India’s Family Planning Mission puts the burden of sterilization on women at the cost of their health

In 1952, India became the first country in the world to launch a national family planning program. Over the decades, the program has transformed in terms of objectives and repositioned itself not only to achieve population stabilization, but also to promote reproductive health and reduce maternal, infant and child mortality and morbidity. juveniles. The methods showed a significant shift from traditional/natural rhythmic practices to modern methods such as condoms, diaphragms, pills, injections, etc.

According to World Family Planning Report 2020, the number of women willing to use family planning has increased markedly over the past two decades, from 900 million in 2000 to almost 1.1 billion in 2020. As a result, the number of women using a modern contraceptive method increased from 663 million to 851 million, and the contraceptive prevalence rate increased from 47.7 to 49.0%. An additional 70 million women are expected to be added by 2030. Sustainable Development Goals (SDG) indicator 3.7.1, on contraceptive use by women of reproductive age (aged 15-49 ), has stagnated globally at around 77% from 2015 to 2020.

Mismatch between male and female sterilization

Sterilization as a method of contraception is on the rise. Contraceptive choices in India are still governed by socio-economic indicators such as level of education, wealth, religion, caste, among many others. Studies indicate that the practice of sterilization is common among women belonging to communities with low economic and educational status. Islam does not favor permanent family planning methods for Muslim women over Hindu women, who tend to prefer sterilization over temporary methods. In contrast, increased use of modern techniques such as condoms and pills has been found among Indian women with higher socioeconomic status, education, and levels of empowerment. Studies in India, Brazil and Bangladesh have found higher parity as a determining factor for female sterilization. But notably, it is still motivated by the preference for sons at lower parities.

The Ministry of Health and Family Welfare launched “Mission Parivar Vikas” in 2016 to improve access to contraceptives in 145 high fertility districts in Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh, from Chhattisgarh, Assam and Jharkhand. It was launched with a focus on reversible, non-surgical and hormone-based contraceptives. In 2021, it was expanded to six northeastern states. In recent years, more comprehensive initiatives have been undertaken by the government. Also Hum do aims to provide eligible couples with information and counseling on available family planning methods and services. Other initiatives include a 360-degree media campaign to generate demand for contraceptives and a home delivery program of contraceptives by ASHA workers to recipients’ doorsteps.

For decades, India has relied on female sterilization as the primary method of contraception, although vasectomies are not only safer but also non-invasive. Nearly 75% of all female sterilizations take place in public institutions, and about a third of them are carried out after childbirth. According to the National Family Health Survey (NFHS)-5, 37.9% of women use sterilization to prevent unwanted pregnancies, far more than non-surgical methods such as the pill (5.1%), injections (0.6%), condoms (9.5%). cent), the IUD (2.1%) or even male sterilization (0.3%). India shows heterogeneous geographical variation in the choice of contraceptive methods. While condoms are the most commonly used technique in the northern and western regions, the northeast and eastern regions have a higher prevalence of pills.

Source: NFHS-5

The graph above puts into perspective the stark gap between female and male sterilization in states in 2021. Southern/UT states like Andhra Pradesh, Telangana, Tamil Nadu, Pondicherry and Karnataka are leading female sterilization with more than 50% coverage. But this is barely matched by the extremely low participation of male counterparts.

Unconscious

The focus on male sterilization appears to have shifted away from the family planning agenda after the Emergency Period scandal of 1975, when nearly 6.2 million forced sterilizations were performed in one year. In 1996, the Indian government removed the “targeted approach” to family planning and stopped setting targets or quotas for health officials for contraceptive methods and violation of reproductive rights. Stigma, misinformation regarding side effects/complications, and cultural and religious beliefs remain significant barriers to uptake of male sterilization. Between 2008 and 2019, only 3% of the 51.6 million sterilizations performed were vasectomies.

There is still a critical lack of awareness regarding alternative and reversible methods and knowledge of the side effects of surgical techniques for women. High unmet need for modern contraception has been observed among poor and marginalized women, leading to poor reproductive outcomes and unwanted pregnancies. Poor knowledge of side effects of current contraceptive methods was noted among women in the NFHS-5. Andhra Pradesh and Telangana rank last in terms of awareness of the side effects of current contraceptive methods, despite having the highest female sterilization coverage in the country.

Popular in rural areas, postpartum or post-abortion insertion of Copper-Ts (or copper intrauterine devices) is the only long-term reversible contraceptive method available in the country. Still, uterine bleeding and abdominal pain were ubiquitous side effects. In states like Bihar, with the highest Total Fertility Rate (TFR) of 3 children per woman in the country, the increased prevalence of unwanted pregnancies is attributed to an absolute lack of counseling for women on child spacing. births and alternative methods. Fear of side effects continues to be a major deterrent to switching to other contraceptive methods, even after nearly 70 years of India’s ongoing family planning program. Other reasons are lack of knowledge, cultural beliefs, lack of decision-making power in intimate relationships, and undesirable attitudes of service providers.

Lack of consent, unmet needs

In addition to the lack of awareness of alternative methods of contraception, consent also remains a gray area. Past instances of violation or non-granting of consent have been repeatedly reported, particularly among uneducated, disabled, tribal/minority women. Many women have been coerced, misinformed about the surgery or even never informed of the possible risks it could entail. Moreover, a procedure like mini-laparotomy or laparoscopic tubectomy can easily be performed without women fully knowing it.

Evidence indicates that the emphasis on female sterilization in family welfare programs may lead to disincentives to other methods. Therefore, in the absence of a wide range of choices in remote and rural areas or a sufficient number of surgeons/doctors, poor quality of care becomes an acceptable norm. Chhattisgarh, for example, has historically been known for time-limited and targeted mass sterilization in camps with cases of botched surgeries and substandard standards of care. Surguja (2021) and Bilaspur (2014) incidents are some infamous examples of blatant disregard for government regulations and prescribed standards.

The skewed burden of permanent family planning is indicative of broader trends in early marriage and childbearing and health problems stemming from unmet needs of adolescents. A significant gap in the actual understanding of the country’s contraceptive needs stems from the exclusion of unmarried women and adolescent girls who are typically not included in research studies. Consequently, a large portion of the population has growing and unmet needs for family planning. Surveys in Bihar reveal that more unmarried and sexually active women used contraceptives than married women in the 15-49 age group.

Evidence shows that smaller families can reduce infant mortality rates and improve maternal health. Improving access to and use of family planning methods, improving health infrastructure and improving the education and status of women can bring significant gains in terms of child survival. With the push for a two child policy in states like UP, Assam and Gujarat, sterilization is further encouraged and propagated. But that push seems unnecessary because most states are near replacement-level fertility. Four of the seven initial target states of the Parivar Vikas Mission have already achieved the goal of a fertility rate of 2 or less.

To achieve the Sustainable Development Goals, it is imperative that the government ensure better access and scale-up of family planning services. The family planning program must ensure that it is voluntary, informed and does not violate the dignity of women, in order to truly empower them to make their own choices and involve men in the process.

Mona is a Junior Fellow and Shoba Suri is a Senior Fellow at the Observer Research Foundation. The opinions expressed in this article are those of the authors and do not represent the position of this publication.

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