De-stigmatizing family planning, improving access to contraceptives to tackle India’s silent crisis of unwanted pregnancy: Andrea Wojnar of UNFPA

Between 2015 and 2019, the world reported approximately 121 million unintended pregnancies each year, which accounted for 48% of all pregnancies. More than one in seven unintended pregnancies have occurred in India. This is a serious health hazard since 61% of unwanted pregnancies – more than three out of five – worldwide end in induced abortions. An estimated 45% of all abortions remain unsafe, leaving approximately 7 million women hospitalized worldwide each year. The estimated cost of the treatment alone is $553 million per year.

These are some of the findings of the State of World Population Report 2022, published by the United Nations Population Fund (UNFPA), the UN’s sexual and reproductive health agency. Published annually, the 2022 report focused on the crisis of unwanted pregnancies. In an exclusive interview, Andrea Wojnar, UNFPA’s Resident Representative in India, tells Associate Editor Kaushik Deka what the report says about maternal health in India and what the country can do to avert this unwarranted crisis.

Q State of the World Population Report 2022 says that pregnancy should be an aspiration and not a fatality. How can India achieve this?

Meeting the unmet need for family planning is crucial to achieving this. The Total Fertility Rate (TFR) in India has fallen to 2.0, the replacement level of fertility. This means that one mother is replaced by approximately one daughter, a demographic milestone and a notable achievement for the country’s family planning program.

However, about 10% of married women are unable to practice family planning due to factors such as stigma, lack of correct knowledge, inaccessibility of contraceptives, inability to negotiate their use, and fear of side effects.

Some of the actions that can be taken are:

Increased focus on high priority states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand and Assam), which have high TFR, and therefore higher unmet need for family planning.

Intensify efforts to increase the use of reversible contraceptive methods.

Empower and equip young people with age-appropriate family planning information.

Respond to the high unmet need for contraception in the post-pregnancy period (after childbirth or abortion).

Greater involvement of men as facilitators and beneficiaries.

Ensure continuity of essential family planning and safe abortion services during emergencies, disasters, pandemics and in humanitarian settings.

Q While young women, aged 15 to 19, are most at risk of dying from abortion-related complications, teenage pregnancy in India has not shown a significant decline.

I would like to refer to data from the National Family Health Survey-5, which indicates that teen pregnancy has only slightly decreased by 1%. This sobering figure requires immediate attention. Government flagship national and youth programs such as Mission Parivaar Vikas (MPV) and Rashtriya Kishor Swasthya Karyakram (RKSK) can prove to be key platforms as they provide adolescents and young people, especially young women, with appropriate counselling, contraceptives and other health services to meet their reproductive health needs.

It is necessary to continue our work, to examine the gaps and to fill them effectively. These include:

Ensure easy and stigma-free access to information on contraceptives and family planning. Addressing myths and misconceptions about contraceptives is key to facilitating increased use and continuation, especially for younger clients.

Explore the possibility of expanding the current contraceptive basket by adding reversible contraceptives, such as subcutaneous hormonal injections, implants, etc., thus providing more choice.

Facilitate communication for young married couples about reproductive intentions and choices by helping them decide when they want a pregnancy.

Mobilize the media, influencers and opinion leaders at the community and local level to raise awareness against early pregnancy and close pregnancy.

Q Of all unintended pregnancies reported annually globally, about 15% occur in India. What are the factors behind unwanted pregnancies in India?

For many, pregnancy is a default rather than a deliberate choice. We need to understand that unwanted pregnancies can also be the result of violence, coercion and vulnerabilities encountered during crises and disasters. It is not always the failure or non-use of contraceptives that motivates her.

To further highlight this, we need to understand all the other factors:

A young girl may lack information on how to avoid pregnancy because comprehensive sexuality education (CSE) is not offered in her school. She may assume that pregnancy is a default option because she lacks opportunity and choice; without the possibility of completing her studies, for example, she may see no reason to postpone motherhood.

Contraceptives may be inaccessible, unaffordable, or unavailable in a form that individuals would choose, fear, or experience side effects from certain methods.

Shame, stigma and fear can subvert willingness to seek contraception.

Health providers may not be able or willing to give a full choice or explain different methods.

Even if contraception is available and acceptable, women may not have the power to safely negotiate use with a partner.

Q Your report mentions that unintended pregnancies are associated with lower utilization of maternal health care and poorer maternal and child health outcomes. What can India do to overcome these obstacles?

The effects of the silent crises of unwanted pregnancies are multiple and present blockages to reaching critical health indicators. The Indian government has already taken steps to reverse this. The recently launched Midwifery Services Initiative is a low cost, high impact approach. It aims to increase accessibility to quality and respectful maternal services, including a transition to physiological childbirth, given the large births that occur in health facilities.

Beyond that, India can take these steps:

Advice and education on delaying early pregnancy and following a healthy timing and spacing of pregnancies.

Given young women’s lack of autonomy to seek maternal health services, counseling should include family members (including men and boys).

Community leaders should facilitate the use of maternal health care as early as possible and make the required number of visits.

Maternal health services should be non-discriminatory and respectful, while preserving the confidentiality of the individual so that clients do not hesitate to avail themselves of these services.

There is a need to link antenatal services to delivery and immediate postpartum care, as a continuum of services with strengthened referral links.

Q Seven Indian states have very high maternal mortality. What is wrong with these states and how can they reduce the maternal mortality rate?

While India’s Maternal Mortality Ratio (MMR) improved to 103 in 2017-19 from 113 in 2016-18, states such as Rajasthan, Uttar Pradesh, Madhya Pradesh, Chhattisgarh , Bihar, Odisha and Assam still have very high maternal mortality (130 or more maternal deaths per 100,000 live births).

Anemia is a major indirect cause while hemorrhage, pregnancy-induced hypertension and sepsis are the most direct causes. Social determinants also play an important role. Illiteracy, below average socio-economic conditions, remoteness from health facilities, are further compounded by ignorance of obstetric complications, inadequate utilization of maternal health services and sub-standard health infrastructure .

The following basic strategies should be adopted to accelerate progress:

Family planning with related reproductive health services.

Skilled and timely care during pregnancy and childbirth.

Immediate postnatal care.

Finally, successful implementation and scale-up of the Midwifery Initiative is imperative. Indeed, the 2014 Lancet The Midwifery series showed that interventions provided by midwifery staff could reduce maternal and newborn deaths and stillbirths by 30-80% in low- and middle-income countries (LMICs).

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