Contraception
and Population
What
is contraception?
 Contraception
is the deliberate prevention of the
conception of offspring by any of various
means. In general, birth control or
contraception is anything that prevents a
woman from becoming pregnant. The most basic
form of contraception is abstinence.
However, abstaining from sex entails
fighting the natural human sex drive.
Medical technology allows contraception
through various means, which can be
temporary or permanent, so that those not
practicing abstinence can control
conception.
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.
What
is the pattern of contraceptive use of
"method mix" in India?
Modern
medicine 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 with
most couples preferring to achieve their
desired family size and opting for a
permanent method.
Why
have we not been able to bring about a
change in the contraceptive behaviour of
people in spite of our mass media campaigns?
Mass
media campaigns have the potential to
provide visibility to a product, spread
information, build interest and influence
public opinion. They can lead people to the
shop, but cannot always make them buy the
product. The inherent quality of the
product, salesmanship, inducements to try
the product, and after-sales service are
what ultimately influence the decision
towards the purchase and successful use of
the product.
Often, these
basics are ignored when it comes to
promoting contraceptive use, a subject that
demands a higher level of communications
skills because it concerns personal and
intimate choices. The very successful mass
media campaigns of the 1960s and 1970s
brought near-universal knowledge about
contraceptives in India. However, they
failed to translate information into action
because the health system lagged behind in
service delivery.
People in
different phases of change process require
different communication inputs. The various
phases of the change process (understanding,
experimenting, adopting and advocating)
require counselling, service support,
follow-up and creation of opportunities to
espouse the cause. Such a systematic
communication strategy, also called
Behaviour Change Communication, was absent
or not operational till a decade ago.
Why
is the use of spacing methods so low in
India?
The
low prevalence of spacing methods is
attributed to :
-
Lack
of knowledge/access to these methods
-
Poor
counselling and follow-up services
-
Incidence
of method-related complications
aggravated by the poor health status of
women, like anaemia, reproductive tract
infections and sexually transmitted
diseases.
-
Dovetailing
of the contraceptive services with
mother and child health made it
difficult to promote the use of condoms,
which requires the male partner to be
involved. However, in the light of the
looming threat of HIV/AIDS, efforts are
being made to promote condom as a dual
protection method
-
Couples
prefer to have the desired number of
children in quick succession and opt for
sterilization, which reduces their need
for spacing methods
-
Excessive
focus of the family welfare programme on
sterilization also sidelines promotion
of spacing methods
-
India's
family planning programme has largely
failed to encourage the use of
reversible methods, particularly among
young women (age 15-30) who are in the
most fertile years of their reproductive
period. While it has been easier to
design communication campaigns on small
family norms, promoting spacing has not
been successful in the prevailing
context of excessive preference for
sterilization.
Why
is spacing of births important for
population stabilization?
Irrespective
of the number of children, the timing of
births has an independent impact on
population stabilization. Spacing, or the
gap between two successive pregnancies,
would naturally help reduce the momentum of
population growth because children born
later would in turn reach their reproductive
phase at a later date.
Spacing also
ensures better maternal and child health,
which in turn leads to better survival of
children and so diminishes the desire for
larger families.
Spacing is
important not only for reducing births but
also for improving the quality of life of a
population. Well spaced and fewer births not
only promote better mother and child health
but also improve the development
opportunities available for men and women,
be it education, employment or social
cultural participation. These in turn reduce
"wanted fertility" - the number of
children a couple desires to have in the
family.
Hence,
policies and programmes that encourage
spacing between births through temporary
methods of family planning need to be
promoted in a big way.
How
can spacing methods be promoted?
The
key to increasing the use of spacing methods
is enhanced communications on the one hand,
and efficient service delivery on the other.
The importance of communications is brought
out by the fact that 99% of married women
are aware of at least one modern
contraceptive method. However, knowledge
about all the methods, which is a
prerequisite for informed choice, is only
58%, and only 42.8% use any modern method at
all. This is so because counselling and
inter-personal communications, so essential
for informed choice, are not pursued as an
integral part of service delivery by the
health workers.
