The power of choice to plan families

Bindiya Devi lives in Okri, a small hamlet in southern Bihar’s Jehanabad district. Like most of her counterparts in the area, she is industrious and adept at multi-tasking – a typical day starts off with a race to finish the household chores after which she rushes off to the fields where she works as a small-time agricultural worker.

Bindiya’s life isn’t ideal but it’s the demand of providing for a large family. In fact, this is the lived reality of several families in Bihar, a state where, on an average, a woman has around four children whether or not her health or financial position allows it.

Ask Bindiya why, in times when making ends meet is becoming tougher than ever, does she not limit the size of their family, and she replies: “Do we have another option?” She goes on to describe the prevailing situation when it comes to accessing contraceptives, “Doctors visiting the health centre emphasise the need for a gap between pregnancies. But our choices are limited. Apart from taking birth-control pills that I have to procure, sterilisation seems to be the next best option.”

Bindiya belongs to a generation of rural women that is aware of the merits of planning their family but then, it’s not enough to know. What is even more essential is to have the freedom to choose the method they feel would be most suitable to their needs and gain access to it. And this is not true just for the women in Bihar or Uttar Pradesh, which are priority states because of their high total fertility rates (in UP its 3.4), but in the rest of the country as well.

As such, India’s family planning agenda has traversed a long trajectory to arrive at a strategy that transcends the simple goal of controlling population growth to one of ensuring better maternal and child health outcomes, reducing morbidity and mortality among mothers and young children, and promoting a choice-based approach to contraception. It was the National Population Policy of 2000 that first acknowledged the centrality of quality of care and gender equity as part of the overall reproductive health agenda. Later, at the 2012 London Summit of Family Planning, India, along with 60 other countries, pledged to increase women’s access to family planning services by 2020. As part of the FP2020 commitments, a gradual outlay of over two billion dollars has been earmarked to provide services to an additional 48 million women in the country.

More recently, the mandate for securing women’s reproductive rights has been further consolidated by the Sustainable Development Goals. Family planning plays an important role in achieving multiple targets: Goal Three concerning ‘good health’ and Goal Five related to ‘gender equality’ call for reduced maternal mortality, reduced premature, neo-natal and child deaths and universal access to sexual and reproductive health care and rights, including family planning information and education.

The need of the hour has been established: India needs to move on from a strategy that willy-nilly depends on female sterilisation to control the family size and consciously work towards scaling-up investment and service delivery across all states and especially in 246 districts that have significantly poor public health indicators.

However, here’s a reality check: a new study by the Population Foundation of India (PFI) that focuses on projections about India meeting the FP2020 commitments cautions that at the current rate of increase of modern contraceptive prevalence, the country will have about 32.8 million additional users by 2020, that is, about 15 million short of the committed goal.

Although greater focus on strengthening the health system’s capacity to reach the unreached and improve service quality are central to filling this gap, efforts to do so have, so far, been uneven. The PFI study suggests encouraging public-private partnership models along with much higher health allocations by the government. 

As such, grassroots women do feel the paucity of contraceptive choices. Kusiya Devi, from Saharanpur in UP, expresses her disappointment on the fact that family planning continues to solely be a woman’s responsibility. She says, “Advertisements talk about condom use but it is very difficult for women to demand it of our men.”

 Rajni, another resident of Saharanpur, says, “I went in for sterilisation because I felt it would the easier thing to do. However, I fell sick after the procedure and had to be taken to the city for treatment.”

Even in urban areas, women point to the absence of awareness and advocacy on reproductive health. Anisha Sharma, 35, an education professional in New Delhi, says, “Often it is only by suffering through adverse consequences that one comes to know what methods to use and what to avoid.”

Ultimately, family planning has to be about a woman’s dignity, privacy and safety, promises that can be fulfilled by mobilising public funds for wider availability of modern contraceptive methods – including intra-uterine device, condoms, male non-scalpel vasectomy, injectables, pills, and so on – and assuring reproductive rights. To deliver on these, three aspects need to be factored in: understanding the role of private sector in family planning; providing quality assurance mechanisms at the ground level; and creating avenues for community involvement in generating demand.

(Names of the women quoted have been changed to protect their identity.)