Decomposing spatial signatures of high-risk fertility behaviors in India

Maternal and child health vulnerability resulting from high-risk fertility behavior (HRFB) has been a significant concern in India and other developing countries. Although India has achieved below-replacement fertility, substantial district-level variation in fertility behavior persists. This study, therefore, seeks to examine the spatial heterogeneity of HRFB and identify the key factors driving these spatial disparities. The fifth round of India’s National Family Health Survey (NFHS) 2019-21, a cross-sectional survey data is used which comprises 1,268,079 birth records of women aged 15–49 years. Univariate LISA delineated hotspots, coldspots, and spatial outliers of HRFB, while the bivariate LISA identified spatial autocorrelation between child marriage and HRFB. Multivariable logistic regression model examined the predictors of HRFB. Fairlie decomposition model presented the factors responsible for spatial heterogeneity in HRFB. Almost one in three women experienced HRFB, with a significant geographical variation. The hotspots of HRFB were predominantly located in Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand. Women’s age, education, mass media exposure, and engagement in family planning programs were significantly associated with the spatial heterogeneity of HRFB in India. To address HRFB vulnerability in India, there is need to prioritize small-area and community-level approaches that consider spatial socio-economic, demographic, and fertility variations.