Government family planning programme
India has more women who rely on sterilisation to prevent pregnancy than any other country. On this episode of We The People, we ask: why should the burden of family planning fall on women alone and whether the policy of providing financial incentives for sterilisation needs to be scrapped.
Guests: Shailaja Chandra (Former ED, Population Fund) ; Dr. Sambit Patra (BJP), Shobha Ojha (president, All India Women Congress), Sujatha Rao (Former Secretary, Health), Dr. S.K. Sikdar, (Deputy Commissioner, Family Planning) , Poonam Muttreja (Executive Director Population Foundation of India) and Anchor: Barkha Dutt, Executive Editor.
I come in at 6.21 minutes, 9.31.08 minutes, 16.45 minutes, 26.30 minutes, 37.16 minutes, 42.32 minutes and 45.51 minutes.
This article attempts to uncover widespread assumptions about women’s fertility, contraception and the role that religion plays in birth control. The good news is that 44 per cent of the population living in 21 states and UTs has already achieved replacement levels of fertility. Kerala and Tamil Nadu achieved this more than a score of years ago.
Population stabilisation efforts in the rest of the country are of relatively recent origin but none-the-less commendable. The added good news is that the increase in contraceptive prevalence has been larger and faster among illiterate and uneducated women than those with schooling.
According to the International Institute of Population Sciences (EPW Arokiasamy 2009), more than two fifths of the reduction in Total Fertility Rate country-wide is attributable to illiterate women. The study calls it “remarkable demographic behaviour which has given significant direct health benefits to women and children — almost equal to what educational improvement has done for progress in human development.”
Now some disappointments: States which continue to lag behind are the same — Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand, Chattisgarh and Rajasthan — some 284 problem districts account for nearly half India’s population and 60 per cent of the yearly births countrywide.
Among 18 to 24-year-old couples the contraceptive prevalence rate is not even 19 per cent. In many districts it is as low as 10 per cent. According to NFHS -3 and the latest Annual Health Survey, in Bihar more than half the women in the child bearing group are not using any family planning method.
Ideally one should wait for the unravelling of the 2011 Census data and the results of NFHS- 4 to see the extent of improvement but both reports are expected only in a year or two.
Even so, lessons that existing reports provide will only get updated — certainly not set aside.
In India, female sterilization continues to be the most dominant method of birth control even though women overwhelmingly favour non-invasive options. In the absence of tools that do not depend on partner-co-operation (condoms) or adherence to rigid regimens (pills), a poor woman confronts the prospect of an unwanted pregnancies every month, until somebody agrees to escort her for an operation. The policy question is whether by facilitating more acceptable birth control options one can accelerate fertility regulation and in the process improve health outcomes for women (and newborns).
That brings one to a widespread myth relating to the practice of contraception by religion. Professor P.M. Kulkarni at JNU who has researched differentials in population growth among Hindus and Muslims (using NFHS data) says that all religious communities have experienced substantial fertility decline and contraceptive practice has been well accepted by all. Within religious faiths, 85 per cent of Hindu women would like to limit the family to two children whereas in the case of Muslim women, the figure is 66 per cent.
Even so, fertility levels among the poor, be it Hindus or Muslims are not so widely different and have in fact narrowed considerably.
The difference in births boils down to less than one child per woman.
“This,” says Kulkarni “belies the general belief that Muslim women are barred from using contraceptives.”
The belief that religion and religious fiats discourage contraception among Muslims is not borne out by statistics.
An even more significant aspect of his analysis of NFHS data shows that the unmet need for family planning is one and a half times more among Muslim women than Hindu women.
In terms of contraceptive use, Muslim women’s use of the pill is almost twice that of Hindu women and the use of IUD is also higher compared to Hindu women. Two things can be concluded: First that among the rural poor, the difference in fertility between Hindus and Muslims is not as marked as is usually supposed.
Second: there is a perceptible difference in the preferred method of contraception: Muslim women seem to be more open to the use of it.
This leads one to ask what might be the trends in Muslim dominated countries like Bangladesh, Indonesia and Iran which have achieved high levels of contraceptive use.
According to the UN Economic & Social Affairs Population Division’s Contraceptive Use by Method (2012,) in Bangladesh the use of the pill is more than 25 per cent. Women also use IUDs and injectables in sizeable measure. In the case of Indonesia injectables are the preferred choice, followed by pill use. The use of condoms is comparatively small. Iranian women seem to rely hugely on the pill but they also use IUDs in high proportion.
To sum up, the focus of the reproductive health programme has appropriately been on the laggard districts — mostly in the Hindi belt. But reduction in fertility has to be pursued by meeting the unmet demand for specific contraceptive choices and not by depending predominantly on sterilizing women. This requires three approaches: first by encouraging spacing among 18 to 24-year-olds; second improving access to contraceptive choices for women who are averse to sterilization. Finally what other countries have done to great advantage needs a re-look. In China, 40 per cent of the women rely on IUCDs. In India more and more women with children have begun opting for IUDs but access needs to increase manifold because the device gives a 3 to 10 year protection against pregnancy and can be reversed at will. Finally, latest research on the safety of injectables needs to be investigated afresh, looking at international best practices.
