For A Boy, Forever

Imarti doesn’t want to be sterilised. The 35-year-old and her husband, a farmer from Mukhtiarpur village in Madhya Pradesh’s Morena district, want to have more kids, in the hope of adding a male child to their brood of six daughters and a son. Manoj, a 38-year-old mother of six, including three sons, would understand their predicament. For she too wants more sons in her fam­ily. Manoj and her husband Rajendra are predictably wary of local health workers who pester them with unsolicited opinion on why the woman should get sterilised.

In Uttarakhand, a woman went into depression after giving birth to her sixth daughter and then slipped into coma and eventually died. Her bereaved husband Nirmal married another ­woman and went on to have a son with her. Clearly, the number of male children in a family continues to be a marker of social prestige, more so in rural areas.

Another factor that keeps people from opting for female sterilisation are fears around what it does to the woman’s body. On this, the opinions of men and women often match—just as the idea of male sterilisation used to evoke fears of lost virility, the premium placed on motherhood as the index of a woman’s worth is a major barrier to making female sterilisation a popular method of population control. Health workers also find it difficult to convince family elders, especially mothers-in-law, who are often looked down upon if their daughters-in-law fail to bear children.

It’s not as if nothing has changed. Younger couples are more aware about methods of contraception, with growing exposure to information on television, social media and so on. More and more couples have star­ted waiting for three to five years after the first baby before they plan another child. The central government, too, has been making efforts to promote population control. It has identified 146 high-fertility districts across seven states—Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand and Assam. These are districts where the total fertility rate (TFR) per woman is three or more, and together they comprise 28 per cent of the country’s population. Thirty per cent of maternal deaths and nearly half of all infant deaths in India also occur in these districts.

According to the National Family Hea­lth Survey (NFHS) 2015-16, TFR per woman is 2.2—an imp­rovement over the 2005-06 ­figure of 2.4. Sources in the health and family welfare ministry, however, point out that it is still above the acceptable 2.1. NFHS 2015-16 puts the infant mortality rate (IMR) at 48 per 1,000 live births, much better than 66 in 2005-06.

In Uttar Pradesh, there are 11 districts where TFR is 4 plus per family, 19 districts where it is 3.5-3.9 and 27 with 3.0-3.5. In other words, out of 75 districts in UP, family planning interventions are necessary at least in these 57 dis­tricts. The situation is worse in Bihar, where all districts except Patna have high TFR figures.

Although health is a state subject, the Centre is intervening through Mission Parivar Vikas (MPV) for better access to contraceptives and family planning services so that the issue of maternal and infant morbidities and mortalities can be addressed at the root. Instead of forcing people to go in for family planning, the government is providing various options, including augmentation of PPIUCD (post-partum intrauterine contraceptive device) services at all delivery points, and of sterilisation services through HFD compensation scheme. Social marketing of condoms and contraceptive pills is being done under the government scheme and steps such as placing boxes of condoms at strategic locations such as health facilities and panchayat offices are also being taken. The injectable contraceptive DMPA (Depo Medroxy Progestrone Acetate), which prevents pregnancy for three months, is being introduced under the tradename Antara. The injections will start rolling out from July 11.

Women who opt for interval sterilisation (i.e., with a substantial gap from last pregnancy) are being given a lumpsum of Rs 2,000, up from the earlier incentive of Rs 1,400. For post-partum sterilisation (soon after delivery), they get Rs 3,000—the same amount men get for undergoing vasectomy (male sterilisation). Family planning kits called ‘Nayi Paheli’ are also being distributed among newly-weds. Local health workers hold ‘saas-bahu sammelans’ for orientation and counselling of family members. Awareness campaigns are also run on radio and television.  

According to the SRS (Sample Registration System) Statistical Report 2015, TFR among illiterates in Uttar Pradesh is as high as 4.6. Dr Pankaj Saxena, in-charge of family planning in the state, says many aspects of socio-economic dynamics need to be factored in when UP’s population is put under the microscope. The challenges include education and decision-making capacity of women, fertility rate and issues related to complexities of the family structure. On the positive side, performance on the ground has improved due to intense campaigns, counselling and interactions. Male sterilisation figures have gone up from 3,101 in FY 2015-16 to 8,219 in 2016-17. Female sterilisation went up from 2.52 lakh in 2015-16 to 2.94 lakh in 2016-17., while acceptance of PPIUCD rose from 1.16 lakh to 2.42 lakh.

It is a similar story in Madhya Pradesh, where usage of PPIUCD was only 15,000 in 2012-13, but which has touched 1,90,000 now and getting ­closer to the target of 2 lakh, according to Dr Nidhi Patel, in-charge of family planning in the state. Population Foundation of India executive director Poonam Mattr­eja points out: “Lack of access to family planning ­jeopardises the health of the mother and subsequently that of her child, resulting in higher rates of maternal and infant mortal­ity. This imp­lies an unhe­althy ­pop­ulation, which impedes our progress as a nation. Family planning is a tool that can empower people by preventing the vicious cycle of unplanned and unhealthy families, which is also bad for economic growth.”

Among all the states, Assam is one that plans to bring in a law to tackle population explosion. A bill is set to be introduced in the coming assembly session, which, if it becomes law, will debar couples with more than two children from getting government job. There is unlikely to be any cut-off date, according to sources. With its high TFR and fast depletion of land, population explosion has become a major concern for the state. Dr Iliyas Ali, member of the state’s committee on population policy, tells Outlook, “We are losing cultivable land gradually due to land erosion. If it is not tackled now, it will be a complet­ely different Assam after some years.”

Assam is spread over 78,000 sq km and loses 8,000 hectares of land every year due to erosion. Over the past 65 years, the loss has been nearly 4.27 lakh hectares. However, as the two-child norm looks odd in a state whose health minister, Himanta Biswa ­Sarma, has three children, it’s no surprise that many see this as part of the BJP’s ­alleged agenda to curtail the Muslim population in the state.

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• 146  high-fertility districts across seven states—Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand and Assam

• 28% of the country’s population comes from these districts

• 30% of maternal deaths and nearly half of all infant deaths are reported from these districts