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Family Planning Beyond Sterilization in India

Despite half a century of efforts to reduce population growth, India faces challenges in delivering a family-planning program that goes beyond female sterilization to help couples delay and space out their children.

Written by Christine Chung Published on Read time Approx. 4 minutes
A woman touches the belly of her nine-month pregnant friend in Anand, India.AP/Allison Joyce

With a population of 1.3 billion and counting, India is predicted to overtake China as the world’s most populous nation by 2022, according to a recent U.N. report. Despite the government’s long-standing goal to achieve population stabilization, India is still gaining about 18 million people each year, with more than half its population within reproductive age.

For decades, female sterilization (tubal ligation) has been India’s main form of family planning and accounts for around 65 percent of contraceptive use, significantly higher than anywhere else in the world. According to the Population Council, more than three-quarters of India’s sterilized women had not used any other contraceptive method previously, while more than half were sterilized before they reached 26 years of age.

However, the U.N.’s Population Division notes that the dominance of permanent contraception in a population so young “suggests a potential mismatch” between available methods and those that, instead of ending a woman’s fertility, might help her control and plan it. According to government figures, 21 percent of Indians don’t have access to family planning – among married adolescents, that figure goes up to 27 percent. And that doesn’t count unmarried people, whose family-planning needs are disregarded.

If India is going to avoid a population time bomb, experts say, it has to move away from sterilization as the preferred form of contraception. Reversible contraception should be accessible to everyone, they say, giving women the tools they need to have children later in life and further apart.

India’s family-planning efforts have a complicated history, beginning in 1952 with the establishment of the world’s first national program to reduce birth rates. For many years, the program relied on targets, and in some states, public-sector health workers resorted to coercion to meet them. Focusing on men, officials reportedly hijacked buses and seized men to be sterilized, while others were said to be bribing unwitting men with offers of radios or other incentives. These abuses eventually turned the public against the idea of a national policy to sterilize men, so the focus shifted to women.

India’s government no longer uses coercive measures to meet quotas. “Today, the government is not oppressive; choice and rights are the official stance,” says John Townsend, vice president and director of the Population Council’s Reproductive Health Program.

But the country still has high rates of female sterilization, reflecting a social pattern of early marriage and early childbearing. “If a girl got married at 14 or 15 years old, she had to quickly demonstrate her fertility in order to maintain the marriage agreement,” says Townsend. “Then she had children in relatively quick succession [and] if she had four or five children by the time she was 24, the notion was that they were done.”

Encouraging a move away from sterilization is more complicated than simply improving access to contraception choices, experts say. It also means ending child marriage, breaking taboos that prevent formal sexual education and improving the quality of health services.

The government has already committed to addressing some of those factors. It announced that family planning would be central to its efforts to achieve Universal Health Coverage in its pledge to FP2020, the partnership between governments and donors resulting from the 2012 London Summit on Family Planning. It recently added to the national program three new products to aid birth spacing – an injectable contraceptive, a progesterone pill and a non-hormonal weekly pill – in addition to the current basket of oral contraceptive pills, condoms and IUDs available to women.

At the same time, India is implementing other recommendations, including deploying accredited social health activists – community health volunteers who provide services such as delivering contraceptives directly to women.

The more difficult challenge is changing the social norms that allow child marriage and foster gender inequality, preventing women and girls from making their own choices. Despite being illegal in India since 2006, child marriage remains a huge problem: More than 22 percent of girls get married before they reach 18, according to the government. In states such as Bihar and Rajasthan, that figure is over 40 percent. According to UNICEF, one in three child brides worldwide are in India.

The government included “increased attention to social determinants of health” in its commitments to FP2020. The low status of women, reflected in a strong cultural preference for sons, is high on that list. Across India, women have low levels of both education and formal labor force participation, with profoundly negative impacts on their health status. According to researchers at Gulbarga University in Karnataka, only half of India’s women are involved in making decisions about their own healthcare, and 60 percent of women did not seek antenatal care, believing it was “not necessary.”

Social inequality, too, is one of the main barriers to improving women’s health in India. The median age at first marriage for women in India’s richest quintile is 19.7 years, while for the poorest women it’s 15.4. And when it comes to dealing with unplanned or unwanted pregnancies – which make up some 20 percent of all pregnancies in India – it’s mainly wealthier women who can afford the two key drugs for medication (medical) abortion, mifepristone and misoprostol, which have been approved for sale and manufacture in India since 2002.

If India can address the issues that stand in the way of women making choices about their own health and improve family-planning access, experts believe it will be possible for the country’s total fertility rate to drop to replacement level. And with the world’s second largest population still expanding, India is feeling the pressure to find a solution soon.

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