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Demographic Transition in South India |
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Population Foundation of India works at improving
the quality of life through planned families.
Established in 1970 by a group of socially
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focuses on reproductive, child and adolescent
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programmes and policies with a gender sensitive
and rights-based approach.
New Corrected10.02.12
Special Series Paper
Demographic
Transition
in South India
Leela Visaria
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi - 110 016
Tel.: +91-11-43894100, Fax: +91-11-43894199
Website: www.populationfoundation.in
Population Foundation of India
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The Special Series
The Population Foundation of India is happy to launch the Special
Series papers. The papers will deal with topics vital to the current
discourse on population, stimulating new thinking and guiding action.
It is a privilege to have the first paper in the series, Demographic
Transition in South India, by eminent demographer Leela Visaria. Leela
is an Honorary Professor at the Gujarat Institute of Development
Research. She holds a PhD from Princeton University and is a former
Professor and Director of GIDR.
Poonam Muttreja
Executive Director
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Introduction
The four South Indian states of Andhra Pradesh, Karnataka, Kerala and Tamil
Nadu, where 20.7 per cent or 251 million of India's estimated total population of
1.21 billion (2011 Census) resides, have completed their fertility transition. Kerala
and Tamil Nadu attained Total Fertility Rate (TFR) i.e. the replacement level of 2.1
(which is the average number of children born to a woman after allowing for a slight
mortality factor) in the years 1986 and 1996, respectively. They were followed by
Andhra Pradesh, where TFR of 2.1 was reached in 2004, with Karnataka joining the
league two years later in 2006. Historically, even when time-series data on vital
rates were not available, fertility and mortality measures estimated from the inter-
censal growth rates and the age distribution of population available from the
decennial censuses, showed that fertility in the southern region of India was
somewhat lower than in the rest of the country. This was even though there was no
evidence of a deliberate birth control practice, and when marriage was universal
and also early (Visaria and Visaria, 1982). It is difficult to establish that some of the
traditional practices that impose restrictions on sexual intercourse during the
postpartum period or on certain days of religious importance were more widely
followed in the southern states compared to other regions, leading to somewhat
lower fertility.
Comparatively robust and direct annual estimates of fertility and mortality are
available from 1970 with the advent of the Sample Registration System (SRS). A
number of demographers and other scholars have analysed these and the household
level data collected in national surveys, such as the three National Family Health
Surveys (NFHS) conducted during 1992-2006 and the three District Level
Household and Facility Surveys (DLHS) during 1998-2008 to discern
geographical contours and determinants—proximate and cultural and socio-
economic factors of fertility decline in the southern states of India since about
1980 (Guilmoto and Rajan, 2005; Rajaretnam and Deshpande, 2004; Zachariah,
Rajan and Sarma, 1994; James, 1999). To understand the demographic transition in
these states, I will briefly discuss the level and pace of decline in both fertility and
mortality. This will be followed by examining the different pathways to
demographic transition in the southern states, and the socio-economic and cultural
explanations for the transition. Finally, I will explore the lessons it holds for the rest
of India, especially for the large economically backward states.
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Level, Onset and Pace of Fertility Decline
According to the latest estimates available for 2008, total fertility ranged between
1.7 and 2.0 in the four southern states of India.1 The estimates clearly suggest that
fertility transition in these states has been completed.2 An examination of SRS data
from 1970 for the major states of India points to two important facts. One, even at
the beginning of the 1970s, total fertility rate in all the four southern states was
lower than in the rest of the country. TFR ranged between a little less than four in
Kerala to 4.5 children per woman in Andhra Pradesh, whereas the average for India
was 5.2, and in some of the large North Indian states, it was close to six. The gap of
one child in fertility level between the two distinct regions continued until about
1980. Two, since 1980, the pace of fertility decline in the two states of Kerala and
Tamil Nadu quickened until mid-1990s, leading to an increase in the gap in the level
of fertility between them and the other states. By early to mid 1990s, the TFR of
Kerala and Tamil Nadu reached replacement level fertility and has now plateaued a
few points below the replacement level. In the other two states of Andhra Pradesh
and Karnataka, the pace of fertility decline became faster by 1995 and they began to
catch up with their two neighbours (Figure 1). It appears that a decline in fertility
Figure 1: Three Year Moving Average of Total Fertility Rate in All
India & Southern States, 1971-2006
6.00
5.00
4.00
3.00
2.00
1.00
0.00
1971- 1974- 1977- 1980- 1983- 1986- 1989- 1992- 1995- 1998- 2001- 2004-
73 76 79 82 85 88 91 94 97 00 03 06
Year
All India
Tamil Nadu
Kerala
Karnataka
Andhra Pradesh
from between four and five children to three children per woman took 15-20 years,
but once the threshold of three was reached, the decline to around two children took
just about 10 years. One may venture a guess that TFR in the country as a whole
would reach replacement level by 2015; it has been inching towards it from a level
1. All the total fertility rate data, unless otherwise specified, is from the various volumes of Sample Registration Bulletin, which is published
now twice a year by the office of the Registrar General of India, New Delhi.
