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.
India’s population growth rate has been declining over the years but the overall population will continue to grow as more than half the people are in the reproductive age group and more will join this group each year
IND1A S 2001 census puts the country’s population at over I billion, In the next twenty years India will be the most populous nation in the world overtaking even China. The population of India’s a states is comparable to large countries.
India has grappled with the issue of population stabilisation* for over 60 years. Although stabilisation was projected to take place by 2045, the performance of several states indicates that this will shoot past this forecast with serious implications for sustainable development. On the positive side India has the benefit of a young population and it can expect high levels of productivity and lower levels of dependency. even as the developed world is confronted by the prospect of aging and low fertility. While India’s youth could be a huge asset it could also be a dangerous liability, because unless the population is healthy it will pull hack development.
In the next 16 years, the bulk of the population growth will take place in Uttar Pradesh, Utrarakhand. Bihar. Jharkhand, Madhya Pradesh, Chhattisgarh and Rajasthan-accounting for more than 50% of the growth. In contrast the Southern states will add only 13% to the total population growth.
Fertility Pattern among Different States -The Challenge Ahead:
The Total Fertility Rate (TFR) signifies the average number of children a woman will produce in her childbearing years. Alok Ranjan Chaurasia and S. Gulati in “India the State of Population 2007” have divided the country into three groups.
1. In the first group there are the Hindi belt States and some north-eastern states like Manipur and Meghalaya. Together they will account for more than half the population growth in the country by 2026. In these States. lowering fertility will be very difficult as the majority of couples use no contraception.
2. In the second group, stand States like Maharastra, West Bengal, Gujarat, Haryana and Orissa, which have achieve the two child goal.
3. The third group of States comprises Andhra Pradesh, Goa, Hirnachal Pradesh, Karnataka, Kerala. Punjab and Tarmil Nadu. These States will account for hardly 15 per cent of the population growth by 2026 and have already achieved replacement levels of fertility with two children per woman.
Enforcement of the legal age of marriage — The Challenge ahead:
Marriage take place very early particularly in rural India. Later marriages will do more to stabilise India’s population momentum than any other measure. In rural areas 60 to 70% of the women are married by 18 particularly in states like Bihar, Jharkhand. Rajasthan. Uttar Pradesh and Madhya Pradesh. The percentages are as low as 20% among rural girls of Kerala and Himachal Pradesh where girls continue to study and get married at a later age. This shows that over time, change is possible but the challenge lies in focusing on the age of marriage which has a direct relationship with the mother’s and child’s health.
Very early child bearing and an absence of spacing increase risks to mother and child. Teenage pregnancies are the cause of a high number of maternal deaths. Repeated pregnancies increase the risk of death and disability to both mother and child.
Apart from the Hindi belt states., Andhra Pradesh and West Bengal also stand out as examples of states where the marriages before the legal age are unusually high. The Jansankhya Sthirata Kosh, (JSK) also called the National Population Stabilisation Fund has started implementing a strategy in districts where the prevaicnce of the practice of early marriages is exceptionally high by giving awards and financial rewards for girls to marry after 19, where the first birth this when the girl’s 21 years old and the second after she is 24 years old. These are all responsible parenting practices. Role models from the community have been showcased at public functions emphasizing why it is necessary for the girl to be in good health at the time of pregnancy and childbirth.
To give a positive example, Himachal Pradesh placed strong emphasis on the enforcement of the legal age of marriage and simultaneously encouraged girls to stay in school. It has the lowcst percentage of boys and girls married before the legal age. School retention is also far higher than the rest of the country with (be exception of Kerala. That is the model that would work in the northern states but ii requires a new focus which is completely absent at present.
Legal and Social aspect: The only way that this can he enforced is by making the registration of marriages compulsory and at that time documentary proof of to be shown about the age of the girl and boy.
The Supreme Court order: On 25th October 2007 the Apex Court directed that all marriages should be registered. It was reiterated by the Supreme Court that marriage should be compulsorily registered ‘sin respect of persons who are citizens of India even if they belong to various religions.’
