Using data from the recent Family Planning Survey conducted in UP, the present study used different family planning coverage indicators with a special focus on demand satisfied by modern methods to identify the coverage gaps between and within administrative divisions. Between and within the divisions the inequalities were observed in family planning coverage irrespective of different coverage indicators. The inequity in family planning demand satisfied by divisions into four quadrants was useful in identifying Jhansi division as the highest family planning demand satisfied with lowest inequality; Basti as the division with the lowest family planning coverage with one of the highest inequalities and in Gonda division both demand satisfied for modern family planning methods and corresponding inequalities are one of the lowest. Figs. 5, 6 and 7 revealed intersectionality of education, wealth, place of residence and geographic divisions in identifying inequality patterns. There are no noticeable divisional differences in demand satisfied by modern contraceptive methods between literate and illiterate women, except in the case of Jhansi, Mirzapur and Varanasi divisions for illiterate women, the coverage is better (Fig. 5 ). These divisions indicate reverse pattern in case of traditional family planning methods use among women by education. However, further analysis of the data revealed changes that have occurred in use of sterilization and condom across divisions in UP from 2015-16 to 2021. According to the results, there are 7 divisions in UP that experienced decline in sterilization use and increase in condom use while 8 divisions experienced increase in both sterilization and condom use. The notable divisions are Jhansi with a 6% decline in sterilization use while 7% increase in condom use; on the other hand, Prayagraj division experienced 6% increase in condom use and Varanasi division with 8% increase in sterilization use. Additionally, stock-out of commodities is the important factor in the poor use of modern methods. Stock-out and limited contraception method availability limit method options, forcing people to choose methods that may or may not meet their preferences and needs. The results showed that higher modern methods use geographies have lesser stock-out of condom/oral contraceptive pills among frontline health care workers than those who belonged to poorer modern method use areas. It is also observed that there is increasing demand for other modern spacing methods such as Injectable/Antara including in poor performing divisions such as Gonda and Basti (results are not presented in the paper but available on request). It is probably due to lesser stock-out of commodities with ASHAs in their geographies, modern contraceptive methods such as condom use was higher. As expected, in most of the divisions, poor and rural residents are in a disadvantaged position compared to their respective counterparts in family planning demand satisfied for modern methods (Figs 6 and 7).

The success story of family planning demand satisfied by modern methods in Jhansi division is intriguing. Unlike Western Uttar Pradesh, Jhansi division or Bundelkhand region is not economically developed and, in many respects as bad as Eastern Uttar Pradesh [20, 21]. In fact, one of the lowest demand satisfied divisions, Aligarh, is part of economically developed region, Western Uttar Pradesh [20, 21]. Researchers have also shown that Jhansi division or Bundelkhand region has the lowest fertility rate in Uttar Pradesh [22]. It is difficult, if not impossible, to explain this anomaly in the absence of recent research. According to UP TSU FP survey, female sterilization and condom are the most preferred modern methods of contraception in UP and it is more so in Jhansi division irrespective of education and residence [23]. In our field visits (some authors were involved in FP Survey data collection as well as maternal and child health programming), it is observed that the demand is met by highly motivated service providers in public health care facilities. The motivation is there among both the young and senior doctors, and it seems, exemplary leadership of the senior providers seems to be having positive influence on the young doctors. The younger doctors tend to be locals and derive lots of pride and satisfaction in serving their community members. There seems to be a healthy competition in performing a maximum number of sterilizations, and it is re-reinforced by recognizing the best-performing service providers and front-line workers in an annual district level function attended by all healthcare employees. The front-line workers such as ASHAs and Auxiliary Nurse Midwives (ANMs) are making sure that community members can access the services. However, as indicated earlier, in recent years, in Jhansi division demand for sterilization has declined but demand for condoms has increased.

The status of women also might have played a role in effective use of modern contraception in reducing fertility to a replacement level in Jhansi division. For instance, unlike in other parts of UP, in Jhansi division, women participate in agricultural activities. Women in this division actively participate and, in many cases, lead agricultural cultivation. There is also historical evidence to show that women in this region are better empowered. According to Jhansi history, Jhansi was ruled by the Queen, Rani Lakshmi Bai, after her husband died [24]. Indian history books indicated that soon after her marriage, Rani Lakshmi Bai put together the women wing of Army as she believed protection of Jhansi Kingdom is not just the responsibility of men. Consequently, her women army wing took an active role in fighting the British invaders towards end of 19th century. Moreover, Jhansi division or Bundelkhand region is different from rest of UP and more like border districts of Madhya Pradesh state and hence, there was a bill introduced in the parliament to form Bundelkhand region as a separate state by including border districts of Madhya Pradesh [20]. It is not surprising that the sterilization uptake in Jhansi division is about 50% and same as in Madya Pradesh. Whereas in case of India it is about 35% but in case of UP it is about less than 18% [22]. Another contributing factor in this region could be, the smaller proportion of Muslim population, around 5% compared to more than 17% in UP. Generally, amongst Muslims, the usage of modern contraception is lower [25], however, Muslim couples in this region seem to have influenced by the regional sub-cultural norms and are better motivated to practice modern contraception.

