Unmet need for family planning and persisting unintended fertility: Evidence from India

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

Today, around 50% of currently married women (ages 15-49) in India use or whose sexual partners use any form of modern contraception. In 1980, that figure was less than 25%.  Despite this dramatic increase, about one in eight married women still has an “unmet  need” for family planning: that is, she  wants to postpone her next pregnancy or stop having children altogether but, for whatever reason, is not using contraception. As a consequence, 6 million women in India still experience unintended pregnancies each year; and around 4 million resorts to unsafe abortions as per the World Health Organization. It is estimated that currently there are around 450 million people in India out of 1200 million who are product of unintended/unplanned pregnancies, and most of them are from the lower economic strata. The consequences of such an unwanted fertility are serious, slowing down the process of socio-economic development[1]. India’s policy makers have not recognized important linkages between large unwanted fertility and sustainable development.  The post uses   data from three consecutive rounds of the National Family Health Surveys (NFHSs)[2] to argue its point.  The post argues that high level of unmet need is a major cause of unintended/unwanted fertility, which is mainly responsible for chaotic governance and policy paralysis.

The concept of unmet need was developed more than 35 years ago[3]  and has been refined several times over the years. The concept was highlighted first time in India in a study conducted by the author in Rajasthan in 1988 on behalf of Ministry of Health and Family Welfare, Government of India[4].  The National Family Health Survey  defines unmet need for family planning as the proportion of currently married women who are not using any method of family planning but do not want any more children (unmet for limiting) or prefer to space births for at least two years (unmet need for spacing). The sum of the two is the total unmet need for family planning.  An analysis of NFHS data reveals that the unmet need of family planning has declined from 15.8% in 1998-99 to 12.8% in 2005-06, but it is very high.

The results of NFHS-3 show that most of the unmet need women (or eligible couples) were enumerated in the Four Large North Indian (FLNI) States of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh and overwhelming wanted to limit their fertility, as shown in Table 1. Around 70% of India’s unmet need was recorded in these States. In fact, Bihar recoded the highest unmet need for family planning (23%), followed closely by Uttar Pradesh (21%) among the major States of India.

Table 1: Unmet need for modern contraceptives in India, 2005-06

Category	Total number of Currently married women (In million)	Currently married women using any modern methods (In million)	Total currently married women having unmet need for modern methods
			(In million)	Per cent
FLNI States	69	25	8.6	69.9
Rest of India	119	66	3.7	10.1
Total	188	91	12.3	100.0
Source: Devendra Kothari and Sudha Tewari. 2009. Slowing Population Growth in India : Challenges, Opportunities and the Way Forward, MUPD Policy Brief No. 2, Management Institute of Population and Development, a unit of Parivar Seva  Sanstha, New Delhi.

Table 2 indicates that unmet need decreases sharply with age. Younger women (15-19) have a greatest unmet need; especially for spacing methods.  For the older women (35 -49), the   reverse pattern is evident. Unmet need for family planning varies by women’s education, but only within a narrow range, however, unmet need for limiting decreases significantly with education. The unmet need for limiting is highest for women with no education.  Rural women have a higher unmet need than urban women for spacing as well limiting. Total unmet need for family planning is substantially greater among Muslim women as compared to their Hindu counterparts. Further, unmet need especially for limiting methods decreases significantly with an increase in economic status.  These background findings indicate that the family planning program’s strong emphasis on limiting methods results in failure to meet the spacing needs of younger couples who are still in the process of forming their families.

