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Yojana Article 2011 July _Family Planning |
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Family Planning: The Need to Reposition
in context of Maternaland Child Health
Poonam Muttreja
Reduction of
population growth
in EA G states
are essential to
improve the socio-
economic condition
of the population
and attainment of
MDGs
ITH THE Census of
India 2011 reporting
good news on the
population growth
front, there is an
urgent need for the XII Five Year
Plan to further accelerate the
stabilization ofIndia's population
by repositioning family planning
within the broader framework of
reproductive health and primary
health care, delaying age at
marriage and motherhood, spacing
births and expanding options for
reproductive health.
The good news
India has a long history
of addressing the population
question. Beginning with the
launch of the largely clinic-
based National Family Planning
Programme in 1952, the latest
National Population Policy (NPP)
of 2000 is much more embedded
in the framework of women's
empowerment and reproductive
rights. An important landmark in
the evolution ofIndia's population
policy was the establishment in
1966 of a full fledged Department
of Family Planning within the
Ministry of Health. However, the
global obsession at that time with
numbers and targets triggered
by the pessimistic forecasts of
a 'population explosion' by the
Club of Rome and others had
an adverse impact on India's
family planning programme. The
programme became 'centrally
sponsored', financial incentives
were introduced for sterilization
acceptors; and sterilization
was made target-oriented. The
compulsory and coercive
nature of the programme during
1975 and 1976 made it highly
unpopular. An effort was made
. to correct the situation in 1977
beginning with the rechristening
of the Department of Family
Planning as the Department of
Family Welfare and advocating
The author is Executive Director, Population Foundation ofIndia, New Delhi
YOJANA July 2011
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voluntary acceptance of
contraceptive targets without any
coercion. Progress was however
slow during the 1980s. The
1990s witnessed several shifts
in policy especially after the
1994 International Conference
on Population and Development
(ICPD) when the focus shifted
to a target-free community based
approach. India's NPP 2000
states in no uncertain terms that
stabilizing population is not
merely a question of making
reproductive health services
available, accessible and
affordable, but also increasing
the coverage and outreach of
primary and secondary education,
extending basic amenities like
sanitation, safe drinking water,
housing and empowering women
with enhanced access to education
and employment.
India's sustained efforts over
the years to achieve population
stabilization
are finally
beginning to yield the desired
results. Preliminary results from
the Census of India 2011 reveal
several positive trends in India's
population growth:
. 2001-2011 is the first decade
(with the exception of 1911-
1921) when the absolute
increase in population over
the ten-year period has been
less than in the previous
decade.
. The percentage decadal
growthduring2001-2011has
recorded the sharpest decline
since Independence.
. The average exponential
growth rate for 2001-2011
has declined to 1.64 per cent
- downfrom 1.97per cent for
1991-2001.
. Fifteen states and Union
Territories have grown by
less than 1.5 per cent per
annum between 2001-2011
as against only four states
during the previous decade.
. The growth rate ofpopulation
has fallen significantly,
perhaps for the first time, in
the eight Empowered Action
Group (EAG) states (Bihar,
Chhattisgarh, Jharkhand,
Rajasthan, Madhya Pradesh,
Orissa, Uttar Pradesh and
Uttarakhand) that have
traditionally reported higher
than average rates of fertility
and population growth.
. The percentage growth rates
ofthe six most populous states
- Uttar Pradesh, Maharashtra,
Bihar, West Bengal, Andhra
Pradesh and Madhya Pradesh
- have all fallen during 2001-
2011 compared to 1991-
2001.
