The Autonomy–Coverage Disconnect: Reproductive Autonomy, Family Planning, and Structural Constraints in India (NFHS-5, 2019–21)

Background: Reproductive autonomy is a core component of sexual and reproductive health and rights, yet it is commonly inferred from service coverage indicators such as contraceptive use and institutional delivery. This practice risks conflating access to services with women’s capacity to make informed and voluntary reproductive decisions. Evidence from national surveys is therefore often interpreted in ways that may overstate improvements in reproductive autonomy. Methods: This study undertook a diagnostic reinterpretation of nationally aggregated data from the National Family Health Survey (NFHS-5, 2019–21) to examine women’s reproductive autonomy in India. Key indicators related to fertility, family planning, maternal healthcare utilisation, educational attainment, and marital timing were analysed descriptively. The analysis avoided causal inference and focused on assessing the relationship between reproductive health service coverage and structural conditions relevant to women’s reproductive decision-making. Results: The results showed extensive reproductive health service coverage at the national level, including near-replacement fertility, widespread contraceptive use, and high levels of institutional delivery. At the same time, the unmet need for family planning and early age at marriage remained evident. These patterns indicated the coexistence of high service utilisation with persistent structural constraints relevant to women’s reproductive autonomy. Conclusions: The findings highlight a persistent autonomy-coverage disconnect, wherein improvements in reproductive health coverage do not necessarily translate into gains in women’s reproductive autonomy. Interpreting coverage-based indicators as proxies for autonomy may therefore overstate progress toward rights realisation. Greater interpretive caution is required when using nationally aggregated reproductive health indicators, alongside complementary measures that better capture informed choice and reproductive agency.