World Contraception Day 2021: Why India’s contraceptive method mix is skewed towards female sterilisation

By 2027 India will become the most populous nation in the world . Adolescents and youth constitute close to one-third of India’s population. The sheer magnitude of India’s young population (10-24 years), comprising of 365 million young people, reflects the wealth of human resource available to the country today. Never before has such a demographic advantage existed but leveraging it will depend on investments that we make to meet the needs and aspirations of this large population group. Even if this cohort of young population produces only one or two children per couple, it will still result in a quantum increase in population size before stabilizing. Ensuring the availability of a basket of contraceptive choices, especially spacing methods, can go a long way in ensuring population stabilization. Availability of a variety of modern methods of contraception, especially Long Acting Reversible Contraceptives (LARC), allows couples to select a method based on their specific needs and preferences. Global evidence shows that for every additional contraceptive method made available to most of the population, there has been an increase in overall modern contraceptive use by 12 percentage points. According to data from the fourth National Family Health Survey, India’s health system currently includes female sterilisation (36 percent prevalence), male sterilisation (0.3 percent prevalence), condoms (5.6 percent prevalence), oral pills (4.1 percent prevalence), IUD or PPIUD (1.5 percent prevalence), injectable contraceptives and (0.2 percent prevalence) in the basket of contraceptive choices. These contraceptives together contribute to the country’s overall modern contraceptive prevalence rate of 47.8 percent. As is evident from the trends above, India’s contraceptive method mix is highly skewed towards female sterilisation, with very limited uptake of male contraceptives. The use of male contraceptive methods, particularly male sterilisation is marred by myths and misconceptions, which need to be systematically addressed. Sadly, access to health services continues to be determined by factors such as where a woman lives, how educated she is, her wealth quintile and the community she belongs to. This has placed an undue burden on women to address their health and reproductive needs, without really having the agency or autonomy to make their own health and fertility decisions. The limited and unequal access that women belonging to the most vulnerable and underprivileged communities have to family planning services is a matter of serious concern. Societal control on women’s choices is often reinforced by patriarchal norms, which manifests in practices such as early and forced marriages, limited access to contraceptives, unplanned pregnancies and preventing adolescents from receiving comprehensive sexuality education. Despite the recognition and evidence that family planning contributes to reductions in maternal mortality and poverty and can help the country in uniformly achieving population stabilization, the unmet need for family planning remains high. Currently, 13 percent married women age 15-49 years have the unmet need for family planning, including a 6 percent unmet need for spacing methods. Couples in the reproductive age group continue to have children they do not want because contraceptive services do not reach them. This places women and girls at grave risk of death or disability during pregnancy and childbirth, especially where the quality of care is inadequate. Every couple has the right to decide whether, when and how many children to have. For this to be achieved, it is critical for women and men to have access to a range of contraceptives to choose from. Expansion of the basket of contraceptives should be complemented by a robust supply system, adequate infrastructure, improved quality of care in services, appropriate training of providers, counselling on the effectiveness of the method and its potential side effects and, finally, rigorous follow up. Sustained awareness-raising activities are critical for attracting users to adopt a family planning method of their choice. Clients may be spread out across a large geographical area and have limited access to health services, a challenge that was exacerbated during the pandemic. We need increased efforts to deepen women’s sexual and reproductive health literacy, promote self-care and make health systems inclusive of women’s needs and circumstances. Front line workers should be trained to communicate with eligible women and encourage them to make informed contraceptive choices. This would also help create a feedback loop in which existing users become a medium of communication to new users. Finally, targeted social and behaviour change efforts which promote men’s participation in family planning, both as enablers and beneficiaries, are much needed to address the skewed contraceptive method mix. Treating family planning as an essential service available to all men and women and ensuring uninterrupted access to contraceptives is the way forward. It is critical that policies and programmes are non-coercive and centred on dignity, choice, and the empowerment of women. And, ultimately, it is up to us to recognise that unless family planning and access to contraceptive services are equitable and reach the last mile, we cannot ensure health, safety and wellbeing of our people. The author is Senior Manager, Knowledge Management and Partnerships, Population Foundation of India.