The worst performing divisions in terms of family planning demand satisfied are Gonda and Basti (Fig. 2) and these are part of Tarai belt, border to Nepal. Divisions in Tarai region recorded lower mCPR and predominantly traditional family planning methods users [23]. These are backward divisions, and modern family planning services, especially female sterilization, are not easily available [26, 27]. Since Public sector is the predominant service provider of modern methods including sterilization and condom in UP , accessibility of these services is also a problem because of out-of-pocket expenditure on public transportation to visit the facilities [19, 23]. Moreover, the couples of these divisions cannot afford to buy condoms from private facilities either. As seen in case of Basti, the modern contraception demand met is only 16% in rural areas. Since these divisions are predominantly rural and hence, it is not surprising that mCPR is much lower. In addition to the data presented above, recent research indicates that poorer people are more likely to use traditional family planning methods and in more developed Western region, couples are 19% less likely to use the traditional methods [8, 23]. Due to lack of accessibility to modern contraceptive methods, it is not surprising that couples from these divisions predominantly use traditional methods [23]. Recent research conducted in UP suggests that supply issues play an important role for increasing use of traditional methods [23, 27]. Since, the family planning services in UP are mostly available in Public Health Facilities, only 25% of the facilities provide female sterilization services, 11% male sterilization and 83% provide condoms [23, 28]. Hence, it is not surprising that in Basti and Gonda divisions, condoms and traditional methods are more being used [23].

To demonstrate the persistence of inequity both in best and worst performing divisions, figure 4 is useful. The best performing division, Jhansi, the demand met for modern family planning methods by ASHA areas (very small areas with population of about 1000) varies from as high as 85% to less than 22%. Similarly, the Gonda division with lowest coverage and lowest inequity for demand satisfied for modern contraception, there are some ASHA areas with less than 5% and more than 36% coverage. The situation is no different for other two divisions presented in figure 4, Mirzapur and Basti. In fact, there are quite a few ASHA areas in Basti division are doing as good as many ASHA areas in Mirzapur and Jhansi divisions but there is also an ASHA area where the coverage is almost nil (3.7%). India is a signatory to the 25th of September 2015 declaration of the United Nations General Assembly to adopt a resolution for the 2030 agenda for sustainable development goals, including goal 3, to ensure healthy lives and promote well-being for all at all ages [29, 30]. If the 2030 Countdown slogan “No One Left Behind” is to be achieved, the Governments of India and Uttar Pradesh cannot afford to focus only on worst performing divisions, Gonda and Basti, but also many ASHA areas of best performing divisions such as Jhansi and Mirzapur need attention as some of the ASHA areas are worse than Gonda and Basti divisions.

The divisions are not homogeneous in their socio-economic development [31], to throw some light on socio-economic inequalities, based on the recent literature, important stratification variables considered are education, income, and place of residence [9, 19]. In case of Jhansi, Mirzapur and Varanasi divisions, the demand satisfied is higher among illiterates (Figure 5). This is consistent with the previous research. [9, 13] Indian Family Planning Program has been successful in its efforts to popularize a small family norm, and couples are motivated to access contraceptive services to achieve their desired family size. This does not mean that economic resources and being in urban areas are not relevant in accessing and utilizing modern contraceptive methods. In one of the worst coverage divisions such as Basti, the demand met by modern contraception in urban areas is 60% compared to only 16% in rural areas. These above results are also corroborated by district level analysis of fertility decline by others [22]. The study has shown that the sterilization usage has increased substantially in very low and middle TFR clusters, while the contribution of the same method has declined, and traditional method has increased in high TFR cluster [22]. According to the study, it is due to lack of availability and accessibility of preferred method of choice. It also seen in case of High Priority Districts (these are disadvantaged districts defined by Government of India) and non-High Priority Districts comparison, one of the factors contributing to the decline in fertility in very low TFR and middle TFR clusters is increase in the usage of sterilization [22, 32]. The patterns in figure 6 reveal that the poor couples are less likely to use modern methods, and this is indicative of lack of affordability. Even if the modern contraceptives are provided free in government facilities, the facilities are not easily accessible to rural and poor people as the services tend to be in higher facilities away from their place of residence. The out-of-pocket expenditure on public transportation to reach the facilities is an issue for these couples. Therefore, family planning programmes in UP need to continue with emphasis on improving availability, accessibility, utilization, quality of care, counselling, and better management of side effects of all modern methods, specially to meet the target by 2030 of “No One Left Behind”.