When coverage is not autonomy: Reproductive health indicators, inequality, and governance in India's national family health survey (NFHS-5).

Abstract

Reproductive health monitoring systems typically measure progress through service-coverage indicators, such as contraceptive prevalence and institutional delivery rates. This article argues that treating high coverage as evidence of women's autonomous reproductive choice creates interpretive risks for rights-based accountability, a problem we term metric conflation. Using published tables from India's National Family Health Survey (NFHS-5, 2019-21), we show how national averages obscure structural inequalities across wealth groups. Despite high institutional delivery (90.4%) and modern contraceptive use (56.4%), unmet need remains 9.4% nationally, and 23.3% of women aged 20-24 were married before age 18. The poorest quintile faces higher unmet need (11.4% vs. 8.6%) and far lower secondary education attainment (37.9% vs. 88.7%) than the wealthiest quintile, structural differentials obscured by aggregate reporting. Female sterilisation accounts for 67.2% of modern method use, raising governance-relevant questions about choice that coverage metrics cannot detect. State-level contrasts (Kerala, Bihar and Uttar Pradesh, selected as high-performing, low-performing, and large-population benchmarks, respectively) further illustrate subnational heterogeneity. We propose a minimal reform package: strengthened use of existing wealth-quintile disaggregation, interpretive guidance for SDG dashboards, and piloting of autonomy-sensitive companion indicators to strengthen equity and accountability in reproductive health monitoring.