Every month, ASHA workers in Dholpur receive family planning kits under the “Nayi Pahal” [New Initiative] scheme. These kits are stocked with a range of family planning methods including oral pills, injections, condoms, and information on other products. The supplies are free and ASHA workers counsel the women who visit health centres. Awareness campaigns are regularly conducted, also driven by government schemes.
Yet the uptake of these products is extremely low, even dismal. While writing this draft, I spoke with 2 ASHA workers and 1 ANM [Auxiliary Nurse Midwife]. They estimated that out of every hundred women that come to the centre‚ only eight to ten take the oral contraceptives‚ another seven to ten women avail free‚ and a very small number avail the three-month injectable contraceptive․ A significantly large number do not avail any modern family planning methods.
"The products are available‚" she says․ "But women don't avail them․"
The latest National Family Health Survey (NFHS-6‚ 2023-24)‚ suggests a falling fertility rate in Rajasthan․ However, that does not relate the entire story of women’s agency and access to family planning health.
The total fertility rate [TFR] in Rajasthan is at the replacement rate at 2․0 births per woman‚ with family planning and reproductive healthcare access gaps closing․ However, there is a contrast between rural & urban Rajasthan - Urban Rajasthan has a TFR of 1․7‚ while rural Rajasthan is at 2․2․ There is another data that we need to closely observe - Only 57․1 percent of women currently married and in need of family planning in Rajasthan are using a modern method of contraception․ 17-18 percent of women in Rajasthan are rely on traditional contraception methods․
Access to reproductive healthcare has increased for women in recent years, but when it comes to exercising their choice and decision-making power regarding their health, several challenges remain.
Family planning is not only a reproductive health intervention but also a vital component of maternal health, as well as child health and development programs. Inadequate spacing of births results in a host of preventable risks to the health of women and children.
Spacing between childbirth allows sufficient time for a woman’s physical health to recover from a previous birth as well as from any emotional distress she may have experienced. This allows for the best start in life for her infant, ensuring that the child receives the correct nutrition in the first critical years of life. It is well established that these years have a lasting impact on a child’s health and intellectual development.
Moreover, by enabling women to have a child at the time of their choice, family planning programs can also be powerful tools for promoting women’s economic empowerment and improving their chances for continuing their education, gaining employment, and full participation in economic and other activities in public life.
While women and their spouses may decide to opt for spacing and delaying families, there are several gaps in the system. Some of these reasons are external and others are related to weaknesses in the health system. While some women may be opposed by family traditions and pressures, other women may not have access to methods or materials that would enable them to plan their family on their terms.
During my work with Jagan Foundation, I have interacted with several women in villages. Many of them carry deep mistrust of family planning methods, including side effects, while lack of information leads to severe myths amongst communities.
Above all, however, deeply ingrained social norms continue to have more of an influence on reproductive health decisions than women’s own preferences.
India's maternal care programs have done a tremendous job at increasing institutional deliveries․ Financial incentives and sustained public health campaigns have led to rising rates of hospital delivery‚ and the proportion of institutional deliveries in Rajasthan has exceeded 94 percent․
Similarly, the public health systems have built financial incentives for families opting for sterilization – a cash incentive or Rs. 2,000 for women opting for sterilization, while Rs. 3,000 for men. In my conversation with a Dholpur based medical practitioner, this cash incentive is a strong drive behind women undergoing the procedure.
According to NFHS-6‚ female sterilization accounts for 37․2 percent and male sterilization‚ 0․4 percent‚ of all contraceptive use in Rajasthan․ In contrast, female sterilization pan India is at ~30%.
While the cash incentive for men is higher, cultural norms have pushed women in droves to avail these surgeries.
One ASHA worker mentioned, “In practice‚ most women get married young‚ have children soon after marriage‚ reach their desired family size‚ and then get sterilized․ Due to years of government policy emphasis on permanent methods‚ sterilization is encouraged and incentivised‚ and an accepted norm in villages, while the temporary methods which allow women to space or delay births are neglected․”
This is also a family planning system that focuses on regulation rather than empowering women to plan their own births․
That there are more female than male sterilization operations is further evidence that family planning is still women's domain․ Women are expected to use pills‚ other procedures‚ deal with side effects, and cope with changes their bodies undergo to control fertility; this is not as often expected of men․
Myths about vasectomies persist despite decades of evidence that the procedure is safe and effective․ Physical weakness‚ reduced productivity, and losses of masculinity are cited as reasons that men resist getting vasectomies․ The result is that most of the contraceptive burden is borne by women․
A woman’s participation in the labour force is influenced by her familial responsibilities. If a girl gets married young and conceives, this restricts her opportunities to acquire education and skills to enhance productivity and increase earnings - thereby perpetuating a cycle of dependence and restricting her ability to make decisions within the household.
Multiple pregnancies can adversely affect the employment opportunities of women of reproductive age in the rural and unorganized sector.
In essence for women, restrict their reproductive choices and constrain their livelihoods and development.
On the other hand, when women are able to plan their families with better agency, they are able to continue to go to college, gain skills, gain employment, and therefore earn income to support their families. In this way, reproductive health is crucial to achieving a range of other development goals.
Rajasthan's reproductive health story is often told through encouraging statistics, in which fertility declines‚ health services expand‚ and nearly all women experience institutional deliveries‚ does not capture the full story․
These successes have improved health and saved lives․ But that does not tell us whether women are making informed reproductive choices․
The question is not whether fertility has fallen‚ but whether women have the power to choose when to have children‚ how many to have, and how long to wait between pregnancies․
The next phase for Rajasthan's family planning program must go beyond setting targets for lowering fertility rates and sterilization․ The government should work to increase access to temporary spacing methods‚ strengthen counselling‚ involve men as equal stakeholders‚ and create an environment that enables women to make informed voluntary choices․
Because family planning shouldn't be measured just by how many births are prevented․ It should be measured by whether women have the freedom to decide the course of their own lives․
- The author is a public policy professional specializing in social impact and policy advocacy. She is the founder of Jagan Foundation, a social impact enterprise and think tank operating in rural Rajasthan.
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