In 1952, India, a fresh-faced nation, was one of the first countries to recognise the need for family planning and formulate a National Family Planning Programme. The country's sustained efforts over the years to achieve population stabilisation have yielded positive results. Most recent data reveal that India has attained a total fertility rate of 2.3 and the urban fertility rate has fallen to 1.8, which is below the replacement level of fertility.
The turning point for the discussion on family planning arrived late in the 20th century at the Cairo International Conference on Population and Development (ICPD) in 1994.The conference called upon countries to agree that population is not only about counting people, but about making sure that every person counts. India's thinking on population over the past two decades has been shaped by the ICPD, marking a paradigm shift from population control to sustainable development, reproductive health and reproductive rights. This became the basis of India's National Population Policy (NPP) in 2000.
While a positive policy environment has resulted in gains at the national and state levels, the implementation of family planning programmes has tended to fall short of expectations.
Taking into consideration the changing understanding on population, reproductive health, equity and rights, the policy calls for a comprehensive approach to population stabilisation. Recommendations included addressing the social determinants of health, promoting women's empowerment and education, adopting a target-free approach, and encouraging community participation. Socio-cultural factors such as age at marriage, age at first birth and education of girls for maternal and infant well-being also feature prominently in the policy along with promoting a basket of contraceptive choices.
However, there is a gap between policy and its implementation on the ground. While the creation of a positive policy environment has resulted in gains at the national and state levels, the implementation of family planning programmes has tended to fall short of expectations. The NPP eliminated the word "target" from the policy's vocabulary; however it was replaced with "expected level of achievement" –ELA. The performance of the health staff in family planning continues to be determined by the number of women they round up for sterilisation camps, health workers are pressurised to achieve targets, and the monetary compensation they receive is directly linked to their performance on numbers instead of the quality of services offered.
In India, female sterilisation has for decades remained the mainstay of the national programme. According to NFHS III data, in 2005-2006, female sterilisation accounted for 66% of contraceptive use; 77% women who underwent sterilisation had not used any method before they were sterilised; and more than half were sterilised before they reached 26 years of age. The lack of appropriate counselling and awareness on sexual and reproductive matters, and contraceptives, is further weighed down by gender inequality and rooted myths and misconceptions. Although vasectomy is a safer, quicker and easier procedure, several studies have suggested that Indian men do not undergo the procedure as they're worried about losing their virility.
Historically, the emphasis has been, largely, on contraceptive methods for women, and there has been little effort to involve men.
The ingrained disregard for women's dignity and the dismal quality of care for India's family planning programme was evidenced in the 2014 Bilaspur incident. More than a dozen young women died and several others were in critical condition due to gross medical negligence and violation of operating procedures during tubectomies at a sterilisation camp in Bilaspur district, Chhattisgarh. The news was disruptive to say the least and led to the Devika Biswas vs. Union of India ruling. On 14 September, 2016, Justice Madan Lokur, a member of the two-judge bench of the Supreme Court, gave three clear directives—it called for the end of sterilisation camps within the next three years, it asked state governments and union territories to ensure that family planning was not target-based, it gave a number of recommendations to improve the implementation of these programmes.
But media reports of cases of negligence still pour in. In January this year, a woman died during a sterilisation procedure after the surgeon cut the intestine instead of the fallopian tube. In Karnataka, 15 women were hospitalised when they were given injections of adrenaline instead of atropine sulphate before a sterilisation surgery.
While family planning is a necessary measure it cannot be at the cost of women's rights, dignity and quality of care. Instead, we need to open up the possibilities, provide them with a wide range of quality contraceptive methods for spacing, and give adequate medically accurate information including the benefits and risks, so that women and men can choose the method they want to adopt. There is evidence that increasing the basket of choice increases access to family planning, but it has to be accompanied by counselling and an effective supply chain management system.
It is also time to get the men involved. Historically, the emphasis has been, largely, on contraceptive methods for women, and there has been little effort to involve men. The public health system, family planning programmes and communication strategies need be redesigned to encourage men to accept vasectomy as a family planning method.
Repositioning family planning as a health and development issue could contribute to designing programs that address women's reproductive health needs alongside fertility control.
Further, working with India's young population is critical in order to reposition family planning and make the most of the demographic advantage that it enjoys. 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.
Finally, though about 25 states have already achieved replacement level fertility, this has not resulted in improved maternal health, because of early marriage and closely spaced births. For instance, in Andhra Pradesh, despite low TFR (1.8), 32% of women between 20 to 24 years were married before the age of 18 and 11% of women in between 15 to 19 had already borne children. Sixty percent of women in the age group of 15 to 49 are anaemic and 17% have Body Mass Index (BMI) below normal. The recently released NFHS IV data reveals the sorry state of affairs in the state. Repositioning family planning as a health and development issue could contribute to designing programs that address women's reproductive health needs alongside fertility control.
With 12 February flagged as the day to reckon with the need for Sexual and Reproductive Health Awareness globally, we are reminded that we have a responsibility not only to our women, but to their partners, the men and the large adolescent group who need to be encompassed into the country's family planning programme. In the words of Mr J R D Tata, on receiving the UN Population Award in 1992, "I have always believed that no real social change can occur in any society unless women are educated, self-reliant and respected. Woman is the critical fulcrum of family and community prosperity."