Policy Context Of Family Planning (national Policy) In India

Within this paper we will deal with development policy suggestions that reflect the role that education plays for fertility reduction and population control as well as the importance of making free and informed decisions by individuals and how that is most pressing need of the hour.

Fertility decline are not just a by-product of economic growth, it depends on improvements in specific conditions that are conductive to changed fertility goals and that help parents realize these goals.

The policy efforts can be traced back to India’s Five year development plans which have been the basis of planned social and economic development in the country since independence. The first five year plan (1952-57) recognised the increase in population and the pressure exercised on India’s limited resources had brought to the forefront the urgency of the problem of family planning and population control. The Plan argued that application of medical knowledge and social care had lowered the death-rate, while the birth-rate remained fairly constant which had led to rapid increase in the growth of population. It recognised that a lowering of the birth-rate might occur as a result of improvements in the standards of living but such improvements were not likely to materialise if there was a concurrent increase in population.

Within the global population control movement especially within the low income and rapidly decolonising regions of the world a series of state-led and internationally funded family programs took shape. The history of twentieth century population is largely one of bio medicalized surveillance to women’s fertility. The development of new contraceptive technology to aid population control was almost exclusively focused on female contraception. This in turn strengthened the state-led management of women’s fertility, as national family programs have typically focused on popularizing female contraceptive technologies. Finally, while international feminist discourse since the early 1990s has touted contraception’s role in securing women’s reproductive autonomy, women have also borne the brunt of states’ violent attempts to coerce contraceptive use in the service of population control.

Against this global backdrop, India became the first country in the world to institute a national population control policy in 1952. The Indian government at that time hoped to popularize contraception- mainly sterilization to achieve its population control goals. Yet against the larger literature’s explanations of how global population control efforts have rested on surveilling women’s bodies, it’s strange that from the early 1960s through the mid-1970s India’s population control programme was pivoted largely around men and male contraception. Vasectomies constituted around 21.1 million of all 32.7 million sterilizations recorded between 1956 and 1980 - i.e. almost 65%. Most of these occurred between the early 1960s and 1977 with annual numbers highest during India’s emergency period from 1975-77. The Indian government prioritized condom manufacturing and distribution in the 1960s and 1970s, heavily marketing and distributing the government-manufactured brand “Nirodh”. Furthermore, government publicity materials and fieldworkers’ promotional activities during this period targeted men and encouraged them to use contraception and desire fewer children. 

A new family planning programme focusing on voluntary acceptance evolved in the 1980s after the fallout of coercive programme. This era saw a stark shift from male sterilization to female sterilization. This shift can be largely attributed to the development of new techniques in female sterilization and women centred programmes like reproductive and child health (RCH) and cash initiatives. Since then, the focus of Indian family planning programme has remained largely on female sterilization. Although men are increasingly inducted in family planning efforts, women continue to be the linchpins of the program. The ‘cafeteria approach’ of making several fertility regulation methods available is endorsed, but in reality, women-oriented methods are more widely promoted. Female sterilization continues to be the preferred method of permanent birth control.

Reasons for prevalence of female sterilization

Multiple factors have contributed to surgical sterilization becoming the primary method of contraception in India especially among the low income groups. First, the government has long encouraged the use of both male and female sterilization to control population growth due to the permanency and an absence of follow-up care or adherence. Second, reversible contraceptives have not been accessible for the urban and rural poor. Third, the prevalence of child marriage which is extremely rampant where more than 22% Indian women marry before 18 resulting in early child birth and early need to permanently end childbearing. Fourthly, the ideal family size has shifted to maximum of two children. As a consequence, 31.5% of women aged 15 to 24 and 77.5% of women aged 25 to 34 want no more children and 1-.1% of women below age 30 surveyed in the National Family health survey dataset were sterilized before age 30. 

The United Nation’s population division notes that the dominance of permanent contraception in a young population suggests a potential mismatch between available methods and those that, instead of ending a woman’s fertility, might help them control and plan it. According to the National Family health survey report, 21% of Indians do not have access to family planning among married adolescents that figure goes up to 27 percent.