Table 2: India- Need for family planning among currently married women by background characteristics

Background characteristics	% of married women having unmet need for family planning
	NFHS-1 (1992-93)			NFHS- 2 (1998-99)			NFHS-3 (2005-06)
	Total	Spacing	Limiting	Total	Spacing	Limiting	Total	Spacing	Limiting
Age Group: ·         15-19 ·         35-39	30 14	28 02	02 12	28 10	26 01	02 09	27 08	25 01	02 07
Education: ·         Illiterate ·         High school +	20 18	11 11	09 07	16 15	08 09	08 06	14 12	06 07	08 05
Residence: ·         Urban ·         Rural	17 20	07 12	08 08	14 17	07 09	07 08	10 14	05 07	05 07
Religion: ·         Hindu ·         Muslim	19 26	11 13	08 13	15 22	08 11	07 11	12 19	06 09	06 10
Economic Status: ·         Lowest ·         Highest	NA NA	NA NA	NA NA	18 13	09 07	09 06	18 08	08 04	10 04
Total	20	11	09	16	08	08	13	06	07
National Family Health Survey - 1, 2, and 3, IIPS, Mumbai.

Available data indicate that there is limited progress towards converting unmet need into demand in India. There are many reasons why women do not use modern methods of contraceptives. Major barriers to reducing unmet need for contraception persist for various reasons:

·         Inadequate knowledge of contraceptive methods and incomplete or erroneous information about where to obtain methods and how to use them.

·         A woman does not believe she is at risk of getting pregnant, or she is concerned about health risks and side effects.

·         Contraception is not readily available or too inconvenient to use or the range of available methods is limited. For example, Injectable Contraceptives (ICs) are available in more than 106 countries and they are popular especially among the Muslim women and working women belonging to low economic strata; however they are not the part of the public sector family planning program in India even after nearly two decades of discussions and scientific trials[5].

·         The woman, her partner, or other close family members are opposed to family planning methods or religious strictures against family planning.

It is interesting to note that more and more women today choose not to use available public sector modern contraception because they are concerned about the health risks and side effects of various methods, or they find available contraception too inconvenient to use. Around 21% of married women in 1995 cited one of these method-related reasons, but 29% of women recently said the same in the study conducted by author in Rajasthan[6]. This suggests that, although programs have been successful in educating women about their family planning options, a number of both perceived and real risks associated with some forms of contraception continue to prevent use.  

The right to decide freely and responsibly the number and spacing of children and to have the information, education and means to do so is well recognized as an important component of reproductive rights. Contraceptives enable men and women to exercise these rights. Modern technology has provided us with a range of contraceptive choices. The distribution pattern of usage of various methods to prevent pregnancies is called method mix. India is unique in that female sterilization is the predominant method, since it is aggressively promoted by the program. Sterilization accounts for roughly 80% of all modern contraceptive methods used. Less than 20% of currently married women use the officially sponsored spacing methods (pills, IUD and condoms).  Further, there is no significant change in the so called “method mix” since the introduction of contraceptive pills in the program in the eighties. It appears that India’s family planning program has largely failed to encourage the use of reversible methods, particularly among young women (age 15-25) who are in the most fertile years of their reproductive period. And there is urgent need to promote convenient and effective spacing methods like ICs.

While India’s population continues to grow by 16-17 million people annually, 13 million women, mostly belonging to the “bottom of the pyramid” seek to postpone childbearing, space births, or stop having children, but are not using a modern method of contraception. Often, these women travel far from their communities to reach a health facility, only to return home “empty handed” due to shortages, stock outs, 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 and sexually transmitted infections, including HIV/AIDSs. Further, most women and men do not have access to a wide choice of contraceptives, particularly those who are dependent on the public sector. And this type of incomplete control over the reproductive process leads to relatively high levels of unwanted childbearing.

Despite improved availability and access to contraceptive services, a substantial proportion of pregnancies (21% of all pregnancies that result in live births) are mistimed or unplanned. Around 26 million children are born in India every year and out of this about 5.5 million births have been classified as unplanned/unintended in 2005-06. Further, based on the National Family Health Survey-3[7], it is estimated that   about 30 per cent or around 218 million people in the age group 0-35 years in India was the product of unwanted childbearing. The level of unwanted fertility in this age group has increased from 23 per cent in 1992-93 to 30 percent in 2005-06. It is mainly due to slow conversion of unmet need into acceptance, as shown in Table 3.

