Success, and the accolades that come with it, can hide many problems. Something similar may be happening in the space of population planning and management. In demographics, the target variable to control high population growth is the Total Fertility Rate, or TFR, which is the number of children every couple of child-bearing age will have, who can survive and go on to reach child-bearing age. The ideal (statistical) number is 2.1, which means every couple will have two children, eventually replacing themselves in terms of numbers in the population. This is also called replacement level fertility.
The most popular method of contraception is the largely irreversible way of family planning involving surgery
By 2016, almost half of all Indian districts had attained below-replacement fertility, and 15% had a TFR of above 3.0. Thus began a family planning programme called ‘Mission Parivar Vikas’ (MPV), aimed at reducing TFR in areas where it was high. This programme has been largely successful. Three of the seven “high-focus” States have been able to reduce their TFR to about 2.0, which is lower than the target of 2.1 set for the year 2025 by MPV. The three States are Madhya Pradesh, Rajasthan and Assam. They are among seven States that have 146 districts which were originally identified as “high fertility” areas. Two others, Chhattisgarh (TFR 2.2 in 2020) and Jharkhand (2.26 in year 2022) are getting close while Uttar Pradesh and Bihar will take more time to reach the target of 2.1 set by MPV which is now in its seventh year.
Usually, TFR goes down naturally with development as child survival rates increase, aspirations grow and communities fare better in general health, well being and their economic condition
While the plan to focus efforts in certain districts is yielding results when you look at the numbers, there are hidden problems that these numbers do not or cannot reveal. For instance, the most popular method of contraception is the largely irreversible way of family planning involving surgery. This is good from the point of view of outcomes but not always good from the point of view of the women. There are a number of examples of endless grief caused by tubectomy. Take the case of Kali from Dungarpur district in Rajasthan. She opted for tubectomy after three sons, but lost two of them a few years ago and can’t have the operation reversed.
Population is less a case of numbers but more a case of development
Despite this almost insurmountable problem, the popularity of the permanent method is similar to the national preference, where 36.3% (NFHS-5 findings in 2019-20) of currently married women took the option, making it the most popular choice. Across States with MPV districts, many more women opted for the permanent method. But because the MPV runs essentially in districts with a higher level of backwardness, signaling weaker communications and poorer delivery of healthcare, the negative side of female sterilisation is more pronounced here. This points to the problems when targets are reached but the attendant development that must come with it is not close. Usually, TFR goes down naturally with development as child survival rates increase, aspirations grow and communities fare better in general health, well being and their economic condition. That is why population is less a case of numbers but more a case of development. We can target numbers, but without the accompanying development, the change is not sustainable. Something like this may be happening in the MPV districts. This is a problem beneath the success that we must face now.
Not having timely access to healthcare often leads to the death of the child. There have been cases where women who opted for the permanent method after two or three children find themselves suddenly with fewer children, or without a son, after mishaps in the family
A permanent method like female sterilisation is usually adopted when the couple have had the number of children they wanted and opt to have no more. But even today in rural India, the death of children and young adults is not unusual, particularly in tribal communities where many unexpected incidents happen, including snake bites and panther bites, falls from a tree, drowning in the village pond, and many caused by preventable or treatable diseases. Not having timely access to healthcare often leads to the death of the child. There have been cases where women who opted for the permanent method after two or three children find themselves suddenly with fewer children, or without a son, after mishaps in the family. In such cases, reversal of surgery is very difficult, if not impossible, and the trauma of the family is endless.
These are the unfortunate consequences of the growing acceptance of female sterilisation in rural India, made worse in the MPV districts They also highlight the uniquely Indian problems of irreversible methods of contraception, given the poor health infrastructure that leads to preventable complications and even deaths during the surgery and a bigger trauma if the woman survives surgery, then goes on to lose her children and can’t have any more.
Rural families are also noting the small family size and lifestyle in cities and are ready to adopt it for themselves as well
A total of 358 deaths in the years 2014-2017 were reported after sterilisation, the minister of State for Health & Family Welfare Ms. Anupriya Patel told the Lok Sabha in March 2018. The minister told the Lok Sabha that “prescribed norms have been laid down in the Standards & Quality Assurance in Sterilization Services, 2014, published by the Government of India and made available to all States and service providers in order to ensure quality standards in service provision while performing sterilization procedures.”
In terms of numbers alone, female sterilisation in rural areas (as a percentage of currently married women) grew from 32.2% to 44.5% in Rajasthan 22.6% to 35.3% in Bihar, 39.8% to 47.6% in Chhattisgarh, 19.8% to 37.4% in Jharkhand, and 46.9% to 55.7% in Madhya Pradesh in the period from NFHS-3 to NFHS-5
Three recent developments have possibly contributed to the steady increase in sterilisation numbers. There are ASHAs (Accredited Social Health Activists) in every village. This has given a human face to the system, built credibility and trust, and has taken system-driven persuasion to the last household in the village. Second, the arrival of smartphones, has upped connectivity and aspirations. DJs at rural marriages, birthday celebrations, the changing attire of rural girls, are cases in point.
A common fear that exists with Copper-T is that “it will move up in the abdomen”. Overcoming this will require listening and acknowledging their fears, and helping them understand why these may be unfounded
Rural families are also noting the small family size and lifestyle in cities and are ready to adopt it for themselves as well. The third factor is male migration from rural areas to cities for work: in southern Rajasthan itself, some 70% of the households see at least one male member migrating to cities in Gujarat or Maharashtra, for their livelihood. In the absence of the husband, it becomes doubly difficult for the women to bring up children.
Senior obstetricians recommend that operations should be the last option as opening the body has its risks, so other safer methods should be used. Complications and fatalities from female sterilisation are not uncommon but appear not to impact the number of women opting for this method (or lured into the method with appropriate incentives). Yet, we cannot run away from the problem: The entire burden of population control in India has been borne, by women. And this is especially the case with sterilisations. This has remained true over ten years, from the last NHFS in 2005-2006, all the way to the survey by the government for 2015-2016.
Saying ‘no’ to tubectomy is much more possible today with emergence of several choices for women that work almost like a permanent method: intrauterine contraceptive devices (IUCD) such as Copper-T or other hormonal devices, which are effective for long durations. Using these once or twice may be sufficient to prevent a pregnancy for the entire reproductive cycle of the woman, thus also acting as a permanent method.
The onus on our healthcare systems
Where PHCs are not regularly open, doctors and nurses not fully present, and people have little trust in the public health systems, tubectomy is a sure-fire way to ensure birth control. The alternative will require training of doctors and nurses, making these methods available, and strengthening communication to dispel fears and myths associated with the different methods. As an example, a common fear that exists with Copper-T is that “it will move up in the abdomen”.
Overcoming this will require listening and acknowledging their fears, and helping them understand why these may be unfounded. It will also require the primary healthcare facilities to be open 24X7 and the healthcare workers to be present, to be able to manage any side effects of the other methods such as bleeding and abdominal pain.
The renewed emphasis on primary healthcare, emergence of the Health and Wellness Centres, growing numbers of doctors and skilled staff across the PHCs and sub-centres, are welcome steps that can make this paradigm shift possible.
(Sanjana Mohan is a doctor and co-founder of Basic Healthcare Services, a Rajasthan-based non-profit that runs primary healthcare centres. Lekha Rattanani is the Managing Editor of The Billion Press))