Wednesday, 26 March 2014

India’s high fertility: The myths and the reality

This article by Shailaja Chandra attempts to uncover widespread assumptions about women’s fertility, contraception and the role that religion plays in birth control. The good news is that 44 per cent of the population living in 21 states and union territories of India has already achieved replacement levels of fertility. Kerala and Tamil Nadu achieved this more than a score of years ago. This post is part of the Wikiprogress series on measuring progress on gender equality.

Population stabilisation efforts in the rest of the country are of relatively recent origin but none-the-less commendable. The added good news is that the increase in contraceptive prevalence has been larger and faster among illiterate and uneducated women than those with schooling.

According to the International Institute of Population Sciences (EPW Arokiasamy 2009), more than two fifths of the reduction in Total Fertility Rate country-wide is attributable to illiterate women. The study calls it “remarkable demographic behaviour which has given significant direct health benefits to women and children — almost equal to what educational improvement has done for progress in human development.”

Now some disappointments: States which continue to lag behind are the same — Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand, Chattisgarh and Rajasthan — some 284 problem districts account for nearly half India’s population and 60 per cent of the yearly births countrywide.

Among 18 to 24-year-old couples the contraceptive prevalence rate is not even 19 per cent. In many districts it is as low as 10 per cent. According to NFHS -3 and the latest Annual Health Survey, in Bihar more than half the women in the child bearing group are not using any family planning method.

Ideally one should wait for the unravelling of the 2011 Census data and the results of NFHS- 4 to see the extent of improvement but both reports are expected only in a year or two.

Even so, lessons that existing reports provide will only get updated — certainly not set aside.

In India, female sterilisation continues to be the most dominant method of birth control even though women overwhelmingly favour non-invasive options. In the absence of tools that do not depend on partner-co-operation (condoms) or adherence to rigid regimens (pills), a poor woman confronts the prospect of an unwanted pregnancies every month, until somebody agrees to escort her for an operation. The policy question is whether by facilitating more acceptable birth control options one can accelerate fertility regulation and in the process improve health outcomes for women (and newborns).

That brings one to a widespread myth relating to the practice of contraception by religion. Professor P.M. Kulkarni at JNU who has researched differentials in population growth among Hindus and Muslims (using NFHS data) says that all religious communities have experienced substantial fertility decline and contraceptive practice has been well accepted by all. Within religious faiths, 85 per cent of Hindu women would like to limit the family to two children whereas in the case of Muslim women, the figure is 66 per cent.

Even so, fertility levels among the poor, be it Hindus or Muslims are not so widely different and have in fact narrowed considerably. he difference in births boils down to less than one child per woman. “This,” says Kulkarni “belies the general belief that Muslim women are barred from using contraceptives.” The belief that religion and religious fiats discourage contraception among Muslims is not borne out by statistics.

An even more significant aspect of his analysis of NFHS data shows that the unmet need for family planning is one and a half times more among Muslim women than Hindu women.

In terms of contraceptive use, Muslim women’s use of the pill is almost twice that of Hindu women and the use of IUD is also higher compared to Hindu women. Two things can be concluded:

First that among the rural poor, the difference in fertility between Hindus and Muslims is not as marked as is usually supposed.

Second: there is a perceptible difference in the preferred method of contraception: Muslim women seem to be more open to the use of it.

This leads one to ask what might be the trends in Muslim dominated countries like Bangladesh, Indonesia and Iran which have achieved high levels of contraceptive use.

According to the UN Economic & Social Affairs Population Division’s Contraceptive Use by Method (2012,) in Bangladesh the use of the pill is more than 25 per cent. Women also use IUDs and injectables in sizeable measure. In the case of Indonesia injectables are the preferred choice, followed by pill use. The use of condoms is comparatively small. Iranian women seem to rely hugely on the pill but they also use IUDs in high proportion.

To sum up, the focus of the reproductive health programme has appropriately been on the laggard districts -  mostly in the Hindi belt. But reduction in fertility has to be pursued by meeting the unmet demand for specific contraceptive choices and not by depending predominantly on sterilizing women. This requires three approaches: first by encouraging spacing among 18 to 24-year-olds; second improving access to contraceptive choices for women who are averse to sterilization. Finally what other countries have done to great advantage needs a re-look. In China, 40 per cent of the women rely on IUCDs. In India more and more women with children have begun opting for IUDs but access needs to increase manifold because the device gives a 3 to 10 year protection against pregnancy and can be reversed at will. Finally, latest research on the safety of injectables needs to be investigated afresh, looking at international best practices.

Instead of lamenting over irresponsible parenthood, the focus needs to target the unmet needs of specific population cohorts to empower women with what they need the most - liberty to decide when to have the next child or not to have one. Without being subjected to an operation.

Religion is not the issue --- women’s freedom to decide about pregnancy and childbirth is.
This blog originally appeared on Shailaja Chandra's blog, here

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