Here's why contraceptive use across India has declined despite high awareness

According to data from the latest National Family Health Survey (NFHS-4), there has been a decline in the use of contraceptives in 10 out of 14 states surveyed in India. That’s a six percent drop – over the span 10 years – in the use of what considered as “modern methods” among women of childbearing age (15-49), according to IndiaSpend. This drop comes even as awareness about contraceptives has grown: according to NFHS-4, Andhra Pradesh has the highest awareness (86.3 percent) about condom use among women. So, what can we learn about contraceptive use across India, and what might be behind this mismatch between theory and practice? [caption id=“attachment_2999916” align=“alignleft” width=“825”] A file image of a sex worker blowing a condom during an AIDS awareness campaign in Kolkata. Reuters[/caption] “Traditional” vs “modern” methods aren’t in a life-and-death struggle. Let’s look at what we mean by “modern” methods: it includes female and male sterilisation, the contraceptive pill, intra-uterine device (IUD), post-partum IUD (PPIUD, used after childbirth), injectables, male and female condoms, and emergency contraception. “Traditional” methods refer to periodic abstinence — also known as the “rhythm” method: not having sex when the woman is likely to be ovulating — and withdrawal (i.e. the pull-out method). With the exception of condoms, none of the methods above provide protection from sexually transmitted disease. And “traditional” methods don’t necessarily always have a high rate of failure, or mean that those relying on them are uneducated or ignorant. (For an exploration of the fascinating complexities behind this, read Alaka Malwade Basu’s 2001 paper on the use of “traditional” methods among upper-class women.) Data on contraception across states varies rather widely Although the Ministry of Health and Family Welfare cautions us that the figures from this latest survey may not strictly be comparable to previous rounds of NFHS due to differences in sample size, the latest data tells us some interesting stuff about contraceptive use. While 50 percent of women in Karnataka – a state with high HIV prevalence – were aware that consistent use of condoms would reduce the chance of HIV/AIDS, only 1.3 percent were reported using the contraceptive method. The most widely used method by far (to which condoms came in second) was female sterilisation at 48.6 percent. Overall, across rural and urban areas, 51.3 percent of women reported using any modern method of contraception. A decade ago, this figure stood at 62.5 percent. In Goa, where 37.2 percent of women used modern methods a decade ago, only 24.8 percent do now (female sterilisation accounts for 16.3 percent of this) — the sharpest decline of all states. In Manipur, condom use fell drastically from 4.1 percent a decade ago to 1.3 percent. In six of the 14 states surveyed, the use of IUDs has risen. Clearly, not all of this data corresponds with what we might anticipate. Tamil Nadu has a high rate of contraceptive use, but where 60 percent of women used “modern” methods in 2005-2006, this figure has now dipped to 52.6 percent. NB Sarojini, founder and director of the Sama Resource Group for Women and Health involved in issues of women’s health and rights, says, “In Tamil Nadu, female sterilisation rate is very high, education levels and health facilities are also better. So, one would think that Tamil Nadu may be doing much better, but such is not the case and that is very surprising.” [caption id=“attachment_2999920” align=“alignleft” width=“825”] An expert points out that the drop in contraception use should also be weighed against whether the number of abortions has increased. Reuters[/caption] Total fertility rate has declined too “One good thing,” says B Paswan, “is that although family planning has gone down, TFR [Total Fertility Rate: the number of children born per woman of child-bearing age] has not increased. It has gone down too.” Paswan is a professor and head of the department of Population Policies and Programmes at the International Institute for Population Sciences – the designated nodal agency responsible for providing coordination and technical guidance for the survey. Interestingly, data on the states that were surveyed under the NFHS-3 as well show that the TFR dropped in all 14 of them. Goa has the lowest TFR with 1.7 percent, down from 1.8 percent, while Bihar has the highest with 3.4 percent, down from 4 percent in 2005-2006. Paswan thinks one reason for lower contraceptive use might be because people are getting married late. The median age of marriage among Indians according to WHO and Ministry of Health and Family Welfare in India – 2011 report is 22.2 years for men and 26 years for women as compared to 20.2 years for men and 24.8 years for women in 2001. By his reasoning, the need for contraceptive use starts later among individuals. Only married women surveyed on contraceptive use Sarojini points out that the NFHS does not take into account statistics on unmarried women. If late marriage is one of the contributing factors to this decline, it raises questions: Anyone who marries late abstains from sex until then? If we take the ‘sanskaari’ route and assume that we don’t need to collect data on pre-marital sex, will we ever get a clear picture of contraceptive use in India? The rate of female sterilisation has, thankfully, dropped Dr Sreeparna Chattopadhyay, Assistant Professor at the School of Development, Azim Premji University, says that NFHS-4 data shows a decline in the practice of female sterilisation as contraception. She sees this as a good thing and says it needs to be cross-referred with women’s age at marriage for a clearer picture of whether other kinds of contraception have taken its place, such as “traditional” methods. Chattopadhyay also points out that the drop in contraception use should also be weighed against whether the number of abortions has increased. Sarojini further says that it is important to note that the use of contraceptives and family planning always falls on the woman’s shoulders, men are never equal participants in it. She says, “Either the women who need family planning methods are not accessing the services or the services are not being available to them with the methods they want. We need to take a serious look at the service provisioning and address critical gaps in the quality and reach of these services.” The Ladies Finger (TLF) is a leading online women’s magazine delivering fresh and witty perspectives on politics, culture, health, sex, work and everything in between.