Managing unwanted fertility – India’s priority # one

Dr. Devendra Kothari

Population and Development Analyst,

Forum for Population Action

The problem of unwanted fertility is extremely serious considering India’s pressing economic and social scenarios.

The World Population Day, annually observed on July 11, is an occasion to engage people, spur commitment and spark actions related to the opportunities and challenges presented by the growing population.

With 1.27 billion (2013) people and still growing, India is getting dangerously overcrowded. India is currently the second most populous nation in the world. It will surpass China as the most populous within 8-10 years. Its population is projected to peak at 1.65 billion in 2065. China at its peak in 2030 will have 1.45 billion people. In fact, when China peaks, India will have already surpassed it in population (UN World Population Prospects, 2012). Many Indians see these emerging demographics as a critical advantage in competition with the nation it regards   as its chief rival – China. With around 70% of the population under 35, India can afford to dream to become economic power in the world before the middle of this century. However underneath, this rosy outlook for India epitomizing the country’s ability to surpass China on the back of a younger population lays some difficulties, especially deteriorating level of education and nutrition. It is not enough to have lots of young people — these young people need to be properly educated/skilled to fully contribute to the economy. Today, more children are going to school but what they are learning is not clear. The Annual Status of Education Report 2012 by Pratham shows that the number of Class V students who could not read a Class II level text or solve a simple arithmetic problem has increased. In 2010, 46.3% of children in this category failed to make the cut and this shot up to 51.8% in 2011 and 53.2% in 2012. Can they get any job in the market if they continue such education? Can industry get the professionals it is looking for?[1]

Current population growth is mainly fueled by unwanted fertility. More than four in ten pregnancies are unintended by the women who experience them, and half or more of these pregnancies result in births that spur continued population growth. Around 26.5 million children were born in the year 2012 and out of this almost 6.0 million pregnancies had been classified as unplanned. The government has to spend on an average around Rs. 8760 per year to raise a child until the age of 15. By avoiding unwanted pregnancies, the government would have saved at least around Rs. 52560 million in that year alone. Further, it is estimated that currently there are around 460 million people out of 1270 million in India in 2013 that are product of unplanned pregnancies, and most of them are from the lower economic strata (based on the findings of National Family Health Surveys). 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 this is reflected in widespread hunger, malnutrition, poverty, unemployment, weak governance as well as increasing scarcity of basic resources like food, water and space in several parts of India despite concerted developmental efforts since 1991. [2]

How to mange unwanted fertility? A popularly held belief by India’s policy makers is that as a country becomes economically more prosperous, its fertility declines significantly and leads to a stable population. However, this is a simplistic view of a complex phenomenon.  Since the introduction of market-based economic reforms in 1991, India has become one of the fasted growing major economies in the world. The reforms completed 20 years in July 2011, however, during this period, India’s population increased by 365 million, much more than the population of USA - the third most populous country in the world.  This raises the question: Is Development the Best Contraceptive or Are Contraceptives?  It is argued that there is a need to go beyond the prevailing notion that socio-economic development is an essential precondition for fertility transition, since it provided only a partial explanation for the monumental changes taking place in fertility behavior, especially in low-income economies like Bangladesh and Andhra Pradesh.[3]

More than four in ten pregnancies are unintended by the women who experience them, and half or more of these pregnancies result in births that spur continued population growth. While India’s population continues to grow by 17-18 million annually, 15 million married women in the reproductive ages, mostly in Four Large North Indian (FLNI) States of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, seek to postpone childbearing, space births, or stop having children, but are not using a modern method of contraception that is having unmet need for family planning services. 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 pregnancies. Rural Development Minister Jairam Ramesh candidly admitted that in many parts of India, public health system does not exist. “We all know that the health system in India has collapsed”, he added. Today, the single most important measure to manage unwanted fertility is to revamp the public health system to provide services looking to the needs of clients.

Incidence of unintended frequencies can be dramatically reduced, if not eliminated, within a decade by revamping family planning program,   as has been done in Andhra Pradesh.  If Andhra - with little outside help - can manage its population issue under relatively low literacy and high poverty, there is no reason why Four Large North Indian States, with lesser problems and with increasingly generous support from the Government of India under National Rural Health Mission (NRHM), should fail so spectacularly in managing unwanted fertility.

