‘Male engagement in family planning could act as a catalyst in improving contraceptive uptake’

Poonam Muttreja, Executive Director, Population Foundation of India, in a conversation with Viveka Roychowdhury, elucidates about the need to focus on dispelling myths and misconceptions. She also talks about many benefits in terms of health and nutrition outcomes which will result in a better uptake of contraceptives and an increased shared responsibility within the family

What have been the major developments in family planning and reproductive health in India in the past year?

The year 2016 has been a significant one in terms of developments for family planning in India. To my mind, the most notable of these has been the Supreme Court verdict on the Devika Biswas Vs Union of India case, which has greatly encouraged many of us, who work in this field. What makes the judgment exceptional is the fact that it lays out the groundwork for organisations and people who anchor their work in a human rights framework, to come together – and work in concert to make sure that the guidelines that have been laid down are implemented and adhered to.

Additionally, the judgment has three critical directives that make it a defining moment in family planning legislation. It calls for: the phasing out of sterilisation camps in the next three years; asks states and Union Territories to desist from setting targets, which could be misused to coerce people into undergoing sterilisation; and lastly, directs them to make family planning programmes better in terms of access to doctors that are empanelled, availability of information in the vernacular, and making certain that the client has been fully informed about the pros and cons of the procedure before deciding to go for it – all these combine to tackle the challenges hitherto prevalent in this regard.

On the need to increase the method mix of contraceptives on India, we witnessed the forward-looking steps taken by the Ministry of Health and Family Welfare (MoH&FW) in the family planning programme, including the introduction of three new modern spacing methods, which included: injectable contraceptives, progestin-only pills and centchroman in 2015. These have all been supported by an implementation plan and a series of trainings to ensure smooth and effective delivery.

India is still a fairly patriarchal society, what have been the approaches which have succeeded in family planning and reproductive health rights?

The existence of patriarchy has led to an all-round infringement of women’s rights and in the process also impacts deterioration of women’s health in the country, adding to the already existing adverse health outcomes for women in general – early marriage, early age of pregnancy, desire for a son which leads to several abortions and pregnancies, lack of education and choice. There is a need for policies that are more’ comprehensive, which keep girls and women at the centre of the policy framework with an approach that focuses on empowerment as opposed to welfare – and which is not dictated by just an elevation of indicators. There is a need to translate the language of rights into action plans.

We need sustained engagement of men in reproductive health and family planning practices and services – not just as clients, but as responsible partners. This has the potential to dramatically improve the use of family planning services and bridge the gap of current unmet need for contraception, which according to NFHS III stands at 12.8 per cent. Evidences suggest that male engagement in family planning could act as a catalyst in improving contraceptive uptake in an already aware and willing population (according to NFHS-III) apart from system issues such as accessibility or availability etc.

Given that the contraceptive use by men in India is riddled with social barriers and challenges, a systematic integrated approach with IEC activities for women and men are required. There needs to be a targeted focus on dispelling myths and misconceptions and on presenting the many benefits in terms of health and nutrition outcomes for the family with messages which will work. This would result in a better uptake of contraceptives and an increased shared responsibility within the family. Towards this end, we need sustained behaviour change communication and on-ground work to engage men while promoting women’s rights and decision making. This is absolutely vital.

Population Foundation of India (PFI) has been working to bring about behaviour change through its edutainment TV series called Main Kuch Bhi Kar Sakti Hoon – I, A Woman, Can Achieve Anything (MKBKSH), targeted at men, women, couples, adolescent girls and boys. We believe that the overwhelmingly adolescent population in India is a demographic advantage that we need to capitalise on. Targeting them to bring about the necessary mindset and behaviour change will impact the overall healthcare status of India in the long-run. The series episodically touches upon various aspects of family planning and reproductive health and the myriad prevailing social taboos. It has been well received with the audiences and has shown us that by weaving appropriate messages into a compelling story that entertains, educates and resonates, edutainment increases knowledge, promotes positive attitudes and changes behaviour.