Table 3 India:  Level of unplanned /unwanted fertility, 1992-2006

Item	1992-92	1998-99	2005-06
Unplanned  pregnancies
Per cent of unplanned births	23.1	21.6	21.0
·         Unplanned Births (in million)	5.8	5.8	5.5
Unwanted fertility
Per cent of unwanted  fertility	22.1	25.5	29.6
·         Persons in age 0-35 resulting from  unwanted fertility (in million)	140	178	218
Based on data obtained from National Family Health Survey 1, 2 & 3 and Sample Registration Bulletins. For details, see: Kothari, Devendra. 2010.  “Empowering women in India through better reproductive healthcare”, FPA Working Paper No 5, Jaipur: Forum for Population Action.

The consequences of unwanted fertility are serious, slowing down the process of socio-economic development. It is because unwanted childbearing results in poor physical growth, reduced school performance, diminished   concentration in daily tasks thus impacting work capacity and work output resulting in diminished earning capacity. The impact of unwanted childbearing is reflected in widespread hunger, poverty, unemployment as well as increasing scarcity of basic resources like food, water and space in several parts of India despite concerted developmental efforts since 1991. India’s large unwanted fertility, a threat to sustainable development, demands immediate attention.  In other words, India has to take steps to reduce the incidence of unwanted fertility by concentrating unmet need, otherwise the country would be down to “Hindu” rates of growth, and therefore would have to bid goodbye to any prospects of pushing the growth rate or making a serous dent on poverty.

One has to recognize that the concept of unmet need is realistic one and substantial amount of unmet need can be converted into demand and acceptance with proper management of family planning program[8]. Improving the management of the program and introducing effective strategies for capturing the unmet need for family planning services can push India towards the till now elusive goal of population stabilization.

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[1] For details, see:  Devendra Kothari, “To beat the gloom, India needs to focus on real issues”, January 31, 2012 at link: kotharionindia.blogspot.com .

[2] India: National Family Health Survey- 1 (1992-93), 2 (1998-99) and 3 (2005-06), IIPS, Mumbai.

[3] For details, see: CF Westof, The unmet need for birth control in five Asian countries. Family Planning Perspectives, 1978; 10(3):173–181. Also see:  John B. Casterline and Steven W. Sinding, "Unmet Need for Family Planning in Developing Countries and Implications for Population Policy," Policy Research Division Working Paper 135 (2000).

[4] For details, see: Devendra Kothari, Family Planning Programme in Rajasthan: beyond the Existing Approach, Indian Institute of Health Management Research, Jaipur, 1989.  The study was supported by the Ministry of Health and Family Welfare, Government of India,

[5] For details, see: Devendra Kothari, “Controversy over Injectable contraceptives in India: How to resolve it?” August 1, 2011. Also see: “The revolutionary new birth control method for men and India’s lukewarm response”, October 10, 2011 at link: kotharionindia.blogspot.com .

[6] For details, see: Kumar Vikrant, Aniraban Rudra, Anoop Khanna and Devendra Kothari, 2005, “Unmet need for family planning and its conversion into demand and acceptance: Some operational issues”. FPA Working Paper, Forum for Population Action, Jaipur

[7]India: National Family Health Survey (NFHS-3), 2005-06, IIPS, Mumbai, 2007.

[8] Devendra Kothari, Anopp Khanna &  Shameem Abbasy.  1997. “Operationalsing  the Concept of Unmet Need  for Family Planning  Services: A case Study”, Policy Brief 1, Indian Institute of Health Management Research ,Jaipur

India: Policy action for achieving the Millennium Development Goals

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

In the year 2000, the Heads of 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. These goals are: 1: Eradicate extreme poverty and hunger, 2: Achieve universal primary education, 3: Promote gender equality and empower women, 4: Reduce child mortality. 5: Improve maternal health, 6: Combat HIV/AIDS, malaria and other diseases, 7: Ensure environmental sustainability, and 8: Develop a global partnership for development. In September 2010, the world recommitted itself to accelerate progress towards these goals[1].