It appears that the population and related issues have not been given due importance in the development debate of India. Demography, therefore, in the next 10 years or so will pose serious challenges to economic growth, democracy and national unity by its sheer size. The writing is on 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. Hope India’s political landscape which suddenly has energetic younger leaders will take it seriously and lead the way.[4]

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[1] Refer: Kothari Devendra, “Galloping population, a huge concern”, One India One People, July 2013.

[2] Refer: post by the author: Food Security Bill and malnutrition in India, dated June 30, 2013 at link: kotharionindia.blogspot.com.

[3] Kothari, Devendra and S.  Krishnaswamy. 2003. “Poverty, Family Planning and Fertility vis-a vis Management of Family Planning Services in India: A Case Study”. In Maria Eugenia COSIO-ZAVALA (Ed.). Poverty, Fertility and Family Planning, Paris: CICRED, 335-58.

[4] The term younger is a flexible one, ranging from Akhilesh Yadav and Rahul Gandhi in their early 40s, Shivraj Singh Chauhan, Vashundhra Raje, Mayawati in their 50s, and Nitesh Kumar  and Narendra Modi in their early 60s.

Food Security Bill and malnutrition in India

Dr. Devendra Kothari

Population and Development Analyst,

Forum for Population Action

Investing in agriculture, reproductive health and living conditions is right thing to manage malnutrition & hunger

India’s high economic growth rate in the past decade has not been fully reflected in the health status of its people. According to the National Family Health Survey-3 (2005-06), 40% of children under the age of three are underweight and 33% of women in the age group of 15-49 have a body mass index below normal. Latest data indicate that things are not improving at all. In fact, things are going from bad to worse. The  Global Hunger Index (GHI) 2011 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.[1]  The HUNGaMA (Hunger and Malnutrition) survey carried in 2011 reconfirms that malnutrition among children 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. The report reveals that over 40% of children are underweight and almost 60% are stunted. [2] Further, about 34 per cent of girls aged 15 to 19 are stunted in the country, as per The Lancet Maternal and Child Nutrition report. These adolescents, part of the post- economic liberalization generation, have benefited the least from economic growth. Without active intervention to improve their access to appropriate food, the young women are bound to face complications during pregnancy and many are certain to deliver stunted babies, “continuing the distressing cycle”, noted by The Hindu (June 13, 2013) in its editorial  “Stunting a Country”.  These are disturbing facts which point to nutritional deficiencies. 

Given its impact on health, education and economic productivity, persistent under-nutrition is a major obstacle to human development; impacting India´s much awaited demographic dividend and the country’s prospects for future economic growth. It was felt that it should be addressed. The proposed National Food Security Bill 2011 is perhaps the most important national effort yet to address these deficiencies in India.[3]  Is the Bill a right step to resolve issue of malnutrition in India?

Food security implies access by all people at all times to enough food for an active, healthy life. In 2010, the National Advisory Council (NCA) under chairmanship of Mrs. Sonia Gandhi drafted a National Food Security Bill to address nutritional deficiencies of the population by proposing legal entitlements for 75% of the population.  The Bill was forwarded to the Prime Minister of India in October, 2010 for needful.  In January 2011, an Expert Committee examined the Bill and made several recommendations. A draft Bill was circulated for the public feedback in September 2011, and it was introduced in Parliament in July, 2011. The Bill seeks to provide a legal entitlement to subsidized food-grains to 75% of the country's rural population and 50% of urban India. The estimates suggest that around 68% of the country's population (820 million) would get legal entitlement after the bill is enacted. The "priority" group will get rice at a fixed 3 rupees a kg, wheat at 2 rupees a kg and coarse grain at 1 rupee a kg. The general category will get grains at half of the price the government sets for payment to farmers. The annual requirement for rice and wheat under the proposed Bill will be at least 45.6 million tonnes, calculated on a monthly outlay of 3.8 million tonnes, based on the 2011 population. The requirement will increase significantly in coming years since population has been growing by around 17 to 18 million every year.Further, The Bill is expected to cost Government of India an additional Rs. 470,000 million in the year 2014-15.

