Empowering Women With Choices In Family Planning

From April this year, injectable contraceptives will be available in district hospitals across India.

At the recently held International Conference on Family Planning in Bali, top health ministry officials from India said that they were determined to meet their stated target of providing 48 million women with access to contraceptives by the year 2020.

In 2012, at the London Summit on Family Planning, India had pledged to commit almost $2 billion dollars until 2020. As a result, today more women and girls have access to family planning. In 2013 alone, three million additional women and girls in India were equipped with the tools and the information needed to choose a modern contraception method.

To fulfil this goal of 48 million, the government will increase the basket of contraceptive choices offered to women, and promote spacing between births. Apart from injectables, this will include Centchroman, a non-steroidal agent, and POPs or progesterone only pills.

Centchroman, marketed as Saheli, 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.

“We are determined that no woman should be left behind and no partner be left behind,” said C.K Mishra, Mission Director, National Health Mission.

Phase 1 results from the fourth National Family Health Survey or NFHS-4 for 2015-16 that covered 13 States and two Union Territories are quite promising with total fertility rates or the average number of children per woman dropping considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.

All states in this phase, except Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade.

However, what remains problematic is the female sterilisation rate, which at 34% is very high. Health officials hope to bring down the numbers by offering more contraceptive choices and improving service delivery.

“All along there has been greater emphasis on terminal methods of family planning and we have not given spacing the attention needed,” said Mishra. “The goal ahead is to focus on adequate spacing”.

Also of concern is the total unmet need for contraception in India, which at 21.3% is the highest in the world. Bringing down the unmet need was a key Millennium Development Goals target that India was unable to meet.

A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. India accounts for 19% of the world’s maternal deaths and meeting the need for contraception is critical to saving lives.

“Today more girls and women have access to contraception but we are still 10 million behind in terms of what the figure should be,” said Chris Elias, president of the Global Development Program, Bill & Melinda Gates Foundation, while speaking to a group of journalists on the sidelines of ICFP 2016.

Last November, the Gates Foundation had announced that it would invest an additional US$120 million in FP programs over the next three years to meet the Family Planning 2020 goal of giving 120 million additional women and girls’ access to contraceptives.

“If there is spacing, half of the lives lost would be saved. Women should be able to decide when they should have babies,” believes Elias.

Health ministry officials in India seem to be moving forward in the right direction. However, there is quite some distance to travel before the revised plans are implemented, cautions Poonam Muttreja, Executive Director, Population Foundation of India.

“Apart from issues like inadequate budget allocation, the bigger challenge India faces is wide disparities and inequities in women’s access to healthcare and family planning. Access to health services still depends upon where one lives, how educated one is, and economic and social status”, says Muttreja.

Clearly, the approach will have to go beyond simply making these choices available at various health centres. “It is not just about making the full range of methods available,” says Elias. “Women have to be empowered to make those choices”.

This was published in ndtv.com

The women who refuse to do India’s dirtiest job

Every morning I would take a broom and tin plate to the homes of the upper caste thakurs to pick up their faeces. I would collect the waste in a cane basket and later throw it in a dumping ground outside the village.”

As you watch a confident Ranikumari Khokar educate a group of boys and girls on how to file a police case, it is hard to imagine that this 21-year-old spent most of her adolescence working as a scavenger.

Today she is a “barefoot lawyer”, an initiative started by Jan Sahas, an NGO that has been campaigning against the practice of manual scavenging for 12 years. Since the launch of the programme in 2014, 800 girls and young women have been trained in the states of Madhya Pradesh and Rajasthan.

A caste-based role, manual scavenging condemns mostly women to clean excreta from dry latrines with their hands and carry it on their heads to dumps. Men from the community clean open gutters and sewerage lines, often with no protective gear.

Derogatorily called bhangis, which means “broken identity,” most of the scavengers are dalits, ranked lowest in the caste system and expected to carry out tasks regarded as beneath the dignity of those higher up in the hierarchy.

