Saturday, 13 April 2013

Relevance of Two-Child Norm in emerging demographic scenario of India (Part II)


Dr. Devendra Kothari
Population and Development Analyst,
Forum for Population Action

The concept Two-Child Norm (TCN) as a policy measure was introduced in some States of India through the Panchayat Raj Institutions as well as population policies in the late nineties, as noted earlier (see part I). The governments of these States insist that those with more than two living children are debarred from contesting panchayat elections or remaining in office. Now question arises whether this intervention   has been able to achieve its intended impact on the population growth.

Over the past 20 years there has been a steady decline in the annual population growth rate from 2.14% in 1991 to 1.95 in 2001 and further to 1.62% in 2011. The rate of growth has declined in all the States and Union Territories (28 States and 7 UTs) during 2001-2011 except Tamil Nadu, Chhattisgarh and tiny Pondicherry (UT), and this is a good sign. The rate of decline was slow in the Four Large North Indian States of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh as compared to other States of India.  Though the annual growth rate during 2001-2011 has registered the sharpest decline since independence, in absolute terms the population of India has increased by a whopping 181.5 million during the period. The absolute addition during the decade was slightly less than the previous decade (182.3 million). Demographic projections show that India is likely to cross China as the most populous nation before 2025.[1]

India's Total Fertility Rate (TFR) - the average number of children that would be born to a woman over her lifetime - that has remained stagnant at 2.6 since 2009 could finally see a drop in 2011, as per the Registrar General of India. However, India has seen a steady decline in TFR during the last two decades that has come down by 31% from 3.6 in 1991 to 2.5 in 2011. Among major States of India having population 25 million or more in 2011, Bihar (3.6 children per woman), Uttar Pradesh (3.4), Madhya Pradesh (3.1), Rajasthan (3.0), Jharkhand (2.9) and Chhattisgarh (2.7) have worst TFR; while Tamil Nadu (1.7), West Bengal (1.7), Andhra Pradesh (1.8),  Kerala (1.8),  Maharashtra (1.8), Punjab (1.8), and  Karnataka (1.9) have already  achieved targeted  replacement level fertility required to initiate  the process of population stabilization.  According to the National Population Policy 2000, India should have reached replacement-level fertility rate of 2.1 by 2010, and attain population stabilization at 1450 million by 2045. The stable population is a stage when the size of the population remains unchanged. It is also called the stage of zero population growth. However, India expects to reach population stabilization of 2.1 TFR at 165 crore by 2060.

As noted earlier, Andhra Pradesh, Rajasthan, Madhya Pradesh and Uttar Pradesh adopted State-specific Population Policies with a provision of TCN in late nineties but except Andhra Pradesh remaining States could not achieve the   targeted fertility goals, as shown in  Table 1 (Cols. 2 and 3).   For example, Madhya Pradesh aimed at achieving the replacement level fertility of 2.1 children per woman by 2011 but it is far away from the targeted goal – it recoded TFR of 3.1 in 2011. On the other hand, Andhra Pradesh was able to achieve the goal of   replacement fertility, as targeted.  It appears that incentives, disincentive or legal restriction on couples over the number of babies they can have (like TNC) are not going help to achieve the goal of population stabilization. What we need is the client centred service delivery system.

Table 1: Targeted Total fertility (TFR) to be achieved by 2011 as per population Policies and actual TFR in and level of unwanted fertility and unmet need for modern contraceptives.
States with  Population Policy (with year of adoption )
Targeted TFR  to be achieved by 2011 as per Population Policy*
Actual TFR in 2011**
No. of unwanted children/ woman@
% of total  births 4+@
% of unmet need for contraceptives@
1
2
3
4
5
6
Andhra Pradesh (1997)
1.5
1.8
0.3
08
05
Rajasthan (1999)
2.6
3.0
1.0
32
15
Madhya Pradesh (2000)
2.1
3.1
1.0
31
11
Uttar Pradesh (2000)
2.6
3.4
1.5
38
21
Bihar#
--
3.6
1.6
36
23
India (2000)
2.1 (2010)
2.4
0.8
25
13
Note” # Bihar does not have a state- specific population policy.
Source: * Population policies, **Registrar General ,  India : @National Family Health Suvey-3


