In 2016, India had the highest number of new TB cases (27.9 lakh), the highest number of infant and child deaths (about 9,00,000) and the largest number of malnourished children (about a third of the world total of 180 million).
The root cause of all is another figure — every year, 2.6 crore babies are added to India’s population figure of 121 crore, as per Census 2011, now estimated to be around 125 crore. Of the 640 districts in the country, in 146, the total fertility rate (TFR — the average number of children expected to be born to a woman in the reproductive age span of 15-49 years) is 3, against a national average of 2.2 as per the National Family Health Survey-4 (covering years 2015-16).
A recent report by the UN forecast that India’s population could surpass that of China by around 2024. And this is despite the fact that the country has one of the oldest family planning programmes in the world, dating back to 1951. For years the family welfare component of the Ministry of Health has been about birth control. An entire generation grew up with the “Hum do hamare do” tagline.
Countries battling similar economic, literacy and population numbers as India in the neighbourhood are more or less in the same bracket, with Pakistan’s TFR at 3.55, Bangladesh’s at 2.14 and Nepal’s at 2.17. Only Bhutan, as per the Bhutan Living Standards Survey Report 2017, has achieved a total fertility rate of 1.9 — which means it is on its way now to population reduction.
Over the years, family planning measures have moved from withdrawal (before ejaculation) to intra-uterine contraceptive devices (IUCDs). The 1990s saw the advent of the contraceptive pill. In 2000, in a bid to boost the anti-population drive, the government set up a 100-member National Population Commission with then Prime Minister Atal Bihari Vajpayee as its chairman.
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Last year, as part of its latest national family planning initiative, the government launched Mission Parivar Vikas. It marks the first attempt at the government level to deal with family planning as a social issue rather than just a health issue, to be dealt with at a health centre. The initiative incorporates a component called ‘Saas Bahu Sammelans’ aimed at improving communication between mothers-in-law and daughters-in-law.
But over the years, sterilisation has remained the mainstay of India’s family planning initiatives. Poonam Muttreja, Executive Director of the Population Foundation of India, says there are a number of factors for it. “Temporary methods always come with some side-effects. For example, both IUCDs and pills make periods irregular. Counselling services are poor and because of the ostracisation during periods, women do not like these. Also, societal norms do not put enough emphasis on women’s agency to make these choices viable. For 77 per cent women undergoing sterilisation, it is their first brush with birth control. The level of empowerment needed for temporary methods to be adopted is not there,” Muttreja says.
As per the NFHS-4 data, 53.5 per cent of couples use “modern” birth control measures in India. Women undergoing sterilisation make up 36 per cent of that number — despite this being by far the most complicated of all options. The least preferred is male sterilisation (0.3 per cent), that earned a bad name during the Emergency. However, while it is widely acknowledged by both the government and NGOs that forced sterilisation were carried out during the Emergency, there is no data on the uptake of vasectomies before it. So the perception is largely empirical rather than quantitative.
Among other modern methods used now, IUCDs are used by 1.5 per cent people, contraceptive pills by 4.1 per cent and condoms by 5.6 per cent. Even in “advanced” states such as Kerala, which is already on its way to population
reduction with a TFR of 1.6, the percentage of couples opting for male sterilisation is a dismal 0.1 per cent — the same as the most populated state of Uttar Pradesh.
Interestingly the low uptake of male sterilisation is a global phenomenon, though the disparity in India is particularly striking. A 2015 UN report said: “Male sterilisation accounted for 10 per cent or less of all sterilisation among couples in 29 countries. There are, however, several countries where the prevalence of vasectomy equalled or exceeded that of female sterilisation, ranging from 7 per cent male sterilisation prevalence in Ireland to 22 per cent in Canada.”
In the United States, the most common contraceptive is the pill, with 16 per cent of all users opting for it. In Canada the percentage of pill users is 20.7, in the United Kingdom it is 28 per cent, and in Australia, 28.8 per cent.
It was partly to exorcise the ghosts of the Emergency and partly to ensure safety of patients that in 2000 India discontinued the practice of setting family planning “targets”. In order to meet these targets, officials were known to organise sterilisation camps where hygiene was an issue. In 2014, 11 women died at one such camp in Chhattisgarh.
In 2017, India introduced one more measure in the family planning basket — injectable contraceptives called Antara for women.
A senior Health Ministry official says that to encourage men to share the burden of family planning, its recent set of advertisements feature Bhojpuri star Ravi Kishan talking about this. “The focus of the (family planning) programme is on mother and child health, on spacing methods that empower the woman to make a choice. That is why we have so many options — pills, injectable contraceptives, IUCDs. We have also told states that vasectomy facilities have to be available everywhere. However the myths about male sterilisation are so deep-rooted that all our efforts can’t change that,” said the official.
But the government holds that there is progress. At the time of NFHS-3, the country’s TFR stood at 2.7, which means there has been a steep fall to 2.2 in 10 years. A senior Health Ministry official adds that teenage marriage rates have declined from 47 to 27 per cent, and teenage fertility rate halved from 16 to under 8 per cent. As many as 1.35 crore of 2.6 crore babies born in 2016 had a birth interval of more than three years.
Currently, 14 crore couples are using modern methods of contraception. As a result of this, four crore unintended pregnancies, 80 lakh births, 13 lakh unsafe abortions and 21,600 maternal deaths would be averted in 2018.