India accounts for nearly one-sixth of the world’s population while occupying less than 2% of the world’s land mass. Almost half of its population falls within the reproductive age group, making fertility regulation a critical public health priority (1). The country has a long history of family planning programmes, beginning in 1952 as the world’s first national programme for population control and maternal health. Over time, the programme evolved from a target-driven sterilisation approach to one centred on informed choice and reproductive rights (1). Despite this progress, unsafe abortion continues to contribute substantially to maternal morbidity and mortality worldwide, accounting for an estimated 13% of maternal deaths (2). In India, according to NFHS-5, the contraceptive prevalence rate in Assam is 52.4%, while the unmet need for contraception remains 12.2% (3). Maternal mortality ratios also remain high: nationally at 167 per 100,000 live births, and in Assam at 237 per 100,000 live births, according to the most recent Sample Registration System estimates (4). Contraception has the potential to avert nearly one in four maternal deaths by preventing unintended pregnancies and unsafe abortions (6). Yet despite the availability of effective methods, nonuse persists due to multiple barriers — ranging from myths about side effects and infertility to inadequate counselling and weak service delivery (5). Research among tribal women and other marginalised populations in India further highlights low fertility awareness and high unmet need, particularly in resource-limited settings (7,8).

Study design and setting This hospital-based, cross-sectional study was carried out in the Department of Obstetrics and Gynaecology at Assam Medical College and Hospital, Dibrugarh, a major tertiary-care centre in North-East India that serves both urban and rural populations. Study period and duration The research was conducted over one year, from July 2018 to June 2019. Participants Married women aged 18–45 years attending the outpatient department during the study period were included. Exclusion criteria were refusal to consent, severe illness, or psychiatric conditions. Sample Size and Sampling The sample size was calculated as 300, based on a 95% confidence interval, 15% relative precision, and reference to findings from Alakananda et al. A total of 300 women were selected through systematic random sampling from OPD registers. Data Collection Data were collected using a structured, pretested proforma through face-to-face interviews, supported by case record reviews. The proforma captured socio-demographic variables, fertility awareness, contraceptive knowledge, attitudes, and practices. Statistical Analysis Data were entered in Microsoft Excel and analysed using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used for baseline data. Associations between categorical variables were tested using Chi-square or Fisher’s exact test, and continuous variables with t-tests. Statistical significance was defined as p < 0.05.

Socio-demographic profile The study enrolled 300 women. Ages clustered at 25–29 years (41.7%), followed by 20–24 years (34.3%) (Table 1), consistent with a young, high-fertility cohort. Literacy skewed toward primary schooling (36.0%), while 27.0% reported no formal literacy. Occupation was predominantly homemaker (51.3%), followed by daily-wage work (45.7%). These distributions are visualised in Figure 1A–C (age, literacy, occupation). Table 1. Distribution of participants by age group (n=300) Age (years) n % 15–19 21 7.0 20–24 103 34.3 25–29 125 41.7 30–34 13 4.3 35–39 20 6.7 40–45 18 6.0 Table 2. Socioeconomic status (BG Prasad) Class n % II 39 13.0 III 97 32.3 IV 164 54.7 Reproductive History Nearly half had been married 1–6 years (47.7%), and 34.3% reported 7–12 years of marriage. Parity concentrated at one child (46.7%); 19.3% were nulliparous. Figure 2A–C visualises duration of marriage (A), parity (B), and abortions per woman (C). Regarding abortion history, 36.7% reported one abortion, 24.0% reported two, and ≥3 abortions were 6.7% (Table 3). Across 173 total abortion events, 68.8% were spontaneous and 31.2% induced (Table 4). Figure 2D presents the event-type distribution. Table 3. Number of abortions per participant (n=300) Abortions n % 0 98 32.7 1 110 36.7 2 72 24.0 3 19 6.3 ≥4 1 0.3 Table 4. Type of abortion events (N=173) Type n % Spontaneous 119 68.8 Induced 54 31.2 Fertility awareness, contraceptive use, and reasons for non-use Only 62 women (20.7%) correctly identified the fertile window; 49.3% responded incorrectly, and 30.0% did not know (Table 5). Among current users (n=120), the method mix was OCP 45.0%, tubectomy 24.2%, IUD 20.0%, condom 5.8%, injectable 2.5%, FAM 2.5% (Table 5a). Among non-users (n=180), leading reasons were desire for a child (32.2%), fear of side effects (23.3%), and husband’s opposition (15.5%) (Table 6). These domains are depicted together in Figure 3A–C. Table 5. Awareness of fertile period (n=300) Response n % Correct (mid-cycle) 62 20.7 Incorrect 148 49.3 Don’t know 90 30.0 Table 5a. Current contraceptive use (n=120 users) Method n % OCP 54 45.0 Tubectomy 29 24.2 IUD 24 20.0 Condom 7 5.8 FAM 3 2.5 Injectable 3 2.5 Table 6. Reasons for non-use (n=180) Reason n % Want a child 58 32.2 Fear of side effects 42 23.3 Husband’s opposition 28 15.5 Inconvenience 18 10.0 Lack of information 12 6.7 Lack of facilities 9 5.0 Other 13 7.3 Statistical associations Educational attainment and parity showed significant associations with contraceptive use (Chi-square, p < 0.05), whereas socioeconomic class did not. Women with higher literacy were more likely to recognise the fertile window and to report modern method use. (Associations as reported in the thesis results.)