Despite the many achievements
on the population front, many
worry, somewhat unnecessarily,
about the 'serious problem of
rising numbers' and the lack of
conviction to contain or stabilize
India's population. While it is
theoretically accepted that family
planning cannot be treated as a
vertical program, in practice it
continues to be so with very little
attention to quality of c.are.Despite
clear evidence that population
momentum is the greatest driver of
population growth in India., there
is continued reliance on the old
belief that' control' approaches
with targets, incentives, and
disincentives work. There are
some who disregard the evidence
and .advocate for strict population
control strategies. Some even
suggest that India should adopt
China's one-child policy, ignoring
the overflowing evidence on the
negative consequences that China
confronts today. However, things
are changing not only because of
the focus of major international
donors but also because of the
domestic climate, where the
Government of India recently
restarted the National Commission
on Population (NCP) after a five
year gap, with the specific aim
of revisiting and repositioning
family planning in .India. The
Union Minister for Health and
Family Welfare, ShriGulamNabi
Azad, has called for repositioning
family planning. What does this
entail?
Repositioning family planning
Discussions on repositioning
family planning need to be strongly
grounded in the principles of
human rights (that respect the
dignity of human lives) and
ethics (that offer a normative
basis for ensuring that rights
are not violated). Unfortunately,
understanding of the policy and
programmatic implicati~ns of
these two perspectives remains
poor. The inclusion of the key
principles of a rights based
approach viz accountability,
participation, transparency,
empowerment, sustainability, and
non-discrimination into all family
planning strategies will ensure
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YOJANA July 2011
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that 'people' are at the centr,e of
it all. A rights-based approach
in the context of Maternal and
Child Health will not only provide
a conceptual framework but
will also contribute directly to
the achievement of the health-
related Millennium Development
Goals (MDGs) i.e. reducing child
mortality (MDG 4) and improving
maternal health (MDG 5).
Ultimately, women should be able
. to exercise their right to participate
in decision-making processes,
including those affecting their
sexual and reproductive health,
family planning, contraception,
pregnancy, childbirth, and in
addressing unsafe abortion.
Experience from across
the world suggests that family
planning can prevent as many
as one in every three maternal
deaths by enabling women to
delay motherhood, space births,
avoid unintended pregnancies and
abortions, and stop childbearing
when they have reached their
desired family size.
Repositioning family planning
is directly linked with advancing
family planning on national, state,
and community agendas, with a
renewed emphasis on enhancing
the visibility, availability, and
quality of services provided for
increased contraceptive use and
healthy timing and spacing of
births, and ultimately, improved
quality oflife. At the national level,
policymakers, donors, scientists,
and business leaders ought to
create or support budget line items
dedicated to family planning,
enact supportive family planning
laws and policies, participate
in multi-sectoral partnerships,
and publicly demonstrate their
support for family planning.
At the local level, it means that
community leaders should educate
and mobilize families, providers
should offer reproductive health
and family planning counselling
and referral with skill, enthusiasm,
and consistency, and informed
clients should act effectively on
their desire to delay, space or limit
childbearing.
Core interventions
Repositioning family planning
calls for addressing the three
drivers of population growth:
Population momentum:
Accounts for approximately two-
thirds ofthe projected population
increase. It can be slowed down
mainly by delaying age at marriage
and childbearing in women. A
shocking 47.4% ofIndian women
aged 20-24 years were married
by the age of 18; the proportion
was 69% in Bihar and 63.2% in
Jharkhand. Early marriage is
associated with early and repeated
pregnancies, and contributes to
maternal and infant morbidity and
mortality greatly compromising
both women's and children's
health.
Unmet need is a disconnect
between a woman's desired
fertility and her access to family
planning services. It is expected to
contribute to approximately 20%
of projected population growth. It
is as high as 22.8% in Bihar and
23.1% in Jharkhand. Interestingly,
even though 83% of women with
two or more children do not want
anymore children, only 48.5% use
modern family planning methods.
Unmet need can be addressed by
increasing the supply of quality
family planning services and
contraceptives.
High desired fertility: This
is caused by several factors,
including parents giving birth to
more children than they actually
want to compensate for high rates
of infant mortality; the low status
of women, the limited voice that
women have in family and fertility
decisions as well as a strong
preference for sons. The mounting
pressures of modern society to
have a small family combined
with a strong preference for sons
often leads to female feticide or
sex selective abortion. Both high
desired fertility and population
momentum can be addressed by
interventions that stimulate a
demand for contraception, such as
interventions that promote social
norms around small families,
delayed age at marriage, and
delayed childbirth.
