Activists and experts from around the globe have gathered at Bali, Indonesia, for the 2016 International Conference on Family Planning. It’s an opportunity to take stock of goals that have been met with, and for countries to evaluate how to boost workforces and tweak their approaches toward achieving the new Sustainable Development Goals.
India has a lot to feel proud about. Phase 1 results from the National Family Health Survey-4 for 2015-16 that covered 13 States and two Union Territories show that total fertility rates or the average number of children per woman have dropped considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.
All the states in the first phase, barring Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade. All have rates below 51 deaths per 1,000 live births, although there is considerable variation among the states.
However, there is plenty to be done when it comes to how we approach family planning at the policy level. On this count, India lags behind countries like Sri Lanka and Bangladesh despite being the first country, globally, to have a government-backed family planning program.
India still reports the highest unmet need for contraception worldwide at 21%. In Bihar it is 31% among women between 15-19 years and 33% between 20-24 years. Maternal and neo-natal mortality is five times higher among girls who conceive before they hit the age of 20. They are also more likely to experience spontaneous abortions, infections and anemia.
This is largely because on the ground the emphasis on female sterilization remains high. According to UN data, in India, over 37% of women between 15-49 years use sterilization as a method of contraception. Only 3.1% use a pill and 5.2% rely on condoms.
“The rights perspective on family planning is missing at the policy level and it is high time that this changed”, says Dr Pranita Acharya, Gender, Poverty and HIV/AIDS specialist at the International Centre of Research on Women. “It is the right of couples to decide when and how many children to have. This is only briefly touched upon at the policy level and forgotten on the ground”.
Other contraceptive choices require counseling and careful monitoring – an investment that most states find burdensome. Sterilization, on the other hand, is a one-time, “gunshot” intervention. The result is that many women have been sterilized even before they need it.
Bridging the gap between the two genders in family planning matters is key believes Sushma Shende, Program Director, Maternal and Newborn Health, at SNEHA, a Mumbai-based non profit that works in urban slum communities.
“Considering the socio-economic set-up of the areas in which we work, it is difficult for women to take decisions with respect to FP”, says Shende. “Her husband and mother-in-law play an important role in decisions regarding child bearing and family planning. Moreover, the pressures of bearing and rearing the child is considered to be the responsibility of women so increased awareness amongst the men will make them more supportive and help address misconceptions or fear”.
There is also a near complete lack of awareness when it comes to contraceptive choices among married adolescent girls and newly married couples. Filling this gap is critical given that India accounts for 19% of maternal deaths, worldwide. Educating newly married couples about various contraceptive methods could help prevent many more such deaths.
Challenges top health ministry officials said they are addressing by offering a wider choice of contraceptives, improving service delivery and taking these services to the doorstep of those who need it. Speaking at the India Caucus held on the eve of the 2016 International Conference on Family Planning, C.K Mishra, Mission Director, National Rural Health Mission said that the goal ahead was “to ensure no woman should be left behind and no partner should be left behind”.
Admitting that the focus on female sterilisation was troubling, Mishra said there was now greater emphasis on expanding the basket of contraceptive choices to include injectables, Centchroman, a non-steroidal agent and POPs or progesterone only pills. Centchroman, marketed as Saheli, is a potent non-steroidal non-hormonal birth control method, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.
Attractive packaging for contraceptives, a sharper FP communication campaign and mobilising local health workers is also being looked at to add momentum to India’s family planning program.