Female sterilisation still dominates India’s contraceptive mix, three decades of survey data show

Despite three decades of policy commitments to offering couples a full menu of contraceptive options, female sterilisation remains the dominant method in India, according to a new analysis of national survey data published in Contraception and Reproductive Medicine. The study, which examined five rounds of the National Family Health Survey conducted between 1992-93 and 2019-21, finds that the country’s contraceptive method mix has diversified only modestly, with permanent methods continuing to outweigh reversible options among currently married women aged 15 to 49.

Overall contraceptive prevalence among currently married women of reproductive age rose from 40 percent in 1992-93 to 67 percent in 2019-21. That increase, however, has not translated into a broad spread of method choices. Female sterilisation accounted for more than half of all contraceptive users in every survey round, falling from 67.3 percent of the total method basket in the first survey to 56.8 percent in the most recent round. Male sterilisation, once a visible part of the programme, declined sharply to below 1 percent of users.

Reversible modern methods such as condoms and pills have gained ground, but only modestly, and they remain considerably less common than permanent methods. The researchers assessed the composition of the method mix using the percentage distribution of contraceptive methods and measured change over time with the Index of Dissimilarity. This measure indicated limited diversification in the method mix since the 2005-06 survey round, suggesting that the pattern of heavy reliance on female sterilisation has been largely stable for nearly two decades.

The study frames these patterns against India’s cafeteria approach, which was introduced to expand contraceptive options and help couples choose methods according to their reproductive needs and preferences. The authors argue that the continued dominance of a single method may indicate method skew, and that the persistence of female sterilisation as the leading choice points to an incomplete realisation of the cafeteria approach in practice.

Beyond the aggregate trends, the analysis examined which socio-demographic groups are most likely to use reversible modern methods, using multinomial logistic regression applied to the most recent survey round. Women from the richest wealth quintile were significantly more likely to use reversible modern methods than women from poorer households, with a relative risk ratio of 1.75 and a 95 percent confidence interval of 1.58 to 1.93. Women with higher education were also more likely to choose reversible methods compared with women who had no education, with a relative risk ratio of 1.67 and a confidence interval of 1.53 to 1.83.

Geography and residence also shaped method choice. Rural women were less likely than urban women to use reversible modern methods, with a relative risk ratio of 0.82 and a confidence interval of 0.77 to 0.87. Taken together, the regression results point to continuing socio-economic and gender inequalities in contraceptive responsibility, with the burden of permanent contraception falling disproportionately on women and on poorer, less educated and rural populations.

The study’s conclusions carry clear policy implications. The authors suggest that strengthening the availability of and access to reversible methods, improving provider counselling services, and promoting equity in access are critical for advancing reproductive rights and autonomy. They note that the findings highlight persistent inequalities in who bears responsibility for contraception, even as the overall share of couples using some form of family planning has grown substantially over the survey period.

The analysis draws on a long observational time series, which allows trends to be tracked across nearly thirty years of national surveys, but it describes patterns and associations rather than testing the effect of any specific intervention. The regression estimates come from a single survey round, and the authors note that the article is being shared early as a peer-reviewed accepted version that is subject to further edits before the final version of record. Even so, the central message is consistent across the data: India’s family planning landscape has expanded in coverage, but the range of methods couples actually use has changed far less, with female sterilisation still shouldering the largest share of the nation’s contraceptive burden.

Subject of Research: Trends and socio-economic inequality in contraceptive method mix and method skew in India from 1992 to 2021

Article Title: The unequal burden of choice: assessing the cafeteria approach and method skew in India’s family planning landscape (1992–2021)

Article References: Sikdar, R., Bansod, D. W., & Mishra, U. S. (2026). The unequal burden of choice: assessing the cafeteria approach and method skew in India’s family planning landscape (1992–2021). Contraception and Reproductive Medicine. https://doi.org/10.1186/s40834-026-00478-4

Image Credits: AI Generated

DOI: 10.1186/s40834-026-00478-4

Keywords: India, family planning, contraception, female sterilisation, method skew, cafeteria approach, NFHS, reversible contraceptives, health inequality, reproductive health, unequal, burden