It is imperative that access to quality family planning information and services is easy and women are given the power of choice and decision-making
When 17-year-old Suguna Devi, a resident of Khagaria district of Bihar, had her first child within a year of her marriage, celebrations were short-lived. Born prematurely and underweight, the infant died a couple of days later. Within a month of this tragedy, Suguna became pregnant again. Fortunately, this time, her daughter survived. But giving birth in quick succession had made Suguna weak. After three months of struggle to take proper care of her baby, Suguna realised that she was going to be a mother again.
According to the National Family Health Survey (NFHS-4) statistics, 13 per cent of currently married women are not using contraception. Yet, they either want to stop having children or want to wait for two or more years before having their next child. Access to contraception can help the woman take this decision. She can decide how many children she wants and will not be compelled by circumstances. Providing contraceptive information, services and supplies so as to allow women and girls take their own decision was what India had promised seven years ago at the 2012 London Summit on Family Planning (FP2020). India had pledged to expand access to contraceptive choices to its 45 million women, who do not use any modern contraception method, by 2020.
But as statistics show, this goal is unlikely to be reached. The 2015-16 NFHS data showed that huge gaps still exist. Of the 45 million women, 31 million are not using any contraception. Further, the report found 14 million women used unreliable traditional methods, which enhanced the risk of pregnancy by three times when compared to using modern methods (birth control pills, condoms, sterilisation and intrauterine devices).
What is surprising is that despite a decline in India’s total fertility rate (the average number of children that would be born per woman in her life) — from 2.7 children per woman in 2005-06 to 2.2 in 2015-16 — there was also a drop in contraceptive use (any method) — from 56.3 per cent in 2005-06 to 53.5 per cent in 2015-16 (NFHS-4). There has also been a decline in the use of modern methods of contraception — from 48.5 per cent in 2005-06 to 47.8 per cent in 2015-16 — even though more contraception methods are now available for free under India’s family planning programme.
But Khagaria’s high Total Fertility Rate (TFR) of four is a clear indication that contraception services still elude women. Moreover, this high TFR has not only remained unchanged over the last decade but surpasses both State and national TFR, which stands at 3.3 and 2.2 respectively. Therefore, not much has changed in terms of usage of contraceptive services over the last 10 years. Incidentally, Bihar retains its position as the State with the highest TFR in India of 3.3 children per woman, according to UN Fund for Population Activities’ report titled, ‘The State of World Population 2018’.
One of the reasons for this is that nearly 41 per cent of the population in Bihar has an unmet demand for modern contraceptive methods. This is the highest in our country. Coupled with unmet need in the State is the fact that teenage birth rate stands at 12.2 per cent. This is the third highest among 20 States in the country after West Bengal (18.3 per cent) and Assam (13.6 per cent). While adolescent pregnancy raises the risk of mother and child death, what further increases the risk for these teenage births is their low Body Mass Index (BMI). Approximately, 45.2 per cent of the girls, aged 15-18 years in the State, have a BMI less than 18 kg/m, indicating that they are underweight. Further, 60.3 per cent of the women aged between 15 and 49 years suffer from anaemia. This means that the chances of post-partum haemorrhage, especially for these 3.5 lakh teenage births in Bihar, are higher and expose the women and girls to maternal mortality and morbidity. The survival of children, who are underweight, and that of anaemic mothers is also bleak. Bihar’s infant mortality rate (IMR) is 38 per 1,000 live births compared to 34 for the rest of the country.
High-risk births occur because girls and women are unable to understand the risks of early pregnancy. Nor are they empowered to delay or space their pregnancies. Bihar has the lowest spacing time duration (44.4 per cent) with approximately 15 lakh high-risk pregnancies, compared to the national average of 51.9 per cent. Less than three years between pregnancies enhances the risk of maternal and child mortality. This is also a big reason for high Maternal Mortality Rate (MMR) in Bihar, which stands at 208 per 100,000 live births, as per Sample Registration System survey 2015. This is way above the national MMR of 130.
Every woman should be able to decide whether, when and how many children she wants to have. But several factors prevent her from doing so. Early marriage is one of the major reasons why girls are unable to exercise agency. Bihar not only has the highest number of child marriages in India (39.1 per cent) — the national incidence of child marriage among girls aged between 10 and 18 years is 4.5 per cent, according to NFHS-4 — the State also has the maximum number of districts (20 out of 38) in the country that remains plagued by child marriage.
So, in Khagaria district, which has the highest prevalence of child marriage in the State, it is not uncommon to see early marriage that is followed by quick motherhood. The percentage of girls marrying below the legal age of marriage in Khagaria is 34.4 (NFHS-4).
Not only is the high percentage of early marriage in rural Bihar (91.4 per cent) worrying but the fact is also that 78.9 per cent of the marriages in the age group between 15 and 19 occur among the poor households (2018 NCPCR-Young Lives study). Poverty often means that education remains out of reach for these girls. A 2017 Population Council study found that two in three unmarried girls and less than one in seven married girls were currently in school. Families appeared to invest less in girls with 41 per cent of unmarried girls not attending school regularly.
Once they are married, fertility for women like Suguna begins too young. Lack of information, coupled with inability to access reproductive and sexual health services, means too many and frequent pregnancies. But by ensuring that adolescents are aware of the services available to them and educating them about their sexual and reproductive health, the Government can help them plan their pregnancy.
This is where family planning corners located at public health centres in Bihar have a pivotal role to play. By providing information about reproductive and sexual health as well as on contraceptive choices, trained counsellors at these family planning counselling desks can help couples space their children. Since unmet contraceptive needs lead to unwanted fertility, an increased use of temporary methods to stop child-bearing may lower total fertility significantly. Family planning counselling corners can give women the freedom to defer having children by using temporary contraceptive methods. And counselling is a crucial component in decision-making.
If couples are educated and allowed to make an informed choice, based on the advantages and disadvantages of contraceptives available, they will want family planning services. There is a clear relationship between TFR and contraceptive prevalence rate. Data has shown that where there is very low contraceptive prevalence, fertility is very high as is in Bihar. In States like Tamil Nadu and Andhra Pradesh, fertility is lower because contraceptive prevalence is much higher.
By providing an appropriate range of contraceptive services, India can avert 23.9 million births and prevent one million infant deaths and over 42,000 maternal deaths by 2020. It has been proven that as contraceptive use rises, maternal and infant deaths decline. It is estimated that MMR could be reduced by a third through spacing of births. A Lancet study has shown that India would save $18.2 billion in consumption expenditure in 2020 if the FP2020 goal were to be achieved. This would also improve the chances of achieving the Sustainable Development Goal (SDG) 3.7 goal of eliminating unmet needs by 2030. But it is imperative that access to quality family planning information and services is ensured and women are given the power of choice in planning their families.
(The writer is a senior journalist)
