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India’s high fertility: The myths and the reality

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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.


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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.

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Marvel or myth?

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While the southern States have all achieved admirably low fertility rates, there are problems that persist. Taking stock on the occasion of the World Population Day, observed on July 11…

 

July 11 was World Population Day when all defining speeches that originated from New Delhi’s Vigyan Bhavan uniformly chastised the laggard Hindi belt States, while admiring the achievements of the southern States. But, by constantly comparing t he Southern miracle with poorly performing States, crucial challenges which still persist in the South often get overlooked.

The old emphasis on measuring crude birth rates and death rates is passé. For the last couple of decades, demographers have been measuring fertility by the average number of children a woman produces in her lifetime. TFR (Total Fertility Rate) is now the standard benchmark to assess population change. The general feeling is that since the southern States achieved fertility goals set for the country some 10, even 20 years ago, they need only fortify and maintain those achievements. Moreover, lower fertility is widely seen as shorthand for the higher status of women in the South, and more broadly, for superior delivery of public health services. However, while saluting what they have accomplished, let us explore further the most recent National and District Family Health surveys.

Behind the statistics

NFHS-3 and DLHS-3 show that Andhra Pradesh reduced its fertility rate to 2.1 (average number of births per woman) in 2002. Not so long ago, the fertility was at the same level as Maharashtra, a progressive State that, nonetheless, will attain the goal set by the Population policy only this year (2009). So, in comparison, Andhra appears to be a huge success story. But this overlooks the fact that nearly 20 per cent of AP’s girls have started childbearing or are already pregnant by 18. And two thirds of these girls have less than five years of education. AP’s percentage of non-literate girls is two and a half times greater than Maharashtra. In comparison, Himachal Pradesh, which also realised the national TFR goal by 2002, successfully cut child marriages to less than 14 per cent compared to Andhra Pradesh’s prevailing 63 per cent. No wonder then that nearly three quarters of Himachal’s unmarried rural girls have 10-plus schooling. Andhra has a long way to go when judged by this all-important yardstick.

Karnataka presents an analogous picture. The number of early marriages increase exponentially when girls are between 16 and 18, resulting in a fivefold increase in fertility in just three years. An overwhelming majority of these teenage girls have less than five years of schooling or no schooling at all. Such uneducated hands that rock cradles have no chances of ruling the world. Added to that, Karnataka’s maternal mortality is higher than all the other southern States, a truthful mirror of a woman’s place in society and her access to social and economic opportunities.

Things are not all that rosy even in Tamil Nadu, forever cited as a shining example of the successful South. Although the State’s fertility indicators compare with those of Nordic countries like Denmark and Sweden, Tamil Nadu’s maternal mortality is, at the same time, six times higher than the developed world and triples that of Sri Lanka’s. Despite bringing fertility to an all-time low, Tamil Nadu also loses its lustre because 30 per cent of the under-five children in the State are stunted and malnourished. The State ranks below Kerala, Punjab, Jammu and Kashmir and Himachal Pradesh judged by the health of its progeny. Besides having a large percentage of both men and women suffering from severe anaemia, the State also has a poor record of iodine deficiency intake, something that causes miscarriages, retardation, and depleted energy levels in children. Another shocking revelation is that violence against women in Tamil Nadu is very high — comparable to Uttar Pradesh, a State notorious for its parochial attitudes to women.

Coming to Kerala, 20 years ago this exemplary State achieved the TFR set for the country by 2010 — virtually unattainable by the Hindi belt States even by 2030 in the case of ultra-prolific Bihar, Madhya Pradesh and Uttar Pradesh. But in Kerala too, when one looks at childbirths between the ages of 15 and 19, the gradient is very steep. Followed by a cycle of unspaced pregnancies, with heavy emphasis on female sterilization, Kerala’s maternal mortality is twice that of Sri Lanka’s, despite equal levels of education and far higher levels of economic advancement. For a country that is facing double-digit inflation and the aftermath of civil strife, Sri Lanka’s achievements in containing maternal mortality make Kerala’s achievements pale into insignificance.

Areas of concern

The southern States need to place a renewed emphasis on making people understand the need for postponing the age at first birth to ensure that the girl has basic schooling and health when she produces a child. The Union Health Minister wants to award girls who marry only after 25. The links between early marriages, onset of pregnancy and the birth of underweight children need to be viewed holistically. That around a quarter of the children less than five in all the southern States are underweight or malnourished, should have rung alarm bells by now.

Only if children’s health improves can they become a genuine asset for the State and the country. The Southern miracle, were it to be judged by more challenging benchmarks, far from being termed a marvel, may prove to be a myth.