India is one of the signatories which have committed to achieve MDGs. The realization of these goals in India is vital not only for attaining human development and economic growth within the country, but given its enormous size since every fifth person in the world is an Indian,  they are  critical for reaching the MDGs world wide.  To review the progress, the UN Secretary-General Ban Ki-moon visited India during the last week of April 2012.  During his three-day trip, the Secretary-General had discussions with the senior leadership of both public and private sectors including the Prime Minister of India and top business leaders.

With less than four years left to achieve the MDGs, this writing provides a quick snapshot of India’s progress towards the MDGs and highlights a roadmap outlining what is needed to meet the goals. This post is also timely since   India just entered the 12th Five-Year Plan period (1912-17) aiming at “achieving faster, sustainable and inclusive growth”. 

The Government of India claims that the country is on track to meet the MDG targets by 2015. It argues that the number of people living below the poverty line has reduced. It claims that child and maternal mortality rates are reducing at a pace commensurate with its plans. It maintains that during the past one decade, the country launched several new programs capturing the sprit of MDGs. The Mahatma Gandhi National Rural Employment Guarantee Scheme has increased rural employment. The Sarva Shiksha Abhiyan, a national policy to universalize primary education, has increased enrolment in schools. The National Rural Health Mission has resulted in massive inputs in the health sector. It asserts that the Rajiv Gandhi National Drinking Water Mission and the Total Sanitation Campaign address crucial MDGs.

It is, however, difficult to endorse the government's confidence and optimism[2]. Experts argue that the poverty reduction claims are the result of a sleight of hand, which employs debatable measurements and methods for assessment. Further, recent international reports indicate that things are going from bad to worse. India’s rank in the latest UN’s Human Development Report has fallen from 119 in 2010 to 134 out of 187 countries in 2011. In addition, the 2011 Global Hunger Report (GHI) report places India amongst the three countries where the GHI between 1996 and 2011 went up from 22.9 to 23.7, while 78 out of the 81 developing countries studied succeeded in improving hunger condition.  The HUNGaMA (Hunger and Malnutrition) survey carried in 2011 reconfirms that malnutrition among children in India has taken ominous proportions, and the situation in many districts of the country has worsened when compared to what it was about a decade back. India is simply not doing enough for its women either. According to the Gender Gap Index 2011, released by the World Economic Forum, India’s ranking has been falling steadily since 2006 when the Index was launched. In 2006, India was ranked 98th. Between 2007 and 2011, the ranking has swayed between 112 and 114. In addition, recent studies paint a grim picture of school education in India. It appears that progress bypassed those who are lowest on the economic ladder or are otherwise disadvantaged because of their sex or ethnicity. Disparities between urban and rural areas are also pronounced and daunting.

All this is a rather   shameful reflection of the prevailing conditions in a country that is said to be on a growth song, and indicate that India is heading towards an unstable situation of extreme danger or difficulty that could lead to despair, social instability, political strife, policymaking paralysis and capital flight as well as a rapid collapse in growth rates. In this connection, the statement made by  Kaushik Basu,  Chief Economic Advisor of Government of India, should be taken seriously when he acknowledged that “economic reforms in India have slowed down and may remain that way till 2014”[3].

India could have done much better in achieving MDGs if the government as policy making body and officials as implementing agency had serious but focused concern, commitment, good governance, transparency and accountability. Government in its unwarranted enthusiasm to achieve double digit growth has completely neglected to accord high priority  for MGDs. China has done much better in this by  focusing initially on core areas like improving the quality of reproductive health  and education.

Is India on track to meet the MDGs in 2015? There is evidence that while some States are on track, many others lag behind and will lower the country's overall achievement.  For example, in 2007-09, on average 212 women died giving birth to a child for every 100,000 live births  (maternal mortality ratio) down from 327 in 1999-01. The Four Large North Indian (FLNI) States of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh had the highest numbers ranging from 359 to 261. Kerala at 81, Tamil Nadu at 97 and Andhra Pradesh at 134 have the best figures. This calls for an areas specific strategy/approach  to achieve MGDs. Further, India must also take more determined and focused steps to achieve goals. The people of the world are watching.

