Birth By Choice: Myths and Realities of Family Planning in Rural India

There's a major challenge in acceptance of contraceptive measures like condoms, pills or IUD among rural couples. MOHD MUSTAQUIM reports on the mammoth task in front of the government and other agencies to control the exploding population across the rural domain.

Birth By Choice: Myths and Realities of Family Planning in Rural India
Birth By Choice: Myths and Realities of Family Planning in Rural India

There’s a major challenge in acceptance of contraceptive measures like condoms, pills or IUD among rural couples. MOHD MUSTAQUIM reports on the mammoth task in front of the government and other agencies to control the exploding population across the rural domain.
A country of 1.21 billion, where 52 per cent of births come from 15-24 years of age groups, India has very low recognition of contraceptives among the youth. According to a data of union ministry of health and family welfare, contraceptive prevalence rate among the same age group is just 18.6 per cent in Uttar Pradesh, Bihar, Rajasthan and Jharkhand which accounts for country’s one third of population.

A large number of youths in the countryside are still unaware of contraceptives and births take place by chance, rather than by choice. For prevalence of social stigma and unawareness in the Indian societies, contraceptives such as condoms, copper Ts and emergency pills are the least spoken subjects in India.

“People in rural areas do not have appropriate understanding on contraceptives, it is not considered a good thing if a man talks to a woman on these things. So, we have to deliver these messages through females. Rural women can understand easily if the message of family planning is delivered by a woman”, says Ghulam Nabi Azad, union minister for health and family welfare.

Reverberating with the minister, Dr. Madhulikha Bhattacharya, head of office at Jansankhya Sthirta Kosh (JSK), an autonomous body under the MoHFW, “Social stigma are the major challenges in running family planning programmes in the country. Even in the urban societies you cannot talk to anyone openly about contraceptives.”

Neeraj K Pawan, district magistrate of Bharatpur in Rajasthan who has received three awards as district magistrate of different districts in Rajasthan for his innovative and encouraging programmes for family planning in the villages, says, “The acceptance of contraceptives, whether they are condoms, intrauterine device (IUD) or emergency pills. People in villages do not even want to talk about these things. We are running incentive based programmes which are finally bringing results.”

There are many kinds of contraceptives, promoted by the government’s family planning programmes. The easiest method is known as condoms, then emergency pills. If one gets injectables, she cannot get pregnancy for three months. There are two types of IUDs which is also known as copper Ts because of its shape; one works for five years of duration another one for ten years. As permanent contraception, the government also promotes sterilisation tubectomy (for female) and vasectomy (for male).

To overcome these deep routed challenges, the family planning division of ministry of health and family welfare and National Rural Health Mission (NRHM) run awareness programmes at ground level and assign work to accredited social health activists (ASHA) and Auxiliary Nurse Midwife (ANM).

JSK is assisting and working together with the ministry and NRHM. AHSA and ANM talk to women in the rural areas and work as communication channel between the government and the intended beneficiaries. ASHA not only gives counseling to the women in the hinterlands, but also supplies contraceptives door to door, talk directly to the women living in Indian villages, on the benefits of small families.

ASHA activists have larger role in family planning programmes. They encourage rural youth for late marriage and not to have child till two years of marriage. They counsel for using condoms, oral pills and facilitate for injectables, IUDs, tu-bectomy and vasectomy operations.

“ASHA is counseling couples along with providing contraceptives, condoms and emergency pills. The activists get Rs 500 as incentive for each activity”, says Anuradha Gupta, additional secretary, union ministry of health and family welfare and mission director, NRHM. To encourage and convince people for adopting small families, family planning division of the ministry of health and family welfare provides incentives of Rs 500 to the couples for not having child till two years of marriage and another Rs 500 for maintaining three years gap between other children. After two kids, Rs 2600 for tubectomy and Rs 3100 for vasectomy in which Rs 1500 is contributed by NRHM fund.

Often ASHA activists and intended beneficiaries complain over not getting incentives and payments on time. Sometime, the payment can be delayed more than six months. It necessarily discourages and derails the entire programme. Dr. Bhattacharya expresses the concern and says, “We release funds to the state health societies and the societies send funds to the district health societies or directly to the hospitals. However, we get larger number of complaints of they do not get funds on time. This is the very big problem in the government’s system which finally affects the programme.”

“The ASHA workers and incentive receiving hospitals sometimes deny providing their services because of the delayed payments”, she further adds.

Jansankhya Sthirta Kosh which was set up in 2003 and became fully functional in 2007. The intention of JSK is to work on population stabilisation on focussed way. Its programmes are focused on high populous states of Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, Rajasthan, Odisha and Chhattisgarh which account 45 percent of country’s population. However, it acts like a gun without bullets.