“We were looked down upon by the villagers,” recalls Ranikumari. “They would never walk with us. At the village well, we were made to wait at a distance until everyone else had filled up.”

Even worse was the discrimination in school. “The teachers would call us bhangans [children ofbhangis] and expect us to clean the toilets and the classrooms. We sat apart from everyone else and were never given a chance to participate in school functions,” adds Ranikumari.

Caste-based discrimination or untouchability was banned in India in 1955 and down the decades several policy measures have been announced to end the inhumane custom of manual scavenging. Article 17 of the country’s constitution clearly abolishes the practice, while the 1993 Dry Toilets Prohibition Act forbids the employment of manual scavengers.

But none of these policies have been effective because manual scavenging was categorised as a health and sanitation issue, a responsibility implemented by state governments. Many states like Delhi and Rajasthan did not even bring the policy into force, and those states that did showed little will to enforce it on the ground. People remained unaware they had the right to refuse this role. The few who dared to came under intense social pressure, and received no support from local government officials. They risked violence and eviction.

The International Dalit Solidarity Network, which works towards ending caste-based discrimination, estimates that there are about 1.3 million manual scavengers in India, most of them women. These women are victims twice over: looked down upon by the upper castes and discriminated against within their homes.

“People from my village would walk far away from us as if we gave out a smell they could not bear,” says Mayu, a resident of Sava village, Rajasthan. “We were made to draw water from a well in which dead animals and birds were found and if anyone gave us any food, it would be thrown in our direction. Even my husband would tell me to bathe many times because I was cleaning other peoples’ shit although he had no problem eating the rotis I brought home.”

It was these attitudes that Jan Sahas had to battle when it started its campaign in 2003.

“They were socialised to believe that they have to be low caste,” says Aashif Shaikh, the founder of Jan Sahas. “They would tell us ‘this work has been given to us by god and we are at an advantage as we get food’. The reality was that they were being treated worse than animals.” Because they were rarely paid in cash, they were dependent on the upper castes for the basics – food, clothing and shelter.

Jan Sahas started working in two villages in Rajasthan. It would take nearly two years before they were able to convince the community to put down their brooms. The gamechangers were the children, especially girls.

“The girls were determined to end the practice,” says Shaikh. “They were deeply unhappy about the discrimination they faced in schools so we would make them speak at our meetings.”

But there was fierce resistance from the upper castes; some Dalit homes were even burned down. The local police refused to act and it was only after district level officials intervened that action was taken.

Since 2003, Jan Sahas claims to have liberated more than 21,000 women in Madhya Pradesh, Bihar and Rajasthan. These women have become ambassadors for the movement and it was their countrywide agitation in 2013 that led to the Indian parliament enacting a new, stronger law against manual scavenging.

Those who employ manual scavengers face a one-year prison term and a fine of 50,000 rupees (over £500). For repeated violations, the prison term is two years and a fine of 100,000 rupees (£1,000).

Stronger penalties apart, the Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013 makes it mandatory to rehabilitate rescued manual scavengers. They now get 40,000 rupees (over £400) as compensation from the government and get trained for alternative employment.

Many women now work in government-funded construction projects and small factories. Others have enrolled in community initiatives started by NGOs that offer training in skills like tailoring and embroidery.

Changing minds, however, remains a challenge as caste-based discrimination is still deeply entrenched in Indian society.

“You can change your religion in India but you cannot change your caste,” says Shaikh. “You hear of people converting to another religion but their caste remains the same, and this is true for even Muslims and Sikhs although neither religion has the caste system. Even politics runs on the basis of caste.”

The way forward, activists believe, is to educate the younger generation, who are open to change. The barefoot lawyers initiative, which trains men and women from all communities, is a step in that direction.

“I go to different villages and educate the youth about laws relating to caste discrimination, sexual assault and rape,” says Ranikumari. “I even speak to school authorities if I hear complaints of discrimination. As a child I could not speak up for myself but now I have a voice.”

This article was published in The Guardian