Among eight goals, improving maternal health (Goal 5) and  promoting  gender equality and empower women (Goal 3), are  most crucial in achieving sustainable development as well as MDGs. Maternal ill health and death impact families, communities and societies and has far reaching effects across socio-economic strata. Further, decreasing the rates of maternal mortality and morbidity is important because poor maternal health is both an indicator and a cause of extreme poverty. Available data indicate that   the lack of education, poor health conditions and discrimination in opportunities for work and income still haunt women. It appears that India is simply not doing enough for its women to improve access to resources and freedom of movement.  There is an urgent need to rethink as how to expedite the process of women empowerment in a patriarchal and traditional society like India with innumerable obstacles.

Here, the provision of client centred maternal health care could be an answer. It refers to the health of women during pregnancy, child birth and the postpartum period. It encompasses the healthcare dimensions of preconception, prenatal and post natal   care in order to reduce maternal and child morbidity and mortality as well as fertility. The preconception care includes education, family planning, health promotion, screening and other interventions among women of reproductive age to reduce risk factors that might affect future pregnancies. The goal of prenatal care is to detect any postnatal complications of pregnancy early, to prevent them if possible, and to direct the woman to appropriate specialist medical services as appropriate. The postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, infant immunization and family planning.

It is interesting to note that maternal mortality, child survival, and fertility are not independent factors, but rather involve a series of biological and social mechanisms in close interaction with one another. Impact of the use of reproductive health services is reflected on the level of maternal and child mortality, as well as on unwanted/unplanned fertility. Higher use of reproductive health services, leading to good maternal health, is making positive effect on health indicators like Infant Mortality Rate (IMR) and Maternal Mortality ratio (MMR) and Total Fertility Rate (TFR). Data from some high and low performing States of India supports this observation, as shown in Table 1.  Since Uttar Pradesh and Bihar, two lowest  performing and most populous  States located in North India, recoded very low utilization of antenatal (col. 2) and family planning (col.3) services in India, their MMR (col. 4) and TFR (col. 5) are very high -  in fact highest in the country. They also recorded the highest unwanted fertility per woman (col. 6) and low level of women empowerment, measured in terms of decision-making power (Col. 7).  On the other hand, by simply improving the availability and accessibility of quality antenatal care (col. 2)[4] and family planning services, the States of Andhra Pradesh and Tamil Nadu, located in South India, achieved a significant improvement in maternal health indicators as well as in the status of women (Col. 7), as shown in Table 1.

   Table 1:  Interaction among maternal mortality, child survival and fertility, evidence from India

Selected States of India (Population in million, 2011)	% mothers received 3+ Ante natal care (2005-06)	% of Couples using modern contraceptive (2005-06)	Maternal deaths/ 100,000  live births (2007-09)	Number of children/ women (2010)	Number of unwanted births/ woman (2005-06)	Level  of women empower-ment (%) (2005-06)
1	2	3	4	5	6	7
Uttar Pradesh (200 million)	27	29	359	3.8	1.5	34
Bihar (104  million)	17	29	261	4.0	1.6	33
India (1210 million)	44	48	212	2.7	0.8	37
Andhra Pradesh (85 million)	85	67	134	1.8	0.3	41
Tamil Nadu (72 million)	96	60	97	1.8	0.4	47
Source: Registrar General of India and National Family Health Survey-3 (2005-06)

While the India’s population continues to grow by around 16-17 million annually, more than 15 million women, mainly from the lower classes, lack access to basic reproductive health services. Often, these women must travel far from their communities to reach a health facility, only to return home “empty handed”, due to shortages and stock-outs, as well as non availability of staff. When women seeking reproductive health, including family planning services are turned away, they are unable to protect themselves from unintended pregnancies and sexually-transmitted infections, including HIV/AIDS.  Further, by all accounts, population growth in India has been rapid; however, relatively high population growth mainly due to unwanted fertility makes it more difficult to lift large numbers of people out of poverty. Around 26 million children are born in India every year and out of this about 5.5 million births have been classified as unplanned/unintended. Further, based on the National Family Health Survey[5], it is estimated that   about 30 per cent or around 224 million people in the age group 0-35 years in India in the year 2005-06 was the product of unwanted childbearing. The level of unwanted fertility in this age group has increased from 23 per cent in 1992-93 to 30 percent in 2005-06.  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 unintended/unplanned pregnancies, and most of them are from the lower economic strata.