Present framework of family planning

In 1994, India participated in the United Nations International Conference on Population and Development where a need for more personalized approached to women’s health was emphasized. This commitment necessitated changes in reproductive health policies of member countries including India. India, on paper, shifted to a decentralized, client centred approach to reproductive and child health care.

India’s current policy utilizes a community needs assessment approach that emphasizes localized development of women’s health services.[footnoteRef:10] Community health workers, midwives, nurses or non-governmental organization workers are expected to be involved in conducting needs assessments for communities in which they work and provide input on district-level planning. Additionally, outreach is done by nurses, midwives, or CHWs to provide information and some contraceptives. There is also an emphasis on prescribing contraceptives tailored to the individual client’s needs. Many researchers reviewing the new approaches have noted that the presence and quality of these approaches are uneven.

Target system still exists however instead of being focused on specific contraceptive methods they are now related to reproductive and child health. Within public facilities, the sterilization is free and incentives are also offered. Incentives are higher for permanent sterilizations that for IUD insertions, they are also higher for individuals below poverty line. There is not incentive system in private facilities.

India’s Family Planning 2020 goals aim to drive access to family planning services. It also highlights the aim to provide a wider choice and higher quality of services. Since first making a commitment in 2012, India has integrated family planning into the Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) Strategy. Increasing awareness and generating demand for family planning services through comprehensive media campaigns have been priorities. It has added to its national program three new products to aid birth spacing- an injectable contraceptive, a progesterone pill and a non-hormonal weekly pill- in addition to the present oral contraceptive pills, condoms and IUDs available to women.

The change in the planning practices of India since 2017 with the end of the five year plans and the introduction of Niti Aayog by the present prime minister, Narendra Modi has not resulted in any significant changes in family planning policies within the country. The Twelfth and last Five-year Plan recognised that the total fertility rate continues to be above the replacement level that was supposed to be achieved by 2012. There has also been an urgent call for population stabilisation as the widely differing rates of population in a democratic set-up could potentially generate regional conflicts

Need for a reform

Curbing population growth is the most important consideration for India at the moment. There is no quick fix or any immediate miracle for population growth. In India where abortion, contraception and infertility are considered as deplorable topic and family planning is dictated by socio-cultural norms, there is an urgent need to break the inhibitions. The stigma of the past aggressive sterilization methods continues to overshadow the current family planning initiatives. In light of all the factors, the women are sent to ‘cattle’ camps for sterilizations where they are paid. Often these camps are in medically unfit conditions. There is a need for a wholesome population policy which takes into account the socio economic diversity and sensitizes and empowers women as well.

Although there is a growing demand for both limiting and spacing births, female sterilisation, is the dominant method in the empowered action group (EAG) states which contribute about 40% of population growth to the country and also depict sad statistics for other socio-development indicators. Collapse of the public health system, corruption, non-existent or ineffective social marketing, focusing on singular approaches are some of the other major problems that exist within the family planning policies.

If India is going to avoid a population time bomb, it has to move away from sterilization as the preferred method of contraception. In an exclusively sterilization-oriented programme a much higher contraceptive prevalence rate would be required to achieve a given reduction in the birth rate which would be the case of a programme that relies on a higher mix of methods. Reversible contraception should be accessible to everyone, giving women the tools they need to have children later in life and further apart. Reversible contraceptives are also important for birth spacing, especially with the gradual erosion of traditional birth-spacing practices and a probable increase in fecundity with better health and nutrition levels. Encouraging a move away from sterilization is more complicated than just improving access to contraception choices. It also includes ending child marriages breaking taboos that prevent sexual education and improving the quality of health services.

Factors affecting contraceptive choice

Education

There is a proven connection between increase in female literacy and drop in fertility rate. This direct link between female education and fertility is prevalent without any regional effects. Female literacy has a strong impact on fertility even after there is control over male literacy and male literacy does not contribute to fertility decrease independently of female literacy. In addition to this, if parents value sons and daughters more or less equally so that they are satisfied with for example two surviving children irrespective of their sex, the incentives for additional births is correspondingly lower. Thus, fertility decline and reduction in gender bias are complementary goals. Female education in particular is known to affect a host of social, economic and demographic variables such as age at marriage, employment status, and fertility and is positively related to the use of contraceptives. Even small improvements in educational attainment could result in substantially greater contraceptive use.