It is argued that the Bill, an election promise of the ruling party, could ease voter anger at near 10% inflation and give the government a political breather at a time when it is struggling with corruption scandals and policy paralysis. However, some believe that this is right step to manage malnutrition. Talking about the food security Bill , Noble laureate Amartya Sen said that the bill has several flaws yet any initiative taken in the direction of ensuring food security to public is more than welcome. He argues that nourishment is very important for the nation’s development and cited the example of Asian countries which had focused on healthcare and nutrition to propel themselves forward. 

Arvind Panagariya, Professor of Indian economics at Columbia University and former chief economist at the Asian Development Bank, counters Sen's argument that it is high social spending that has contributed to the economic growth of Indonesia, Singapore, Malaysia, Thailand, South Korea and China. He believes that that the food security Bill will not boost food grain consumption for the poor as has been seen in Chhattisgarh and Tamil Nadu since these States already provide households more grain at even lower prices. He thinks that such measures are huge waste of resources.[4] A recent paper by Arvind Virmani, ex Chief Economic Advisor to the Government of India argues that the most important cause of malnutrition in India was the abysmal state of public health in terms of sanitation, pure drinking water and public knowledge about the importance of cleanliness and nutrition.

I agree with Prof. Virani that the Food Security Bill and anti-poverty programs are not the best way to resolve the issues of malnutrition, poverty and hunger. For example, despite its best intentions to provide employment, Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), launched in 2006, is beset with controversy about corrupt officials, deficit financing as the source of funds, poor quality of infrastructure built under this program, and unintended destructive effect on poverty.  Further, the major idea behind MGNREGA program was to create as many jobs as possible for people. But between 2009-10 and 2011-12, the proportion of workers slipped in India, as per the National Sample Survey Organization (NSSO).

The Bill will have little or no effect on malnutrition, poverty and hunger. The food security scenario in India has drawbacks in its Public Distribution System. In addition, the grain yield of Indian farmers is not going up and there is growing gap between demand and supply. Per capita availability of food grains and pulses has declined significantly in the last few years.  The availability of food is just not growing.  In the eight years between 1996 and 2004, when agriculture was growing at a low 2%, there was, in fact, zero growth in food-grains.The Food Security Bill has the potential to do serious damage. If the Bill is implemented, it can lead to a situation where small farmers, who primarily farm for self consumption, stop producing food grains altogether, expecting the government to feed them with highly subsidized food grains. So the implementation of the Bill could actually result in an overall reduction in food grain production.  The neglect of government to made adequate investment in the country’s food storage system is another major reason for rising level of threat to the available food to the poor and hungry. The increase in population can be cited as another major reason for the rising food threat in India. India’s population has grown from 361 million in 1951 to 1210 million in 2011,  and is still growing by around 17 to 18 million every year. India’s population is projected to peak at 1700 million in 2060.To feed the large population we require millions of tons of food grain. It is estimated that India would require 343.0 million metric tons of food grains in 2020 to feed the whole population.[5]

However, malnutrition especially child malnutrition can be dramatically reduced, if not eliminated, within a decade by removing structural constraints.   The interaction between agriculture/food policies and socioeconomic factors at the micro and macro-level is now considered crucial to ensuring food availability or security.  What is sincerely required is Government must prioritize agricultural development sincerely investing adequately in research, extension, education, irrigation, processing, markets, infrastructure, among others, and drastically revamping organizational structure of agricultural departments and agricultural universities thereby creating enabling environment that can motivate farmers to increase productivity of crops and net profit. Besides, create rural employment through productive and income generating assets which can increase purchasing power of people to help them purchase food grain, vegetables, pulses, fruits, milk, meat etc from open markets.[6]

In addition, one has to revamp the reproductive health services to reduce the burden of unwanted fertility. The galloping population growth is mainly fueled by unwanted fertility. More than four in ten pregnancies are unintended/unwanted by the women who experience them and half or more of these pregnancies result in births that spur continued population growth.  Around 26.5 million children are born in India every year and out of this about 6 million births have been classified as unwanted. Further, as per the National Family Health Survey-3 about 30% (around 224 million persons) of the total population in the young age group 0-35 years in India was the product of unwanted childbearing. The level of unwanted fertility has increased from 23% in 1992-93 to 30%t in 2005-06, as shown in Table 1.