What percentage of the health budget gets spent on family welfare?

An adequate budget is the key to sustaining a number of important initiatives under the country’s Family Planning Programme. The allocation for health in 2016’s budget has been increased by 22 per cent over the previous year’s budget estimated at ` 39,533 crores. However, despite the increase on paper, the relative importance to health in the budget is inconsequential.  The share of family welfare increased marginally from four to five per cent of the health budget in 2016. The Health & Family Welfare Budget estimate for the current financial year is around 3.7 per cent of the total central government budget, which is almost the same as that of the FY 2015-16.

As per the Economic Survey of 2015-16, Government of India’s public spending on healthcare is only 1.3 per cent of GDP, which is about 4.9 per cent  of the total Government expenditure. This is substantially lower than many developing countries such as Sri Lanka and Cuba which spend 2.0 per cent and 5.5 per cent respectively. Even though allocations for health have risen three – fold from 2005-06 to 2014-15, spending on health and family welfare as a percentage of the overall expenditure accounted for less than two per cent.

Much higher allocations are necessary to successfully carry forward the family planning agenda with a sharpened focus on reproductive health and rights, quality of care and spacing methods.

Given that 70 per cent of India’s population is in the reproductive age group, how much does India spend on contraception, family planning as part of the health budget? Is this sufficient?

India’s population has a huge youth bulge which is in the reproductive age group. Currently, as the 2011 Census shows, the country has over 225 million adolescents (10-19 years), which is around 21 per cent of the population and over 189 million youth (15-24 years), which is 19 per cent of the population. Together they form 311 per cent of India’s population. Given India’s young population, it is important that comparative attention is paid to spacing methods with a budget that is adequate – this needs to be much higher than the current 1.45 per cent of the total family planning expenditure. Based on the MoH&FW approval to the introduction of new methods and emphasis on spacing methods in the family planning programme, there is a need to increase investments in family planning. These are essential requirements to address the unmet need in family planning and for India’s economic and social sustainability.

Investments in family planning contribute significantly to improving the health of women and children. An analysis of India’s recent family planning budgets reveals that the Family Welfare Budget of the Central Government (Department of Health and Family Welfare) actually reduced by 87 per cent, from Rs 12,278.65 crores in 2013-14 to Rs 1605.37 crores in 2014-15. Consequently, the share of family welfare in the total health budget of the Central Government reduced from 34 per cent in 2013-14 to 4 per cent in 2014-15. Family planning expenditures constituted just 6 per cent of the Reproductive Child Health (RCH) expenditure and hence two per cent of the National Health Mission (NHM) expenditure in 2013-14.

A PFI study shows that India needs Rs 187.3 billion in the coming four years (almost Rs 47 billion per year) if it has to cover 48 million new users of contraceptives by 2020 (all by the public health system), a commitment made by India at the London Summit on Family Planning in 2012. This is Rs 113.8 billion more than what is projected by the government budget allocation. It is time that the government allocates the much-needed resources and gives family planning a boost. Family planning is a key investment. Let us use it to our advantage.

Several states in India have skewed sex ratios, reflecting high female foeticide rates. How has PFI addressed this issue?

The decline in the child sex ratio – CSR (0-6 years), as reported by the Census of India, from 945 in 1991 to 927 in 2001 and further to 919 females per 1,000 males in 2011 is cause for alarm and urgency. India’s 2011 Census revealed a growing imbalance between the numbers of girls and boys aged 0-6 years, indicating that India is still hesitant to daughters being born.

Out of 640 districts in the country, 429 districts have shown a decline in the child sex ratio. Haryana recorded the worst CSR of 834 while Arunachal Pradesh had the highest CSR of 972. 13 out of 35 states and UTs have CSR lower than the national average of 919.

