Planning Families, Planning Progress

As India moves closer to the deadline for achievement of its Millennium Development Goals, the critical need for effective family planning interventions and greater awareness of the same become more pronounced. 

Matlab, a riverine sub-district in Bangladesh, about 50 kilometres from capital Dhaka, has attracted the attention of the world for some time now because of the data it provided on an important social trend. In fact, the reputed medical journal, ‘The Lancet’, in a special focus on family planning last July, trained the light on Matlab yet again.

So what is the Matlab story and why is it so important? Over a period of 19 years, from 1977 to 1996, family planning programmes had reached 71 of Matlab’s 141 villages. What was striking was that while the figures from the 1974 census - conducted before the programmes had begun - indicated a uniform level of human development in all of its villages, whether in terms of fertility, average schooling or housing, the scenario was very different 19 years later.

According to the evidence gathered, family sizes declined by 55 per cent in the villages that had access to family planning programmes, while it declined by only 39 per cent in those that did not. This, of course, is not surprising. What, however, does warrant pause for thought is the fact that the level of child mortality was significantly lower in the villages accessing the services and the body mass index (BMI) of the women here was higher.

That was not all. Women in these villages also reported earning 40 per cent more in terms of monthly income than their counterparts in villages not serviced by family planning. Income, we know, translates into assets – and indeed the households in the villages that had family planning services reported 25 per cent more physical assets per adult. The multiplier effects of such access were many and included healthier children and higher levels of schooling.

In other words, the message from Matlab was clear: In the long term, effective reproductive health services translated into positive changes in terms of health and human – particularly women’s – development. It was evidence like what emerged from Matlab that had led John Cleland, Professor of Medical Demography, London School of Hygiene and Tropical Medicine, and his colleagues to conclude that access to family planning can reduce maternal deaths by 40 per cent, infant mortality by 10 per cent and childhood mortality by 21 per cent.

Examples from India also suggest an important link between human development and effective family planning interventions. Tamil Nadu, for instance, could bring down its total fertility rate (TFR) – defined as the average number of children born to a woman during her reproductive period – from 3.8 in the mid-seventies to 2.0 by 1997, thanks to an effective family planning programme. By 2001, it figured as the third best performing state, behind only Kerala and Punjab, in terms of human development, according to the National Human Development Report 2001.

This transformation could only have happened because the family planning programme was an enlightened and community-friendly intervention. Noted development academic, Leela Visaria, has written at length about how Tamil Nadu was able to achieve replacement levels of fertility. Discarding the target-oriented and coercive approaches that had made family planning interventions in the country so controversial in the mid-1970s, the Tamil Nadu government crafted a holistic approach that expanded the basket of contraceptive choices available to people, raised levels of awareness, addressed fears of side-effects and introduced new technologies, like non-scalpel vasectomies.

Today, the Government of India, anxious to leave the negative perceptions about family planning firmly behind, is consciously adopting a more broad-based approach through its National Rural Health Mission (NRHM). In a recent speech, Union Minister of Health and Family Welfare, Ghulam Nabi Azad, flagged various factors – including delaying marriage and spacing birth – as crucial to pegging down India’s numbers. But what he saw as particularly crucial was the need to raise awareness about the issue.

As the Minister put it, “Vast numbers of people cannot avail of family planning services due to problems of knowledge and access. There is therefore a need for the NRHM to respond with appropriate family planning counselling and services that focus on the individual’s choice and decision-making in planning the timing of a pregnancy and number of children desired. In particular, NRHM should design a way to reach comprehensive health information and services to young girls, which will prevent marriage under the legal age of 18, early childbearing and keep girls in school.”

It is an approach that Poonam Muttreja, Executive Director of the Population Foundation of India, would advocate. As she puts it, “There are also many far-reaching, catalytic effects of women being able to control their fertility. Girls, who marry as adults, delay their first pregnancy and space child births, are more likely to complete their education and join the work force. Enhanced household income helps in meeting the nutritional needs of their families.”

Such an approach assumes urgency as concerns that India will fail to meet some of its commitments on the Millennium Development Goals (MDGs) grow by the day, even as the deadline year of 2015 draws steadily closer. According to MDG 4, countries are required to reduce by two thirds, between 1990 and 2015, the mortality rate of children under five years of age. Similarly, MDG 5 enjoins them to peg down by three-quarters, between 1990 and 2015, the maternal mortality ratio (MMR). Going by current indications, the figures on both counts do not stack up for India.

Data from the Statistical Year Book 2013 reveal that while India is required to reduce its child mortality rate to 42 per thousand live births by 2015, going by the current rate of decline the level would be around 52 per thousand, which is ten points short. As for its MMR, India will achieve a figure of 139/100,000 live births by 2015, which would miss the target by 29 points.

According to ‘The Lancet’s analysis, access to reproductive health and family planning helps to bring down not just infant and maternal mortality levels but helps in achieving other MDGs, like eradication of extreme poverty and hunger (MDG 1), universal primary education (MDG 2), gender equality and empowering women (MDG 3) and environmental sustainability (MDG 7). In fact, it was this realisation that led to the inclusion of a new MDG target – universal access to reproductive health – in 2006.

For a young country like India, this is an extremely important target. With half its population in the reproductive age – the reason why the population continues to grow despite its growth rate having declined considerably – access to contraceptive choices and care has become a critical need.

Elaborates Muttreja, “To take advantage of the demographic dividend, India must focus on providing family planning services to its young people along with reproductive and sexual health education, skills development and education. Access and choice to quality family planning is not only a human right, it is critical to the health and well being of individuals and the country's development."