         Table 1 India:  Level of unwanted fertility, 1992-2006

Year	Level of unwanted fertility or childbearing (%)	No. of persons in age group 0-35 resulting from unwanted fertility (in million)
1992-93	22.1	140
1998-99	25.5	178
2005-06	29.6	218
Based on data obtained from National Family Health Survey 1, 2 & 3 and Sample Registration Bulletins. For details, see: 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.

It is estimated that around 450 million people out of 1200 million in India in 2011 were the product of unwanted 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 as well as process of change, and  is being  reflected in widespread malnutrition, hunger, poverty, unemployment, regressing governance as well as increasing scarcity of basic resources like food, water and space despite concerted developmental efforts since 1991.

Now question arises why unwanted childbearing? Around 15 million currently married women in the reproductive ages in 2011, mostly in poor performing States, 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 government 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.   Thus, there is an urgent need to revamp reproductive   heath services. 

The provision of basic services such as piped water, sanitation and hygiene (WASH) as well as electricity could be another effective way to handle malnutrition. Available data, however, indicates that   sub-human living conditions in terms WASH factors can be cited as another major cause of malnutrition.[7]  Only 47% of households have source of water within the premises in 2011. In addition, poor water supply has obvious health costs, since only one in three households are supplied ‘treated’ water in the country.   This problem is further compounded by lack of access to sanitation. About half of total households in India still defecate in open. This situation is particularly piquant for women and girls.  It is estimated that around 290 million women in India in 2011, the worst sufferers of open defecation, continue with the age-old practice even after 20 years of economic reforms. Nearly 65% households in rural India do not have drainage connectivity and the risk of seepage of waste water into the hand pumps and tube wells is quite high. Research on health outcomes suggests that both the quality and the quantity of water are important determinants of the prevalence of gastrointestinal diseases and improving the maternal and child health. Improvements in environmental sanitation are the clearest and most effective policy program tool to reduce, if not eliminate, the excessively high levels of malnutrition in India.

Along with above interventions, sensitizing the society to change its mind-set about importance of cleanliness and nutrition should also be put into action throughout the country with a special focus on the problem districts and communities. Also, the need of the hour is raising civic sense and teaching the right values through mainstream entertainment channels, the media and so on. Further, it is known fact that an educated female/mother changes the health, nutrition and economic status of not only of the entire family but also of the community/nation.   A recent paper by Economist Nisha Malhotra of University of British Columbia shows that lack of knowledge on nutrition and not just access to food plays a vital role in keeping children malnourished. The same also applies to adult malnutrition.

In short, provision of food to people by significantly subsidized rate is not the remedy in longer term. What is sincerely required is Government must prioritize its options. The political class is facing a very perplexing dilemma. It has arrived at a decisive movement of history where it must choose between the antiquated (or populist) and dynamic options available to it. It is time that we take cognizance of the fact that antiquated measures does not help anyone.  As the country’s voter profile increasingly turns young, the political class has to focus on real issues, as noted above, to fight malnutrition, hunger and poverty.

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[1] For details, see: 2011 Global Hunger Index Report, International Food Policy Research Institute.

[2] For details, refer: URL:[http://hungamaforchange.org/HungamaBKDec11LR.pd.

[3] The Government of India on June 13, 2013 deferred a decision on a proposal to promulgate an ordinance on the Food Security Bill. 

[4] Refer:  Arvind Panagariya, “A Waste of Resources: Why the food security Bill will not boost food grain consumption for the poor”, Times of India, June 1, 2013 

[5] Refer: Food Security: Need to establish food democracy, CIVIL SERVICES TIMES MAGAZINE, 30 JULY 2011

[6] Refer: Food Security: Need to establish food democracy, CIVIL SERVICES TIMES MAGAZINE, 30 JULY 2011

[7] See post on: “Quality of life and living environment in India” dated September 30, 2012 by the author at the link: kotharionindia@blogspot.com. Also see article by the author “West Bengal: Household amenities with special reference to water, sanitation and hygiene (WASH) and their implications”, UNICEF West Bengal, Kolkata, 2012.