A declining sex ratio is only the conclusion of a long drawn out matrix of social and cultural interactions. Patriarchal cultural and social norms continue to influence mind-sets and attitudes and promote gender inequalities on a daily basis in peoples’ lives. In addition to the awareness campaigns and advocacy with the stakeholders, including elected representatives, corporates, civil society and media at the state and district level in more than 10 states, PFI embarked upon a multi-media edutainment initiative called Main Kuch Bhi Kar Sakti Hoon which translates to ‘I, A Woman, Can Achieve Anything’. Central to the initiative is a soap opera series which aims to increase girls and women’s agency by promoting gender equality, women’s empowerment and access to healthcare. The media initiative has worked to enhance knowledge of social issues such as child marriage, family planning and pre-natal sex selection and challenge discriminatory social norms affecting women and girls.

It has been very encouraging to note that the findings of the endline evaluation which sought to assess changes in the Knowledge, Attitude and Practices (KAP) on family planning, child marriages, son preference, gender discrimination, domestic violence and sex selection, have shown positive changes. They distinctly show that programme has had a measurable and positive impact on the knowledge and perception of the viewers and women’s agency.

A major lacuna in family planning was that there was little choice in contraceptive methods, especially those that put the decision in the woman’s hand. Has the situation improved? Are there contraceptive measures which empower the woman to make the choice hers alone?

Giving women autonomy over their bodies and the power of making decisions related to their sexual and reproductive health is one of the most significant ways to empower women. Family planning plays a major role in this and access to contraception and choice is one of the most effective ways of doing so. Efforts need to be undertaken to make women aware that they have the right to decide when and how many children they wish to have as well as the fact that they have the right to access family planning services and counselling. However, it is equally important to ensure that quality family planning services and choice in the method mix is available. These steps will enable her to take informed decisions and choices.

According to the UN Committee on Economic, Social, and Cultural Rights (UNCESCR), four interrelated and essential elements of the right to the highest attainable standard of physical and mental health are: availability, accessibility, acceptability and quality. However, the availability and accessibility of contraceptive services has been a concern for women in India. As per the National Family Health Survey (NFHS III) data the desired family size in India is less than two children and almost 32 million women’s family planning needs are not met. This indicates that despite the fact that women want to delay or stop childbearing, they are not able to access or use contraceptive methods. The lack of information, insufficient access and limited choice of spacing methods have resulted in India relying heavily on female sterilisation.

Expanding the basket of choices of contraceptive methods is the only way to ensure that family planning doesn’t turn into a forced operation due to a lack of choices and access. Over the past year, things have appreciably improved with the MoH&FW introducing three new methods – Progesterone-only-Pills (POPs), centchroman and injectable contraceptives, to the basket of contraceptive choices. These have not only increased methods which are easily accessible to women but have also made available options which focus on spacing.

This stride made by the Ministry will certainly go a long way in empowering women with the choice and the right to make an informed decision about their sexual and reproductive health.

In 2015, India accounted for an estimated 15 per cent (45,000) of all maternal deaths (303,000) worldwide. India lags other developing nations when it comes to meeting the Sustainable Development Goals (SDGs) related to health, especially where women’s and child health is concerned. What are your recommendations to policy makers to plug the gaps in the current policies and schemes?

India has taken some commendable steps to progress towards ensuring safe motherhood for women in recent years. However, any satisfaction one may derive from the decline in the maternal mortality ratio is tempered by the fact that the country still accounts for a significant percentage of all global maternal deaths.

Rights and empowerment principles are central to strategies for realising the SDG’s and Family Planning 2020 vision and goals. Indeed, much more needs to be done to meet them. There is a need to ensure that human rights are treated as the foundation for the sexual and reproductive health programme in the country.

To begin with, the right to sexual, reproductive and population education is lacking – which itself is a violation of the right to informed decision-making. To exercise full, free and informed decision-making, access to accurate, clear and readily understood information and the full range of safe and effective services that are obtainable should be made available.

Both the choice of methods in family planning and the lack of counseling have on many an occasion led to coercive practices infringing the rights of women and girls. There have been instances where the protocol of quality of care has not been followed, thereby putting women’s lives at risk.

