Ultrasound of a growing fetus in the womb at 23 weeks of age. Photo: Flickr / hose902, CC BY-NC-ND 2.0
Among all the goals of the Sustainable Development Goals (SDGs), family planning is recognized as the second best return on investment after education. The goal of “every pregnancy a planned pregnancy” and the realization of “gender” and “reproductive” rights are fundamental to strengthening women’s self-determination, gender equality and progress in health and economic development.
To underline its importance, the world celebrates September 26th as World Prevention Day. Awareness and knowledge of family planning are important to India, where nearly 27,000 women die each year during childbirth, sterilization camps and abortions can be avoided.
But despite seven decades of government-sponsored family planning campaigns in India that mainly focused on women, the dialogue about “sex” and “contraception” remained private and confined to the family. Public discourse on sex education and contraception has been hampered by social taboos and has also escaped the attention of the mainstream media. Due to a lack of access to quality contraception and awareness raising, women in India get pregnant when they are not ready or do not want to become pregnant. A significant proportion of women also have no freedom of choice when it comes to family planning.
Of the four main family planning goals – the time of birth, the interval between births, the birth control and protection from sexual and reproductive infections – India is only making good progress on the third. Most states have already achieved their goal of two children per woman; some others are on track to achieve the goal. The unmet need – i.e. when women want to limit births but have no access to the desired contraceptives – is still around 20% of family planning. A “major demographic conundrum” that experts have still not been able to explain is how the average number of births per woman in a country can fall if general contraceptive use either stagnates or declines.
There are three main reasons for the poor performance of the family planning program in India.
1. Failure to implement a gender equitable, reproductive rights-based approach
From the beginning, female sterilization has been the dominant method of fertility control. Except during the emergency (1975-1977), male sterilization did not contribute significantly to family planning programs. And even during the emergency, the man’s sterilization was compulsory. Unsurprisingly, the “contribution” of male sterilization has decreased from 8% to less than 1% over the past three decades.
Condoms gained popularity in the mid-1990s, when HIV / AIDS became more prevalent, thanks to public awareness and free distribution – but not so much afterwards. Methods such as injections and intrauterine devices have never been popular in India due to the lack of expertise and assistance and quality of care.
In fact, even female sterilization suffers from quality problems. In India, many women have died after sterilization procedures, especially in mass sterilization camps.
2. Poor quality of care and overworked health workers
The conscious choice of contraceptives is the key to guaranteeing the reproductive rights of the individual – as advocated in the 2030 Agenda of the SGDs. But such decisions are not common in India. Only every third user has information on how to deal with side effects etc.
Ensuring the quality of care requires well-trained health service providers on the ground. Currently, incentive-based health workers on the front lines, like the Accredited Social Health Activist (ASHA) staff, are overwhelmed with multiple tasks and are poorly trained and paid. Incentives are based on quantity rather than quality of care. Therefore, the program design, implementation and evaluation itself often neglects the quality of care.
3. Reduce spending on basic family planning programs
The state is the primary source of contraception in India, so public spending on family planning is key to ensuring universal access. But at just 1.2% of GDP, India’s public health spending is among the lowest in the world.
This spending has decreased since the Government of India integrated the family planning program into its broader reproductive and maternal health program following the Cairo International Conference on Population and Development in 1994. And since India has reached reproductive fertility levels, public spending on family planning has become even less of a priority.
The goals of the Indian family planning program have always been skewed in favor of goal-oriented ways of limiting births at the expense of improving the quality and timing of birth. As the number of children per woman falls from year to year, the share of spending on core family planning services also falls. As a result, overall advances in the introduction of advanced contraceptives for distance methods have almost stagnated over the past decade.
Keep it up
We call for more investment to expand the possibilities for more and better self-administered contraception methods and to improve their accessibility, acceptance and affordability. Encouraging the participation of men and women in contraception decision-making also helps protect reproductive and gender rights.
Increasing the number of skilled and better paid frontline health workers is important to ensure better access to quality family planning with informed decision making for users. Further important measures are the expansion of research and development of contraceptive methods, the generation and evaluation of data on the quality of care and the consideration of the needs of different subpopulations (especially young adults).
Ultimately, the social stigma associated with family planning use and reporting must be removed in order to improve the health of the population. India needs to give family planning a new and big boost in order to achieve its SDGs.
Srinivas Goli is Assistant Professor at Jawaharlal Nehru University, New Delhi, and Research Fellow at the University of Western Australia, Perth. MD Juel Rana is a postdoc at the International Institute for Population Sciences, Mumbai.