By the time she was 17 Meena had lost two children. One was a stillbirth, the other she miscarried.
Meena was 13 when she got married, a common practice in Marathwada, Maharashtra. Here nearly 60 per cent of girls get married before they are 18. Across India, 47.3 per cent of women between 20-24 years are married before 18.
Many of them come under pressure to give birth within a year of marriage. Those who want to delay having children don’t know how to as there is little awareness of, or access to, contraceptive methods.
At 21% India reports among the highest unmet needs for contraception in the world. Unmet need was also a key target under MDG 5 that the country has been unable to meet. This is despite the fact that India was the first country to have a government supported family planning programme. Countries like Bangladesh and Malawi have fared much better in comparison.
A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. The risk of maternal and neo-natal mortality is five times higher among girls who conceive before 20 They are more vulnerable to experiencing spontaneous abortions, infections and anemia.
Various studies show that the unmet need is highest among 15-19 year olds from less educated and poorer homes. Clearly there is a desperate need to provide information on, and access to, a variety of contraceptive methods.
However, for decades, the mainstay of India’s family planning programme has been female sterilization. UN data shows that over 37 per cent of women in India between 15 and 49 years use sterilization as a method of contraception, compared to 3.1% who use a pill and 5.2% who rely on condoms.
“Female sterilization is like a gunshot intervention”, says Dr Ashok Dyalchand, Director, Institute of Health Management, Pachod. “There is no follow up required. Contrast that to contraceptives where you have to ensure that they are available and monitor their use. It’s a month on month, year or year effort so both policymakers and providers have preferred to promote female sterilization, often coercively.”
Since fertility levels in women peak at 25 years, the focus should instead be on creating awareness and supplying contraceptives to delay the first conception. and for spacing.
“Girls are married at 15 and are get at 16”, says Dyalchand. “They don’t know whom to ask and what to choose because there is a total lack of communication. The government needs to focus on behaviour change communication and the easy, regular availability of contraceptives, which is currently lacking. We also need to understand unmet need from the couples’ perspective”.
An IHMP-led, community-based intervention for married adolescent girls across five districts of Marathwada between 2003-2009 saw a 300 per cent increase in the use of contraceptive methods.
Clearly there is a need felt for contraceptives. “A large proportion of very young woman have expressed the desire for it so we have to start defining unmet need from the clients’ perspective, not that of providers”, says Dyalchand
Another outstanding example is Prachar, Promoting Change in Reproductive Behavior of Adolescents, a Pathfinder International program implemented in Bihar.
Unmet need for contraception in Bihar is 31 per cent among women between 15 to 19 years and 33 per cent among those between 20 to 24 years.
“We realized that there was lack of awareness regarding contraceptive options among married adolescent girls and newly married couples”, says Mahesh Srinivas, Director of Programs, Pathfinder International. “And young married girls find it hard to communicate frankly with their husbands about such issues”.
To promote behaviour change, PRACHAR held events for newly wed couples where they would celebrate their marriage and emphasize the benefits of delaying having children. Along with the advice, oral contraceptive pills and condoms were provided as well.
Counselors also spoke to young married men and women individually in their homes, and workshops were held for unmarried adolescents.
“A big challenge was the availability of men”, says Srinivas. “These areas witness high migration so people would not be available for long periods. We also realized that there was a large unmet need among men. Many of them didn’t want their wives becoming pregnant soon after marriage or they wanted a gap between the births of their children. Men do want to get involved but don’t know how”.
Over it’s 12-year intervention, PRACHAR reached out to nearly 960 villages in Bihar. The program was successful in delaying the marriages of both girls and boys and led to an increase in contraceptive demand and use among married women under 25.
Although India’s total fertility rate is down to 2.5, and the country is approaching replacement-level fertility, this has not translated into saving maternal and infant lives. India accounts for 17 per cent of the world’s maternal deaths. Meeting the unmet need for contraception will help save many.
This article was published in the Indian Express