The consequences of unintended pregnancy are serious, slowing down the process of socio-economic development. It is because unwanted childbearing results in poor physical growth, reduced school performance, diminished   concentration in daily tasks thus impacting work capacity and work output resulting in diminished earning capacity. The impact of unwanted childbearing is reflected in widespread hunger, poverty, unemployment as well as increasing scarcity of basic resources like food, water and space in several parts of India despite concerted developmental efforts since 1991. India’s large unwanted fertility, a threat to sustainable development as well as in achieving MDGs, demands immediate attention.

Here, the maternal-healthcare-centred approach or intervention  is a positive option that has been largely unrecognized by policymakers, as well as by many bilateral and philanthropic organizations. The need of the hour, thus, is to create confidence among policy makers and programme managers that a breakthrough is possible. The 12th Five Year Plan must re-emphasize its commitment to maternal health and provide essential leadership in promoting reproductive health and increase awareness of the social, economic, and environmental consequences of poor maternal health. Although simply provision of maternal health alone is not going to solve all the problems faced by poor women, it will help in giving   them a level playing field and it will provide a boost to their confidence. And that will lead to accelerated progress towards achieving MDGs.

Another issue which needs equal attention is quality of education. Unless education is rescued from quagmire of mediocrity, all talk about developing a skilled human resource pool and realizing the country`s demographic dividend will be without substance; and the country would be inching closer to demographic disaster. As such, 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.

The writing is on the wall. The question is not whether we act or not, but whether we act now or later and deal with much more dire and expensive consequences. What we do in the next few years especially during the period of Twelve Five Year Plan (2012-17) will determine India’s future as well as its capacity to achieve MDGs.

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[1]  For details, see: The Millennium Development Goals Report, 2011, United Nations. 

 

[2] For more information on these points: see wirings of the author in blog: kotharionindia.blogspot.com, especially refer “What the poverty debate in India misses?” dated 31.10.2011, and “To beat the gloom, India needs to focus on real issues”. Also see: news paper article by KS Jacob, Millennium Development Goals & India, The Hindu, dated 20. 10. 2010.

[3] In Washington to attend the Annual Spring meeting of the International Monetary Fund (IMF) and the World Bank (April 20, 2012), Dr Basu was addressing the concerns expressed by the US corporate on some recent decisions of the Indian government and its reluctance to initiate the series of next phase of reforms.

[4] Antenatal care covers at least five basic services - pregnancy monitoring, tetanus toxoid vaccine, iron and folic acid tablets (IFA) and nutrition/ safe delivery counseling. These can help women go through the pregnancy safely and ensure that the new born is in good health.

[5]India: National Family Health Survey (NFHS-3), 2005-06, IIPS, Mumbai, 2007.

International Women's Day: Empowering women in India through reproductive rights

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

International Women's Day (IWD) is an occasion to review how far women have come in their struggle for equality and development. The condition of women in India has undoubtedly improved in last twenty years. However, the extent of this improvement is mainly confined to the middle classes. Even among the middle class families this change has been very slow and it has benefited only a small proportion of women, mainly in the educated ones and that too in big cities. Women from this class have achieved remarkable success and are piecing the glass ceiling, but they are still the exceptions.  According to the Gender Gap Index Report 2011, released by the World Economic Forum, India is simply not doing enough for its women. The country ranked 113 out of 135 countries in 2011. Further,   India’s ranking has been falling steadily since 2006 when the Index was launched. In 2006, India was ranked 98th. Between 2007 and 2011, the ranking has swayed between 112 and 114. That is a shameful reflection of the condition of the women in a country that is on a growth song. Available data indicate that   the lack of education, poor health conditions and discrimination in opportunities for work and income still haunt women. It appears that India is simply not doing enough for its women to improve access to resources and freedom of movement.  There is an urgent need to rethink as how to expedite the process of women empowerment in a patriarchal and traditional society like India with innumerable obstacles.