2. The other states that have joined this league of TFR at or below 2.1 are: Himachal Pradesh, Delhi, Maharashtra, Punjab and West Bengal.
Also, except for the urban areas of Madhya Pradesh, Haryana, Rajasthan, Bihar and Uttar Pradesh, the urban TFR in the rest of the country
has reached 2.1 or less. This suggests that fertility transition has been completed in nearly 47 per cent of India's population.
4 Demographic Transition in South India
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of three in 2003 and reached a level of 2.6 in 2008. However, it may be noted that
not all states of India would attain TFR of 2.1 by 2015.3
In all the four southern states, as in the rest of the country, fertility differentials by
place of residence, level of education, caste, religion, economic status, or
occupation did exist. However, once fertility decline gathered momentum, it fell at
a faster rate in rural areas compared to urban areas such that the differences in TFR
between rural and urban areas have virtually disappeared. According to NFHS-3
data for 2005-06, TFR in urban areas was estimated to be 1.9 in Karnataka and 1.7
in the other three states. Rural TFR was only a little bit higher by 0.2 points than the
urban TFR in all the states. Further, fertility differences by education of mothers, or
among social groups and within states, between districts have also narrowed
considerably leading to homogenisation in reproductive behaviour.
The age specific fertility rates for the four states show that the greatest fall in
fertility has occurred in ages above 25 (Figures 2a and 2b). This is strongly
Figure 2a: Age Specific Fertility Rates in Kerala
250
200
150
100
50
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Age
1971
1981
1991
2001
2008
Figure 2b: Age Specific Fertility Rates in Karnataka
250
200
150
100
50
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Age
1971
1981
1991
2001
2008
3. States like Uttar Pradesh and Bihar are unlikely to attain replacement level fertility before 2025 given their current TFR is around four.
However, the pace of fertility decline among the late entrants may quicken in response to a number of factors ranging from changing
aspirations to the role of mass media in spreading the two-child norm and influencing behaviour.
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indicative of increasing control of fertility within marriage through the adoption of
family planning. The typical bell-shaped age-specific fertility curve has become
narrow in all the four southern states and compressed. At ages 15-19, the decline in
age specific fertility mainly reflects a rise in the age at marriage of women, which
has increased in all the states by varying measure. These changes mean that the
average span of childbearing (measured in years) has declined considerably. In all
the four southern states, childbearing has become concentrated into a very short
period of six to seven years. Women marry, have their children and then adopt a
fertility limiting method or sterilisation.4
Trends in Mortality
Among the components of population change, mortality has historically played an
important role in determining the growth of population. During the first and second
stages of demographic transition, it is mortality that starts declining first, initially
slowly and then rapidly, contributing to a gradually rising rate of population growth
as fertility decline generally starts with a time lag.
From 1970 onwards, the annual estimates of crude death rates (CDR) and infant
mortality rates (IMR) available from SRS indicate that the declining trend in
mortality in the four southern states continued through the decades of 1970s and
1980s. This decline was possible due to advancements made in the field of
medicine, improvement in public health, availability of immunisation services and
the general betterment in living conditions. The pace of decline in mortality
somewhat slowed down in the 1980s, but picked up some momentum later.
However, it is to be noted that among the four southern states, Kerala has been well
ahead in mortality transition compared to the other states.
As shown in Figure 3, even at the beginning of the 1970 decade, Kerala recorded
Figure 3: Three year Moving Average of Infant Mortality Rate
in India & Southern States, 1971-2009
140
120
All India
100
Tamil Nadu
80
Kerala
60
Karnataka
40
Andhra Pradesh
20
0
1971- 1974- 1977- 1980- 1983- 1986- 1989- 1992- 1995- 1998- 2001- 2004- 2007-
73 76 79 82 85 88 91 94 97 00 03 06 09
Year
4. According to NFHS 3, the median age at sterilisation in the four southern states ranged between 23.3 and 27 years, the lowest being
reported for Andhra Pradesh (IIPS and Macro International (2008) for Andhra Pradesh, Karnataka, Kerala and Tamil Nadu).