Andhra Pradesh is one such example. During the early nineties, the State government decided to revamp its reproductive healthcare delivery system looking to the needs of clients[2]. It was a political decision and this increased the use of reproductive health services significantly.[3] As per the NFHS-3,[4] more than two-thirds of married women in Andhra Pradesh used modern contraception in 2005-06, one of the highest in India. It had dramatic impact on fertility by reducing unwanted pregnancies.  Andhra Pradesh exhibits one of the lowest fertility among major States of India – 1.8 children per woman. It is interesting to note that women with no education or less than 5 years of education are more likely to use contraception than women with more education, since reproductive health services are easily available looking to the needs of clients.  As a result, only 5% of currently married women have an unmet need for family planning, down from 8% in NFHS-2 (1998-99) and 10% in NFHS-1 (1992-93). Currently, 94% of the demand for family planning is being satisfied, up from 82% in NFHS-1. The impact of client centered reproductive health care could be seen from a comparison of the birth order distribution in NFHS-1, NFHS-2, and NFHS-3 for married women. The proportions of births of order four or higher decreased from 22% in NFHS-1 to 15% in NFHS-2 and 8%t in NFHS-3. All these had an impact on the level of unwanted fertility.  Andhra Pradesh recorded one of the lowest unwanted children per woman in India (0.30, as shown in Table 2 (Col.4).   Not only in family planning but in other areas of reproductive healthcare, Andhra Pradesh has done equally well. In the State, 85% of women had at least three antenatal care visits for their last birth. 

On the other hand, total fertility in Rajasthan is the third highest among the major states of   India. The largest differentials in fertility are by economic status and education. At current fertility rates, women with no education will have twice as many children as women with 10 or more years of schooling (3.7 children per woman compared with 1.8). Among the major States of India, total unwanted fertility is the third highest in Rajasthan (one child per woman), as shown in Table 1. Despite a 15 percentage point increase in current contraceptive use among currently married women since NFHS-1, less than 45% of women in Rajasthan are currently using any modern contraceptive method. Around 15% of married women in Rajasthan have an unmet need for family planning (Col. 6), down from 18% in NFHS-2.  The distribution of births by order is yet another way to view fertility and performance of reproductive healthcare service delivery system. Around one third of total births in Rajasthan in 2005-06 were of order four or higher, which was the third highest among the major States of India. Further, no significant decline was seen in the higher order births between NFHS-2 and NFHS-3: 34% versus 32%.  Despite substantial improvement in the coverage of antenatal care for mothers, only 4 in 10 women in Rajasthan received at least three antenatal care visits for their last birth in the past five years. Full immunization coverage is lower in Rajasthan than in any other state except Uttar Pradesh, as per NFHS-3. A little more than one-quarter of children age 12-23 months are fully vaccinated against six major childhood illnesses: tuberculosis, diphtheria, pertussis, tetanus, polio, and measles.

It appears that poor performing States, containing around 50% of total population of India, are not able to provide clients centred reproductive health services.  More than 15 million currently married women in 2011, mostly in these Srares have an unmet need for family planning,[5] and that figure is increasing. Often, these women travel far from their communities to reach a government health facility, only to return home ‘empty handed’ due to shortages, stock outs, lack of choices and/or non availability of doctors and paramedical staff. When women are thus turned away, they are unable to protect themselves from unwanted/unplanned pregnancies.  More than 26 million children are born every year in India; and out of this about 6 million births have been classified as unplanned/unintended or simply unwanted. Based on findings of the National Family Health Surveys 1, 2 and 3, it is estimated that currently there are around 450 million people out of 1200 million in India who are product of unwanted pregnancies, and most of them are from the lower economic strata.[6]   

