– by Vidushi Gupta
Family planning and access to reproductive healthcare are seen as major goals of development across the world, as is evident from Target 3.7 of the United Nations Sustainable Development Goals. Moreover, the inter-relationship between the population of a country and its development, with gender equality, family planning and women’s reproductive health as the cornerstones, was emphasised upon at the International Conference on Population and Development (ICPD), 1994.
India has a population of 1.37 billion and is projected to surpass China in 2027 as the world’s most populous country. A large population impacts the economy, the environment, and the development of the country. Moreover, the population needs to be healthy, in order to create a demographic dividend. Thus, population control has always been a major concern in India and “family” has been the pivot of all population control goals. Hence, India became the first country to adopt a national family planning programme to control population growth, as part of its socio-economic development policies in 1952. Since then, it has undergone various changes, adopting different approaches over time.
This article employs a feministperspective and analyses the need for a shift in the approach of the Indian family planning programmes, in order to ensure better reproductive and sexual health for women in India. It is argued that despite the state claiming that the current family planning initiatives have promotion of women’s health as the primary goal, in reality, they are largely oriented towards population control.
PROBLEMS THAT PLAGUE THE CURRENT SYSTEM
After the ICPD 1994, India’s National Population Policy (NPP), 2000 rejected the target-based approach and addressing unmet need for contraception and reproductive health became the immediate objectives. The unmet need for family planning refers to the percentage of married women of reproductive age (15-49 years) who want to limit or space childbearing, but are not using contraception. Although there was a decline in the level of unmet need from 19.5% to 13.9% between National Family Health Survey (NFHS)-1 and NFHS-3, there has been almost a stagnation from NFHS-3 to NFHS-4 (12.9%).
There are several shortcomings in the current method of measuring unmet need, which highlight the broad outlook adopted for family planning in India. It does not include women who are currently using traditional contraceptives within its scope. It thus refers only to the overall unmet need, not the unmet need for modern contraception. Further, it fails to acknowledge the contribution of contraceptive discontinuation to current and future unmet need, despite the fact that women’s contraceptive needs change over time, and women may discontinue use, but may still have an unmet need. Consequently, while looking at women with current unmet need, it does not distinguish between past users of contraceptives and never-users. This is crucial because strategies aimed at past users will be more cost-effective, since they have already overcome attitudinal, cultural access and cost barriers that often inhibit first-time contraception use, than strategies that enable never-users to start using a contraceptive. Moreover, it does not account for future unmet need, which may be created by women with currently met need or no need, but may develop a need later because of changed fertility preferences. Further, unmet need only focusses on women (if a man uses a contraceptive, it is his wife whose unmet need is considered to be satisfied), thereby reinforcing the idea that only women have the responsibility of using contraception and undertaking family planning. Even among women, unmarried women are excluded, although they are also sexually active and have a need for contraceptives. Further, with the coming up of the postmodern ideas of ‘family’, unmarried women and adolescents should also be the focus.
Due to unmet need, women are denied reproductive choice. The poor and the minorities like Muslims who have a higher unmet need are the worst affected (due to intersecting marginalised identities), indicating the lack of an inclusive approach and the failure to ensure that all sections of society are covered. Met need is higher among urban, upper-class people who can afford private services, for instance, through apps delivering sexual-wellness products to homes. The situation has worsened after the COVID-19 pandemic, as it has led to reduction in the manufacturing of and access to contraceptive services.
Some people are averse to using contraception, due to fear of side effects and adverse health impact, social resistance, insufficient information regarding methods, son preference etc. However, little is done to provide guidance and advice.
Another major issue is the lack of adequate government budgetary allocation for health and family planning, which has resulted in inequities, insufficient access, poor quality of healthcare services, and high out-of-pocket expenditure. 53% of India’s population is in the reproductive age. Moreover, at the 2012 London Summit, India committed to provide family planning services to 48 million new users by 2020. Thus, we need increased spending. Although the National Health Policy, 2017 proposed raising public health expenditure to 2.5% of the GDP by 2025, we are far from achieving this goal.
Yet another problem is that India’s family planning programmes have placed a disproportionate burden on women, thereby compromising their health. Most men in India use no method of contraception, since they perceive contraception as only women’s business. Some even believe that contraception can make a woman “promiscuous”. So, the onus to take precautions and avoid unwanted pregnancy falls only on women. However, it is the men who control the resources and make decisions relating to childbirth and contraception, leading to violent outcomes for couples. Most wives cannot use contraception without their husband’s permission. Even the mothers-in-law impose restrictions on women’s access to healthcare and family planning. Thus, family planning is fraught with entrenched social and gender norms, which even women yield to.
