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

Family planning programmes aim to provide individuals with informed choices across a range of contraceptive methods. In India, the cafeteria approach was introduced to expand contraceptive options and help couples to choose methods according to their reproductive needs and preferences. However, continued dominance of a single method may indicate method skew. This study examines whether contraceptive method mix in India reflects the cafeteria approach by analysing patterns of method skew and socio-demographic inequality. The study uses data from five rounds of the National Family Health Survey (NFHS), conducted between 1992-93 and 2019-21. We examined trends in contraceptive prevalence and method composition among currently married women aged 15–49 years over time. Method skew is assessed using the percentage distribution of contraceptive methods, and the Index of Dissimilarity (ID) is used to evaluate changes in method composition. Multinomial logistic regression is conducted by using NFHS-5 data to identify socio-demographic determinants of contraceptive method choice. Overall contraceptive prevalence has increased from 40% in 1992-93 to 67% in 2019-21. Despite this increase, female sterilisation remains the most dominant method across all survey rounds. It accounts for more than half of the total basket of contraceptive choices out of total users (67.3% in NFHS-1 to 56.8% in NFHS-5), while male sterilisation declines sharply to below 1%. Reversible modern methods such as condoms and pills increase modestly, but remain considerably lower than permanent methods. The Index of Dissimilarity indicates limited diversification in method mix since 2005-06. Women from the richest wealth quintile (RRR = 1.75; CI: 1.58–1.93) and with higher education (RRR = 1.67; CI: 1.53–1.83) are more likely to use reversible modern methods compared to poorer women with no education. In contrast, rural women are less likely to use reversible methods than urban women (RRR = 0.82, CI: 0.77–0.87). The continued dominance of female sterilisation, despite historical policy support for a full range of contraceptive choices, indicates incomplete realisation of the cafeteria approach in India. The findings highlight continuing socio-economic and gender inequalities in contraceptive responsibility and suggest that the need to strengthen the availability of and access to reversible methods, improve provider counselling services, and promote equity in access is critical for advancing reproductive rights and autonomy.