A birth control controversy

In its zeal to bring down the fertility rate, the Rajasthan government plans to implement methods of contraception that have women and the poor as the main target groups.

AN ambitious programme for population stabilisation conceived by the Ashok Gehlot government in Rajasthan has run into trouble as several organisations in the State have criticised it and urged the government not to proceed with its implementation. To be carried out under the specially conceived Rajiv Gandhi Population Mission (RGPM), the programme seeks to achieve certain demographic goals by 2011, including the lowering of the total fertility rate to 2.1 births per woman.

Questions are raised about the methods prescribed and the conceptual understanding to achieve the targets more than whether the targets can be achieved. Which is why organisations such as the Medicos Friends Circle, Prayas, the Jan Swasthaya Abhiyaan, the Rajasthan People's Union for Civil Liberties, the Janwadi Lekhakh Sangh, the Mazdoor Kisan Sangharsh Samiti, the Bharatiya Gyan Vigyan Samiti, and the National Muslim Women's Organisation have criticised the draft action plan. In fact, Narendra Gupta, the director of Prayas, a Chittorgarh-based non-governmental organisation (NGO), wrote to State Chief Secretary R.K. Nair expressing his reservations over the thrust of the action plan, which is scheduled to be implemented from the next financial year.

The demographic goals include a reduction in maternal mortality and infant mortality and an increase in the proportion of couples using family planning methods. However, what the plan of action document prescribes in order to achieve these goals is shocking. A set of targets has been identified, and the first target is to increase the number of sterilisations from three lakhs in 2002-03 to eight lakhs in 2010-11. The second target is meant to ensure that at least 50 per cent of the newly sterilised couples must have two children or less by 2011. The rest of the targets are to achieve high immunisation levels, increase the registration of pregnant women and provide a full range of ante-natal care services and to increase the level of institutional deliveries to 40 per cent by 2008 and 50 per cent by 2011.

By emphasising permanent methods of contraception, such as sterilisation, it is apparent that Rajasthan's population programme is more about contraception rather than overall development. The document says that the replacement level fertility can be reached by helping those people who have a large unmet need, with the Reproductive and Child Health (RCH) and Family Planning Services. While there is little about the RCH needs of women and children in the entire plan of action, the stress is on family planning programmes and targets.

A lot of comparison has been made between the family planning services of Rajasthan and those of States like Andhra Pradesh, Kerala and Tamil Nadu where human development indicators and overall health delivery systems are far better. The plan of action document presupposes that the people in the State are not against the small family norm. It reasons that there has never been any kind of organised opposition to the population stabilisation programme and that despite poverty and illiteracy, people want small families. Thus the government felt that there was a huge unmet need, which it felt obliged to fulfil, unmindful of the fact that there were other needs of the people too that needed to be met similarly. The document says that Rajasthan was not able to join the list of "advanced" States owing to a high population growth.

A major cause for concern is the fact that the sections who are targeted are the poor people and women. Also frightening is the missionary zeal with which the government expects to achieve this end. It even advocates widening the basket of contraceptives by including injectible ones, which the document claims are "popular especially among those belonging to the lower strata". The basis of this popularity is not explained. Needless to say, almost all the contraception techniques are directed at women.

The organisations that have written to the Chief Secretary have also pointed out that injectible contraceptives were known to create havoc with the menstrual cycle of women apart from having other side effects. They have also pointed out that women had already taken the brunt of the two-child norm legislation introduced in 1994. There were cases where women had been sent permanently to their natal homes after the birth of a third child so that their husbands could contest elections; some husbands had disowned their wives by disclaiming the fatherhood of the third child; and in some cases elected women leaders were forced to quit their posts as their families were keen on a third child.

One of the indicators of unwanted fertility, the document states, is the high incidence of abortions. According to the Directorate of Medical and Health Services, Government of Rajasthan, more than 50,000 medical terminations of pregnancy (MTP) procedures were performed each year since 2000-01. But whether these are a result of teenage pregnancies or are sex-selective abortions is not clear. In fact, there is no mention of the skewed juvenile sex ratio prevalent in the State. This is one such indicator that should have effectively dissuaded the government from embarking on an aggressive programme of family planning as this would only lead to fewer girl children.