To address these concerns, there is a need for better on-ground implementation of programmes, instituting strict monitoring for quality of care and the formation of a redressal mechanism – to address SRHR grievances for women and men to reach to their full potential.

One aspect of maternal health, often overlooked in India, is unwanted or early age pregnancies and the high unmet need for contraception. According to the NFHS III, adolescents (15-19 years) contribute about 16 per cent of the total fertility in the country and the 15-25 years age group contributes to 45 per cent of the total maternal mortality. Nearly 21 per cent of all pregnancies are either unwanted or mistimed. This not only exposes women to avoidable maternal health complications, it also affects their overall development and well-being. A more accessible and equitable family planning programme that offers a wider choice of contraceptive methods to couples constitutes a simple, low-cost investment which can reduce maternal and child mortality by preventing early age pregnancies and unwanted pregnancies at a later age. The addition of a new method made available to at least half the population correlates with an increase of four to eight percentage points in total contraceptive use.

However, it is important to note that the issue of safe motherhood in India is much wider in scope than providing healthcare and family planning services for women. It involves a wider debate about their education, dignity, and reproductive rights and denying them the choices, they should be making on their own.

What is your vision for the coming year in terms of family planning and reproductive health, and women health issues?

We have started an exciting journey this year with the Supreme Court judgement. We need to be vigilant and monitor the on-ground implementation of the SC directives. The government needs support and we must review adherence to quality guidelines in implementing the injectable roll-out. Alongside, we should look at the successful models in other nations ahead of us on various health indicators and consider adopting good practices and striving constantly to expand the basket of contraceptive choices for women and young people.

PFI will continue to work with the government and other civil society organisations to collate evidences and further expand the basket of contraceptive choices based on scientific evidence and global best practices. In the coming year, we are looking to creatively use the behaviour change communication tools and the media to change the social determinants that inhibit contraceptive use and male participation in family planning.

We look towards greater convergence between the efforts of the government, civil society organisations, parliamentarians and the private sector to collectively take strides towards realising India’s commitments to the FP2020 goals and the SDGs.

What is the role of civil society in India’s policy related to reproductive, maternal, newborn, child, and adolescent health (RMNCH+A)? Is civil society as proactive as required?

PFI does not believe in population control and has worked hard to shift the discourse from control to population stabilisation. In fact, post the ICPD Conference in Cairo in 1994, there has been a paradigm shift in India as well as at the international level with population stabilisation gaining increasing currency. The emphasis on family planning in a population stabilisation framework has further amplified after the 2012 London Summit on Family Planning.

Often population stabilisation continues to be viewed as population control. However, these are two very different concepts. Organisations such as ours, strive towards advancing reproductive rights and choice for women and men. To achieve this, multiple stakeholders, including NGOs and corporates need to work along with the Government. NGOs can play a significant role by: i) increasing public and political participation in family planning and contraception; ii) creating awareness on the need for family planning; iii) advocating for an increased basket of choice and increased budget; and iv) by ensuring a rights-based approach in family planning policy and programmes in the country.

Which are the states which have fare better in terms of family planning and reproductive health? What are the indicators PFI tracks and your comments on successful interventions?

Total Fertility Rate (TFR): TFR indicates the average number of children expected to be born per woman during her entire span of reproductive period. This is assuming that the age specific fertility rates, to which she is exposed, continue to be the same and there is no mortality. The TFR for India in the year 2013 was 2.3 per woman and varies from 2.5 in rural areas to 1.8 in urban areas. Among the major States, the TFR level of 2.1 has been attained by Andhra Pradesh (1.8), Karnataka (1.9), Kerala (1.8), Maharashtra (1.8), Punjab (1.7), Tamil Nadu (1.7) and West Bengal (1.6). Thus, the southern states are faring well in the total fertility rate, which is one of the important family planning indicators.