One way in which the burden has shifted on Indian women is through the oral contraceptive pills. They rely on these pills to have unprotected sexual relations, which gives them an impression of freedom and choice. But in reality, this places the liability of avoiding pregnancy on them, while also making them prone to sexually-transmitted diseases. Regular consumption of the pill results in adverse health effects. However, private companies continue to manufacture these pills, highlighting that patriarchy is interwoven with capitalist profit motives. Still, banning over-the-counter sales of pills may not be actually desirable, because many women prefer the cheap and private pill purchase (although it may be unsafe), as they can access it without the husband’s knowledge.
One barrier to male participation is the predominance of female healthcare workers. They can’t discuss contraceptives with men, since they are supposed to maintain a respectable distance from them. Although some initiatives to promote vasectomy and use of condoms (including financial incentives) have been launched, they have little chance of success in the absence of male healthcare workers.
Excessive emphasis on female sterilization is another problem, which attracts 80% of the funds available for family planning in India. State governments treat sterilisation as a population control measure, by setting targets and organising sterilisation camps, despite the central government formally abandoning targets in 1996. Although female sterilisation is the most prevalent mode of contraception, majority of the women (as young as 25) are coerced to undergo sterilization, either by government officials or their own families, in order to avail the incentives or benefits offered to meet annual targets. This is despite the fact that the NPP encourages only voluntary sterilisations. Thus, poor women are forced to give up their reproductive rights in return for small payments, thereby reducing them to a mere commodity in the entire transaction. Further, female sterilization surgeries are done in unhygienic conditions, without medical expertise, adequate infrastructure, surgical equipment, lacking proper procedure listed in the directions issued by the Court in Ramakant Rai (I) v. Union of India. Thus, due to poor public health services, safety measures get bypassed, thereby increasing the possibility of contamination, side effects, and even death.
In India, very few men opt for sterilization due to misconceptions like decline in their physical strength and consequent inability to work and earn, loss of virility etc. Accessible sterilization has been an evil for illiterate, poor, rural women, who are not provided counselling or made aware of other contraceptives, rendering them unable to given consent and make informed choice. Taking note of this, the Supreme Court in Devika Biswas v. Union of India (2016) ordered the state governments to give up the target-based approach and shut down all sterilisation camps. However, it remains unclear as to what extent this has been complied with.
Thus, in the male-dominated patriarchal Indian society, governments and men suppress female sexuality and control women’s bodies, negating their reproductive rights, sexual freedom, autonomy and agency. They decide the policies and laws that regulate women’s reproductive choices, making motherhood an alienating experience for women.
Earlier, vasectomy was a popular method of contraception, but after the male sterilisation campaign during Emergency, it was abandoned due to public anger. The fact that women have continued to be forcibly sterilized since so many years shows how women’s health concerns are disregarded by those in power. Society regards women as the “second sex”, and perceives them as being submissive, with little bargaining or protesting power. This also shows how “the personal and the political are one.” When women are unable to use contraception, the causal chain of “maternity—family—absence from production and public life—sexual inequality” continues to bind them to their subordinate status.
Yet another issue is that India’s programmes are exclusively aimed at stabilising population, while neglecting women’s reproductive health and rights. This is highlighted by the government-imposed restriction on the access of Chhattisgarh’s Particularly Vulnerable Tribal Groups to contraceptives, with the aim of maintaining their populations despite high mortality rates, leading to multiple pregnancies and impoverishment. It was only in 2018 that the High Court, in the case of Ranichand Baiga v. State of Chhattisgarh, quashed the restrictions as being violative of Article 21 of the Indian Constitution.
Further, a press release by the Ministry of Health and Family Welfare states that the Family Planning Programme is guided by the NPP and oversees its implementation. While the NPP deals with family planning, unmet need, and reproductive health care, its ultimate objective is to stabilise the population, for achieving development. Thus, family planning is not seen as an instrument for ensuring women’s health, and women’s health is not treated as an end in itself. They are only intermediate objectives or the means to achieve a larger end goal i.e. population control and the welfare and development of the nation.
Moreover, the fact that population control and family planning are part of the same Entry 20A under the Concurrent List, with public health being a separate state subject (Entry 6) in the Constitution shows how family planning has been oriented towards population control in India.