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infant mortality rate (IMR) of around 60 per 1000 livebirths compared to above 100
in Tamil Nadu and Andhra Pradesh and above 90 in Karnataka. The all-India IMR
was 125. Over time, although the pace of decline in IMR in the other three states has
been somewhat faster than that in Kerala, the gap between them and Kerala
continues to be quite wide. The IMR of Kerala is only 12 — a level very close to that
of some of the developed nations of the world. The pace of decline in IMR in Tamil
Nadu seems to be faster and at IMR of 28 reported for 2009, it is significantly ahead
in its mortality transition of Andhra Pradesh and Karnataka, where the
corresponding figures are 49 and 41, respectively. The IMR for Andhra Pradesh is
almost the same as for India as a whole, a level that is not only unacceptably high
but is also indicative of the fact that the state has quite a long way to go before
completing mortality or health transition.5 While general mortality responds rather
quickly to public health measures, changes in infant mortality depend on a number
of factors like availability and accessibility to antenatal and postnatal care facilities,
services and facilities for infant care after childbirth, effective management of
diarrhoeal diseases and respiratory tract infections besides improvements in the
level of mother's education and general socio-economic development. Both
Andhra Pradesh and Karnataka states need to allocate greater resources in
improving the health of its children.
Factors Associated with Fertility Decline
It is important to understand what wide-ranging changes have taken place in the
social milieu of each of the four South Indian states to bring about a decline in their
fertility. Evidently, the onset, pace and paths to fertility decline in the four states
have been distinctly different, and yet, today they all are at the same level of around
replacement level fertility. It is important to understand the different pathways for
lessons for other states and regions of the country. I shall discuss very briefly for
each of the four states the associated factors of fertility—both proximate
determinants and the socio-economic explanations.
Fertility Decline in Kerala and Tamil Nadu
Among the four states in South India, the demographic transitions in Kerala and in
Tamil Nadu have been much more extensively studied in a historical context than
that of the other two states. Kerala's transition is linked to the pattern of social
development in the state since the nineteenth century. Religious reforms were
5. Health transition refers to the transitions in morbidity and mortality from infectious to non-communicable diseases as a consequence of
medical interventions and improvements in material conditions of living. Health transition relates to the role that cultural, social and
behavioural determinants of health play in raising life expectancy at birth (the mortality transition) and the decreasing proportion of all
deaths caused by infectious diseases (the epidemiological transition).
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introduced in order to break the rigidities of the caste system. Education was
provided to members of lower castes. In addition, the forward-looking rulers of the
region introduced land reforms, set minimum wages and also provided public
health care, all of which contributed to a fairly egalitarian social structure. Many
economists and social scientists have argued that the spread of education among
women and changing perceptions of the cost of childcare played a very significant
role in the control of fertility. This has been called the 'human development' path of
fertility transition (Krishnan, 1998; Srinivasan, 1995). Zachariah's empirical study
showed that in the 1950s and 1960s, the spread of female education and the related
rise in age at marriage were the major factors behind fertility decline in Kerala. In
the subsequent decades, adoption of family planning became an important
determinant of further fertility decline. All social and occupational groups accepted
family planning and lowered their fertility such that the socio-economic
differentials in fertility levels have virtually disappeared in Kerala (Zachariah,
1994; Zachariah and Rajan, 1997).
On the other hand, the experience of Tamil Nadu suggested that the decline in
fertility could take place even with a much lower level of female literacy and a
higher rate of infant mortality than those observed in Kerala. Historically, in spite
significant inter-district differentials in Tamil Nadu, fertility was never reported to
be very high anywhere within the state and the relatively moderate level of fertility
in the 1920s and 1930s has been attributed to the social and economic reforms that
were initiated in the first half of the 20th century by E.V. Ramasamy Naicker,
popularly known as Periyar. He advocated a higher age at marriage for women, a
better status in society for them, widow re-marriage, the importance of family
limitation, rejected the caste system and questioned the supremacy of Brahmanism
(Anandhi, 1991).
More recently, Tamil Nadu's fertility decline has been explained in terms of the
state pursuing a mixed path, involving elements of both social and economic
development (Kishor, 1994; Ramasundaram, 1995; Mari Bhat and Rajan, 1990). It
is even argued that given the high level of income poverty in the state, fertility
decline is 'poverty driven'. The reasoning is that poor parents curtail their fertility in
order to be able to invest their limited resources in their children's education. This
would enable the children to get an urban employment, and in turn, improve the
economic status of the family. A few qualitative studies undertaken in Tamil Nadu
have suggested that the aspirations of young couples to provide better levels of
education and health care for their offspring, compared to what they themselves
received as children, have increased. Also increased is the awareness in the rural
areas that with several children, land gets divided between them to such an extent
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that the small piece of land that each son inherits becomes unviable for cultivation
and survival. Such calculus prompts couples to desire and bear fewer children.
Nagaraj (1997), terms this as 'social capillarity' where a large section of the
population adopt family planning as a means for bridging the gap between
increasing aspirations and expectations on the one hand, and the limited resources
to meet these aspirations, on the other. Agrarian modernisation, strong rural-urban
linkages, changing pattern of mobility, spread and reach of mass media and films,
progressive Dravidian movement in the state are all perceived as the facilitators for
the social capillarity to occur. Others have also alluded to the success of backward
class movements in the state (Anandhi, 1996) and to the implementation of a
vigorous family planning programme (Anthony, 1992).