Among the bigger states, it varies from 1.6 in West Bengal to 3.4 in Bihar.  For rural areas, it varies from 1.7 in Himachal Pradesh, Punjab and Tamil Nadu to 3.5 in Bihar.  For urban areas, such variation is from 1.2 in Himachal Pradesh and West Bengal to 2.5 in Bihar and Uttar Pradesh.

The TFR has a direct and an indirect correlation with various factors such as whether it is a rural or an urban area, education, economic status etc.

Education, more precisely female education, has a direct impact on fertility. To ascertain the levels of fertility by the educational status of women, three indicators viz. general fertility rate, age-specific fertility rate and total fertility rate have been mentioned for rural and urban areas.

The total fertility rate for women having the educational status ‘Illiterate’ for 2013 is 3.1. This is much higher than the ‘Literate’ group of women. Among the ‘Literate’ (2.1), there is a gradual decline of TFR with the increase in the level of education. At the national level, for the same year, the total fertility rate going by the women’s level of education, has been calculated separately for the rural and urban areas.

Education level

The percentage of female population in the age group 15-49 by level of education, at the national level and for the bigger states is described in the table below.  At the national level, 29.0 per cent of the female population is reported as ‘Illiterate’ against 71.0 per cent in the ‘Literate’ category. Of the literate women, about 81.1 per cent have an education up to Class X, 11.1 per cent an education level of Class XII, with only 7.6 per cent having reported levels of graduate or above. Among the illiterates, Kerala 1.1 has the lowest and Bihar 47.7 the highest percentage of illiterate women. Since the TFR has an established relationship with education, it can clearly be seen that the southern states, which have a higher level of education among women have the lowest levels of TFR.

Age at Effective Marriage (AEM)

The Mean Age at Effective Marriage is the age at consummation of marriage. This is almost stagnant and hovered around 20 years between 2005 and 2009. The State level data show variations in the AEM. It is the highest in J&K (23.6) followed by Kerala (22.7), Delhi & Tamil Nadu (22.4), Himachal Pradesh (22.2), and Punjab (22.1) in 2009. Rajasthan (19.8) has the lowest AEM. The AEM in urban areas is higher than the rural one but the difference is just two years. The rural-urban difference is highest (3.1 years) in Assam and the least in Kerala (0.1 years). For more than 50 per cent females in rural areas, the AEM is 18-20 years whereas in urban areas, the AEM is 21+ for more than 60 per cent females.

Medical attention at delivery

While recording the details of every outcome of pregnancy during continuous enumeration and half-yearly surveys, the enumerators and supervisors are required to enquire about the type of medical attention received by the mother at the time of delivery of the newborn or at the time of abortion. In the new sample from 2004, the options on the types of medical attention received by the mother at delivery have been modified to capture the deliveries specifically at private hospitals/nursing homes. The new options include: government hospital; private hospital; qualified professional; untrained functionary and others in comparison to institutional; doctor, nurse or trained midwife; traditional birth attendants; and relatives or others adopted in the 1991 SRS sample. Statement 40 below gives the percentage distribution of live births separately by rural and urban areas recorded in the year 2013 for India and bigger states by type of medical attention received by the mother at the time of delivery. At the national level, 50 per cent births were attended to at government hospitals and vary from 48.8 per cent in rural to 55 per cent in urban areas. Among the bigger states, it varies from 33.1 per cent in Jharkhand to 67.9 per cent in Rajasthan. About 24.4 per cent of births occurred at private hospitals. Medical attention by qualified professionals constitutes 12.7 per cent of the total delivery whereas untrained and others constitute 12.9 per cent. More than three-fourth of deliveries are occurring in institutions and being conducted by qualified professionals.

Though, we at PFI track all the health indicators, we pay specific attention to those pertaining to reproductive and sexual health, as they are of special interest. PFI also closely tracks and analyses the health and family planning budget since synchronisation between the budget and health indicators is a must for the sustainability of any programme.

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