Honour reproductive rights of women

Poonam Muttreja

India has made some commendable progress towards ensuring safe motherhood for women in the recent years. However, any satisfaction one may derive from the steep decline in maternal mortality ratio (MMR) from 398 per 1,00,000 live births in 1998 to 167 in 2013 is tempered by the fact that the country still accounts for 17 per cent of all global maternal deaths.

Safe motherhood has three significant components that need to be addressed in equal measures: mortality, morbidity and social determinants of fertility. Unsafe delivery and pregnancy related complications are major factors why women die before, during or after child birth. While the direct medical causes of mortality – haemorrhage, sepsis, unsafe abortions, hypertensive disorders and obstructed labour – are largely preventable with provision of better quality healthcare services, a significant proportion of maternal deaths are also attributed to indirect causes like anaemia and malaria.

The unmet need for contraceptives 

One aspect of safe motherhood, often overlooked in India is unwanted or early-age pregnancies and high unmet need for contraception. According to National Family Health Survey 3, adolescents (15-19 years) contribute about 16 per cent of total fertility in the country and 15-25 years age group contributes 45 per cent of total maternal mortality. Nearly 21 per cent of all pregnancies are either unwanted or mistimed. This not only exposes women to avoidable maternal health complications, it also affects their overall development and well-being. A more accessible and equitable family planning programme that offers a wider choice of contraceptive methods to couples constitutes a simple, low-cost investment which can reduce maternal and child mortality by preventing early age pregnancies and unwanted pregnancies at a later age. 

The present-day discourse on maternal health pays insufficient attention to the issue of morbidity. For every woman who dies in childbirth in India, about 20 more suffer from long-lasting illnesses with physical, psychological, social, and economic consequences. Severe and continuing ill-health among women affects their children’s health as well, in terms of nutrition and nurture, thereby having inter-generational consequences. A study by social activist Dr Rani Bang in Gadchiroli has suggested that over half of women in rural India suffer from maternal morbidity, highlighting the widespread extent of the problem.The focus of safe motherhood needs to be widened to include morbidity as an important aspect of maternal health.

Attitudinal shift 

To be sure, family planning has had many successes over the last two decades. There has been a much-needed attitudinal shift. Contraceptives are now no longer considered only a means to stabilise the population but also as an intervention that improves maternal and child health. An analysis of the SRS 2011 report reveals that 8,00,000 births a year are being averted through the provision of family planning. Births among 15-19 year olds have come down by 3,50,000. Additionally, 1,700 maternal deaths are now being prevented each year and 3 out of 4 births are taking place in institutions.

Despite this, significant disparities and inequities in women’s access to healthcare continue to persist and the country remains far away from achieving the Millennium Development Goal of an MMR of 109 by 2015. The decreasing maternal mortality figures, as a whole, mask wide variations between different communities, states and even districts in the same state. Assam’s MMR of 390 compares poorly with 81 for Kerala. Many poor women from marginalised communities continue to exist outside the ambit of the healthcare system. 

High mortality and family planning  

The unmet need for family planning remains a significant challenge in reducing maternal mortality. The District Level Household and Facility Survey-3 (DLHS 3)assesses the total unmet need for contraception at 20.5 per cent nationally, comprising 13.3 per cent for limiting, i.e. women who do not want any more children but are not using any contraceptives and 7.2 per cent for spacing i.e. women who want to delay their next pregnancy. The trend of unmet need shows that the rate of change is very slow, with the figures being 25.3 per cent, 21.1 per cent and 20.5 per cent for DLHS 1 (1998-99), DLHS 2 (2002-04) and DLHS 3 (2007-08), respectively. This directly translates into unwanted and untimed pregnancies.While the total wanted fertility rate is 1.6 in urban areas and 2.6 in rural areas, the total fertility rate is 2.06 and 2.98, respectively. The difference can directly be attributed to the unmet need for family planning.

It is estimated that if the current unmet need could be fulfilled within the next five years, India can avert 35,000 maternal deaths and 12 lakh infant deaths.

To ensure proper health and avert maternal deaths, it is important to widen the basket of choices with the addition of more methods, address issues of accessibility and quality of family planning services, and allay myths and misplaced health concerns that prevent women from using modern contraceptives. 

Of equal significance for safe motherhood are social determinants of fertility. Women’s low status in the family and in society means they eat last and the least, resulting in a low body mass index. About 33 per cent of all women in India are malnourished, and 52 per cent are anaemic. This, along with marriages at an age is not ideal for conception, this makes women vulnerable to maternal morbidity and mortality, with a long-term negative impact on the entire family.