Is Abortion being used as a form of contraception in India?

According to the Brihanmumbai Municipal Corporation (BMC) – a civic body that governs the city of Mumbai, that the city witnessed a 44% rise in the number of abortions in the year 2012.  While 19,701 abortions were registered in 2011, BMC data from various public and private hospitals and nursing homes in 2012 showed 28,455 abortions.[1] So, what is the reason for the sudden increase? It would be interesting if given information about abortions has been presented by age and socioeconomic status.

The health experts say that the steep increase in the number of abortions shouldn't be linked to sex-determination tests. "Most of these abortions have been carried out in the first trimester when it isn't possible to detect the sex of the fetus," said a doctor with a BMC hospital. Public health officials say it is largely due to better reporting of data by hospitals/clinics brought on by computerization. However, it appears that young women are increasingly using abortions or repeat abortions as a form of birth control.

Abortion is the termination of pregnancy by the removal or expulsion from the uterus   of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy. It can be medical or surgical.  Abortion is legal in India. The Indian abortion laws fall under the Medical Termination of Pregnancy (MTP) Act, which was enacted by the Indian Parliament in the year 1971. The MTP Act came into effect from April 1, 1972 and was once amended in 1975. India’s abortion law is liberal. As per India’s abortion laws only qualified doctors under stipulated conditions can perform abortion on a woman in an approved clinic or hospital.[2]

If Mumbai alone has so much of abortion cases, if the whole country is taken into account the figures would be blasting. Officially there is no precise estimation on annual incidence of induced abortion. The statistics which Ministry of Health and Family Welfare (MoHFW) publishes pertains only to the reported MTP cases conducted in government's recognized hospitals/clinics. According to available official statistics, the number of abortions performed as per MTP Act has increased from 388,405 in 1980-81 to 620,472 in 2010-11. However, these figures are only the tip of an iceberg as it is estimated that in India less than ten percent of the abortions are carried out in government recognized institutions.[3]  India recoded around 6.5 million abortions in 2008 of which 66% were deemed unsafe, as per the MoHFW, Government of India.[4] It means an additional 6.0 million abortions are conducted illegally. Majority of these cases are done in rural areas having inadequate facilities and hence done in an unhygienic and unscientific way. All such abortions are considered as illegal and hence not reported in any official statistics. These illegal abortions are a major determinant of continued high levels of maternal morbidity and mortality in India. According to, the MoHFW, 8% (approximately 4,600 deaths annually) of all maternal deaths are due to unsafe abortion

Now question arises: Why Women Choose Abortion? Or what are reasons behind the abortion decision? A woman's decision to have an abortion is "motivated by multiple, diverse and interrelated reasons," as per the   Alan Guttmacher Institute.[5]  In other words, reasons why women have abortions are diverse and vary dramatically across the world. Some of the most common reasons are to postpone childbearing to a more suitable time or to focus energies and resources on existing children. Others include being unable to afford a child either in terms of the direct costs of raising a child or the loss of income while she is caring for the child, lack of support from the father, inability to afford additional children, desire to provide schooling for existing children, disruption of one's own education, relationship problems with their partner, a perception of being too young to have a child, unemployment, and not being willing to raise a child conceived as a result of rape or incest, among others. An additional factor is risk to maternal or fetal health, which was cited as the primary reason for abortion in over a third of cases in some countries and as a significant factor in only a single-digit percentage of abortions in other countries.[6] Some abortions are undergone as the result of societal pressures. These might include the preference for children of a specific sex, disapproval of single or early motherhood, stigmatization of people with disabilities, insufficient economic support for families.

The MoHFW collects information about reasons behind MTP cases at the time of abortion. Table 1, based on more than 330,000 responses, clearly indicates that “failure of contraceptive” was the main cause behind the induced abortion.  It means about half of women having abortions were using a form of contraception (traditional or modern) at the time of becoming pregnant. Inconsistent use was also part of this response including lack of access to or rejection of available contraceptive methods. More than one fourth felt that negative impact on the mother's physical and mental health was another important reason. Taken at face value, this reason may sound selfish. But a pregnancy that occurs in the wrong place at the wrong time can have a lifelong impact on a woman's ability to raise a family and earn a living. Less than half of the acceptors were illiterate and literate below primary (45%). Official statistics also indicate that more than 60% of acceptors were between 20 to 29 years of age. It means most of them were married.