Additional contributory factors to the fertility decline in Tamil Nadu have been the
strong political backing from the leaders as well as the bureaucracy and an efficient
transportation network (where even remote rural areas are well connected by public
transport) and effective communication. All these have assisted the health and
family welfare programme to promote the use of family planning among the
masses. Studies also found that the media had strong negative influence on fertility
(Ramasundaram, 1995; Srinivasan, 1995; Visaria, 2000).
Fertility Decline in Andhra Pradesh and Karnataka
In the states of Andhra Pradesh and Karnataka, the rapid decline in fertility is very
recent; the pace increased only in the 1990s. Also, factors conducive to changing
aspirations leading to fertility decline were more or less absent in these states, or
were confined to very small pockets and did not spread across districts within
states. The few studies undertaken are by and large based on the reanalysis of the
NFHS data in the case of Andhra Pradesh, and linking the NFHS data with the
Mysore Population Study conducted in 1951-52 and the Bangalore Population
Study conducted in 1975 in the case of Karnataka. The studies have examined the
trends in fertility and associated factors.
The analysis of NFHS data for Andhra Pradesh separately for its three major agro-
climatic regions—Coastal, Telangana and Rayalaseema—undertaken by James
(1999) showed that although contraceptive use has increased in all the regions,
there are regional differences in the factors associated with the reported level of use.
In the coastal region, literacy of mother or father had no significant association with
contraceptive use (implying that contraceptive use increased among the illiterates
also). Instead, mass media exposure and asset holdings of the household were
found to be important in explaining family planning acceptance. However, in the
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other two relatively backward regions, the influence of mass media was
insignificant; instead, work participation of women was found to be positively
related to the use of contraception. Clearly, when data are analysed at a
disaggregated level, the results are inconclusive.
Some further analysis of the NFHS-2 data carried out more recently by James and
Subramanian (2005) and Chakrabarty and Guilmoto (2005) indicated that the
negative relationship between female literacy and fertility was not strong. Also, the
positive association between fertility and infant mortality, which has been found to
be quite significant in many settings, was also not found to be very strong in Andhra
Pradesh. But, the widespread access to antenatal care available to mothers in
Andhra Pradesh has a stronger association with fertility level and is likely to have
contributed to fertility decline.6 This implies that programmatic intervention
through the provision of antenatal care to mothers (which may also include creating
awareness about small family) has created a favourable environment for the
acceptance of family planning in Andhra Pradesh. Exposure to cinema is also found
to be positively associated with the practice of family planning in Andhra Pradesh.
Even after controlling for the various background characteristics of women, those
who regularly watched cinema were found to be more aware of the legal age at
marriage for girls, used fertility control measures to limit their family size and
initiated reproductive health care seeking behaviour (Rama Padma, Roy and
Sureender, 2004). Cinema stars who are perceived as role models or whom people
would like to emulate, are widely believed to influence and accelerate behaviour
change in people.
It is also argued in the case of Andhra Pradesh that the policies of the government
giving generous subsidies to the poor in the form of rice or pension to widows, and
the widespread implementation of the Integrated Child Development Scheme
(ICDS), which provides supplementary food, have led to some reduction in the
incidence of poverty and a decline in fertility. Also, Andhra Pradesh's commitment
to spreading and effectively implementing the family planning programme as well
as improved governance in lowering fertility has drawn the attention of many
policymakers, programme managers and advisors as a replicable model of fertility
decline that can be pursued in other states of India.
Karnataka state was formed in 1956 by amalgamating the princely state of Mysore,
districts from the two neighbouring presidencies of Bombay and Madras and also
from the former Hyderabad state. Interestingly, unlike the neighbouring states,
6. According to NFHS-2, 93 per cent of mothers in Andhra Pradesh had accessed some antenatal care, with very small differences by place
of residence, education level of mothers, caste, or religion (James and Subramanian, 2005). The recent NFHS-3 showed that 86 per cent of
Andhra women had at least three antenatal care visits for their last birth with no significant rural-urban differences.
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Karnataka did not experience any significant social and political movements,
which could influence attitude and behaviour of people. The disparities in socio-
economic development between the districts are quite high and get reflected in the
demographic parameters as well. Based on the data from the earlier two surveys
conducted in 1951-52 and 1975, it has been shown that the small decline in birth
rate noted in the state was due to changes in marriage patterns and not due to a
decline in marital fertility, which, in fact, had gone up due to relaxation of some
traditional checks.
Apparently, the inter-district differences in the level of fertility that have narrowed
significantly in the other three states, persist in Karnataka (Rajaretnarm and
Deshpande, 2004). In the mainly coastal districts, where fertility is lower compared
to other regions of the state, women marry later, their level of literacy is high, the
participation of workforce in non-agricultural activities is higher and infrastructure
development such as roads is also better. On the other hand, in the districts of the
north eastern plateau, where 25 per cent of the state population resides, the mean
age at marriage is still quite low and health infrastructure is quite poor. The region is
also characterised by limited exposure to mass media, low status of women and
rather slow decline in fertility (Sekar, Raju and Sivakumar, 2005).