Communications
and counselling services are essential to
address myths and misconceptions that abound
as also to address method-related problems
that inevitably lead to discontinuation of
contraceptive use. Women need to be treated
with greater respect, and empowered to make
informed choices by educating them about the
various methods and related side-affects.
Follow-up care, particularly in the event of
method related complications, is also
crucial.
Alongside, it
is important to improve the availability of
quality contraceptives as in their absence
no communication effort can be successful.
Social franchising of services through local
practitioners, community based service
providers, and social marketing through
corporates are being tried out in the
country under various programmes.
Why
is it that fewer couples opt for male
sterilization?
Over
a period of time, the population programme
in India has become women-centric, a sea
change from the days when vasectomy or male
sterilization was the dominant method. Of
the couples opting for a permanent method of
contraception, as many as 67.3% chose
vasectomy in 1963. This increased to 75%
during 1976-1977 but dropped steeply to
21.4% in 1980-81, 6.2% in 1990-91 and 2.3%
in 2000-2001.
The drop is
directly attributed to excesses committed
when a target drive mindlessly pushed
vasectomies. The development and promotion
of laparoscopic techniques in female
sterilization had also made it easier for
women to undergo the procedure.
Though
equally easy, non-scalpel vasectomy is not
being preferred due to various myths and
misconceptions. Fear of loss of libido and
strength, method failure, and an attitude
that makes birth control as the
responsibility of the woman explain in large
part the poor acceptance of the method.
Apart from
increasing access to male sterilization
services by making them available on a
regular basis at the level of the primary
health centre, there is a need to strengthen
communication support to the programme at
the field level and at the macro level
through mass media campaigns.
If
people prefer a particular method over
others what is wrong in promoting that
method on a large scale?
The
contraceptive needs of couples vary
depending on their life situation. For
instance, a newly married couple may need a
spacing method while a couple completing
their family size may opt for a permanent
method. Also, the needs of a lactating
mother are different from a woman who has
infrequent sex. Logically, it is not
possible for people to opt for any
particular method on a large scale. Ideally,
women and men of varying age groups and
family situations should have the option to
pick and choose from a variety of methods
available.
But if one
method is preferred over all the others, it
is often due to poor information and
knowledge about other options, limited
access to services, cost factors or myths
and misconceptions.
Often, it
also reflects aggressive promotion of a
particular method by service providers
concerned about meeting programme targets. A
case in point is sterilization, which is
irreversible, needs limited follow up and
therefore tends to get promoted over other
methods. This should not be construed to
automatically mean that sterilization is
that most preferred method.
Promoting a
single or few methods limits contraceptive
choice to only women in certain life
situations. Thus, the excessive emphasis on
female sterilization in India means that
only those women who have attained their
desired family size are able to use
contraception. For sustained decline in
fertility rates, it is imperative that we
have a more balanced "method mix".
Why
do some groups oppose the introduction of
injectable contraceptives in India?
New
contraceptive technologies such as the
hormonal injectables and implants are
invasive, longer acting, provider-controlled
and have a high potential for abuse when
they are targeted at women in developing
countries. Besides, injectables also have
higher associated health risks that cannot
be easily addressed with the poor health
infrastructure in India. So, while the usage
may spread with ease, it may simultaneously
breed a new set of health problems for which
the woman may have nowhere to go.
Most Indian
women have poor health status and poor
awareness levels, and when this segment
receives invasive technology, the results
can be disastrous. Screening and follow-up
is the key to effective use of these
technologies. Since these two cannot be
ensured in a system which is hard pressed
for infrastructure and human resources, many
argue that it is best to keep out such
methods, particularly from the public health
service system. Injectable contraceptives
are not a part of the public sector health
and family welfare programme in India but
are available in the market.
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