Repositioning family planning
in the context of maternal and
child health can be made possible
only when the three drivers of
population growth are addressed
effectively and an attempt is made
to shift ('reposition') the discourse
from 'population controF to
'population stabilization.' This
can be achieved, by focusing on
five key focus 'areas: delaying
age at marriage; delaying age
at first pregnancy; promoting
spacing between births; improving
quality of care of family planning
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and reproductive health (RH)
programs; and prevention of sex
selection.
A critical starting point is to
focus on women and children,
and to ensure that all children
have access to quality health
care; and adolescents and women
have additional access to quality
reproductive health care. A
woman's health directly influences
the health and development of
her child. A vicious cycle of
malnutrition is created ifnutrition
before and during pregnancy is
not taken care of. A stunted child
becomes a small mother, a small
mother gives birth to a small
baby, small babies grow less, and
girls who grow less become small
mothers, and the vicious cycle
continues.
Society and policy makers
need to view health, and
particularly reproductive health,
within the holistic life cycle
approach. The discrimination
against girls and women that
begins in infancy determines the
trajectory of their lives. Neglect
of education and appropriate
health care arises in childhood
and adolescence. These continue
to be issues in the reproductive
yeaJfs,along with family planning,
sexually transmitted diseases
and reproductive tract infections,
adequate nutrition and care
in pregnancy, and the social
status of women and concerns
about cervical and breast cancer.
Unwanted pregnancies may lead
to unsafe abortions, child neglect,
malnutrition, disease, and social
problems. This implies ensuring
effective contraceptive advice
and availability as young people
approach puberty and during their
reproductive years.
Increased public dialogue
among awide range of stakeholders,
developed or modified relevant
policy, better and more efficient
service provision and program
implementation and families
taking control of decision making
around their health should be the
envisaged outputs.
At the national level population
stabilization should be viewed
from the population momentum
perspective, looking in particular
at delaying the age of marriage
and thereby of childbearing. At
the state level unmet need and
high desired fertility should be
addressed through increasing
people's access to quality family
planning services as well as by
.. "o,sting in education and health
services which would impact
social norms and awareness
around the benefits of smaller
families. And at the community
level, individuals, families
(including male members), and
members ofthe larger community
should engage actively in the
enhancement of their health as
well as in community monitoring
of services, as it is recognized
that lack of proper involvement
of local communities in the
implementation of programs has
been identified as a principal
reason for the low accountability
in the system.
Looking ahead
Working with young people
is critical as India looks ahead to
reposition family planning and
make the most of the demographic
advantage of having a young
population that it enjoys. It is all
the more important to focus on
young people as almost one-third
of India's population is between
the ages of 10-24 years. The need
for effective family planning has
never been greater than it is today,
as the largest group of people
in Indian history move through
their reproductive years. Access
to quality family planning is not
only a human right, it is critical to
individual and family health and
well-being, and to the country's
economic development.
Urgently needed are advocacy
initiatives that concentrate on
viewing health and particularly
reproductive health within the
holistic life cycle approach; call
for an end to discrimination against
girls and women; emphasize
importance of education and
appropriate health care in childhood
and adolescence; campaign against
unwanted pregnancies as they lead
to unsafe abortions; that address
child neglect, malnutrition, disease,
and social problems; give effective
contraceptive advice and promote
improved services especially
better quality and access to timely
and responsive health services.
Ultimately it is only by
repositioning family planning
within a rights based framework
can India ensure planned and
healthier famil,ies, a positive
outcome for every pregnancy, and
most importantly, that every child
is a wanted as well as a healthy
child.
0
(E-mail.pmuttrejapopulationfoundation.in)
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YOJANA July 2011