Reproductive rights 

The Economic Survey this year has taken a closer look at “Unleashing Naari Shakti” or empowering women, who constitute 48 per cent of Indian population. It talks about reorienting family planning towards reproductive health and rights, paying greater attention to quality and spacing methods, and doing away with targets and incentives for sterilisation as well as sterilisation camps. This is an extremely significant statement of intention by the Government, but words need to be translated into action.

To create a more productive, egalitarian and sustainable world, it is essential to recognise women as equal stakeholders in human progress. While positive outcomes of women’s empowerment can come from a bouquet of opportunities, such as education and earning capacity, the crucial role of contraception and modern spacing methods in transforming gender inequality has been missing from the national discourse. The heavy skew of Government expenditure on family planning towards only female sterilisation has not been debated and questioned in any significant way.

Out of the total family planning outlay of Rs 397 crore in 2013-14 Budget, as much as 85 per cent was spent only on sterilising females. The recent Economic Survey reveals that tubectomy and laparoscopic sterilisations together accounted for 97.4 per cent of the total number of sterilisation operations performed in India in 2012-13. Male vasectomy procedures, considered much less complicated and risky, accounted for the rest. What is more shocking is that even in the developed states of Tamil Nadu and Maharashtra, female sterilisation accounts for 90 per cent and 76 per cent, respectively, of all family planning methods used. The gender imbalance in sterilisation is too big and worrisome to be swept under the carpet, with women bearing the cross of meeting the Government’s family planning targets.

Female sterilisation, though a straight-forward operation, is often life-threatening in India due to poor quality, infrastructure and callousness, engendered by the pressure to meet Government-mandated targets. Last November’s incident in Bilaspur, Chhattisgarh, is still fresh in memory when 16 women, many of them in their prime, lost their lives in a mass sterilisation camp. Every such incident is not only a tragic loss of life, it is also a setback to the family planning efforts. The Government needs to reorient its efforts at stabilising population. Instead of employing the ill-conceived strategy of driving family planning through female sterilisation camps, it needs to focus on respecting the reproductive rights of women and expanding the choices available to them in terms of modern spacing methods. The shift from terminal methods like sterilisation to implants, oral pills and injectables is a national imperative because of the reproductive momentum generated by a youthful population. Young women and men need wider contraceptive choices to plan their families and space childbirth. 

Modern spacing methods account for a small fraction (10 per cent) of contraceptive use in India. Between 1998-1999 and 2005-2006, there was a minimal increase (from 6.8 to 10.1 per cent) in the proportion of couples using oral contraceptives, IUCDs, and condoms. Data indicates that India’s family planning programme has not, so far, succeeded in providing contraceptives in any significant way to delay the first birth and space subsequent births. It currently offers five methods — female sterilisation, male sterilisation, intrauterine contraceptive device (IUCD), oral contraceptives, and condoms. In contrast, other countries in the region like Nepal, Bhutan, Bangladesh and Indonesia have seven contraceptive methods available, including injectables and implants. This is significant because global experience shows that overall contraceptive use rises with every additional contraceptive method made available. The addition of one method available to at least half the population correlates with an increase of 4-8 percentage points in total use of modern methods, studies have shown. India’s family planning programme should therefore strive to provide widespread access to a range of methods, in line with international norms. This will empower women, families and communities. 

New contraceptives 

If the country were to introduce new contraceptives in the public health system, the immediate options are progestin-only pills, injectable contraceptives and implants. The former two are already approved and available in the private sector. The health benefits of increase in contraceptive choices are dramatic: universal access to reproductive healthcare could prevent two-thirds of unintended pregnancies, 70 per cent of maternal deaths, 44 per cent of newborn deaths, and three quarters of unsafe abortions in the world. Unfortunately, Introduction of new and modern methods of contraception has not been easy in India. It has been contentious, not in the community, not among the women for whom the contraceptive is meant, but among those who have the luxury to debate, discuss and oppose, who do not have to rely on unhygienic and life-threatening sterilisation camps as their only choice for contraception.

The issue of safe motherhood in India is much wider in scope than providing healthcare and family planning services for women. It involves a wider debate about their education, dignity, and reproductive rights and denying them the choices , they should be making on their own.

The writer is Executive Director, Population Foundation of India.