 

       Table1: Distribution of MTP cases by reasons for terminations, 2003-04

Reasons	Per cent
Failure of contraceptive	46.3
Grave injury to physical and mental health	26.1
Danger to life	12.1
Substantial  risk and rape	4.9
Others	10.6
Total	100.0
Total number of MTP cases who responded	331,441
Source: Family Welfare Statistics in India - 2006, Ministry of Health and Family Welfare, GoI. New Delhi.

 

Based on the field study, the Forum for Population Action estimated that most abortions in the study areas were obtained by poor women because they have much higher rates of unintended pregnancy.[7] The following statements recoded during the study reflect concerns that play a role in influencing women to terminate their pregnancies:

·         I don't want more children or I'm done with childrearing

·         I'm not ready to become a mother or not ready for another child

·         My husband/partner/parents  wants me to have an abortion

·         There are problems with the health of fetus

·         There are problems with my own health

·         Available family planning methods are not suitable

·         Quality of family planning services is not up to the mark

·         I don't want others to know about my pregnancy 

        

What is future of abortion in India? In other words, whether number of abortions will increase?  This requires an understanding of relationships between contraception and abortion. According to Cicely Marston and John Cleland[8] that the “relationship between levels of contraceptive use and the incidence of induced abortion continues to provoke heated discussion, with some observers arguing that use of abortion decreases as contraceptive prevalence rises and others claiming that increased use of family planning methods causes abortion incidence to rise”. Based on the data from several countries, the authors concluded that: “Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly”.

In India, looking to the present state of family planning, the contraceptive use alone will not be able to meet the growing need for fertility regulation since fertility is falling rapidly.  Many experts, therefore, feel there is a reason for the rising numbers — fewer options for women with regard to the method of abortion.  Approximately 35 million pregnancies occur each year in India. Out of this, more than two in five pregnancies are unintended by the women who experience them, and half or more of these pregnancies end in abortion including induced abortion.  It is estimated that around 26.5 million children are born in India every year and out of this about 6 million births have been classified as unplanned or unintended. Approximately two-thirds of these pregnancies resulted from non-use of contraceptives; clearly indicating the need for easy availability of quality family planning services with proper “method mix”. 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.[9] In addition, around one-third of unintended pregnancies resulted from the ineffective use of contraceptives, which suggests the need for improved counseling and follow-up of couples that adopt a method. In other words, there is a tremendous need to revamp the family planning program in India to provide services looking to the needs of clients, since abortion is increasingly being used as a form of contraception.

What ever may be the case; the trend of increase in abortions each year like Mumbai is very negative and should be viewed seriously by the government and voluntary/donor organizations, before things go out of hand.

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[1] Refer: News item: Mumbai saw 44% more abortions last year, Times of India, May 20, 2013.

[2] Chandrasekhar, S. 1994.  India's Abortion Experience:  1972-1992. Denton, TX: University of North Texas Press.

[3] For details, refer: Khan M.E., Barge Sandhya and Philip George. 1996.  “Abortion in India: An Overview”, Social Change vol. 26(3 & 4).

[4] Refer: Kounteya Sinha, “Encourage women for safe abortion: NRHM”, Times of India, July, 7, 2012.

[5] Refer a note entitled: “Women and Abortions: the Reasoning behind the Decision”, circulated by the National Organization for Women (NOW), an organization of feminist activists in the United States.

[6] Bankole, Akinrinola; Singh, Susheela; Haas, Taylor. 1998. "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries". International Family Planning Perspectives 24 (3): 117–127.

[7]  Devendra Kothari. 2010. Fertility preferences in Rajasthan: An analysis, FPA Working Paper, Jaipur: Forum for Population Action.

[8] Refer: Cicely Marston and John Cleland. 2003.  “Relationships between Contraception and Abortion: A Review of the Evidence, International Family Planning Perspectives, 26 (1).

[9] Refer: Author’s Blog - Controversy over Injectable contraceptives in India: How to resolve it? August 1, 2011 at link kotharionindia.blogspot.com.