Knowledge gaps in fertility awareness This hospital-based cohort revealed that only one in five women could correctly identify the fertile window. Comparable findings are reported in large-scale analyses of tribal and marginalised groups in India, where knowledge of the ovulatory cycle is consistently low (9). Regional studies likewise document poor awareness and misconceptions about fertility timing among reproductive-age women (10,11). Such gaps matter because an inaccurate understanding of the cycle undermines consistent method use and exposes couples to unintended pregnancies. Barriers to contraceptive use Among non-users, leading reasons for non-use were desire for more children, fear of side effects, and opposition from husbands. These findings mirror multi-state evidence showing that myths, male gatekeeping, and weak counselling remain major obstacles to uptake (12,13). Addressing these requires strengthening the quality of counselling, particularly clarifying side-effect profiles, return-to-fertility expectations, and involving male partners. Education and contraceptive use The significant association between higher literacy and contraceptive use in this study aligns with prior research demonstrating that education consistently improves uptake, although the strength of this relationship varies across Indian states (14,15). A national analysis also shows substantial heterogeneity in how education interacts with contraceptive use, underlining that literacy alone does not guarantee equitable access (16). Trends in unmet need and the Assam context At the national level, the unmet need for family planning has declined from approximately 21% in 1993 to around 9% in 2021 (16). Yet disparities persist across regions. NFHS-5 highlights that Assam continues to face challenges, with high unmet need and a skewed method mix compared to national averages (17). These contextual factors are consistent with the profile observed in the present study, where knowledge gaps and socio-cultural barriers coexisted with moderate levels of contraceptive uptake. Clinical and programmatic implications Nearly one-third of participants reported a history of abortion, with one-third of events being induced. Similar findings from multi-state facility-based studies in India show that provision of post-abortion contraception significantly improves subsequent uptake (18,19). Incorporating structured counselling and ensuring immediate availability of contraceptive methods after abortion could therefore help reduce repeat unintended pregnancies. Cultural anchors and service delivery in Assam Husbands and extended families exerted a strong influence on contraceptive decision-making in this study, echoing previous evidence from NFHS-5 state reports (17). Programmatic strategies in Assam should therefore prioritise couple-based interventions, myth-busting tools for common side effects, and supply-chain reliability. Strengthening cycle literacy within existing counselling frameworks could further enhance informed choice. Limitations This was a single-centre, hospital-based study, which limits generalisability to the wider population. OPD attendees may differ systematically from community women in terms of health-seeking behaviour. Reliance on self-reported contraceptive histories also raises the risk of recall and social desirability bias. Finally, the cross-sectional design precludes causal inference. These limitations, however, are typical of clinic-based research and should be interpreted alongside nationally representative data (14–17). Implications for future research Follow-up studies that track method continuation, satisfaction, and couple decision-making processes could provide richer insights. Incorporating standardised indicators consistent with NFHS definitions would also improve comparability and policy relevance.

This hospital-based study highlights persistent gaps in fertility awareness and contraceptive use among women in Assam. Only one in five respondents correctly identified the fertile window, while misconceptions, partner opposition, and fear of side effects limited uptake. Abortions were common, with nearly one-third being induced, underscoring the unmet need for reliable methods. Improving cycle literacy, integrating post-abortion contraception into routine care, and involving male partners are immediate priorities. Despite limitations of a single-centre, cross-sectional design, the findings align with national surveys and reinforce the need for targeted, couple-centred counselling and sustained supply of modern methods to reduce unmet need.

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