Instead of lamenting over irresponsible parenthood, the focus needs to target the unmet needs of specific population cohorts to empower women with what they need the most — liberty to decide when to have the next child or not to have one. Without being subjected to an operation.
Religion is not the issue-women’s freedom to decide about pregnancy and childbirth is.
How fair is it that men are never targeted to accept blame for the unwanted pregnancies that occur year after year? Must women continue to suffer for policy failure?
Last month I was in Ghadchiroli district. It ranks last among Maharashtra’s 35 districts on a combination of social indices. Synonymous with remoteness, surrounded by forests and inhabited by tribal people, a health worker was to show me how neonatal care had improved survival rates of infants. I asked her how many people used contraceptives. She told me straightaway, no one did. Women went in for tubal ligation as soon as they had two children.
Visits to see newborn babies ensued. Entering a shack, I noticed an infant clinging onto his grandfather. Inside the house an emaciated woman, removed a dirty cloth from a tiny mound on the floor to reveal a shrivelled neonate underneath. As soon as she lifted the cloth, swarms of flies settled on the baby’s face. She had delivered the second baby within a year of the first. She herself was no more than 18 and a bag of bones, her eyes devoid of emotion, and her lips a straight line.
Ghadchiroli is ranked at the 345th position out of the 593 districts surveyed by the International Institute of Population Studies (IIPS). Not bad compared with hundreds of lower ranking districts in the country. At least they had access to sterilisation services.
The percentage of women having three or more children is a direct measure of fertility. The larger that percentage, the weaker the impact of the family planning programme. As can be expected, the worst hundred districts in the country according to the IIPS study done belong to Bihar, Jharkhand, Madhya Pradesh, Rajasthan, Uttar Pradesh and some North-Eastern States where between 50 per cent and 60 per cent of women beget three, four and even more children.
India was the first country to launch a Government family planning programme in 1952. Due to mismanagement, forced sterilisations and chasing fictitious targets, the programme received an unsavoury reputation it just cannot discard although decades have gone by.
Post-1994, Cairo and ICPD, Governments the world over supported by international organisations and NGOs ushered in a new reproductive child health approach. Today, people who talk of population control and explosion are considered barbaric. In the name of giving “reproductive choices” to women and offering “a cafeteria approach”, the old targets, incentives and disincentives have been struck off the strategy list. Rightly so, if one goes back to the horrors of family planning excesses, but wrongly so if there is no cafeteria, no coffee (read condoms), IUDs or oral pills to make that choice.
The emergency contraception pill, the most needed of all, is unheard of in most of the country. The social marketing approach can deliver up to a point – no more.
So steeped is our present culture in the soft new approach that we refuse to face the fact that of the 26 million babies born each year, some 40 per cent are underweight, underdeveloped, often stunted and incapable of later imbibing even elementary education, leave alone become productive citizens. Infant and under five mortality continues to be extremely high, mainly because family planning is denied the thrust it badly needs.
While tender talk about quality issues and women’s rights is well intentioned, how can we enable severely anaemic women not to have to produce unwanted babies and face repeated pregnancies? How can one prevent men from forcing pregnancies? How can one stop adding generations of unhealthy children if there is no insistence on increasing the age of marriage, spacing and male sterilisation?
How fair is it that 98 per cent of all sterilisations performed in the country are on women? How fair is it that men are never targeted to accept blame for the unwanted pregnancies that occur year after year?
The unmet need for contraception continues to be displayed in colourful computer generated bar charts at all population conferences. But who is going to fill that unmet need and how? To provide access to contraceptives more than a modicum of sustained service delivery is essential. A large percentage of villages, particularly in the northern States, are more than 10 km away from a primary health centre (even if such outfits are functional). How do women living there protect themselves from unwanted pregnancies?
Some right thinking industries and tea estates have tried to help and ended up complaining how their efforts to sensitise men to stop child marriages, early marriages, several marriages and multiple partners and to explain how all such behaviour is self-damaging, falls on “deaf ears”. Government schemes, letters, meetings, monitoring supplies and disposal will continue, as it must. But at the end of the day if women are still forced to bear children they do not want, at the cost of their own physical health, what could be a greater denial of a human right?
It is time that spacing and male sterilisation were resolutely brought back on the front line. Lest the next generations require more hospitals than schools to attend to the abysmal levels of anaemia among women, and the resultant wasting and stunting of children, accompanied by high levels of under-five mortality. This beckons a deliberate restoration of family planning services to prevent unwanted pregnancies.
(These are the author’s personal views)