Built-in violence

Stereotypical government policies and global approaches persist in family planning programmes.

Urmila is a 40-year-old domestic worker in western Uttar Pradesh. The mother of six children, all girls, she is now pregnant again and is keen on carrying on with the pregnancy. Her husband is unemployed and is an alcoholic. His relatives have assured her that they will help her to bring up the child and have also hinted that she may finally have a boy. The two sons she bore earlier did not survive beyond a year.

Urmila, who can barely feed her six children, does not really want another child, but she knows she will be valued more if she has a son. Besides, she does not know of any abortion clinic and is worried about what an abortion might cost. She is also not confident enough to opt for sterilisation, given all the horror stories she has heard. I have heard women put on weight and have pain in the stomach and back after the operation. I am scared, she says. She plans to continue working into the last month of her pregnancy in order to keep the family income afloat. The nearest government hospital that offers decent services is seven kilometres away, in Delhi, and that discourages her from making frequent visits.

Her story is representative. Any discussion on family planning in the country should ideally factor in all the problems that women like Urmila confront.

On July 11, at a multi-stakeholder summit held in London on family planning, concerns were raised about providing life-saving, affordable contraceptive services and information to an additional 120 million women in the worlds poorest countries, including India, by 2020. The summit, in which India participated, was an initiative of the United Kingdom government, the Bill and Melinda Gates Foundation, and the United Nations Population Fund along with other national governments and donors.

It focussed on the need to support the right of women to decide, freely and for themselves, whether to have children and how many children to have. One of the presumptions of the summit was that more than 200 million women and girls in developing countries did not want to get pregnant and lacked access to contraceptive information, supplies and services. It was also presumed that in 2012, some 80 million unintended pregnancies would occur in the developing world because of the absence of these services and information, resulting in 30 million unplanned births, 40 million abortions and 10 million miscarriages.

The summit also focussed on pregnancy-related complications that result in maternal deaths, even among teenaged girls. The organisers claimed that the event aligned itself with the broader framework established by the International Conference on Population and Development almost 20 years ago. However, a major difference between then and now is that the emphasis has tilted towards private-public partnerships, even in the delivery of contraceptive services.

Small family norm

The summit also expected governments to invest and spend more on permanent methods of family planning, a suggestion that did not go down well with health activists back home. The emphasis on population control through permanent methods of family planning has raised concerns in India and elsewhere. Pro-life groups in Western countries have their own arguments, though women and health groups working in India believe that the Central government and many State governments have been aggressively promoting the small family norm through various incentives and disincentives, an issue that did not come up at the London summit.

Indias own presentation at the summit has only aggravated these fears. The representative emphasised that there was a paradigm shift in the governments approach, giving emphasis to the promotion and provision of contraceptives for birth spacing. India was also committed, said the representative, to ensuring that family planning would be a central part of its efforts to ensure universal health coverage.

The new strategy, which has a life-cycle approach, focusses on making contraceptives available at the doorstep through 8.6 lakh community health workers who are already going from house to house in rural India distributing contraceptives. As per the latest District Level Household and Facility Survey (2008), of the 54 per cent of the population that reported using any method of contraception, female sterilisation accounted for 34 per cent and male sterilisation accounted for 1 per cent.

Therefore, activists are sceptical. They argue that many State governments continue to adopt coercive policies to meet family planning targets: making sterilisation a precondition for access to development schemes, food rations, free education and water; depriving mothers with more than two children of maternity benefits; and prohibiting persons with more than two children from contesting panchayat and municipal elections. India should eliminate coercive female sterilisation practices as it implements plans for the expanded contraceptive services it announced at the conference in London, noted a statement issued by Human Rights Watch and two reproductive health rights networks, the Coalition Against Two Child Norm and Coercive Population Policies and the CommonHealth Coalition for Maternal-Neonatal Health and Safe Abortions.

Representatives of the National Coalition Against Two Child Norm and Coercive Population Policies, a broad coalition of organisations campaigning against such incentive-based and coercive policies, say that they have documented a variety of negative outcomes of the two-child policy, such as the exclusion of young women and men from political participation; practices such as female foeticide; infanticide and abandonment of female newborns; and desertion and denial of paternity. Haryana, Himachal Pradesh, Madhya Pradesh and Chhattisgarh have discontinued these policies, but States such as Rajasthan, Andhra Pradesh, Odisha, Maharashtra and Gujarat persist with them, with negative outcomes for girl children and families. Family planning camps in several States continue to focus on targets through their front-line functionaries, accredited social health activists (ASHAs).