While examining the factors that have very likely influenced fertility behaviour in
the four states of South India, both historically and in recent times, it is important to
highlight that all socio-economic factors or cultural practices that would influence
fertility behaviour can affect fertility only through intermediate or proximate
variables that determine exposure to sexual intercourse, to conception and carrying
the pregnancy to full term such that it results in a livebirth. I shall, therefore, dwell a
little bit on variations in the proximate determinants of fertility in the region.
Proximate Determinants of Fertility
The important among the proximate variables, which can be relatively easily
measured in surveys, are marriage, use of contraception, breastfeeding and the use
of abortion. Various policy interventions have attempted to influence these factors.
The minimum legal marriage age for women has been raised to 18 years in India.
Abortion has been made legal under fairly liberal conditions. India's family
planning programme that was launched in the early 1950s has made contraceptive
methods widely and freely available through health facilities. Data analysed from
the first and second National Family Health Surveys conducted in the 1990s enable
in estimating the contribution of these variables in the overall total fertility.
Although the interval between the two surveys was only a little over six years, the
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changes in the share of each of the variables over this period are also captured
(Visaria, 1999).
Higher age at marriage and a larger proportion of women remaining single have
some effect on depressing fertility compared to low age at marriage and marriage
being universal for women. Available data indicates that both in Kerala and Tamil
Nadu the median age at marriage of women was relatively high (21 and 19 years
according to the NFHS-3, 2005-06), whereas in Karnataka and Andhra Pradesh it
was estimated to be only 18 and 16 years, respectively. Other things being equal,
this would imply that women in the latter two states stay in marriage for longer
period since they enter marriage early, and thereby, are exposed to a greater risk of
pregnancy resulting in higher fertility compared to the women in Kerala and Tamil
Nadu. However, the TFR in all the four states in recent years, despite some
variations in age at marriage, have been very similar suggesting that even if girls
marry at a relatively young age, fertility can decline, or marriage as a factor to
fertility can be undermined through other measures such as use of contraception or
resorting to a permanent method of contraception at a very early age once the
desired number of children are born. Andhra Pradesh is an example of fertility
being compressed in six to seven years (Padmadas, 2004). According to a survey
conducted in four districts of Andhra Pradesh in 2004, the average age at
sterilisation ranged between 22.5 and 25 years (Visaria L. and Prakasamma, 2007).
In India breastfeeding is prolonged (around 25 months) and the estimated duration
of breastfeeding has not varied much in the country. Longer duration of
breastfeeding extends the period of postpartum amenorrhoea thereby increasing
the inter-birth interval. The average duration of breastfeeding is somewhat lower in
Kerala and Tamil Nadu (six to seven months) compared to that reported in Andhra
Pradesh and Karnataka (10 to 11 months), but the differentials are not significant to
have much effect on suppressing fertility in the latter two states.7 The postpartum
period of infecundability has changed little. Although one may expect that educated
women might be breastfeeding their children for shorter length of time, the
reduction seems to be offset by use of reversible forms of contraception among
some of them, but very likely due to the acceptance of postpartum sterilisation by a
large segment of the women. The drive to encourage women to exclusively
breastfeed their children at least for few months is carried out for its beneficial
effects on child health.
There is some indirect evidence that women in Tamil Nadu undergo induced
abortion to a much greater extent than elsewhere in the country and that they use
7. Overall, the estimated effect of breastfeeding practice and thus of the postpartum period of infecundability in different regions of India is
nearly the same.
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abortion as a family planning method. However, information on induced abortion
collected in surveys such as NFHS is deficient because women tend not to report
having undergone abortion in spite of it being legal in India since 1972. It is
therefore, not easy to estimate the contribution of abortion to fertility decline.
The fertility transition is achieved overwhelmingly through an increase in the use
of modern contraceptive methods, primarily female sterilisation, not only in all the
four states in South India, but also throughout the country. The contraceptive
prevalence rate in all the four states ranged between a high of 69 per cent in Kerala
and a low of 61 per cent in Tamil Nadu as per the NFHS 2005-06 data. According to
the survey, female sterilisation accounted for more than 92 per cent of all modern
methods (in NFHS-2 of 1998-99, the share of sterilisation among modern methods
was 85 per cent) currently used in Tamil Nadu, Andhra Pradesh and Karnataka and
more than 94 per cent in rural areas of these states. The only exception is Kerala,
where the share of sterilisation was 84 per cent (in NFHS-2 it was 67 per cent),
among all modern methods. Apparently, there is an increasing inclination towards
sterilisation not only in these states but through out the country. Among the younger
women, who have not yet completed their family size, there is some use of
reversible methods of contraception reported. But, for majority of the women,
female sterilisation is the first and the last method of contraception ever used. In
fact, the public sector has been the major provider of family planning services.