The government included “increased attention to social determinants of health” in its commitments to FP2020. The low status of women, reflected in a strong cultural preference for sons is high on that commitment list. Across India, women have low levels of education and formal labour force participation, with profoundly negative impacts on their health status. Only half on India’s women are involved in making decisions about their own healthcare, and more than 60% of women do not seek antenatal care, believing it was unnecessary. 

Social inequality

Social inequality is another barrier to improving women’s health in India. The median age at first marriage for women in India’s richest quintile is 19.7 years while for the poorest women it’s 15.4. When it comes to dealing with unplanned or unwanted pregnancies which make up some 20 percent of all pregnancies in India it is mainly the wealthier women who can afford the two key drugs for medical abortion which have been approved for sale and manufacture in India since 2002.

Analysis of the system

Planned family planning efforts are essentially directed to meeting the fertility regulation needs of individual couples, these efforts, to be successful, have to be needs effective and capacity efficient. Needs effectiveness implies that the efforts must be able to reach all the couples that who want to regulate their fertility. While capacity efficiency means that the efforts shall provide a full range of family planning services to couples who are within the reach of these efforts. These two factors then help to determine goal effectiveness which then determines the total realised efficiency of planned family planning efforts. The nature if management and administration comes into play in this context.

The management and administrative system in India for population control and planned family planning is known for its normative, bureaucratic, and top down approach. At the policy level the decentralisation of management and administration of planned family planning efforts have been repeatedly stressed but in reality, the implementation of these efforts have been dictated by normative guidelines issued by the top administrators with negligent recognition of the grass root level realities. There has been a shift in recent years to emphasis on assessing community needs but the people are rarely involved in the assessment process.

The current managerial structure of planned family planning efforts in India was evolved more than 30 years ago. There has been a great change in the scope and approach of these efforts bit there has been almost no assessment of the managerial structure. At the national level, Department of Family Welfare within the Ministry of Health and Family Welfare was responsible for organising these efforts, the department, however ceased to exist. There is almost no involvement of other government agencies in promoting family planning as a development strategy. At present, the ministry does not have a population policy unit that may contribute to improving the policy environment in family planning efforts. The national commission was implemented but it could not hold its individual identity and was merged within the Ministry of Health and Family Welfare.

Policy suggestions

Efforts targeting female education

The national family health surveys over the past decades indicate that women’s education status is a major factor in the number of children they decide to have. For instance, in Bihar, when the percentage of literate women grew from 37% of the population. In 2005-06 to 46% in 2015-16, the fertility rate declined from 4 to 3.4. In Uttar Pradesh when women’s literacy rate improved from 44.9% to 61% during the period, fertility rates fell more sharply from 3.8 to 2.7. Higher literacy rate means fewer children. In Goa, where women’s literacy rate was 89% in 2015-16, the fertility rate was 1.7 and in Kerala the fertility rate was 1.6 and literacy was 97%. Better enforcement of laws, which requires the government to ensure free and compulsory school education, will help states where fertility is still above replacement rates to make the transition to low population growth.

Change in legislation

A comprehensive legislation in the field of contraceptives consolidating and updating the scattered law is the need of the hour. Such law should: (a) provide a definition of contraceptive for the purpose of family planning ; (b) be such which insures that there is no unnecessary restrictions on the advertisement and publicity of contraceptives; (c) ensure that the contraceptive advice is easily available and that the contraceptives are also freely available; (d) prescribe the minimum standards for the quality of such contraceptives sold in the market; (e) remove the import as well as other duty restrictions on contraceptives for providing quality and advanced contraceptive devices in the country; and (f) provide for the availability of all contraceptives and devices in all Primary Health Centers established throughout the country free of charge. While enacting a law on contraceptives due regard has to be given to their impact on the matrimonial relations. It should be enacted in such a way as not to adversely affect the marriage laws bearing particularly on consent, cruelty and divorce.

