- Definition of the Problem
Family Planning Programme
Family planning in India is largely a government sponsored program under the Ministry of Health and Family Welfare. The national family planning program in India was first launched in 1951. This was first governmental population stabilization program in the world. The program later underwent an expansion to include maternal and child health, nutrition and family welfare. The common methods of Family Planning include condoms, birth control pills, Intrauterine devices (IUD) and sterilization. Government efforts to implement Family Planning Programmes have had a significant impact in the country. It is estimated that by 1996, the program had averted approximately 168 million births. While family planning has helped reduce the population growth rate in India, diversification of government strategy from one that focuses mainly on women to that which promotes inclusivity of both men and women is the key to attaining population stability.
During the early 1970s, India’s Prime Minister Indira Gandhi, implemented a mandatory sterilization programme, but it did not succeed (Visaria, Jejeebhoy & Merrick, 1999). Under the program, men with more than one child were supposed to undergo sterilization. However, the program was misused and many unmarried men, poor men, and political opponents ended up being sterilized. The negative aspects in terms of wrongful use of the program are still in the memory of many Indians and it is believed to be the cause of the wrong public perception that Indians have towards family planning (Visaria, Jejeebhoy & Merrick, 1999). Its effects went on to hamper Government programmes on family planning for decades but presently people have begun to appreciate the concept of family planning albeit in a slow but gradual pace.
Contraceptive usage
Contraceptive usage in India is still quite low due to low literacy levels among females coupled with the limited availability of birth-control methods. Most married women in India are aware of contraception methods. However, there still exists a problem of choice access to contraceptive methods for a majority of married Indians. A 2009 study indicated that about 76% of married couples face this problem (Department of Family and Community Health W.H.O, 2009). In 2009, only about a half of married women, 48.3% used contraceptive methods (Department of Family and Community Health W.H.O, 2009).
In the period between 1965 and 2009, the use of contraceptives among married women increased threefold from 13% in 1970 to 48% in 2009 (Department of Family and Community Health W.H.O, 2009). Of those who used contraceptives, about 75% used female sterilization (Department of Family and Community Health W.H.O, 2009). This method is also the most preferred birth control method in India. The use of condoms, which is the next most preferred method, was at 3%. The Indian state of Meghalaya recorded the lowest rate of contraceptive usage at 20% (Department of Family and Community Health W.H.O, 2009). Only three states recorded levels of contraceptive usage that were below 30% (Department of Family and Community Health W.H.O, 2009). These were, Meghalaya, Bihar and Uttar Pradesh.
Fertility rate
Overpopulation is a major problem in India. Although India’s fertility rate is on the decline, it is yet to reach replacement rate. In the period between 1960 and 2009, India’s fertility rate declined by more than a half. In 1966, fertility rate was at 5.7; this reduced to 3.3 by 1997 and was at 2.7 by 2009 (Sidkar, 2011). However, this rate is still high enough to sustain long-term population growth. Presently, the replacement rate is about 2.1 for most developed nations and about 2.5 for developing nations (Sidkar, 2011). Populous nations often target to attain the replacement rate as it helps to control inflation. When a country is able to go below the replacement rate, population stabilization can be achieved and in the long run it is possible to have population reduction. However, this requires a check on immigration and population momentum effects (Ramu, 2006).
Comparative studies indicate a strong correlation between increased levels of female literacy and decline in fertility (Jejeebhoy & Sebastian, 2003). It has also been shown that female literacy levels are a strong predictor of contraception use even in cases where the women do not have economic independence. It is argued that the level of female literacy in India plays a huge role in population stabilization. However, there is a challenge in the progress towards achieving the universal literacy level for women (Jejeebhoy & Sebastian, 2003).
Family Planning Performance
Family planning in India continues to perform well over the years as people increase contraceptive use. In the 2010-11 year, India recorded 34.9 million family planning acceptors (MedIndia, 2011). Of this, there were 5 million sterilizations, 16.0 million condom users, 5.6 million IUD insertions, and 83.07 million O.P. users (MedIndia, 2011). This was a drop as compared to the 2009-10 figure of 35.6 million family planning acceptors (MedIndia, 2011). In the 2010-11 period 16.335 million births were prevented through the use of various Family Planning measures (MedIndia, 2011). This was also a drop compare to the 2009-10 figure of 16.605 million (MedIndia, 2011). Since the inception of family planning, a cumulative total of 442.75 million births have been avoided in India. Family planning has its advantages. It reduces unintended pregnancies, averts abortions, improves maternal health, prevents HIV/AIDS spread, and promotes environmental sustainability and development (MedIndia, 2011).