The results from the four southern states clearly show that the transition from
natural fertility to controlled fertility is not only achieved largely by the use of
contraception but over time, the contribution of contraceptive use has increased.
No doubt, the age at marriage has risen and the proportion of single in the young age
group of 15-19 years has increased over time, thereby contributing to some decline
in fertility. But widespread use of family planning, in the form of female
sterilisation, is the major factor that has brought about fertility transition in the
southern states. It is also likely to be the primary driver of fertility decline in the rest
of the country.
Socio-economic Factors Associated with Fertility Decline
According to the conventional demographic transition theory, a decline in fertility
level below a certain threshold level cannot be achieved without changes in
material conditions, an increase in female literacy, improvement in the economic
wellbeing of people, exposure to urban values and way of life and improvement in
child survival. Many statistical analyses of data from countries across the world,
including India, have so far supported this classical theory of transition.
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A number of socio-economic factors have been identified by social scientists to
understand what triggers fertility decline. In the context of the South Indian states
also, such explorations have been undertaken. Using a range of innovative
methodologies, analyses and interpretations, factors associated with fertility
decline have been identified. An analysis of large-scale data from various sources
has indicated that there is a strong inverse association between fertility and female
education, implying that increasing the education level of women can bring about
fertility reduction. Thus, even after controlling for the influence of other factors, the
effects of higher levels of female education have been observed to be quite strong in
reducing fertility (Jain, 1985). Undoubtedly, the theoretical arguments for these
associations are convincing. Increased education keeps girls in school longer,
which in turn helps raise the age at marriage. Schooling may also give young
women greater awareness of services and confidence in negotiating with the
service providers for better quality health care for themselves and for their children
(Caldwell, 1982 and Caldwell, et al., 1985 for their work on Karnataka). Large
macro-level analyses also found that the level of female literacy was an important
factor in accounting for fertility variations both between regions and over time
(Murthi et al.,1995; Dreze and Murthi, 2001). In contrast, general development
and modernisation variables were found to have small effects. Similarly, a district
level study by Bhat (1996), found that less than 10 per cent of fertility variation
within the country was attributable to structural economic factors. On the other
hand, differences in exposure to mass media and levels of female education
accounted for 40 per cent of the variation.
However, recent evidence available from southern states of India in particular does
not seem to conform either to the classical theory of fertility transition or to the
macro level analyses that stress the role of education as the most important factor
accounting for fertility decline. In states like Tamil Nadu and Andhra Pradesh,
fertility decline has taken place for the most part without any noticeable
improvements in female education or in the material condition of the people. In
fact, fertility has declined among the illiterate as well as among educated women.
The widespread adoption of contraception by illiterate women in the 1990s has
raised questions about the role of education as a prime mover in the fertility
transition. Bhat, for example, demonstrated with fertility data from the Censuses of
1981 and 1991 that 65 per cent of all fertility declines in India occurred among
women with no education at all (Bhat, 2002). He attributed the decline in fertility
among the illiterate women to ideational change, brought about through the
influence of the mass media. A multi-level analysis by McNay et al. (2003), using
the NFHS-2 data, also found that fertility has declined among uneducated women
due to the increased use of contraception. They attributed this to the diffusion of
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new ideas and increased aspirations for the children among the uneducated parents,
which encourage them to limit the size of their families.
Fertility is generally found to be positively associated with infant mortality. It is
argued that couples have more children as a form of a hedge against high infant
mortality. When not all children born are expected to survive, in order to ensure that
at least some survive to adulthood, couples have more children. In spite of steady
decline in infant mortality over several years, the perception among parents that it
has indeed been declining comes with a time lag. Fertility decline in Andhra
Pradesh to a level below the replacement has occurred in spite of its infant mortality
being higher than, or closer to, the national average. This has prompted some to
argue that improvements in education or income levels, or health status, are not
necessary conditions for bringing down fertility. A vigorous programme designed
to promote family planning methods and access to services easier, and linking them
to incentive payment, can achieve the desired result of lowering fertility. This has
often been termed as the Andhra Model of demographic transition, which has
gained some credence for its suitability for other states with similar socio-
economic characteristics.
Another important factor associated with the fall in fertility in the southern states is
the status of women. There is less patriarchal kinship structure in these states
compared to that observed in the North Indian states and many studies have pointed
out that women in South India enjoy greater autonomy and have greater decision-
making power compared to their sisters in North India (Dyson and Moore, 1983).