The Rajasthan government's State population policy was unveiled in January 2000. This was apparently in reaction to a projection made in 1996 by a Technical Group on Population, set up by the Planning Commission, that Rajasthan would be able to achieve a total fertility rate (TFR) of 2.1 births per woman by only 2048 if the State's population continued to grow at the current level. It was decided then that 2016 would be the year by which the TFR would be met. However, when Census 2001 appeared and not much difference was seen in the decadal growth of population, the State government panicked, and ignoring the indicators of sex ratio in the same Census, it revised the deadline to 2011 by which the TFR levels would be brought down drastically. The RGPM was set up around the same time. At its third meeting on May 2003 the RGPM decided on a specific action plan and targets.

While a burgeoning population is a matter of concern, there are time-tested methods of achieving low fertility rates. The State government is justifiably concerned that nearly 40 per cent of the population comprises people under 15 years of age and almost 100 lakh couples are in the reproductive age group. But the State also has the fourth highest infant mortality rate in the country and the third highest maternal mortality rate. While pregnancy and pregnancy-related causes account for the major portion of the maternal deaths, by no means can they be stemmed by contraception. Poor health, poor nutrition and extremely poor delivery services, both ante-natal and post-natal, are the major causes of the high maternal mortality. According to government figures, 12,000 women die as a result of pregnancy-related causes and 1.3 lakh children do not even reach their first birthday. Interestingly, while the government states that the rate of fertility decline is very slow, by its own admission, in 1981, the total fertility rate was 5.2 children per woman, in 1997, it came down to 4.2 and currently it is 3.6.

The demographic transition, if anything, is already under way but the government wants to hasten it by resorting to methods that can only be termed as undemocratic. The State government is proud that it has at least put a plan of action for population stabilisation in place. It has identified various administrative lacunae in the State family planning programme and resolved to rectify them. Its decision, taken in 1994, to debar persons with more than two children from contesting panchayat elections has won the support of all political parties.

The plan of action intends to create an awareness through the administration and through the political set-up to highlight the stabilisation programme among the people. Apart from the Chief Minister reviewing the programme every month, elected representatives are supposed to speak on the subject for a few minutes in every public meeting. The Legislative Assembly would also take up the issue once a year for discussion.

The plan of action suggests that Primary Health Centres (PHCs) would be the centre for family welfare services. They will conduct conventional sterilisations and MTPs and will have the provision for anaesthesia also. There are 1,700 such centres in the State and by October 31, round-the-clock delivery services will be provided and two camps will be held in a month to conduct sterilisation and insertion of intra-uterine devices. It is a matter of irony that the government should link the provision of such basic services like 24-hour delivery services with population stabilisation as the underlying objective.

The auxiliary nurse midwife will also have a new role in that she would be doing a lot of "motivation" work to help couples meet their unmet needs. Said Narendra Gupta of Prayas: "The ANMs will be distracted from the work that they are already doing. They will instead focus entirely on meeting the targets." He said that nowhere had the demographic transition been achieved without bringing down the premature mortality rates which itself was a concomitant of improved access to health care, especially in the case of women and children.

Gupta said that it was lamentable that the government was resorting to strategies such as sterilisation, which were prevalent 10 years ago. He said that a large number of women who had undergone tubectomy in the sterilisation camps in the early 1990s had experienced complications ranging from lower back pain to pelvic inflammatory disease in addition to a high failure rate in contraception. A large number of women conceived after the laparoscopic tubectomies. The plan document hardly had any strategy spelt out for premature mortality reduction while "unmet needs" of contraception had been overemphasised.

Statistics of the National Family Health Survey 1998-99 paint a rather grim picture of the status of health of the people of Rajasthan, especially women and children. The immunisation among children was just 17 per cent; only half of all pregnant women received any kind of ante-natal check-up and two tetanus toxoid injections; about half of all women in the State suffered from various degrees of anaemia; and 43 per cent reported at least one reproductive health problem.

The action plan has fixed targets for every district and Collectors are expected to implement them zealously. It is apparent that the government has not given much thought to the impact of the programme, obsessed as it is with bringing down numbers. If implemented in its present form, the programme will just be another Malthusian juggernaut aimed at the poor and the defenceless in the State.