For a chaotic country full of argumentative Indians many of whom are poor and uneducated, India’s continuous economic growth (not prosperity) remains a surprise. But something else is even more striking. The country has the world’s largest youngest population: 27 million babies are added each year. With such youth to bank on, India’s productivity seems to possess the best ingredients for success for decades to come.
But all great stories have another side that also must be told. Most births in India take place in some of the country’s poorest states where high fertility, low age of marriage, and a disproportionately large number of mother’s and children’s deaths present an ever-distressing picture. A group of five states have had the dubious distinction of accounting for around 45% of the country’s population, suffering and stymied from poor investments in health and education. No wonder these states were officially referred to as the BIMARU states, an acronym for their names of Bihar, Madhya Pradesh, Rajasthan, Odisha and Uttar Pradesh, which denotes much more since the word bimaru in Hindi means sickly.
For decades, these states have defied conventional experience about the process of development and held back the achievements of the rest of the country. The differences are stark: some other states in India reached replacement level of fertility as early as 1989 and 1992. Bihar, Madhya Pradesh, Rajasthan, Odisha and Uttar Pradesh, however, may need another five years to get there. The infant and maternal mortality in the progressive states is lower by half, and in some cases even 70% less, than in these laggard states.
Some 15 years ago, the Indian government decided to pay focused attention to these states, particularly in the highly neglected area of reproductive health. Around the same time, the five states were reorganised and became eight in number with the hope that being smaller would help them respond better to the process of development. They were rechristened the Empowered Action Group (EAG), and the pejorative title BIMARU was wiped out of the official vocabulary. In 2005, the National Rural Health Mission, India’s largest-ever health programme, started pumping resources into these “high-focus states.” Strategies included revamping rural health infrastructure, promoting health centre-based deliveries, facilitating access to emergency obstetric care, and assigning a trained health activist to make family-level contact, undertake pregnancy tracking and provide access to contraceptives.
Many hoped that with such a high dose of attention, the EAG would eventually catch up. Most, however, did not share this optimism, and not without reason. Even today, strong patriarchal attitudes continue to discriminate against women. Girls are denied access to schooling once they reach puberty. They are married off well before the legal age of 18 and subjected to a host of discriminatory barriers. The political leadership in most of these states has seldom accorded high priority to health or education; many have invested in perpetrating caste-based divisions in society. This backdrop naturally fails to inspire change.
Yet the good news is that by focusing attention on these laggard states and monitoring health indicators annually, a decline in fertility has begun and it is faster than anywhere else in the country. The increase in institutional deliveries has been impressive, and family health surveys and other research show that an increase in the age of marriage and greater use of contraception have contributed to lowering fertility. After decades of stagnation, the population growth rate in these states has registered a significant fall for the first time, dropping from 25% to 20.9%. From the point of view of women, the opportunity to have hospital-based deliveries stands out, complemented by such popular incentives as transportation to a health facility, compensation for leaving home, supplementary nutrition and contraception advice.
While these are positive trends, the push has to continue. These states will contribute 50% of India’s population within the next five years, equalling if not exceeding the combined population of the rest of India. The prospect of half of India holding back the other half is a dismal one. Only if the special efforts mounted receive commensurate political support that simultaneously encourage girls’ education and skill learning, later marriages and spacing between children will the laggard 50% eventually catch up. Happily, the process has begun.
India has been a member of the OECD Development Centre since 2001.
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.
The unmet demand for contraception is the highest in Uttar Pradesh, Bihar and Jharkhand. Together with Madhya Pradesh, these States produce the maximum underweight, stunted and wasted children born to under-aged mothers
Were it not for the Hindi-belt States, India might well have been another country. Girl’s married before the legal age, high fecundity of adolescents, recurring childbirths and absence of birth spacing make tedious reading. But when the findings of the National Health Survey-3 are read alongside the Ministry of Human Resource and Development and National Population Commission data, a few surprises and some shocks emerge.