No restrictions on village endogamy, the practice of consanguineous marriages
where women know the families in which they marry, contribute to women's
freedom of movement in the South Indian states. On most measures of female
autonomy, such as ownership of assets, degree of freedom, employment and access
to money, income and participation in self-help groups, women from the south fare
appreciably better than their sisters in the North Indian states. Greater autonomy
enjoyed by southern women has also resulted in low son preference. Strong son
preference evident in desiring at least two sons, does contribute to an increase in
fertility. There may be small pockets within the southern states, which have had the
tradition of female infanticide but overall the preference for sons is not as strong as
observed in many North Indian states.
One of the important supply side arguments has been that all the states in southern
India have made a huge commitment to promote the small family norm. The
commitment has manifested in somewhat different ways, but that it is there, is very
evident. In Tamil Nadu, along with providing family planning services, the state
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machinery has also made efforts to address reproductive health needs of women in
health care facilities. The Primary Health Centres (PHC) throughout the state are
able to cater to women's health needs by keeping the PHCs open taking into account
bus timings, or keeping them open 24 hours by hiring retired nurses on a contractual
basis, ensuring that at least one of the two doctors serving in the PHCs are women,
and also having stock of most essential drugs. In addition, the village health nurses
are encouraged to hold monthly mothers' meetings in the villages they serve where
women's health concerns are discussed.
The political will has been very strong in Andhra Pradesh and a range of incentives
and disincentives has been provided to individuals or village local bodies. The
public health facilities in Andhra Pradesh have ensured that all pregnant women
receive the required antenatal care and checkups, thereby increasing their contact
with the health facilities and health care providers and also providing timely
intervention in case of risk. However, it is sometimes argued that the politicians and
bureaucrats in Andhra Pradesh have initiated fairly aggressive targets and
incentive-driven strategies to promote the greater uptake of sterilisation and that
people are succumbing to pressure tactics employed to promote family planning. It
is important to understand in depth the extent and impact of vigorous promotion of
family planning and also whether women respond to, or accept, sterilisation
because of payment of cash compensation or because they want to control their
fertility, gain and assert their independence, or even defy and undermine the
authority of the elders.
On the other hand, in Kerala, given the fact that literacy among women is nearly
universal, family planning no longer needs to be promoted. Women come forward
on their own to seek family planning services. Many in Karnataka feel that the
backward districts of the state would need special efforts in promotion of family
planning along with developments in their infrastructure and investments in human
capital. The intra-state disparities are a source of concern in Karnataka.
In southern states, the media, both print and visual in the case of Kerala, and mostly
visual in other states, has contributed a great deal to reaching health and family
planning messages, not only through spot visuals, but also by weaving them in
serials and other programmes, including discussions with 'heroes' and popular
icons that are broadcasted on television channels. Television is clearly the most
influencing factor in increasing awareness about conspicuous consumption
portrayed on screen and creating a desire in people to own some of the convenience
goods and thereby improve the quality of their life. Television has also exerted a lot
of influence on the ideas of family building and family size. Feature films in local
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languages are also very popular in the southern states. The percentage of even rural
women, who visit theatres to watch films, at least once a month, is quite high in
southern states compared to northern states.
Challenges and Lessons for the Rest of India
Having painted a somewhat rosy picture of the demographic transition in southern
Indian states, I want to draw attention to some of the unaddressed issues. Before
doing that, I would like to assert that fertility transition has been completed in South
India and is also well established in the rest of the country. There is little reason to
believe that the total fertility rate will stall or plateau for long at a level that is far
above replacement. There is sufficient evidence that in no part of the country
couples report more than three children as the ideal number, and younger women
report only around two children as the ideal number that they would like to have.
That this ideal has been translated into reality is evident from the estimates of total
fertility rates available for all the major states of the country from the 2005-06
NFHS-3 and the SRS data. The 2008 TFR is less than four throughout the country
but below three in all states except for Rajasthan and Madhya Pradesh, where it is
3.3, and for Uttar Pradesh and Bihar where it is 3.8-3.9. At the same time, the per
cent of women with two children who reported that they did not want to have any
more children is above 80 per cent in all the states except for Rajasthan where it is
73 per cent and Uttar Pradesh where it is 64 per cent.
In spite of our assertion time and again that India advocates the 'cafeteria' approach
in promoting family planning, the fact of the matter is that female sterilisation is the
overwhelming method used and available throughout India and certainly in the
southern states. Even if there are no regrets reported by women for relying on the
permanent method, the consequences of it are quite dire. In the zeal to achieve
targets (which do operate even if the nomenclature has been changed), there are no
efforts to collect information on reproductive tract infections (RTI) women may
already suffer from or even information about their husbands' occupation. If before
sterilisation, women are treated for their RTIs, the incidence of some of the
debilitating illnesses such as backache, white discharge, lack of energy that they
report would decline.
In the context of Andhra Pradesh and Tamil Nadu, where the incidence of HIV
infection and AIDS cases are high, its spread in the general population and
especially among largely monogamous women is likely to increase because once a
woman is sterilised she cannot negotiate with her partner for the use of the condom.