It is found that in actual practice there is frequent violation of the administrative instructions concerning requirements of consent, age, licensing of individuals or agencies performing the sterilization. No penal sanction exists in case of violation of these official directives. In the absence of proper regulatory law, the executive authorities at different places may adopt different standards, which may lead to arbitrariness in the implementation of the family planning programs. It is, therefore suggested that a proper detailed law about various types of sterilization should be enacted by the Central government which should lay down the relevant norms and guidelines for sterilization as a family planning measure.

In India, there is a high number of unwanted/unplanned pregnancies as well and a significant proportion of those are aborted. More than half of these abortions are done under unsafe conditions. About 8% of maternal deaths are attributed to unsafe abortion in India. Emergency contraception, a low cost, simple and effective remedy can help alleviate this issue. However, despite considerable evidence-based advocacy with the government to promote this method, emergency contraception pills are provided by the private sector, mainly in urban areas. It is time for the public sector to launch a programme for providing emergency contraception. The strategy should be to reach poor, rural women who do not have access to the private sector. It has been estimated that if all unwanted births were eliminated and the unmet need for contraceptives was adequately met, India's total fertility rate would drop to replacement level.

Contraceptive choice

Contraceptive needs have changed dramatically over the past few decades. In 2015-2016, the unmet need of contraception in India was 12.9% of which 5.7 percent was for spacing methods. Several studies show that the unmet need for family planning is the greatest in the 15-19 year olds, in the less educated and poorest households. This underscores the need to provide information and services to the couples who want to limit their family size and space births but are not using contraception. 

The most important strategy that needs to be underscored is the need to translate within the national programme, the concept of informed contraceptive choice. This broadly includes the treatment of development as a freedom whereby the people have the capability to make informed decisions about their lives. The principle of “the rights if couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so” needs to be operationalised within the national programme. To enable couples as well as individuals to achieve their reproductive goals involves the facilitation on the part of the government to provide a choice of contraceptive methods. 

India’s public sector programme provides several contraceptive methods- female sterilisation, male sterilisation, IUDs, oral contraceptives, injectable contraceptives, and condoms. But the spacing methods account for a very small fraction of just 11%. The increase of spacing methods from 2005-2006 and 2015-2916 is a little more than 1%. Out of all modern methods 36% are female sterilisations and male sterilisations account for only 0.3%. This data indicates that the programme has not succeeded in providing contraceptives to space births, neither has it been able to reach men. Bias towards female sterilisation and a narrow range of choices of modern spacing methods are especially problematic for women who are not ready for a limiting method, consequently insufficient spacing between pregnancies leads to complications resulting in poor maternal and child health. 

Administrative measures

The NFHS-4 data shows that although the number of spacing methods are small it is mostly provided by the private sector. The public sector should encourage strategies to engage the private sector through special marketing and social franchising initiatives. The public sector, which is the major provider of family planning services and the only provider especially for the poor must be strengthened so that a choice of methods can be provided by delivering quality services. The need to strengthen infrastructure, human resources management, accountability and governance of the public health system is ever important now as these are the major impediments to deliver family planning services. This can be done through improving the quality and reach of family planning services that will not only address the issue of unmet contraceptive needs and accelerate fertility reduction but also have an impact on mortality.

Women’s autonomy

An integrated approach must be designed by using a gender lens because the lack of women’s autonomy in reproductive decision-making compounded by the lack of men’s involvement and responsibility in sexual and reproductive health matters which lies at the centre of the problem. Men’s involvement in family planning is negligible in India. In 2015-2016 a mere 9.4% of married couples used male methods or couple dependent contraceptive methods. The need to design strategies to increase male participation is obvious. 

Women's health advocates call for an approach in which women's health and reproductive needs shape the health and family planning services that they receive and their confidence and ability to make reproductive decisions is enhanced. This approach recognises that there are unequal power relations between men and women, between providers and users of services and between the state and its people. Women's health advocates have critiqued the process of contraceptive development because it ignores these power differentials. They have opposed the introduction of new methods into the public sector programme because of the inadequacies of its delivery system. They argue that the process of contraceptive development must incorporate a more comprehensive analysis of the contextual factors that can affect their safety and effectiveness. They advocate for a participatory approach in which women and men are involved in setting the parameters for developing appropriate technologies.