Our beautiful, vibrant and fast-developing country suffers from one significant problem. It is very densely populated. India occupies a miniscule 2.4% of the world’s land area but is home to 17% of its population. And so, population stabilisation — a demographic state where the total population remains unchanged for a considerable period — is a high priority goal intricately linked to many other milestones of the nation’s social and economic development.
We have come a long way since 1952, when the first-ever family planning programme in the world was launched in India. Over the years, it was realised by government and health experts that focus on reducing India’s birth-rate through wide-scale strategies was needed. Since then, efforts have centred on limiting births per family, encouraging birth spacing and improving access to contraception.
The family planning programme has evolved as a critical intervention not only for achieving population stabilisation but also to improve mother and child health and survival. According to the National Population Policy 2000, India should have reached replacement-level fertility rate of 2.1 (an average of 2.1 births per woman) by 2010 to attain population stabilisation at 145 crore by 2045. The National Fertility Health Survey (NFHS) IV data tells us that India’s Total Fertility Rate (TFR) reduced from 2.7 in 2006 to 2.2 in 2016. This six-year delay has had a multiplicative effect and a probable population stabilisation of 2.1 TFR at 165 crore by 2040 is the best we can now strive to achieve.
Our efforts must overcome several barriers to service provision and acceptance. One of our biggest challenges is gender bias: the preference for a male child, resulting in repeated pregnancies till a male child is born.
Secondly, the onus of preventing conception more often falls on women; and only 15.6% of women are informed of all their options.
The government has recognised many of these challenges and has tried to address them through a number of initiatives, as part of a “Vision 2020”, which aims to accelerate access to high-quality family planning choices based on information, reliable services and supplies within a rights-based framework.
The Reproductive, Maternal, Child Health + Adolescent care strategy (RMNCH+A) provides a platform for addressing the reproductive rights while integrating the current family planning services with maternal, child as well as adolescent health.
It is reassuring to note that at present, family planning services are being rendered by 1.8 lakh primary-level public health facilities, more than 6,000 secondary-level facilities and 755 tertiary-level facilities in the country. India has a pool of nine lakh ‘accredited social health activists’ (ASHA), acting as depot-holders for contraceptives at the village level and delivering contraceptives to the doorstep of eligible rural couples.
ASHA workers are involved in counselling beneficiaries on the advantages of spacing, delaying the first birth, ensuring adequate spacing between two children and promoting institutional deliveries to help upscale PPIUCD services. PPIUCD is an intrauterine contraceptive device which is a long-lasting, reversible contraceptive method which is placed in the womb immediately after delivery.
It is a promising option for our country, and currently about 1.5 million women have already benefited from this service. With good counselling during pregnancy, its usage, as well as of other new initiatives is expected to improve in the coming years, as ‘Chaya’, the progesterone-only pill, ‘Antara’, the injectable DMPA, and ‘Saheli’, the non-steroidal pill, are all offered free of cost in public sector hospitals.
Other measures under ‘vision 2020’ are media campaigns and social franchising schemes. This programme is also working to reduce teenage marriages and teenage births, and improving literacy of the girl child. In fact, improvisation on education and empowerment of the adolescent girl on matters regarding reproductive health will be highly productive and take us several steps closer to our goal of population stabilisation.
There is a paradigm shift in service provision from permanent methods of contraception — for example, male/female sterilisation — to spacing methods (like intrauterine devices) for several reasons. One such reason is the huge demographic shift in India’s population with a growing proportion of the youth, making up almost 25% of the total population. Secondly, a target-oriented drive with sterilisation as the goal is now transformed to a target-free approach with better statistical logic.
The government is harnessing the expertise of various partners in the field of advocacy, capacity-building, e-learning modules, social marketing and provision of skilled human resources for successful implementation of the programme.
Strategies for involvement of the private health sector are important to build a firm public private partnership. These efforts will ensure that contraception becomes affordable, accessible and is always the result of a well-informed decision by choice. Hopefully, optimal reproductive health for every Indian woman will be the desired and logical outcome of such intense public health initiatives.
(The writer is an obstetrician and gynecologist)