The promotion of dual methods of contraception, along with appropriate
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counseling where one of the partners has high-risk behaviour has no place in the
family planning programme. Media should be used to spread awareness among
couples and the health functionaries would have to be informed and trained.
While recognising the fact that marriage for women is likely to remain nearly
universal in India, and further that the vast majority of them will marry relatively
young and have fewer children, the childbearing phase is going to be quite short.
Women marry early, have their two or three children in quick succession and then
undergo sterilisation. If the southern states are an example, the average
reproductive span would be only about 6-8 years and would end when women are
still in their twenties. Many believe that the overall condition of women has
improved and they have become more empowered. There is less physical and
mental strain due to avoidance of unwanted and repeated pregnancies. With having
to produce fewer children, women have less childrearing responsibilities and free
time to become actively involved in income generating activities. However, we
have not explored the biological, medical and social ramifications of early
sterilisation, an issue that needs to be explored with appropriately designed
research.
In the pursuit of sterilisation targets, and the goal of attaining population
stabilization, the quality of care before, during and after the procedure appears to
have been compromised in most settings. Very limited information is available on
sterilisation care and quality issues. Concerns such as preoperative assessment of
clients, the choice of method offered to them, information given to them on
consequences, maintaining privacy and dignity before, during and after
sterilisation, following the correct and safe operative procedure, measures taken for
prevention of complications, postoperative follow-up, care and treatment of
complications are rarely addressed when the camp approach is followed for
performing a large number of operations on a single day. The camps are sometimes
held in schools where it is difficult to maintain cleanliness. Toilet facilities are not
available and operation facilities do not meet even minimum standards. There is
hardly any evidence on the extent to which such compromises in care lead to
complications, because once a woman is an acceptor of a permanent method of
contraception, she practically disappears from the trail of the health providers just
as postpartum mothers are also rarely visited after the birth of the child. In the
coming years, the dominance of sterilisation is unlikely to diminish, given its
widespread, promotion and acceptability throughout India. The programme needs
to widen its scope and promote reversible contraceptive methods so that women
and men both have greater access to safe, affordable and effective methods of
contraception.
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The effective state-sponsored family planning programme pursued by Andhra
Pradesh does appear attractive in the short run and is even propagated as worth
emulating, especially in the backward states of the country. It is possible that some
states may adopt similar approaches to Andhra Pradesh in the coming future, in a
context in which state-level population policies are likely to play an increasingly
prominent role in family planning. However, instead of basing the decision on a
macro level, factors like literacy, low income, proportion of population living in
rural areas and social issues including women's autonomy, son preference,
prevailing caste-based equations, would also have to be taken into account. A
backlash and its impact can be worse and longer lasting than even a badly
implemented programme. What is worth emulating is the political commitment and
bureaucratic readiness of Andhra Pradesh and efforts to provide family planning
services along with comprehensive reproductive care as in Tamil Nadu. Good
supervision and efficient monitoring mechanisms must receive priority. Tamil
Nadu has succeeded to a great extent by paying attention to such details and to
issues of quality.
Strong son preference is a thorny issue that seems to be plaguing many societies in
the northern and western states of India, which has led to an increase in sex
detection tests followed by female selective abortions. The liberal Act that does not
permit Pre-Natal Diagnostic Termination of foetus has made the practice costly and
clandestine rather than eliminate it. Occasionally one does hear of the violation of
the PNDT Act in south India, but by and large, states here have not resorted to such
practices mainly because son preference is not so strong. The somewhat liberal
attitude towards daughters, and viewing them not as drain on family resources or
someone else's property, but as assets, cannot easily be transplanted in another
culture. But innovative uses of media and educational tools would hopefully help in
inculcating the value of daughters. It is possible that in the regions of strong son
preference, fertility decline itself may help to generate a more balanced view of the
desirability of having daughters.
In spite of these challenges, one must accept the fact that Indian couples have
changed their fertility in a whole range of different economic, cultural and kinship
contexts, which themselves will change over time. Even within southern states, we
noticed that fertility has fallen when literacy levels of women went up and also
without any significant improvements in their literacy. It fell when age of marriage
increased, but it also fell without any increase in the average age at marriage of
women. It also fell without any significant reduction in infant and child mortality.
There is no denying the fact that today women throughout the country desire few
children to whom they can provide a good education and health care, and for whom
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their aspirations are quite high. One must, therefore, recognise that a
comprehensive package of care and well-executed health programmes would go a
long way in changing the perception of infant and child survival and also to increase
the adoption of the small family norm. Also, if our aim is to pursue the human
development path, then regardless of what triggers fertility decline, the well being
of people in terms of providing literacy, health care and employment, are desired
goals in themselves, and no individual should be deprived or denied these as their
rights.
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