing a comprehensive set of services to further improve health outcomes.
• In addition to increased investment, self-care interventions, task-shifting and integration of services can help to increase access to services and can produce cost savings, as well.
  • Provide information, commodities and support according to World Health Organization guidance for self-care to women who desire to self-administer methods of contraception, such as oral contraceptives and injectables.
  • Enable midlevel health care providers, including nurses, to provide contraception (including injectables) and medical abortion safely at critical points of contact.
  • Improve access to safe abortion care, including medical abortion, with support and follow-up from health care workers.
  • Train frontline health care workers to provide referrals for and information about maternal health care services, which are available free of charge at health facilities.
  • Integrate sexual and reproductive health into health facilities and outreach programs. For example, primary health care centers should offer STI screening, and information on sexual and reproductive health care must be disseminated through existing community resources, such as Pradhan Mantri Surakshit Matritva Abhiyan, Village Health Sanitation and Nutrition Committees, Mahila Arogya Samitis, Urban Health and Nutrition Day, and Village Health and Nutrition Day.
• Investments must focus not only on increasing access to services, but also on improving quality of care.
  • While the majority of women deliver at health facilities, hospital stays are short, and women often do not receive essential postpartum care, including postpartum family planning counseling and provision and care for their newborns. Effective use of the Health Management Information System and other data could allow government officals to identify underperforming facilities and enforce national standards.
  • Pregnant women should be enrolled in the Mother and Child Tracking System to ensure that recommended care is received throughout pregnancy, postdelivery care, and infant and child care.
  • The full spectrum of contraceptive methods must be made available. High-quality contraceptive care must also enhance women’s autonomy, encourage informed decision making, provide medically accurate information on methods and offer follow-up treatment for side effects.
• Funds must be directed toward health worker training and community outreach, to improve access to high-quality health care for women with the greatest unmet need for services:
  • Health worker trainings must include guidance on the proper counseling of clients, provision of services and rights related to sexual and reproductive health.
  • Trainings must be offered to field-level workers such as accredited social health activists (ASHAs), auxiliary nurse midwives and other fieldworkers, who are often the first or only point of contact for women in rural areas and those from poorer households.
  • Educational activities must specifically address misconceptions about modern contraceptive use, particularly the use of IUCDs and injectables.
  • The training of male outreach workers and the development of demand-generation activities targeted at men must be increased to encourage male partners’ involvement in contraceptive care.
• Meeting the needs for contraceptive care, pregnancy-related and newborn health care, and STI treatment will save money and lives. Policymakers must prioritize sexual and reproductive health amid the spread of COVID-19, to ensure India’s progress toward meeting health goals set at the national, regional and global levels.