The Rajya Sabha Committee on Petitions recently in its Hundred and Thirty-Fifth Report 2009 on Introduction of Sex Education in Schools included the following recommendation:
“Students should be made aware qf the marriageable age which is 21 years in the case of boys and 18 in the case of girls…. . Students should also be made aware that child marriage is illegal and is injurious i’o the health of the girl child”
Three factors impact upon population growth and are intrinsically linked, The first is maternal mortality which refers to a woman’s death linked to pregnancy having a direct impact upon population stabilisation because that determines how far a newborn child will receive care during infancy. If mothers die, children are bound to be neglected. Therefore institutional deliveries are being given a lot of emphasis. The good news is that there has been a huge response to the Governments Janani Suraksha Yojana (JSY) and the number of women who have availed of hospital delivery facilities has increased from 29 lakhs to 73 lakhs during 2007-08. Unless maternal mortality reduces it would be difficult to ensure child survival. This leads to a vicious cycle of having several children to compensate for the ones that die.
Maternal Mortality (MMR) – The Challenges Ahead: Within the country there are huge disparities in maternal mortality. The latest figures show a huge improvement over the past. All- India MMR having fallen from 301 in 200 l-0.3 to 254 in 2004-05.
Although the southern states of Tamil Nadu and Kerala have fared comparatively well, still, their maternal mortality levels are far higher than those of neighboring Sri Lanka and China.
The positive development is that hospital deliveries have increased by more than 40% in the Hindi belt states which are now poised to register lower MMR. That in turn wifl impact very positively on population siabilisation as both mother and children will receive institutional care, also essential to deal with obstetric complications.
Infant Mortality – The Challenges Ahead:
High Infant Mortality Rate (JMR) is the second significant factor that impacts on population stabilization, as parents continue to have several children because they know that some will die. Infant deaths refer to children who die before reaching their first birthday. Among infant deaths, IMR is higher in rural areas and excessively so when the mother’s age is less than 20. If the birth interval is less than two years the IMR escalates hugely. The challenge lies in reducing infant mortality and for that two critical factors are the mother’s indifferent health and lack of spacing between children.
The third aspect is improving access to contraceptive products and services. More than half India’s population is in the reproductive age group and only half are using contraceptives. In this we are far behind neighbouring countries like Indonesia. Sri Lanka and Thailand. Sterilisation is the most common method of limiting families but nearly 96% of all sterilisations were until recently carried out only on women with hardly 1% on men.
In the last two years numerous steps have been taken to offer a range of contraceptives and to upgrade the skills of the medical and paramedical workers responsible for providing family planning services. Fixed day services are being widely publicised and there is a revival of interest in male sterilisation. Compensation money for undergoing sterilisation operations has also been increased and private providers have been encouraged to join in family planning activities with a tee for procedures carried out.
As a result of these initiatives, vasectomies (male sterilization) have registered a huge increase which had been declining up to 2007. The increase was 84% increase last year and this year it has crossed 24% increase in the first six months of the year.
Overall the total sterilization figures (male and female) have gone up significantly. In the entire 1-Hindi belt States except Madhya Pradesh and Chhattisgarh the performance has increased appreciably over the last three years. This is a reversal of past trends and the emphasis on family planning given by these states is a very positive sign.
India’s population growth rate has been declining over the years but the overall population will continue to grow as more than half the people are in the reproductive age group and more will join this group each year. With only half of them using contraceptives, it may take several decades more to achieve the goal of achieving planned families which is a necessary requirement for sustainability.
India’s maternal and infant mortality levels are very high and repeated childbirths are seen as an insurance against multiple infant and child deaths. Vast numbers of people cannot avail of services even when they are available, due to problems of knowledge and access.
The progress in the last two years has been remarkable, which gives the hope that the importance of population stabilization has been recognized by people themselves. This has now to be sustained and accelerated particularly in the Hindi belt states where fertility Levels are very high. Many of the factors that impact upon population momentum are cultural in nature. Attitudes to early marriages, expectations about early childbearing, and disregard for the need for spacing between children need to be altered. Low female literacy impacts adversely on safe motherhood and the maternal care that their children receive. Additionally a strong son preference leads to negative feelings towards girls and results in pre-natal sex determination and elimination of the female foetus.
All these issues require that civil society fully understands the importance of driving change. Within civil society, political representatives, the media and religious leaders can play the most influential role.
