Political Leadership and Contraceptive Uptake: Evidence from India

In low- and middle-income countries (LMICs), where more than 80% of the global population resides, the public sector plays a vital role in providing access to essential healthcare products and services, including contraception. For example, in India and Nepal, nearly 70% of the population relies on government health facilities for contraceptive access, a figure that exceeds 90% in other LMICs such as Senegal and Rwanda (Bradley and Shiras 2022). By offering subsidized services that reach even the most remote and rural areas, the public sector aims to address the healthcare needs for all, with a particular focus on those at the so-called “base of the pyramid.” This demographic comprises nearly 3 billion people living on less than $2.50 per day, making it “the largest but most resource-poor economic group globally” (Jónasson et al. 2022, p. 4364). For example, approximately 85% of the poorest populations in India and Nepal access their contraception through public sector channels, with this number reaching almost 100% in countries like Rwanda and Senegal (Bradley and Shiras 2022). Governments, driven by their mandate to promote public health for all, thus serve as pivotal actors in ensuring contraceptive access.

Over the past decade, governments in LMICs have launched multiple initiatives to improve contraceptive uptake, spanning both demand-side (Anderson et al. 2018, Ashraf et al. 2014, 2017, Duflo et al. 2015) and supply-side initiatives (Karimi et al. 2024, 2025, De Vries et al. 2021). For instance, Ashraf et al. (2014) tested the effectiveness of providing women with the option to conceal contraceptive uptake from their partners. Women in the treatment group were offered free injectable contraception in the absence of their partners, while those in the control group received it during their partners’ presence. The study found that the opportunity to conceal led to a significant increase in the uptake of injectables and a reduction in births. Similarly, a 7-year randomized controlled trial conducted in collaboration with the Kenyan government by Duflo et al. (2015) examined the impact of an educational program that distributed information about condoms. While the program improved knowledge about condoms, it did not significantly affect reported use, HIV infections, or early pregnancies. More recently and on the supply-side, Karimi et al. (2024) evaluated a Senegalese government initiative aimed at reducing contraceptive stock-outs at point-of-care health facilities. Their findings showed that the intervention significantly increases contraceptive uptake among women by ensuring consistent product availability on the shelves.

Despite these efforts, contraceptive uptake remains low in many LMICs. For example, over 200 million women face an unmet need for contraceptives in LMICs (United Nations, 2019), contributing to unintended pregnancies and their adverse repercussions, such as psychological distress, unsafe abortions, and maternal deaths. Of note, nearly 95% of all maternal deaths occur in LMIC settings (WHO 2024), the majority of which are preventable through contraceptives. In this study, we investigate the impact of a previously underexplored factor in influencing contraceptive uptake at government health facilities: publicly elected leaders. Specifically, we investigate whether female leaders in LMICs impact contraception uptake differently than their male peers? If so, in what ways? Our inquiry into the impact of female leaders on contraceptive uptake is motivated by past research showing that female leaders tend to prioritize issues in ways that better reflect women’s needs and preferences (Bhalotra and Clots-Figueras 2014, Chattopadhyay and Duflo 2004).

A key identification challenge in investigating this question is that the sex (i.e., female vs. male) of an elected leader is likely to be confounded with unobserved variables such as voter preferences, making it endogenous. We overcome this empirical challenge by utilizing constituency-level information on close elections between women and men in India, which provides an ideal setting for several reasons: First, India is the “world’s largest and oldest democracy” (Bhalotra and Clots-Figueras 2014, p. 170), characterized by highly competitive multi-party elections monitored by an independent electoral commission. In addition, India’s federal structure devolves significant control over governance to the 28 states and 7 union territories, with population health falling under the jurisdiction of State Legislative Assemblies. This allows us to leverage close elections between females and males in State Legislative Assembly races to identify the relationship of interest. Second, as of 2019, the unmet need for contraception in India remains high at 27% implying that nearly one-third of women of reproductive age in India who want to avoid a pregnancy are not using a contraception method (approximately 50 million women in absolute numbers, see Guttmacher Institute 2020). Of note, 45% of the estimated 47 million annual pregnancies in India are unintended, with women experiencing an unmet need for contraception contributing to 90% of these unintended pregnancies. Lastly, despite being one of the first countries globally to launch a comprehensive family planning program in 1952, India recently overtook China as the world’s most populous country; hence, the focus on enhancing contraceptive uptake in India is both timely and relevant.

The empirical analysis utilizes data on the sex composition of state legislators and the uptake of six types of contraceptive methods across 692 districts in India over 10 years (2010-2019). The results provide no evidence of female legislators increasing the uptake of short-acting, reversible contraception methods (i.e., oral pills and condoms) or permanent contraception methods (i.e., female and male sterilizations). However, we do find that a higher proportion of female legislators increases the uptake of intra-uterine device (IUD), a long-acting, reversible contraception method offering the same level of pregnancy protection as permanent methods without requiring their surgical expertise. This suggests that female legislators promote the uptake of IUDs, a highly effective form of contraception method which provides women with the choice of future pregnancies.

Additional analysis uncovers a range of channels through which female legislators advance the reproductive health agenda in their districts. These channels include increased contraception counseling of clients by frontline health workers, an increase in the uptake of sterilizations in the post-partum period, and heightened engagement of female legislators in World Population Day events. Taken together, the key contribution of study lies in providing novel empirical evidence on the various ways female legislators in India promote reproductive health in their districts.