The need of the hour: A fresh perspective on family planning
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/MJDRDYPU.MJDRDYPU_46_17
The right incentive can change perceptions. Women in village Gove, Maharashtra, wanted two sons and one daughter in 1975, and they wanted more or less the same in 2008, according to a paper by Rao et al.[1] The only change Vlassoff noted in three decades, in a study [2] which formed the basis for the paper, was that, of late, some women wanted one son as against two–but not enough women to reduce the average number of sons wanted to one. Moreover, most women considered a daughter an added bonus instead of a must-have. Largely unchanging perceptions of what constitutes an ideal family size kept women availing sterilization services–by far the most common government-sponsored family planning method in rural India–just as in the 1970s. Only after they had a son, or produced three daughters–one wanted, two unwanted–in trying for a son did women get sterilized. Son craze keeps family sizes in rural India larger than the “ham do, hamare do” (we two, our two) the government advises as ideal. We propose that this slogan is also not helping to change perceptions because it puts the focus on children–specifically, on two children. Hence, on the one hand, some women in India try, try, and try again to have a son. In doing so, they keep India's total fertility rate higher than the replacement fertility. And on the other hand, some women have imbibed “ham do, hamare do” so deeply that their early married life narrative reads thus: “Marriage at the age of 17, a baby at 18, a second child at 20 and a tubectomy at 23.” In the early 2000s in District Satara, Maharashtra, this was true of 85% women's lives, we gleaned from an interaction with Vijay Singh H Mohite, district health officer in 2007, who led the European Commission-supported Sector Investment Project survey that concluded thus. Early and successive childbearing keeps India from achieving a critical development goal–lowering the infant mortality rate to 30, a target set for 2012 but still eluding the country.[3] In India, mothers aged <20 years face 1.5 times the risk of losing their baby as compared to women aged 20–29.[4] What if the government family planning policy was to focus on women and couples instead of on two children, and link childbearing woman- and couple-wellbeing? In Gove, a mix of social and economic factors–educating women, exposing them to life outside their village and giving them the freedom to make decisions and work–like men–helped bring about the marginal change in son preference noted between 1975 and 2008. Possibly the biggest change was that 86% of women were willing to stop trying for a son after three daughters in 2008 versus only 24% in 1975.[5] Women's education or the economic prosperity of village households, alone or jointly, were insufficient to impact son preference in a major way. Back in District Satara, Maharashtra, the health officer behind the Sector Investment Project Survey piloted a family planning initiative that put the focus on the couple. It had a much deeper impact. For starters, it helped thousands of couples realize that marriage is not only about having a family. The Second Honeymoon Package (SHP), a district-wide conditional cash transfer scheme that ran between 2007 and 2010, promised newly weds a Rs. 5000 cash incentive for delaying the birth of the first child by 2 years, and Rs. 7500 for a 3-year wait.[6] Focusing on the couple, in turn, put the spotlight on women's health, education, the newly weds' economic standing, and last but not the least, couple bonding. Improving the health of brides before childbearing was a very important aim and benefit of the SHP as most rural girls married young suffer from poor nutritional status and anemia. Postponing childbearing allowed a third of the participating women time to complete their education. These were more likely to be older, educated beyond 12th standard, and from families with incomes above Rs 15,000. A few women even got to join the labour force after marriage. A fifth of the participants reported better husband-wife communication. The SHP essentially involved grassroots workers introducing participants to nonterminal contraceptive methods such as condoms and pills, also used for spacing. Early familiarity with these methods had a secondary benefit–some couples chose to postpone their second pregnancy too. Unfortunately, the SHP dwindled out without reaching its projected term of implementation, due to a change in district leadership and lack of sustained funding. This left numerous couples without receiving their promised financial benefits, causing a good degree of frustration among health workers and prospective beneficiaries. India currently spends 85% of its family planning budget on sterilization,[7] which represents, in essence, the end point of family expansion. Switching the focus to the beginning of this process would entail increasing the allocation for spacing methods from the minimal 1.5% of the budget and increasing the basket of spacing methods distributed for no charge or at a low cost. Granted, this would mark a huge shift in government perception and policy. However why can't it lead the way? The benefits would be manifold. While many would argue that change is slow to come, it can equally be argued that many Indian social change ventures have faltered because leaders at the government and popular levels have failed to deliver or programs were prematurely withdrawn, a fact that was true of the SHP. That it was embraced with enthusiasm by rural women and health workers, husbands and even in-laws, demonstrates that change is possible.
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