Ultrasound of a growing foetus in the mother’s womb at 23 weeks of age. Photo: Flickr/hose902, CC BY-NC-ND 2.0
Family planning is recognised as the second-best return on investment, after education, among all targets set under the Sustainable Development Goals (SDGs). The goal of “every pregnancy a planned pregnancy” and accomplishment of “gender” and “reproductive” rights are fundamental to improve women’s empowerment, gender equality and progress in health and economic development.
To mark its importance, the world celebrates September 26 as World Contraceptive Day. Awareness and knowledge of family planning are important for India, where every year nearly 27,000 women dying during childbirth, sterilisation camps and abortions can be avoided.
But despite seven decades of state-sponsored family planning campaigns in India, focusing largely on women, the dialogue on “sex” and “contraception” have remained private, confined to the family. The public discourse on sex education and contraception has been impeded by social taboos, and has eluded mainstream media attention as well. Because of the lack of access to good-quality contraceptives and awareness, women in India become pregnant when they aren’t ready or when they don’t want to get pregnant. A considerable fraction of women also don’t have the freedom to make family-planning decisions.
Of the four key goals of family planning – timing of births, spacing of birth, limiting of births and protection from sexual and reproductive-tract infections – India is progressing well only on the third. Most states have already achieved their target of two children per woman; a few others are on course to reach the target. But the unmet need – i.e. when women want to limit births but don’t have access to desired contraceptives – for family-planning is still around 20%. A “great demographic enigma”, which experts still haven’t been able to explain, is how the average number of births per woman in a country can decline when overall contraceptive use is either stagnant or declining as well.
There are three major reasons for the poor performance of the family-planning programme in India.
1. Failing to implement a gender-equal, reproductive rights-based approach
From the start, female sterilisation has been the dominant method of fertility control. Except during the emergency (1975-1977), male sterilisation hasn’t contributed significantly to family-planning programmes. And even during the emergency, male sterilisation was coercive. Unsurprisingly, in the last three or so decades, male sterilisation’s ‘contribution’ has dropped from 8% to less than 1%.
Condoms gained popularity in the mid-1990s, when HIV/AIDS was more prevalent, with the help of public awareness and free distribution – but thereafter, not so much. Methods like injections and intrauterine devices have never been popular in India owing to the lack of know-how and assistance and quality of care.
Indeed, even female sterilisation suffers from quality of care issues. Many women have died in India after undergoing sterilisation procedures, especially at mass sterilisation camps.
2. Poor quality of care and overburdened health workers
The informed choice of contraceptives is key to ensuring the reproductive rights of individuals – as endorsed in the 2030s agenda of the SGDs as well. But such choices are not common in India. Only one in every three users has information about how they could deal with side-effects, etc.
Assurance of quality of care needs well-trained healthcare providers at the grassroots. Currently, incentive-based frontline health workers, like the Accredited Social Health Activist (ASHA) workers, are overburdened with multiple assignments, and are poorly trained and paid. Incentives are based on quantities rather than on quality of care. So as such the programme design, implementation and evaluation itself often neglects quality of care.
3. Dropping expenditure on core family planning programmes
The state is the major source of contraceptive supply in India, so public spending on family-planning is key to ensure universal access. But with only 1.2% of GDP, India’s public-health spending ranks among the lowest in the world.
This expense has been dropping since the Indian government integrated the family-planning programme into the larger reproductive and maternal health programme, following the 1994 international conference on population and development in Cairo. And since India attained replacement-level fertility, public spending on family-planning has become even less prominent.
The goals set under India’s family planning programme have always been skewed in favour of target-based ways to limit births, at the cost of improving quality and timings of birth. So as the number of children per woman declines, year by year, the share of expenditure on core family-planning services has been going down, too. Consequently, progress in the uptake of modern contraceptives overall has been almost stagnant in the last decade for spacing methods.
We call for greater investment to expand options for more and superior self-administered contraceptive methods and to enhance their accessibility, acceptability and affordability. Promoting the involvement of both men and women in contraceptive decision-making will also help protect reproductive and gender rights.
Increasing the number of skilled and better-paid frontline health workers is important to ensure better access to good-quality family-planning care, with informed choices for users. Other important measures include expanding R&D of contraceptive methods, data generation and evaluation of the quality of care, and addressing the needs of different sub-populations (especially young adults).
Ultimately, social stigma around the use and reporting of family-planning must be eliminated to enhance the health of populations. India must give a new and big push to family-planning to achieve its SDGs.
Srinivas Goli is an assistant professor at Jawaharlal Nehru University, New Delhi, and research fellow at the University of Western Australia, Perth. M.D. Juel Rana is a postdoctoral fellow at the International Institute for Population Sciences, Mumbai.