First, Orissa has crawled out of the BIMARU (now EAG) stranglehold. It has among the lowest annual growth rates (2001-2010) projected for the country — just a shade higher than Kerala and Tamil Nadu. As far as the age of marriage and adolescent fertility are concerned, Orissa is lower than Gujarat and Haryana. Female drop-out rates from classes’ I-X are better than the All-India average and far better than neighbours Assam and West Bengal. High infant mortality, however, pulls back other achievements.
Let’s move over to Himachal Pradesh. The female dropout rate from class I-X stands only slightly above Kerala. HP also has the lowest percentage of women married before 18 — far ahead of Kerala, Tamil Nadu or any other State. As a natural outcome the percentage of women that started childbearing before 19 was just 3 per cent compared with 27 per cent in Jharkhand and 25 per cent in Bihar and West Bengal. No wonder that the fertility rate of Himachal Pradesh is equal to that of Kerala. This also blasts the belief that only the Southern States have the commitment to propel population stabilisation.
Another shock is how poorly West Bengal performs when it comes to the age at which girls start childbearing. The State is at the level of Bihar on this index with 62 per cent of girls married before 18, belying lofty claims that women’s welfare has pervaded the proletariat. In terms of educational attainment, the class I-X female dropout rates are worse than even Madhya Pradesh.
When it comes to the use of contraceptives, Andhra Pradesh, Himachal Pradesh and Punjab come out the best. Predictably the unmet demand for contraception is the highest in Uttar Pradesh, Bihar and Jharkhand, with the gaps in contraceptive cover resulting in high fertility and appalling levels of maternal, infant and child mortality. Together with Madhya Pradesh these States also produce the maximum underweight, stunted and wasted children in India.
Ultimately, faster development cannot take place unless fertility rates come down much sooner. Much as education, electrification, safe drinking water and toilets are necessary, absence of these can hardly be an alibi for denying reproductive rights, now. Pushing up the age of marriage as exemplified by Himachal Pradesh is a single achievable goal which can make the biggest difference. If we could simply ensure that girls do not get married before the legal age of marriage, up to 3.4 million births each year could be averted. That is 12 per cent of the total annual births in the country. Is it too much to ask Governments to ensure that marriages are stopped before the legal age? The road to population stabilisation need not be preceded by citing the education first approach all the time. Important as education is, Himachal Pradesh and Orissa have shown that other things too can make a difference to fertility and population growth.
The new Prohibition of Child Marriage Act 2006 was notified on 10th January 2007. With its enactment, the Child Marriage Restraint Act 1929 was repealed. Legally and administratively no law exists today to restrain or stop child marriages in States that have failed to notify the rules that accompany the Act. In effect no cognisance can be taken of those who marry off their daughters before 18.
According to information available with the Ministry of Women and Child Development, only Rajasthan, Karnataka, Kerala and Manipur have enacted the rules which are necessary for enforcing the Act. This despite a lapse of nearly 20 months and repeated exhortations to speed up the process. Chief Ministers need to be confronted with their perfunctory attitude to an all important subject which directly affects the health and well-being of mothers and children.
Laws apart, when did the Chief Ministers of Uttar Pradesh, Rajasthan, Madhya Pradesh, Bihar, Jharkhand, Chattisgargh, and West Bengal last review early marriages or order an audit into high levels of maternal mortality? What directions did they give? With what result?
None that is apparent from any published work.
Laws alone will not change the face of India. But in the absence of law and with more than 65 per cent of the girls in several States being married before 18 it is shocking that Chief Ministers can ignore what is happening.
A year ago on the World Population Day, 500 adolescents were brought to Delhi to be sensitised about population issues. It was a sad commentary on the prevailing situation when they stepped on the stage to castigate their Chief Ministers for incentivising more and more deliveries by offering saris and other goodies to reward every birth. If only Chief Ministers cared to listen to what the youth of this country seeks, election manifestos may start caring about fulfilling population goals and reproductive rights.