“We have just two technical staffs and not able to run our schemes and programmes on village level. A decade after its setting up, it is still ignored by the administrative level. If want to run successfully, we need our presence in state level, even in every districts”, says Dr. Bhattacharya.

She wants to work in every village and wants to change the things on big scale, she has a plan to put up a detailed note to the ministry. She suggests, “It is not necessary to appoint separate staffs for this, we can deploy people on incentive basis also. We can incorporate local people to run our programmes in the villages.”

There are the cases of lack of family planning services in the villages. Women in the villages complain about the post IUD bleeding. If it happens, nobody takes care of them. The unmet need or access to service is very poor. If a lady wants IUD for her, there is lack of IUDs. Sometimes ANM is missing who provides this service. If ANM is there, then the intended beneficiary denies taking this service. Sometimes her husband or mother-in-law counsel her for not to have IUD. The problems prevail not only from the supply side, the demand side is also lacking in some parts.

To overcome these issues, the ministry and JSK have accredited some private hospitals. These hospitals provide family planning services and get incentive from the government. Dr. Ravi Pandey, who runs a nonprofit organisation Aastha Sewa Evam Kalyan Sansthan in the tribal areas of Bilaspur in Chhattisgarh, tells a different tale, “Contraceptives and condoms are used only by the educated class in the cities while rural people do not even want to talk on this. People do not have anything to do with these things, they just think about their own bread and butter. Rapid population growth is not a matter of concern for them.” He further says, “Because of prevailing social stigma, if there are four people sitting at a place, do not want to talk anything about these things. They feel ashamed while talking on these issues.”

Poonam Muttreja, executive director, Population Foundation of India stresses on the greater focus on condoms and pills and says, “It has to be greater focus on condoms and pills. We have bigger problem in supply than in demand. In dalits and tribles, the prevalence of contraceptives is very low. In the states of Bihar and Jharkhand, there is a huge challenge in reaching the last mile.”

Incorporating ASHA activists is a good effort by the government for communicating folks. First awareness programmes can be made strong which will enhance the demand side, then supply side need to be strong.

According to Frederika Meijer, India representative of United Nations Population Fund (UNFPA), there are many groups and demographics that are tough to be reached, we need to find out those are the vulnerable groups.

Meijer says, “There are lot of misconceptions that people in rural areas are not willing to talk about contraceptives, people are willing to talk, they just need to be aware and proper communication needs to be in place. As people will be getting awareness, they will start accepting contraceptives and then the supply side should be strong.”

She stresses on the assured supply of contraceptives in these communities. “We need to improve the access to quality contraceptives and family planning services. Keeping in view the rural economy, there is a need of cost effective contraceptives.”

Lack of communication sometimes becomes the reason of maternal death, Dr. Auradha Gupta of NRHM says, “Age of marriage directly relates to maternal deaths. So, there has to be dialogue, communication, interpersonal communication needs to be in place and ASHA is working for that.”

Appropriate communication can play a vital role in convincing the rural communities. Forgetting all misconceptions, if communication is done on right way, it may bring the fruitful results.

Himanta Biswa Sarma, minister of health and family welfare, Government of Assam shares his experience, “There is a myth and misconception about backwards and Muslims that they are not willing to adopt family planning measures. Actually, there is a lack of appropriate communication, wherever, we made proper communication, we got success. They just need proper awareness campaigns.” He further adds, “We are running awareness campaigns among these communities and seeing the changes.”

According to Prof. Leela Visaria of Gujarat Institute of Development Research “Improved communication needs to be done on side effects of contraceptives between suppliers and clients.”

To reach the last mile and run awareness campaigns, mass media can play an important role in contraceptive awareness programmes. According to the health minister, parliamentarians and mass media can play an important role in family planning awareness. Media can show the benefits of small families and quandaries of big families, having five or six children.

Echoing with the minister, Dr. Gupta stresses on media campaigns among rural masses and says, “Media can play an important role in changing behavior and mindsets of people living in the hinterlands. A large number of the youth population does not know about contraceptives. There is an opportunity to talk about family planning among them.”

The programmes are formulated on level of policymakers. However, the implementation has to face various kinds of challenges. The family planning programmes face a major challenge of social stigma on the beneficiaries’ end. This stigma can only be broken by the appropriate communication channel, whether it is on the form of intrapersonal, group or mass communication. The nominal incentives of the government cannot change anything in this era where cost of living is too high. The policymakers need to think on this issue.

The world’s thirds largest developing country, India, if really want to be a developed country. First the development can be taken place where its citizens get birth. The birth should not be by chance, rather it should be by choice.

The Changing Face of Rural India