Protecting reproductive rights of women
Speaking at the 13th JRD Tata Memorial Oration recently, the United Nations Under-Secretary-General and UNFPA Executive Director, Dr. Babatunde Osotimehin, said, “Sexual and reproductive health and rights are the <g data-gr-id="60">foundation</g> on which women and girls build a life of choices, empowerment and equality, and they are the cornerstone of sustainable development. These rights must be protected even in the most difficult circumstances.”
Nowhere do these words ring truer than in India. Although women constitute about half of the Indian population and share the same geographical space as men, most of them inhabit a different world in which they bear a disproportionately large burden of adversities. Despite significant socio-economic progress over decades, their lives continue to be characterised by inequalities and imbalances in all spheres.
Due to a traditional preference for sons, there is today only 943 females for every 1,000 males in India, and the figure is likely to worsen in the future given the adverse child sex ratio. This disparity has negative consequences not only for the shaping of marriage and families, but also for the overall health status and socio-economic development of the country.
Prevailing social prejudices, coupled with challenges of healthcare access and affordability, impact the health as well as sexual and reproductive rights of Indian women. They suffer high mortality rates during childhood and reproductive years and are more often than not considered an economic burden. This has a ripple effect on society because the poor health of women affects entire families and, in turn, communities.
We cannot create a more progressive and egalitarian society without recognising women as equal stakeholders in national progress and providing for their well-being. The health status of women is linked to high levels of fertility and the attendant mortality and morbidity rates. Though India’s Total Fertility Rate (TFR) has declined to 2.2 today from around 6 in 1950s and the urban TFR has reached replacement level, large variations continue to exist across states, education levels and socio-economic status.
With close to half of all Indian women falling in the reproductive age group, an action agenda for their health must address shortcomings in the existing national family planning programme and make it better suited to their needs. Over 41 percent of all girls aged 19 in India are married, due to which childbearing is initiated at an early age. In fact, one in five young women aged 20-24 had their first baby before they were 18 years of age and one in eight young women had three children. The unmet need for spacing births is as high as 21 percent in this age group.
Multiple pregnancies – many of them unwanted – and closely spaced births have severe consequences for female health and life expectancy. Over one lakh Indian women die each year due to pregnancy-related causes. The Indian Maternal Mortality Ratio of 167 compares poorly with many other developing countries in Asia. An effective family planning programme can not only prevent up to one-third of all maternal deaths, but also advance the reproductive health of women and contribute significantly to seven of the eight Millennium Development Goals.
Even though India’s national family planning programme is one of the oldest – established in 1952 <g data-gr-id="70">–</g> and has seen some remarkable successes, the contraceptive prevalence rate remains low at just 49 percent. Worse, modern spacing methods account for a small fraction (10 percent) of contraceptive use, whereas the unmet need is 12.8 percent. Not only is Indian women’s access to reproductive health services limited, with only 47 percent of them having access to a trained attendant at the time of giving birth, the quality of care in the public health system also remains a major concern for women in the country. Technical competence of family planning providers is rarely judged by women, but they suffer the consequences of their poor training in the form of unnecessary pain, infection and dangerous side effects. Sterilization deaths among females are not uncommon due to gross errors in medical procedures or deficiencies in pre- and post-operative care.
The contraceptive choices available in India are limited, compared to even countries such as Nepal, Bhutan and Bangladesh. Injectables are the fourth most popular family planning method worldwide after female sterilization, the intrauterine contraceptive device, and oral contraceptives. Yet they are not a part of the Indian public health programme, which remains heavily skewed in favour of female sterilization that, in turn, accounts for almost 35.8 percent of all the methods used in the country. Even in the developed states of Tamil Nadu and Maharashtra, female sterilization accounts for 90 percent and 76 percent, respectively, of all family planning methods, used. This single-minded focus of the government on female sterilization results in a lack of choice and violation of a woman’s right to voluntary family planning services.
To make a radical difference to the health status of Indian women, the government needs to review and redesign its family planning efforts based on evidence. However, no systematic evaluation of the national family planning programme has been undertaken so far, due to which India has not been able to learn from experience and draw on lessons learned from many innovative approaches and pragmatic solutions that have been tried out over the years. Consequently, the aspirations of Indian people to have small families remain unfulfilled. The country has also not been able to optimally increase access, promote equity and improve quality in the provisioning of family planning services.
The government has to expand the choices available for modern spacing methods and shift from terminal methods to implants, oral pills, condoms and injectables. Young women need wider contraceptive choices to plan birth spacing. Global experience shows that overall contraceptive use rises with every additional contraceptive method made available. Universal access to reproductive health care could prevent two-thirds of unintended pregnancies and three-quarters of unsafe abortions, significantly improving women’s health.
To achieve optimum outcomes, India’s family planning programme needs to be repositioned, backed by a strong service delivery system and technical support. It must include interventions to delay the age of marriage and the birth of the first child, increase spacing between children, improve availability of contraceptive choices, educate and empower women to make those choices, and ensure that healthcare is accessible to all women, especially in rural areas. Only then would every woman be healthy and every child wanted.
The author is Executive Director, Population Foundation of India