- Existing strategies that are already attempting to address the Family Planning Problem
In India, the family planning division of the Ministry of Health and Family Welfare is responsible for the development of Family Planning programs. Under the current system, the government develops indicators to monitor the success of its family planning program. Currently, the key indicators are as follows: The Total Fertility Rate which is the number of children that a woman is able to bear during a reproductive years is 2.5 (Sidkar, 2011). The Contraceptive Prevalence Rate which is the number of couples using some form of contraception is 54% (Sidkar, 2011). Unmet Need which represents the percentage of women not prepared to get pregnant but are not using contraception is 21.3% (Sidkar, 2011). The current percentage use of contraception is as follows: Female sterilization at 24%, Male sterilization at 1%, Pill usage at 4%, IUD at 2%, Condom at 6%, Traditional methods at 7%, Non users at 46% (Sidkar, 2011).
The governments’ program on family planning is outlined as follows:
Family Planning as priority
Slogan: Family planning is a core part in government efforts to ensure Universal Access to Health within the 12th Five Year Plan period.
Paradigm shift in policy: The goal of family planning has shifted from population control to improvement in maternal health care
More Focus on Spacing Methods
The National Rural Health Mission (NHRM) has employed a huge workforce to assist in delivering on family planning policies. This workforce is comprised of Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs).
- Accredited Social Health Activists (ASHAs): Their duty is to make contraceptives available at the doorstep. They also help delay the age of women at first childbirth and help them space between births
- Auxiliary Nurse Midwives (ANMs): Give IUCD services on specific days at communal centres.
Objectives
- Provide information, commodities and services on spacing methods to as many people as possible in every part of the country
- Deliver and improve on services for limiting child bearing
Family Planning Interventions
Programmatic Interventions
Promote spacing methods through IUCD, minilap tubectomy, post partum FP services, male participation, fixed day strategy and deployment of counsellors to high delivery facilities.
Promotional interventions
Improve on compensation scheme, family planning insurance scheme, promote contraception through increased advocacy and promote public private partnership.
Contraceptive Choices
Spacing Methods: These include Condoms, Oral contraceptive pills and IUCD.
Limiting Methods: These include Vasectomy and Tubectomy.
Emergency Contraceptive Pills
Expansion of Contraceptive Choices
Introduction of Post Partum IUCD and introduction of Cu IUCD 375
Other Interventions
Establishment of Quality Assurance Committees and a gradual shift from the camp model to a fixed day state sterilization service. Also, a scale up in Program Learning for Postpartum Intrauterine Contraceptive Device (PPIUCD) in the States
New Schemes
Contraceptive delivery to homes by ASHAs: The goal of this program is to improve contraceptive access by couples.
ASHAs to charge a nominal fee for the contraceptives as follows: Rs 1 for a 3 condom pack, Rs 2 for 1 pack of ECP, Re 1 for 1 cycle of OCPs (Sidkar, 2011).
Promotion of Spacing after Marriage, & Between 1st & 2nd Child
A payment schemes is to be established to reward those who promote spacing as follows: Rs. 500/‐ to ASHA who ensures a 2 year spacing after marriage, Rs. 500/‐ to ASHA who ensures 3 year spacing after 1st child, Rs. 1000/‐ if a couple opts for permanent limiting after the birth of a maximum of 2 children (Sidkar, 2011).
Scheme Evaluation
Scheme evaluation by three independent agencies found that 62% of the people are aware of ASHAs, 95% of women are satisfied with the scheme, 65% cite easy access as a reason to procure from ASHAs, 53% were willing to pay for services and 86% ASHAs believe in long term success of the scheme (Ministry of health and Welfare, 2011). The evaluation also found that ASHAs feel empowered and are confident in distributing the contraceptives.