In sum, over the past three to four decades, many State governments in India have experimented with schemes like TNC including specific incentives and disincentives to lower the rate of fertility. Most such schemes have had only marginal impact and, in some cases, have been counterproductive. Thus, first priority is to provide universal access to family planning, as set out in Millennium Development Goal 5b – achieving universal access to reproductive health by 2015.  Without this, women are unable to exercise their reproductive rights.  The principle of informed choice backed by quality RH services is essential to the long-term success of the family planning programs. Any form of coercion has no part to play. Though very-very small numbers of elected representatives of local-self government including Panchayats have so far been removed under the Two-Child Norm policy,[7] but there is no need to implement such measures or to provide incentives and disincentives to achieve the goal of stable population. I, therefore, strongly urge for removal of the Two-Child Norm in our efforts to achieve population stabilization. In the changed situation most of the couples, even those belonging to the lowest economic strata, do not want more children. But, they still have them, primarily due to lack of client centered reproductive healthcare.  The real need is to provide services in un-served and underserved areas by realigning the capacity of health system to deliver quality care to suit the needs of clients, especially those belonging to the “bottom of pyramid”. Therefore, reproductive healthcare should be an essential plank in achieving population stabilization and empowering the poor. At the same time, investment in education has to be increased to improve the quality of education especially at the government schools and colleges where most of the students are from poor and rural families. It is because the pivot upon which the fate of the nation hangs in balance is education.


[1] Kothari, Devendra. 2011. Implications of Emerging Demographic Scenario: Based on the Provisional Results of Census of India 2011, A Brief, a publication of Management Institute of Population and Development. Parivar Seva Sanstha, New Delhi.

[2] Among many initiatives of the Government of Andhra Pradesh, the establishment of “Round the Clock Women Health Centres”   wan an important one.  470 PHCs (Primary Health Centres) in the backward areas have been designed as Round the Clock Women Health Centres in the nineties. Normal delivery services are being provided round the clock in these centres by nursing staff of PHC. 450 doctors as well as ANMs have been taken on contract in these PHCs. Specialist clinics by Gynecologist and Pediatrician are being provided in these institutions on a fixed day once in a week. Additional facilities like telephone and vehicle for transportation are also provided to improve communication and referral system for emergency cases.   For detail, see document:  Brief of the Family Welfare Department, Office of Commissioner of Family Welfare, Government of Andhra Pradesh, Hyderabad, 20.06.2003.

[3] Kothari Devendra and Sudha Tewari. 2009. Slowing Population i Growth in India: Challenges, Opportunities and the Way Forward. MIPD Policy Brief No. 2, Management Institute of Population and Development. New Delhi.

[4] IIPS.  2007.  India: National Family Health Survey, 2005-06. Mumbai:  International Institute for Population Sciences.

[5] The standard definition of unmet need depends upon the apparent inconsistency between a woman’s contraceptive behavior and her stated reproductive preferences. The concept of unmet need was highlighted first time in India in a study conducted by the author in Rajasthan in 1988-89 on behalf of Ministry of Health and Family Welfare, Government of India. For details, see Devendra Kothari, “Family Planning Programme in Rajasthan: Beyond the Existing Approach”, Indian Institute of Health Management Research, Jaipur, 1989.

[6] Ibid. Kothari Devendra. 2011.

[7] According  to  Nirmala Buch, who runs a Bhopal-based NGO,  412 panchayat members in Rajasthan, 350 in Madhya Praddssh and  275 in Haryana have already  been removed from their posts, because they failed to comply with the two-child norm. Refer: Buch, Nirmala. 2005.  Law of Two-child Norm in Panchayats: Implications, Consequences and Experiences, Economic and Political Weekly, Vol 40, (24), June 11, pp 2421-29.

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