In rural India, domestic violence is easier to talk about than sexual health

Seema Bhaskaran, Lead-Gender, Transform Rural India emphasises that in India, where discussions on sexuality and even basic bodily functions such as urination and defecation are shrouded in secrecy and taboos, adolescents, young women, and men lack a space to access information and knowledge about sexuality, reproductive health, and contraception options

A capacity-building initiative to establish the gender resource centre in Madhya Pradesh, brought up some interesting facts recently. It was found that community resource persons could successfully address issues such as domestic violence and human trafficking within rural communities but encountered difficulty when it came to engaging women to discuss family planning and contraception.

Despite the positive impact of ASHA workers and programs like Janani Janma Suraksha in enhancing reproductive health services, women’s decision-making power regarding their bodies and fertility remained constrained within the patriarchal family structure. The community resource persons also found that women in a particular area often sought medical care at facilities known for sex-selective abortions. The pressure to have sons often grows as economic prosperity and social status increase. Men tend to take charge of contraception and family planning decisions, diminishing women’s autonomy over their bodies.

Meanwhile, according to the National Family Health Survey (NFHS-5, 2019-21), access to family planning measures has increased for rural women. Total fertility rates have decreased to 2.0, approaching the replacement level, which indicates improved access to contraception. The most commonly used family planning methods among the rural population, as per NFHS-5, are sterilisation procedures like tubectomies, followed by condoms. Among currently married women aged 15 to 49, 38 per cent use female sterilisation, followed by male condoms (7.6 per cent) and pills (5 per cent). A concerning finding from NFHS-5 is that 67 per cent of women use abortions as a family planning method, often in unsafe conditions, which is a major contributor to maternal mortality.

Social norms and myths about masculinity also affect reproductive health and contraception

Reproductive health and family planning programs have often instrumentalised and targeted women’s bodies for contraception and family planning measures. In India, where discussions on sexuality and even basic bodily functions such as urination and defecation are shrouded in secrecy and taboos, adolescents, young women, and men lack a space to access information and knowledge about sexuality, reproductive health, and contraception options. Moreover, the desire for male offspring and the practice of sex-selective abortions, along with the misconception that vasectomies could affect men’s masculinity, place the burden of family planning responsibility on women.

Globally, approximately 40 per cent of pregnancies are unintended, occurring either too soon or unwanted. In the Global South, which primarily includes Africa, Latin America, Asia, and Oceania, an estimated 43 per cent of pregnancies are unintended, with 84 per cent of them affecting women with an unmet need for reliable contraception. If all unmet contraception needs in low-income regions were met, unintended pregnancies could decrease by approximately three-quarters and maternal deaths could be reduced by a third. Most of the evidence comes from the Global North, encompassing North America, Europe, and parts of Asia, where barriers include a limited understanding of the reproductive cycle, fertility, and ‘safe’ periods, as well as an overestimation of the effectiveness of withdrawal methods. Women often lack knowledge about accessing services and using contraception correctly, and they face challenges in integrating this knowledge into practice (Source: The European Journal of Contraception and Reproductive Health Care).

The increase in contraceptive use between NFHS-4 (2015-16) and NFHS-5 also corresponds to the rise in women’s education levels and the impact of reproductive health programs. It is also associated with the promotion of institutional deliveries and monetary incentivisation through Janani Suraksha Yojana, contributing to the reduction of maternal mortality rates in India and improved access to institutional services. On the other hand, tubectomies are often linked to the second delivery in institutions, where women receive advice from healthcare providers, and this practice has gained familial and social acceptance.

However, this practice encounters setbacks when a family already has two girls and desires a boy, and the women’s bodies undergo multiple conceptions in pursuit of a male progeny. The ASHA program of the National Health Mission, linked with incentives for institutional delivery, has played a significant role in enhancing information and knowledge, enabling women to utilise family planning measures.

Way forward to enhance reproductive health care

To achieve the goals of the reproductive health program, we must enhance access to institutional services in remote and underserved areas. We need to ensure the quality of services, including labor rooms and access to contraception. Women should receive information and knowledge to empower them to make informed choices about their bodies, fertility, and contraception. This will help prevent unintended pregnancies and support proper spacing and maternal healthcare. It is also important to ensure that the broader network of Self-Help Groups (SHGs) aligns with the reproductive health program. Moreover, it is crucial to dispel patriarchal myths surrounding the body, sexuality, contraception, and reproductive rights.

Also, it is important to introduce sex education into adolescents’ curricula as a means of providing them with information and promoting bodily autonomy. This will help dispel false myths about masculinity and encourage men to share responsibility for contraceptive use. Similarly, gender equality goals should be integrated into reproductive health and family planning programs, empowering women with information and choices to care for their reproductive health.

*Seema Bhaskaran is the Lead-Gender at Transform Rural India, an organisation that is designing solutions to transform rural localities in India