Women and the burden of birth control: New data tells the same old story

As India’s population surges, projected to take over China’s by 2023, women continue to shoulder family planning burdens. The latest National Family and Health Survey (2019-2021), released by the Ministry of Health and Family Welfare, shows a massive disparity between sterilisation rate among married women (38 per cent) and married men (0.3 per cent) in India. In the wake of the upturning of the Roe vs Wade ruling in the US, the disparity undercuts India’s claim at a more forward-thinking approach to birth control.

Birth control disparities  

The fifth installment of NFHS revealed a surge in female sterilisations in 14 of India’s 36 states and Union Territories. The highest number of female sterilisations is in rural Andhra Pradesh, at 70.2 per cent. In fact, the southern states of Telangana (62.2 per cent), Karnataka (59.9 per cent) and Kerala (49.4 per cent) follow Andhra closely to post some of the highest numbers of rural women sterilisations in 2019-21. These states have also posted higher numbers in the use of contraception.

Conversely, states in the Northeast have posted the lowest sterilisation data, with rural Manipur ranking at the bottom with only 3.2 per cent of female sterilisation.

Notably, the lowest female sterilisation rate is almost equal to the highest instance of male sterilisation rate — Himachal’s statewide rate of 3.3 per cent. Most states have less than 1 per cent of their married males practising sterilisation, in urban as well as rural areas. The nationwide sterilisation rate among men, meanwhile, has remained identical since the last NFHS (2015-16), at 0.3 per cent.

Contraception, on the other hand, has seen a bump across the board, with nationwide numbers showing a substantive surge of 6.2 per cent. The percentage of married men using condoms rose to 13.6 per cent in the urban areas. The rural areas still lag far behind at 7.6 per cent. Crucially, contraception in women saw an opposite trend, with more women in rural areas (5.4 per cent) choosing the birth control pill as opposed to their counterparts in the cities (4.4 per cent).

Rural areas also lead in unmet need for family planning, including an unmet need for spacing, at 9.9 per cent, as opposed to 8.4 per cent in urban areas. NFHS defines unmet need for family planning as fertile women who are not using contraception but who wish to postpone the next birth (spacing) or stop childbearing altogether.

Moreover, the United Nations Population Fund’s (UNFPA’s) State of the World Population Report 2022 reveals that more than 20 per cent users of female sterilisation in India were not informed that the method is permanent. The report also revealed that unsafe abortions are the third leading cause of maternal mortality in India, with close to eight deaths related to unsafe abortions each day. Between 2007-2011, 67 per cent of abortions in India were classified as unsafe.  

 

In India, it is possible to get an abortion provided the conditions under the Medical Termination of Pregnancy Act, 1971, are followed. However, while abortions are not illegal per se, they remain stigmatised in most Indian households.

Government measures

Clearly, despite the rise in contraception among men, the onus, risks, and stigma of birth control still falls squarely on the woman’s shoulder. The health and family welfare ministry has taken steps to remedy this though. The Jansankhya Sthirata Kosh (JSK), an autonomous body under the ministry, has implemented several ground-level schemes to spread awareness regarding birth control, contraception, and family planning. Prime among these is the Mission Parivar Vikas aimed at substantially increasing access to contraceptives and family planning services in 146 high fertility districts with a total fertility rate (TFR) of three and above in seven high-focus states including Uttar Pradesh, Bihar, Rajasthan and Madhya Pradesh, Chhattisgarh, Jharkhand and Assam that together constitute 44 per cent of the country’s population. Besides, the JSK has also pushed for new contraceptives including injectable contraceptives, adopted by 0.6 per cent of the married population across India, according to NFHS-5. The ministry has also extended compensation schemes for both sterilisation acceptors as well as the service providers.

Most of the clinical outreach conducted by the JSK is carried out by teams of Accredited Social Health Activist (ASHA) and Anganwadi workers, who deliver contraceptives and pregnancy test-kits to far-flung and geographically difficult areas and educate families about spacing.

Grassroot issues

However, even with such measures in place, why does rural India experience such a massive disparity between sterilisation rate among married women and men? The issue, it seems, is of a more deep-rooted cultural nature. Speaking to Business Standard, A R Sindhu, general secretary of All India Federation of Anganwadi Workers and Helpers (AIFAWH), pointed out how both the participants and the government’s approach to birth control have remained focused on women. “Most of the government’s programmes are driven by population control rather than ensuring the reproductive health of both men and women,” she said.

In primarily patriarchal societies, sterilisation among men is seen as an affront or attack on their masculinity. “This is why, while you would see several public personalities have endorsed various aspects of family planning across awareness programmes, no male public personality has openly endorsed male sterilisation,” Sindhu added.

An overwhelming majority of ASHA and Anganwadi workers are also women, and there have been no efforts made to expand the workforce to include male members dedicated to educating men. Moreover, ASHA and Anganwadi workers remain very poorly compensated for their services. Anganwadi workers receive Rs 4,500 per month, whereas ASHA workers get Rs 2,000. A few states can add to this income, with Anganwadi workers earning up to Rs 10,000 a month, but with ASHA workers receiving an extra state-sponsored monthly income of no more than Rs 7,000.

K Dhanalakshmi, the state general secretary of ASHA Workers’ Association in Andhra Pradesh, also pointed out how, for many families, female sterilisation becomes an easily executable option right after Cesarean births. ASHA workers also face resistance to discussions around male sterilisation, thanks to a common but incorrect perception among men that the operation will confine them to bed rest for 3-4 months. In several rural families, which depend on day wages, the misplaced perception of a loss of occupation for so long is a prominent deterrent against male sterilisation. “The possibility of persuading the men for sterilisation seems quite far fetched as of now,” Dhanalakshmi added.

KS James, head of the International Institute of Population Sciences, agrees that India’s population control policies have been primarily targeted toward women and that there remain a lot of myths and false beliefs deterring a ready acceptance of male sterilisation in our societies. However, he insists that the solution to such a deep-seated problem needs to come from a more comprehensive change in our social structure. “The female labour force participation in India is also very low. A corollary to such low participation rates is the perception that it is then the woman’s responsibility to care for the home, including childbearing and rearing,” he said. “In most developed nations, the increase in women’s participation in the labour forces was a major impetus for fundamental and far-reaching overhauls in socio-economic structures and responsibilities. That needs to happen in India.” According to the Centre for Monitoring Indian Economy (CMIE) India's female labour force participation stands at 9.4 per cent as of December 2021.

Dhanalakshmi and Sindhu also push for long-term solutions, including better compensation for ASHA and Anganwadi workers, improvement in public healthcare, participation of doctors and medical personnel in spreading ground-level awareness, and most importantly, a shift in the focus of government policies towards educating men in remote areas.   

Translation inputs by Akash Podishetty