Trends and patterns of inequality in modern contraceptive use in urban and rural India: are family planning programmes increasingly reaching the marginalized?

India has made good progress in the use of modern contraceptives in recent decades, however identifying women who are left behind is important to policy makers for further improving availability, accessibility, and coverage of family planning services to the marginalized population and hence achieving the international and national development agenda. Using five rounds of the National Family Health Survey data conducted between 1992-93 to 2019-21, this study examined the trends and patterns in inequality-by household wealth quintile and women's education-in modern contraceptive prevalence rates (mCPR) and demand for family planning satisfied with modern methods in urban and rural areas. The findings showed a secular trend of increasing rates in the use of modern contraceptives across socioeconomic sub-groups within urban (mCPR among the poorest quintile increased from 32% to 49%, and among the richest quintile from 51% to 60% in 1992-93 to 2019-21, respectively) and rural (mCPR among the poorest quintile increased from 27% to 49%, and among the richest quintile from 49% to 59% in 1992-93 to 2019-21, respectively) areas. Similarly, the inequality over time-measured by the concentration index-in mCPR has declined from 0.311 to 0.158 in urban areas and from 0.247 to 0.143 in rural areas between 1992-93 to 2019-21. Despite the overall decline in inequality, the pro-rich situation persists in contraceptive use in the country, and the extent of the inequality was high for modern reversible methods, both in urban and rural areas. Our findings underscore the increasing availability and accessibility of modern reversible methods, particularly among marginalized populations, along with improved information provided on the range of choices. This will help in achieving the global commitment of universal access to reproductive health, including family planning, and balance the method-mix in a country that is currently dominated by female sterilization.