One has to recognize that high GDP alone does not automatically empower women nor does it reduce gender inequality. That can happen only from more deliberate public policy interventions. The Report indicates that Indian women have narrowed the gap with men on education, economic and political participation; relative to men, however, “they are slipping further on health”. It is because they have unequal access to basic health resources especially reproductive healthcare services and lack adequate counseling as well as follow-up and management of side effects. The result is an increasing risk of unintended or unwanted, early pregnancies, HIV infection and other sexually transmitted diseases.

As per the latest National Family Health Survey (NFHS-3), every fifth birth has been classified as unplanned or unintended (that is mistimed or unwanted at the time the women became pregnant).  It is estimated that more than 26 million children are born in India every year and out of this about 6 million births have been classified as unplanned. The level of unwanted fertility can also be measured by comparing the total wanted fertility rate with the total or actual fertility rate. The total wanted fertility rate represents the level of fertility that theoretically would result if all unwanted births were prevented.  Overall, the total wanted fertility rate of 1.9 children/woman is lower by 0.8 child than the total fertility rate of 2.7 for the country as a while, as per the NFHS-3. The proportion of births that were unwanted was the highest for births to women from the Four Large North Indian States of Bihar, Madhya Pradesh, Rajasthan and Utter Pradesh as compared to the southern States. The difference between the total fertility rate and wanted fertility rate ranges from 0.1 children in Kerala followed by Andhra Pradesh (0.3 children) and Tamil Nadu (0.4)  to 1.6 children in Bihar closely followed by  Uttar Pradesh (1.5), Rajasthan and Madhya Pradesh (1.0 each).

It is estimated that currently there are around 450 million people in India out of 1200 million who are product of unwanted/unplanned pregnancies, and most of them are from the lower economic strata. The consequences of unintended pregnancy are serious, imposing significant burden on women and families, and in turn slowing down the process of women’s empowerment. Unintended pregnancy breeds powerlessness and powerlessness breeds subordination (quality of obedient submissiveness) and subordination breeds unintended pregnancy.  And women find themselves in a vicious circle. In other words, Indian women, in general, do not have control on their body[1].

We have to agree that the poor performing States of India have neglected the reproductive health programme in spite of extra attention given under the National Rural Health Mission. Had these States been meticulous enough to provide client centered reproductive health services and to frame appropriate policies to manage the programme, India could have, by now, improved the status of women and reduced the gender gap significantly, as observed in many developing countries? Therefore, reproductive healthcare is an essential plank in empowering the women.

We need creative policies to strengthen this foundation. It is because women don't leave their gender behind when they enter the workforce, as argued by the Professor Ruth Pearson of University of Leeds. Women's ability to choose the number and timing of their births is the key to empowering women as individuals, mothers and citizens. Through this  women  gain  greater share  of  control  over resources  -  material,  human and intellectual  in  the  home and out side.  As such, it is much desirable to make reproductive healthcare accessible and affordable in expediting the process of women empowerment in the traditional society like India. Until the policy makers take a focused and long term interest in the advancement of women by ensuring reproductive rights backed by quality health care services, it will be rather difficult to expedite the process of women empowerment in existing environment. Also, the educating the girls could be the fast track to progress.  And this feminist agenda will contribute significantly towards women’s empowerment.


Next four posts discuss the population and development scenario in Four Large North Indian States of India. 

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[1] For details, see: Kothari Devendra, “Empowering Women in India through Better Reproductive Healthcare”, FPA Working Paper No 5, Jaipur: Forum for Population Action, 2010.