Another Inter-national Women’s Day has come and gone. Celebrities and celebrations once again cemented women’s solidarity. Twenty years ago, such a phenomenon was unthinkable. Ten years ago, it was a Page-3 fling-time for elite women. But things are fast changing, at least in the metros. Recently, when a woman Secretary to the Government of India quipped as she replaced her Minister who was held up, “Once again the woman stands in place of the man”, the audience burst into appreciative laughter and after a momentary pause, applause. The jibe had gone home, although the audience was mostly male.
Around the same time, a presentation on the status of maternal and infant mortality in the country was heard in pin-drop silence. Ten years ago, those present would have said: “That is Health Ministry’s problem.” Five years ago, it would have evoked the mantra – first provide literacy and education to women. This time there was universal recognition that something drastic was needed to be done.
The waning sex ratio, the huge percentage of early marriages in nearly half the districts, anaemic teenagers mechanically forced to produce babies, the growing spectre of underweight children evoked disquiet. Instinctively, people rallied around and promised to involve their organisations and associations in bringing these issues to the forefront. Uneasiness was beginning to show, at least in public.
But what would generate a change that penetrates into homes and bedrooms? While men may not proactively promote sex determination tests, they do remain passive partners and acquiesce silently to female relative’s wishes and wants. They happily embrace early marriages for their daughters on the plea that they have to “fulfil a responsibility” – quite forgetting that higher education, the acquisition of greater skills and competencies, necessarily requires pushing up the age of marriage.
How many men would abandon the prospect of marrying a daughter to the proverbial “bada sona munda”, if she insists on pursuing a career instead? How many in-laws would actively encourage sons to delay the birth of the first child, instead of raring to announce a pregnancy to busy-body relatives?
Fourth of April is celebrated in the US as “take our daughters and sons to work”. It was created by a foundation for women to provide an educational experience for America’s children. I witnessed this phenomenon at work in an office in Washington some years ago.
Recognising that adults continually face challenge of balancing work, family, social and personal responsibilities, including late sitting, making time to pick up a child, providing care for a sick parent and taking decisions that are difficult to explain, the “take our daughters and sons to work” day encourages children to think about these questions. The programme is designed to expose children to what adults do during the working day, to show them the value of education, hard work and the occasional price one has to pay for others.
Of course, America is the land of celebrations and gimmicks, ensnaring the gullible consumer to spend slavishly on cards, gifts and SMS messaging – all part of a multi-million dollar business. But the point about drawing attention to a situation is well taken. The younger generations do need to know the pressures and deadlines at work, the environment that surrounds their parent in office, and more importantly, why work has to take precedence at times.
Taking a positive cue from that idea, if today’s adolescents could watch professional women at work, scientists, doctors, lawyers, sportswomen, TV anchors, it would sensitise them as nothing else can. When they grew up (which will happen very soon,) they will shun sex determination and understand the value of careers for their sisters, daughters, daughters-in-law and daughters-to-be.
A cacophony of voices will no doubt chastise me for thinking only of urban elite and health hounds and activists would decry such simplistic ideas. That is precisely why I write this article. Because sometimes even lip service can make the point.
Even if a few schools, teachers and parents were to make a beginning, providing children the opportunity to watch parents at work, even the values of a good citizen might yet get imbibed, creating just the impact we seek. No father would treat his job with disrespect in the presence of children. If he shows off how important the task before him is, perforce his sense of pride would percolate into the psyche of young onlookers. A man’s self-esteem at work be he a bus driver or a CEO, would make children understand the importance of every kind of work, while imparting dignity to those who perform thousands of dead-end jobs that are none-the-less critical for our lives.
Abhorrence for nepotism and bribery could all be woven into the theme of “take your daughters and sons to work”. We can yet change mindsets if we focus on important principles seen through the eyes of children. Who knows it might still restore the sense of self worth we all seek – an infinitely superior strategy to holding out threats of hanging minions, while the master continues to make hay.