In India, five million unwanted births every year could be prevented if there was adequate access to good contraceptive health care. For years, the Indian government has wrestled with the issue, but anxiety over the 'population boom' recently resurfaced among policy makers, especially after recent projections estimated that India could overtake China as the most populated country in the world in about five years. For the first time in 33 years, Parliament witnessed a debate on family planning, with Members of Parliament wanting to know how the 'demographic disaster' was to be averted.
Family planning is clearly more than female sterilisation. It should be about society as a whole, and women's place in it.
But activists say linking family planning and high population growth rates is dangerous. According to Abhijit Das, Director, Centre for Social Health and Justice, "A certain section of people are obsessed with the fact that our population is soon going to exceed that of China. It will happen, not because Indians desire more children, but because India has a sizeable population of young people in the reproductive age group. So, even at low rate of reproduction, this large population of young couples will result in a high population growth rate. This is known as population momentum. Unfortunately, our policy makers don't appear to understand or recognise this fact."
And because the debate is still framed in alarmist terms like "population explosion" and "population control", Poonam Muttreja, Executive Director, Population Foundation of India, believes there is an urgent need to communicate better on the issue. She contends that ways must be found to ensure that the new initiatives of the government have a broader focus on reproductive and sexual health.
So, how can apprehensions that family planning will not lead to coercive initiatives - as it has in the past - be allayed? Although Union Health Minister, Ghulam Nabi Azad, has given a specific assurance that there will be no coercion in family planning initiatives, the fact that India has traditionally depended on female sterilisation as the key method for family planning has been a disturbing trend.
Statistics show that three-quarters of contraceptive users in India have undergone female sterilisation, which had risen from 27 per cent in 1992-93 to 37 per cent in 2005-06, according to National Family Health Survey (NFHS) data. In fact, more than half the women who get sterilised have had the operation before they reach 26 years of age.
Recent studies highlighting the consequences of early sterilisation show higher rates of health setbacks among sterilised women. A review of evidence coming out in the last 10 years indicates some distinct patterns. One, that the failure rates for all methods are highest among women who were young when they had their sterilisation, with the additional risk of ectopic pregnancies. Secondly, there is four times greater risk of a hysterectomy for women who undergo tubal ligation, compared to those women who have not undergone such a procedure. Lastly, there is higher risk of menstrual dysfunction and dysmenorrhoea in these women.
When the risks are many, why do women opt for a permanent method at a point when they are still in the prime of their reproductive lives? It's mostly because of a lack of choice in terms of other contraceptive methods available, compounded by a lack of information and access to government health centres.
According to the National Coalition on Population and Development, a group of activists and civil society organisations working on health across the country, the real problem is that the government has failed to provide choice in the family planning methods. They feel policy makers still seem intent on promoting "sterilisation", or permanent methods, while being totally unmindful of the needs of young couples who may want the option of delaying the first pregnancy and spacing out future births.
Spreading births is the ideal way to slow the momentum of population growth, in comparison to the permanent method where people tend to have children quickly before opting for it. So instead of being effective in reducing fertility, sterilisation actually adds to the momentum, feel experts. One reason for this is that Indian women who choose sterilisation have already had an average of four children.
There are other negative outcomes as well. Nobel laureate Amartya Sen had pointed out that rapid sterilisation leads to an adverse child sex ratio, with daughters being squeezed out in this rapid decline in fertility. Dr Gita Sen, eminent social scientist and a pioneer in the field of gender and development, adds that this was first experienced in China and now India is following suit. "We should not be following China's one child norm; reorientation should actually focus on reduction of population momentum and should shift away from targeting the six per cent wanted fertility. There are only a few things that can be done to achieve this, but they must be done. They are all related to spacing methods, delaying marriage, education of girls, and so on. Family planning efforts on these lines would contribute to meeting the 70 per cent unwanted fertility," Sen explains.
Dr Kiran Ambawani, Deputy Commissioner (Family Planning) of the Ministry of Health and Family Welfare claims that the government wants to encourage post-partum sterilisation. "This way the woman could have her sterilisation immediately after delivery and go home after 24 hours. Another recent initiative is the post-partum intrauterine contraceptive device (IUCD). This device is put immediately after delivery and is expected to stay for 10 years. Of course, it can be removed whenever the woman wishes," she says.
Women's agency is the best contraceptive, according to Jashodhara Dasgupta of Sahayog, a Lucknow-based non-governmental organisation working on women's right and health issues. Improved decision making on the part of women increases their access to appropriate delivery assistance and timely postnatal care. For example, 52 per cent of women who participate in most of the decisions have had a delivery assisted by health personnel and 37 per cent received postnatal care from health personnel within the first two days after delivery, compared with 46 per cent and 30 per cent, respectively, of women who do not participate in any of the decisions (NFHS-3).
The presence of self-help groups (SHGs) and other civil society organisations also help by generating awareness and helping to sensitise women to crucial issues. In addition, an increase in women's income can have a catalytic effect on the demand for family planning. As their income increases, women gain greater control over the use of income, have more voice in family decision making, and help them develop the confidence to participate more effectively in community matters.
An intervention by Ekjut, a NGO based in Chakradharpur, Jharkhand, has been able to empower women by using peer education. Instead of improving access to doctors or medicines, the programme uses local women in Jharkhand and Orissa to talk regularly to SHGs about maternal and newborn care. This approach has helped to bring down neonatal mortality in the participating villages by 45 per cent in two years. The success of the initiative, which was published in 'The Lancet', suggests that bringing women together for monthly chats on safe pregnancy practices and reproductive health may drastically cut neonatal mortality rates in rural communities.
As contraceptive use rises, maternal and infant deaths decline. In fact, some projections estimate that good contraceptive health coverage can peg down maternal deaths by as much as a quarter, besides bringing down child mortality levels. If children are born at least two years apart, three to five million child deaths would be avoided.
Family planning, then, is clearly more than female sterilisation. It should be about society as a whole, and women's place in it.
By arrangement with WFS
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