Female Sterilisation Remains Top Contraceptive Despite Progress

What are the main wins and concerns about family planning in 2020? Do women have increased contractive awareness and choice? Are men equal partners? Where do urban and rural women differ and how can we bridge the access gap?

Findings from the Fifth National Family Health Survey aim to answer all that and more. The comprehensive study of 17 states and 5 union territories in 2019-20 comes four years after the last survey, NFHS-4, in 2015-16. The initial data has been released by the Ministry of Health and Family Welfare.

Overall, the data revealed a positive story with increased contraceptive access and choice among districts. Here’s a look at the wins and worries so far.

The Wins!

• More use of modern contraceptive methods

One of the big wins was that most states are now growing in their use of modern contraceptive methods. Because of how closely tied information, awareness and access are to stigma when talking of women’s health - this progress is huge on multiple fronts. It could point towards an increase in women’s equality as well.

More use of modern contraceptives also points to an increase in availability and choice for women in India than ever before.

• More Rural Households Use Contraceptives

At an online conference organised by the Population Fund of India (PFI) on the key findings, Dr Niranjan Saggurti, Country Director of Population Council said,

“The trend shows that more and more people are using and starting to use contraception in many states. The gap between urban and rural areas in contraceptive use is also decreasing, indicating that in the past 5 years more rural households have started to use contraceptives. This is driven by the increase in availability and access of reversible contraceptives like condoms, pills, IUDs and injectables too. ”

Dr Niranjan Saggurti, Country Director of Population Council

What may have contributed to this increase? Overall declining child marriage and childbearing, and increasing utilisation and availability of maternal health services at district levels are key possibilities. “There has been a vast improvement, in the past 5 years, in the quality of family planning services,” adds Dr Saggurti.

Still, there was a negative change in a few states and districts, in fact, some districts saw an alarming rise in child marriage as seen from the chart below:

• Increase in awareness about contraception

Family planning is a vast topic and awareness and full knowledge about the different types according to need and access is essential. The increasing usage points to an increase in awareness, which is the result of efforts by frontline health-workers, ASHAs and ANMs, who tirelessly have been increasing the knowledge and helping in substantial, sustainable behaviour change among couples.

“This was a long-held hypothesis that has been proved that frontline healthcare workers reaching women in all districts and talking to them about contraction can creative substantial change. This is key critical indicator.”

Dr Niranjan Saggurti, Country Director of Population Council

Another critical indicator is that healthcare workers have been improving the quality of care by explaining thoroughly about side-effects and more. “There has been a substantial improvement in the quality of family planning services by healthcare workers in the past 5 years,” adds Dr Saggurti. This has a strong ripple effect in increasing women’s healthcare across various levels. For example, this has led to more women coming in for maternal care and reaching antenatal centres with more confidence.

Another positive? There have been improvements in women’s empowerment related indicators. More women are able to participate in household decision making in 9 states while 30% more women now have bank accounts in Assam, Bihar, Gujarat and West Bengal, which points to women having more agency and control of their lives as well.

The Concerns

• Traditional method of contraception is also on the rise

One of the worries is that the traditional method of contraception and terminal methods of contraception like female sterilisation is still on the rise - and this may lead to a decline in the use of modern contraceptives in the long run.

Dr KS James, Director, International Institute for Population Sciences (IIPS), a demographer and health expert added,

“There is a switch happening, but female sterilisation remains the preferred method of contraption. The change is still slow, but there are changes in most parts of the country. The result of this is also that the unmet need for family planning and spacing has come down in most of the states which is positive.”

Dr KS James, Director, International Institute for Population Sciences (IIPS)

He adds that this is part of the survey and small fluctuations in states need to be taken “with a pinch of salt.”

• Male involvement in family planning is still lacking

Family planning is unfortunately still seen as mainly a woman’s responsibility. This disparity is called the ‘contraceptive burden’. The Indian Express reported that in 2018, women accounted for at least 93 per cent of sterilisations in India, and bore more than their share of the burden.

In the latest survey too, there was a lack of condom use or male sterilisation as contraceptive options across states. Here is a short video on male contraceptive options.

Healthcare workers need to actively engage men in the process, and family planning programs need to incentivise male contraceptive options to help take the burden off women’s shoulders.

• Increase in Child Marriages & Teen Pregnancies

A worrying trend was that despite efforts made, a few states and districts still showed a rise in child marriages. There has been an increase in child marriages in Tripura (40.1% from 33.1% in 2015-16), Manipur (16.3% from 13.7% in 2015-16) and Assam (31.8% from 30.8% in 2015-16), while states like West Bengal (41.6%) and Bihar (40.8%) still have high prevalence of child marriages.

States like Manipur, Andhra Pradesh, Himachal Pradesh and Nagaland have also shown an increase in teenage pregnancies. While this is not at the level of western countries, and perhaps the increasing marriage age will help counter this, it does pose a worrying trend for women’s health as early childbearing is harmful for young mothers lives.

• Increase in Sexual Violence

Women’s health is often complicated because of gender disparities and violence against women has been called our silent pandemic.

While spousal violence has generally declined in most of the states and UTs, it has witnessed an increase in five states, namely Sikkim, Maharashtra, Himachal Pradesh, Assam and Karnataka. Karnataka witnessed the largest increase in spousal violence, from 20.6% in NFHS 4 to 44.4% in NFHS 5, while sexual violence has increased in five states (Assam, Karnataka, Maharashtra, Meghalaya and West Bengal).

The Bottom Line & What’s Next

The data paints a largely positive picture of women’s healthcare improvements in India - although there is much, much more work to done for equal, affordable healthcare rights. One of the big concerns is that this data was recorded before the pandemic wreaked further havoc on our health and lives - especially women’s healthcare rights which are often at the bottom of the totem pole. For example, FIT earlier reported on how the migrant crisis which resulted from the lockdown, was often worse for women migrants who were also dealing with menstruation or pregnancy and more. Watch the video here.

As the pandemic still rages on, women’s health needs to become a priority in governance. One of the key suggestions by PFI was that health concerns need to receive a higher priority in terms of resources allocated towards public health. Additionally, frontline health workers, who bear the burden of health issues on the ground, must be compensated fairly.