If Iran has been able to bring down its fertility rate from 5.6 births per woman in 1985 to 2 by 2000, India can definitely do the same, if not better. What is needed is political will, apart from better planning and coordination
In January this year, an All Party Parliamentary Group of the UK’s House of Commons published a report on Population, Development and Reproductive Health. The forecast: The Millennium Development Goals espoused by 189 Govern-ments in the year 2000 are practically unachievable, given the current levels of population growth.
The report assumes significance because the evidence of all population stalwarts the world over was recorded before releasing the findings. “Population issues have lost priority,” says the report and “funding has stagnated or decreased at a time when unmet need for family planning information and services is increasing.” Women in developing countries are dying for lack of access to family planning services and having to confront unwanted pregnancies and forced abortions even when options are available.
Ironically, if there is any concern about population it is related only to the extremely low fertility of European countries and Japan. The End of World Population Growth in the 21st Century, a book, which is considered a must for policy-makers, simply overlooked that in the country like India, 17 million more births than deaths take place every year. Western thinking about global warming has overtaken even the Indian psyche, despite the fact that India emits less than half the carbon dioxide of Brazil, only a third of China and a not even a fifth of the European Union, leave aside the United States.
The fact that population pressure is eating into agricultural land, forest, water, and biodiversity is never even mentioned. In countless meetings about ecology, climate change, deforestation, urban migration, demographers are notably absent or unheard.
It was in the late 1980s that the subject of population growth began to be swept away from policy agenda. The 1994 Cairo Conference on Population and Development successfully muffled it behind the nebulous nomenclature of reproductive and child health (RCH). Any mention of numbers and sankhya still draws the wrath of activists, who in their zeal to end coercion and sub-standard family planning services have unwittingly helped to overturn the family planning programme.
India’s discreditable memories of 8.3 million sterilisations, performed in a single year 1976-77 – four times higher as compared to the year before – have sealed the lips of politicians of all hues forever and drawn stony silence from the media.
The RCH alternative has not provided the synergy that was expected observes a paper by Srinivasan et al (IIPS Mumbai). They found no co-relation between per-capita expenditure incurred on RCH and the level or pace of change of indicators. The National Commission on Population charts display decline in sterilisations and IUD insertions – attributable largely to the low performance of Bihar, Rajasthan, Assam and Uttar Pradesh. The IIPS study ends on the unhappy note, “The RCH umbrella seems to be leaking.”
Against this backdrop the story of Iran bears telling. There the equivalent of the Planning Commission painted such a grim picture of the country’s economy and how the nation’s resources simply could not support the services stipulated under its Constitution, that all Government departments were directed to review the population growth rate impact.
The Iranian media disseminated how the country’s population growth was too high and if left unchecked, would have serious negative impact on the national economy and the welfare of the people. Iran’s Health Ministry and its Judicial Council then declared that there is no Islamic barrier to family planning.
Families were encouraged to delay the first pregnancy, and space out subsequent births, to discourage women to become pregnant younger than 18 and older than 35; to limit family size to three children (not even two). Resources were poured into family planning services and to help couples prevent unplanned pregnancies.
The village health workers (two instead of our one ASHA) put up charts of the age and sex profile of each village at a central place, which were updated each month. The data showed the number of children who had been born since the beginning of the year, the number of children vaccinated, the number who died and the cause of death. The data also showed the number of married women, their age and the contraceptive method used.
Contraceptive pills became the most popular method. Population education remains an integral part of the curriculum at all educational levels; university students must take two credit courses on population and family planning. Couples planning marriage have to participate in a family planning class before receiving a marriage license and these pre-nuptial classes are mandatory for both the bride and groom-(to-be). Women’s average age of marriage had crossed 22 years by 1996.
The result of all this has been astounding. From a total fertility rate of 5.6 births per woman in 1985, Iran brought total fertility down to 2.0 by 2000. Infant Mortality, Maternal Mortality, Under 5 Mortality, have all reduced; literacy has gone up, and now more women than men have entered Universities.
What we need is less looking the other way; less emotional outbursts in donor-driven seminars and much more by way of sustained family planning services. And an effective leadership in the northern States which are disproportionately delaying India’s population stabilisation.