Conditional benefit scheme

At the national level, the Indira Gandhi Matritva Sahayog Yojana includes a two-child norm. The scheme, introduced last year following a recommendation in the Eleventh Five Year Plan, is described as a modest conditional maternity benefit scheme where pregnant and lactating women are compensated in part for the wage loss they incur because of the delivery and then in the post-partum period. The scheme envisages paying them Rs.4,000 in instalments until the child is six months old. It applies to only two live births and is contingent on the woman fulfilling certain nutritional and maternal child health conditions.

Why only two live births? The explanation is two-fold: first, the health of the woman should not be compromised and second, family planning is to be promoted. This payment, made through health workers such as anganwadi workers (AWWs) and ASHAs, is fraught with conditions, most of which are well-intended but so bureaucratised that a pregnant woman would rather forgo the benefit than go through with all the red tape. In any case, women like Urmila, who desperately need some form of wage compensation as they are often the sole breadwinners in their families, are deprived of this benefit.

Therefore, even though the target-free approach was introduced as far back as 1996, it has not prevented governments from getting obsessed with numbers.

The coalition argues that the panic mode is unjustified as the population growth rate has been slowing significantly over the past two decades. In any case, the growth registered in the population was mostly caused by the momentum effect or unmet needs and has very little to do with additional wanted fertility. But with son preference being what it is in the country, it is evident that dominant members within families decide the size of the family and are not necessarily motivated by any targets set by the government.

However, the poor are the hardest hit by the system of disincentives. The incentives, on the other hand, have reduced family planning programmes to female sterilisation programmes. In Madhya Pradesh, all kinds of incentives, including cars, washing machines and DVD players, offered to motivators, surgeons and the women undergoing sterilisation have led to the diversion of the funds meant for such programmes. And, because of the lack of trained personnel, camps are still preferred sites for sterilisations.

State Programme Implementation Plans in high-fertility and laggard States such as Uttar Pradesh, Bihar, Rajasthan and Madhya Pradesh have worked out the exact per unit cost and the physical target (the number of people sterilised), which can go up to lakhs. The objective of the family planning programme is to achieve a total fertility rate (TFR) of 2.1. This is the desired TFR, which has already been arrived at in several southern States. The coalition argues that what is required is spacing and not permanent methods of sterilisation.

In States where the TFR is high, as in several northern States, permanent methods are being actively pushed. An overwhelming majority of women are willing to undergo poor-quality sterilisation not out of informed choice but out of desperation, say the coalition members. Women who want to get out of the perennial cycle of reproduction have access to few options, and those that are available are often notional, says Abhijit Das, representing the coalition. Contraceptive counselling or the levels of partner communication essential for the use of temporary methods are missing, he says. Counselling is often given to a woman after she has given birth and is aimed at the adoption of either the intra-uterine device or sterilisation. The male partner continues to be absent from any outreach programme of the government, which makes the family planning programme hugely woman-centric.

Pressured to meet targets

Womens groups and health groups have called for a drastic revision in the countrys approach to contraception. Under the present system, health workers are pressured to meet targets, sometimes with threats of salary cuts or even dismissal. As a consequence, women undergo sterilisation without being provided sufficient information about possible complications, the irreversibility of the method and safer sex practices after the procedure. Health workers who miss sterilisation targets because they give proper counselling and accurate information about contraception risk losing their jobs in many parts of the country, said Aruna Kashyap, womens rights researcher at Human Rights Watch.

In June, Human Rights Watch interviewed more than four dozen AWWs and ASHAs from two districts in Gujarat with large tribal populations. More than 50 health workers said that district and sub-district authorities assigned individual yearly targets for contraceptives, with a heavy focus on female sterilisation. Their supervisors threatened them with adverse consequences if they did not achieve their targets. The threats included withholding or reducing of salaries, negative performance assessments, suspensions and dismissals. One health worker reportedly said that she had been asked to falsify records to show she had met targets or be reported for poor performance.