A Better Approach to Family Planning

A Better Approach to Family Planning

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The recent deaths of 14 women after sterilization at a government health camp in Chhattisgarh triggered international outcry against India’s population control tactics.  However, the issue of population control in India is much more complicated than a single headline can let on. Historically, India has recognized the importance of limiting its population growth, and has sought to achieve this objective in a variety of ways – some better than others. It’s important that we analyze the sterilization camps within their historical and cultural context.

The need for population control in India

Over the last century, India’s population has quadrupled. Nearly every year, our nation adds to itself the entire population of Australia. At this rate, India could surpass China as the most populous country in the world by 2030.

The problem with such rapid population growth is that it strains our economic and environmental resources. For example, according to a report by USAID, India will need 5.7 million teachers in the next 50 years to accommodate the number of students entering school. That’s 3 million more than if fertility declined to replacement level (two kids for every two parents). As it stands today, India already faces a shortage of nearly 1.4 million teachers, which inhibits quality of education. If we maintain current fertility levels, the scenario for future education looks even more daunting.

Furthermore, as India’s population continues to grow, so too will the demand for food. At our current growth rate, the number of people who require a food subsidy will double in 50 years. However, with replacement level population growth, 84 million fewer people will depend on a subsidy. Slower population growth would also buy more time to create jobs for youth entering the labour force, ease high unemployment, and thus contribute to economic development.

The list of benefits goes on, but you get the point. We need to slow down our baby-making to improve standard of living.

India’s history of family planning

Launched in 1951, India has the oldest family planning programme in the world. The government began its efforts by launching an advocacy campaign around the rhythm method, but met with limited success. Therefore, in the 1960s,  the government began pushing male and female sterilization through official quotas and financial incentives to undergo the procedure. However, by late 1970s, the program was notorious for widespread coercion and abuse. The often forced sterilizations of over 8.3 million men led to a major anti-vasectomy backlash in the early 1980s. Combined with this backlash, the emergence of new techniques for female sterilization shifted the population control efforts onto women. (Source)

In 1994, India endorsed the conclusions of the United Nations International Conference on Population and Development that called for abandoning contraceptive targets, improving educational programs and offering voluntary contraceptive choices. Aligning with these global best practices, India’s population policy in 2000 did away with targets and acknowledged the criticality of education, sanitation and employment opportunities for women as a means to achieve demand-driven population control.

Progress in today’s family planning strategies

According to Family Planning 2020 (a global partnership between the UN and various global NGOs), today’s family planning policy in India is focused on increasing the basket of choices available to women and providing information, services and supplies. To expand family planning access to an additional 48 million women by 2020, nearly one million community health workers are distributing contraceptives to households and counseling newly married couples on birth spacing. Another program, focused on adolescent girls, approaches family planning from a comprehensive level, counseling the girls about nutrition, mental health, injuries and violence, substance misuse and non-communicable diseases.

Furthermore, seeking to shift cultural attitudes about family planning, the Population Foundation of India (supported in part by the government) has developed a multimedia “edutainment” serial called Main Kuch Bhi Kar Sakti Hoon (I, a woman, can achieve anything). The serial promotes women’s empowerment through dramatic stories that highlight family planning, reproductive rights, and gender equality issues. To date about 23 million people have watched Main Kuch Bhi Kar Sakti Hoon on television, and the complementary IVR service that it promotes has logged an overwhelming response. (Source)

Continued challenges with quota systems and financial incentives

Despite this progress, the coercive mentality of family planning has been difficult to dislodge. Though the Indian government has replaced family planning targets with “expected levels of achievement,” promotions and pay increases for health staff still depend on meeting this expected level. The doctor arrested in Chhattisgarh, for example, received a reward from the chief minister in January for performing the highest number of sterilizations.

Furthermore, sterilization camps are still seen as the easiest way to introduce birth control to poor women in areas that have sparse health facilities. Though women are no longer coerced as vehemently as they were decades ago, they are drawn to the Rs 1,400 compensation. Sterilization is the only family planning method that offers such financial rewards. (Source)

The way forward: increasing choices, improving quality

Female sterilization is not inherently a bad option for family planning. In fact, it is currently the world’s most popular form of family planning, with 223 million women using it as a form of birth control in 2009. If conducted correctly, it is a minimally invasive surgery that is highly effective, low-risk and inexpensive.  In countries like India, where people have their children early, women would have to use some form of contraception for up to 25 years if they want to avoid pregnancy after their first few children. With sterilization, they don’t have to come back, buy supplies or worry about stores running out of products (which are all very challenging obstacles in rural India).

However, the lack of readily available sterilization processes in India is a major risk factor for post-surgical septic shock and other infections. So too is the ‘assembly line’ attitude to conducting these operations. In the recent tragedy in Chhattisgarh, for example, 83 women were operated on by a single surgeon over the course of six hours. Moreover, financial incentives for the procedure and salary-dependent ‘levels of achievement’ for health workers create an environment in which many women are still subtly coerced into sterilizations.

Therefore, the Indian government must commit to a two-tiered approach to improving family planning. First, they must double down on their current initiatives to increase access to modern contraceptives and offer greater choices in long term contraceptive use. This must, of course, be accompanied by education and counseling for both men and women, so they are fully aware of their contraceptive choices and the benefits of each option. It also requires the current financial incentive structures for both women and health workers to be revised. Second, when men or women do choose to opt for sterilization, the government must stringently adhere to global standards of safety and quality. Often, simple solutions such as power-independent sterilization equipment for surgical instruments and checklists for surgeons can vastly enhance these procedures.