In reality, this stress on population control is misplaced. Over several years, the Total Fertility Rate (TFR) in India has declined to 2.2 in 2019, reaching a near replacement level. Thus, India is on the path to stabilise population, and the fertility impact of addressing unmet need should not be of prime importance to policymakers.
Another problem is that although the legal framework plays a significant role in implementing the socio-economic developmental policies of the state, there is a huge void in the Indian law, since there are no statutes dealing with family planning and reproductive health. However, Article 47 of the Indian Constitution talks about the state’s duty to improve public health. Moreover, several international instruments (like the International Covenant on Civil and Political Rights, the United Nations Convention on the Rights of the Child, the Convention on the Elimination of all Forms of Discrimination Against Women, and the Universal Declaration of Human Rights) ratified by India include family planning and reproductive health within their scope. However, these legal instruments are non-enforceable. Thus, although governments have launched several schemes, policies, guidelines and standards for family planning, they lack adequate implementation due to lack of legal backing.
It is the Judiciary in India which has played a vital role in making reproductive rights justiciable. In Laxmi Mandal v. Deen Dayal Harinagar Hospital, it was held that the fundamental right to health under Article 21 is inalienable and includes reproductive rights. Further, in Suchita Srivastava v. Chandigarh Administration, the Court noted that women’s right to make reproductive choices is part of personal liberty, and that their right to dignity and bodily integrity should be respected. The Court in KS Puttaswamy v. Union of India has also recognised this right as part of decisional autonomy, under the right to privacy.
FAMILY PLANNING AS A MEANS FOR ATTAINING REPRODUCTIVE AND SEXUAL HEALTH
Unmet need leads to higher fertility and frequent, repeated pregnancies. A lot of these are unwanted or unplanned pregnancies, forcing women to access illegal and unsafe abortion, that can cause severe physical and mental injury, and even death. Thus, better access to safe, effective contraceptives through the public healthcare system can lead to better mental, reproductive and sexual health for women and reduce the need for abortions. Moreover, women receiving induced abortions are at a higher risk of subsequent unintended pregnancy. Integrating post-abortion contraception into family planning and other health services can help reduce the maternal mortality and morbidity associated with short intervals between abortion and subsequent pregnancy. This involves various measures including comprehensive service-delivery interventions, ensuring availability of skilled practitioners and contraceptive commodities, offering clinical mentoring for practitioners, identifying and addressing their bias, and improving their counselling skills. Such measures can also help increase women’s contraceptive acceptance for modern methods.
The central and state governments should undertake better coordination, to ensure consistency between policies. They should not implement family planning programmes as a population control measure. Instead, they should make efforts to ensure that there is effective execution of these programmes in accordance with the proposed aims, so that they lead to women empowerment, by providing women with better reproductive healthcare. Thus, unmet need, instead of TFR must be used as the parameter for family planning. The interplay of various socio-economic, political, legal and gender factors in the realm of family planning shows that a more holistic and comprehensive approach is needed, which addresses the reasons behind each of the problems discussed. The state must also enact laws to convert family planning policies into practice, ensure better implementation, create accountability, make reproductive rights justiciable, and strengthen the public healthcare system. However, the State should not adopt a paternalistic approach. Women’s health interests should be seen as an end in itself and should be at the centre of all family planning programmes.
There is a dire need for India to revaluate its family planning programmes and the approach adopted for them. The policies and initiatives cite improving women’s health as a major objective. However, the implementation of these programmes completely neglects women’s reproductive and sexual health. Some of the problems examined here had also been identified in the NPP, however, not much has changed since then with respect to issues like participation of men in family planning. The fact that we are close to achieving the medium-term and long-term objectives mentioned in the NPP, but far from achieving the immediate objectives of family planning and unmet need speaks volumes about the shortcomings in our programmes. Thus, in order to bring about a real difference, structural changes are required. Only then will the reality be in consonance with the purported aims and objectives of the family planning programmes and policies in India.
Views are personal.
Image provided by the author.
ABOUT THE AUTHOR
Vidushi Gupta is currently a third year law student at National Law School India University, Bengaluru.
 This article uses data from NFHS-4, since the data from NFHS-5 has not been released completely yet.
 Refer to the recent decision in the case of Vijayalakshmi v. State [2021 SCC OnLine Mad 317], where the Madras High Court held that the “scheme of the Protection of Children from Sexual Offences Act, 2012 clearly shows thatit did not intend to bring within its scope or ambit, cases of the nature where adolescents or teenagers involved in romantic relationships are concerned.”