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Not numbers but people: Turning family planning around in India

May 16, 2013

The reality is that even though India’s Total Fertility Rate (TFR) has declined to 2.5 and many states have achieved replacement level fertility, it has not meant a significant decline in maternal and infant mortality levels.

Delhi: Poonam of Nangal Salagri village in Una district of Himachal Pradesh was barely 18 when she got married. With no idea of how to prevent pregnancy, she gave birth to a baby daughter at 19. A second daughter followed soon. With two children and an entire household to look after by the time she turned 20, Poonam found herself struggling to fulfil her responsibilities.

When the local anganwadi ‘bahenji’ spoke to her about using contraception – condom or oral contraceptive pill (OCP) – to control her family size she mustered the courage to speak to her alcoholic husband about it. He paid no heed and thrashed her instead. Two traumatic miscarriages later, Poonam was once again pregnant and gave birth to her third daughter. Physically and emotionally exhausted, this 24-year-old is dreading the day she finds herself in the family way yet again. Poonam now gets OCPs from the anganwadi worker and takes them on the sly. If caught, she is sure to be beaten by her in-laws, who are desperate for a grandson.

Each state in India has its share of Poonams, who, in the absence of relevant knowledge and access to family planning services, have no control over their lives. In a bid to make a difference to women like her, the government has been working towards nationally repositioning family planning within the framework of maternal and child health and women’s rights, instead of seeing it as tool for population control.

It started with the National Population Policy (NPP) of 2000 – a document that moved the country away from a target oriented approach hinged on sterilisation to the affirmation of people’s voluntary and informed choices in reproductive health. In fact, a major objective enumerated in the NPP is the focus on delaying age at marriage to 18 years and addressing the vast unmet need for spacing and limiting births.

The reality is that even though India’s Total Fertility Rate (TFR) has declined to 2.5 and many states have achieved replacement level fertility, it has not meant a significant decline in maternal and infant mortality levels. Among the reasons for this is the large unmet need for family planning, which stands at an estimated 32 million.

One-in-six Indian women begin childbearing between 15 and 19 years. So preventing early marriage, then, constitutes the first step. But this, according to the Population Foundation of India (PFI)-initiated systematic review of effective interventions to reposition family planning implemented in various developing countries, is an especially challenging goal, owing to age-old community norms. Through systemic research of literature and intervention studies, this review has identified strategies that have been effective in delaying age at marriage and at first birth, increasing birth spacing and improving quality of family planning services.

According to Dr Shanta Sinha, Chairperson, National Commission for the Protection of Child Rights (NCPCR), “There can be no greater violation of a girl’s human rights than forcing her into a physical relation by way of marriage. A few years ago, the NCPCR did a survey to find out what happens to child brides one year after marriage. We collected stories of 70 youngsters in the 12-14 year age group in the Nalgonda district of Andhra Pradesh. The results were horrific. Some had gone into depression; many had come back to parental homes unable to cope.”

To delay marriage, while the PFI review recommends keeping girls in school, intensive community mobilisation and providing life skills education to young women and men, in Dr Sinha’s experience, too, “talking education with the family along with the possibility of a job is the most powerful weapon against early marriage”.

In a state like Bihar, Sanjay Kumar, Executive Director, State Health Society, feels this can be a credible solution. In Bihar, where the TFR is a high 3.7, 46 per cent of the girls get married at the age of 16 and 60 per cent of them are mothers before they reach 19. Says Kumar, “We want our girls to get married after 18 and to do that ensuring their schooling is important. As of now about half of the 8,000 panchayats in the state have a high school. We are advocating the opening of a high school in every panchayat. Moreover, the state government has been distributing cycles to girls in Class 9 and 10 so that they can travel independently to the nearest high school.”

In addition, government schemes aimed at improving the status of the girl child, such as Dhanalakshmi Scheme, Balika Samridhi Yojana or Laadli, have delaying age at marriage till 18 years as one of the conditions for cash transfer, though, as per the PFI review, whether these have been successful in delaying marriage has not been established.

Besides averting early marriages, engaging young couples on contraception use to delay the first pregnancy and ensure adequate birth spacing is another priority area. Anuradha Gupta, Mission Director, National Rural Health Mission (NRHM), puts it this way, “The only message we have given out these past two years is that family planning is all about families making their own choices. We do tell couples about the importance of having smaller families for the sake of their own health and better quality of life.”

When it comes to delaying first pregnancy, the PFI review flags three key strategies – facilitating interactions with key gatekeepers to build an enabling social environment, providing sexual and reproductive health education to couples, and increasing access to contraceptive and other reproductive health services.

Dr T.K. Sundari Ravindran of the Achutha Menon Centre for Health Science Studies stresses on the need to provide women with an enabling environment, “One-to-one community counselling for couples as well as other gatekeepers like mothers-in-law, local panchayat leaders and even religious leaders are known to remove barriers.”

Introducing young adults to the concepts of building a strong spousal bond and creating a financial base before they begin childbearing are programmes like PRACHAR in Bihar, Pragati in Uttar Pradesh and Khushali Project, run in a Delhi slum. Using multiple strategies, which include counselling through female “change agents” as well as targeted interface with young men, key messages related to delaying first pregnancy and promoting birth spacing are projected. And their numbers speak of their success. For instance, Pragati has registered significant increases in contraceptive use among postpartum women – from 17 to 27 per cent in Moradabad, 9 to 33.9 per cent in Lalitpur and 12 to 27 per cent in Ballia.

But it doesn’t end with motivating couples. This has to be followed up with providing quality service on the ground. Gupta admits this is one of the government’s “biggest challenges”. “If one really analyses the reasons behind the poor acceptance of a method like Intra Uterine Contraceptive Device (IUCD), two things come up – first, insufficient service delivery and second, poor follow up and weak counselling,” she observes. Two strategies, as per the PFI review, offer most promise in terms of their ability to improve contraceptive use as well client satisfaction with services – first, integration of family planning services with post abortion care and maternal health-delivery care, and second, motivating and training health workers like ASHAs to do counselling and deliver basic information and services.

“There are many far reaching transformational effects that family planning have on women’s lives,” emphasises Poonam Mutterja, Executive Director, PFI. Asha Chhabra, 33, of Naun village in Solan district of Himachal Pradesh, is a living testimony to such transformation. Remarks this mother-of-two, “On the doctor suggestion’s I opted for an IUD to space between my two children. It gave me time to regain my strength and also properly care for my daughter, 8, and son, 6. I am using the 5-year IUD now. I truly believe that proper family planning is the first step to ensuring the health and happiness of women.”

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