This dissertation analyzes social, cultural, and structural factors that lead to women’s fertility related decision-making processes, and outcomes, in the Indian context. Although there is a rich literature on fertility in India, my work is the first to use nationally representative panel data from the India Human Development Survey (IHDS) 2005, and 2012, to study the impact of past intentions and actions on subsequent outcomes, and on how intendedness of a birth can affect maternal healthcare utilization.

First, I examine the differences between factors that impact regional differences in fertility preferences, and on the ability to crystallize these preferences. Results show that while a substantial portion of regional differentials in fertility preferences are

explained by socio-economic traits of individuals and their households, a much smaller proportion of differentials in unintended births across regions is explained by these factors. This suggests that unobserved factors, potentially those associated with regional health systems, have a far greater role in explaining underlying differences in unintended births than in explaining fertility preferences.

Second, I evaluate why women who want to limit childbearing in 2005, do not use any contraception (and thus have, an unmet need for contraception); and how this unmet need of contraception translates into subsequent unintended births. Results show that women belonging to poorest households, and residing in neighborhoods with less access to the maternal and child healthcare system, are more likely to have an unmet need for contraception; and women who have an unmet need for contraception in 2005, are more than twice as likely as those without an unmet need to have an unintended birth between 2005 and 2012.

Finally, I examine the consequences of having an unwanted birth on maternal healthcare utilization. Results show that women who have unwanted births are less likely to obtain adequate antenatal, and postnatal care to help support their own health and their babies’ health. Results from this study also highlight inequalities in access to maternal healthcare services, based on socio-economic status, caste group, religious group, and area of residence.

Overall, the dissertation helps obtain a better understanding of unwanted fertility, contraception use, and sexual and reproductive health disparities in the Indian context.