Inference from Evaluation
The scheme has been successful since its inception. It is largely acceptable and satisfactory to a majority of people. ASHAs are important distributors of contraceptives in rural areas. They are also comfortable and happy with their work.
Critique
While the government approach to family planning seems to work, it may not meet the set targets in achieving population stability due to its one sidedness in dealing with family planning. The plan seems to focus mainly on intervention programs for women. Male programs are scarce and have not been given appropriate attention. The apparent lack of serious focus on both genders in a more equal capacity may prolong the progress towards population stabilization than should be necessary. Family planning should involve a couple and not one of the spouses, for it to be highly effective. The inclusion of more male methods of family planning in the model can help increase the effectiveness of the plan. Also the plan should find ways to increase male participation in family planning program in a similar way to that of the ASHAs as a way to diversify the program and increase its effectiveness.
- Program Proposal to Address Family Planning
The current approach to family planning in India lays a lot of emphasis on birth control for women while there is little effort towards contraceptive methods for men. A sound family planning policy should comprise of three objectives: An immediate objective, a medium term objective, and a long term objective. In India, the immediate objective would be to cater for the current unmet needs of contraceptives, reproductive and child healthcare. The medium term objective can be to achieve replacement level fertility by the year 2020. In the long term, the government may target to achieve population stability by the year 2050 (Shanti & Camp, 2005).
A situational analysis of India would reveal that a majority of Indians are willing to use contraception. To address this unmet need in contraception, the government should develop manpower to deliver family planning services. The current family planning scheme by the government is skewed towards women. There is little detail on male approaches to family planning. An alternative to this plan is to develop a male oriented family planning scheme that will ensure that men participate as much as women.
The gender inequalities in India favour men over women. However, pregnancy is caused by an interaction between the couple. By focussing on one half of the problem, it becomes difficult to remedy it because even though one side may be cured, the other half can still cause harm. Male participation is important. A shift in family planning responsibilities from females to males can ensure that population stabilization is attained within a shorter period. There are a number of male family planning methods such as NSV and tubectomy. NSV has several advantages in that it is scapel-less, stitchless, safe, short and simple (Shanti & Camp, 2005). Tubectomy is also good. Its advantages are that it does not require a surgeon to conduct, no anesthesia is necessary in the process and it has less operative distress (Shanti & Camp, 2005).
Discussion of the Political Context and Anticipated Outcomes of the Intervention
The male oriented approach is likely to face resistance especially due to the male dominated culture of the country. Traditionally, it is men who make the rules on sexual and reproductive health in India. It may be a challenge for the men to develop family control policies for themselves given the patriarchal system that exists in India. However, for there to be significant progress towards population stabilization, men must be encouraged to participate more in the program. It is expected that increased participation by men in family planning will significantly increase the number of avoidable pregnancies and as such make a huge contribution towards population stabilization (Jejeebhoy & Sebastian, 2003).
References
Family Planning: An Overview. Retrieved from http:/ / www. searo. who. int/ linkfiles/ family_planning_fact_sheets_india. pdf
Jejeebhoy, S.J. and M.P. Sebastian. (2003). “Actions that protect: Promoting sexual and
reproductive health and choice among young people in India,” Population Council
Regional Working Paper No. 18, New Delhi.
MedIndia Family Planning Programme In India - 2011
Retrieved from http://www.medindia.net/health_statistics/general/family-planning-programme.asp
Ministry of health and Wefare. (2011) Family Health Statistics in India 2011. Retrieved from
mohfw.nic.in//972971120FW%20Statistics%202011%20Revised%203.
Ramu, G.N. (2006). Brothers and sisters in India: a study of urban adult siblings. Toronto:
Sidkar, S. K. (2011) A Review of Family Planning Program in India. Retrieved from
www.icmr.cami-health.org/articles//Session2-Speaker2-SKSikdar.pdf
Shanti R. C., and Sharon L. Camp. (2005) "India's Family Planning Challenges: From
Rhetoric to Action." In The Population Crisis Committee (Now Population
International), CountryStudies Series #2. Washington D.C.
Visaria, L., S. Jejeebhoy and T. Merrick. 1999. “From family planning to reproductive health:
Challenges facing India,” International Family Planning Perspectives 25: S44–49.
