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Contraception and Population

Contraception and Population

What is contraception?
Contraception is the deliberate prevention of the conception of offspring by any of various means. In general, birth control or contraception is anything that prevents a woman from becoming pregnant. The most basic form of contraception is abstinence. However, abstaining from sex entails fighting the natural human sex drive. Medical technology allows contraception through various means, which can be temporary or permanent, so that those not practicing abstinence can control conception.

The right to decide freely and responsibly the number and spacing of children and to have the information, education and means to do so is well recognized as an important component of reproductive rights. Contraceptives enable men and women to exercise these rights.

What is the pattern of contraceptive use of "method mix" in India?
Modern medicine has provided us with a range of contraceptive choices. The distribution pattern of usage of various methods to prevent pregnancies is called "method mix". India is unique in that female sterilization is the predominant method with most couples preferring to achieve their desired family size and opting for a permanent method.

Why have we not been able to bring about a change in the contraceptive behaviour of people in spite of our mass media campaigns?
Mass media campaigns have the potential to provide visibility to a product, spread information, build interest and influence public opinion. They can lead people to the shop, but cannot always make them buy the product. The inherent quality of the product, salesmanship, inducements to try the product, and after-sales service are what ultimately influence the decision towards the purchase and successful use of the product.

Often, these basics are ignored when it comes to promoting contraceptive use, a subject that demands a higher level of communications skills because it concerns personal and intimate choices. The very successful mass media campaigns of the 1960s and 1970s brought near-universal knowledge about contraceptives in India. However, they failed to translate information into action because the health system lagged behind in service delivery.

People in different phases of change process require different communication inputs. The various phases of the change process (understanding, experimenting, adopting and advocating) require counselling, service support, follow-up and creation of opportunities to espouse the cause. Such a systematic communication strategy, also called Behaviour Change Communication, was absent or not operational till a decade ago.

Why is the use of spacing methods so low in India?
The low prevalence of spacing methods is attributed to :

  • Lack of knowledge/access to these methods

  • Poor counselling and follow-up services

  • Incidence of method-related complications aggravated by the poor health status of women, like anaemia, reproductive tract infections and sexually transmitted diseases.

  • Dovetailing of the contraceptive services with mother and child health made it difficult to promote the use of condoms, which requires the male partner to be involved. However, in the light of the looming threat of HIV/AIDS, efforts are being made to promote condom as a dual protection method

  • Couples prefer to have the desired number of children in quick succession and opt for sterilization, which reduces their need for spacing methods

  • Excessive focus of the family welfare programme on sterilization also sidelines promotion of spacing methods

  • India's family planning programme has largely failed to encourage the use of reversible methods, particularly among young women (age 15-30) who are in the most fertile years of their reproductive period. While it has been easier to design communication campaigns on small family norms, promoting spacing has not been successful in the prevailing context of excessive preference for sterilization.

Why is spacing of births important for population stabilization?
Irrespective of the number of children, the timing of births has an independent impact on population stabilization. Spacing, or the gap between two successive pregnancies, would naturally help reduce the momentum of population growth because children born later would in turn reach their reproductive phase at a later date.

Spacing also ensures better maternal and child health, which in turn leads to better survival of children and so diminishes the desire for larger families.

Spacing is important not only for reducing births but also for improving the quality of life of a population. Well spaced and fewer births not only promote better mother and child health but also improve the development opportunities available for men and women, be it education, employment or social cultural participation. These in turn reduce "wanted fertility" - the number of children a couple desires to have in the family.

Hence, policies and programmes that encourage spacing between births through temporary methods of family planning need to be promoted in a big way.

How can spacing methods be promoted?
The key to increasing the use of spacing methods is enhanced communications on the one hand, and efficient service delivery on the other. The importance of communications is brought out by the fact that 99% of married women are aware of at least one modern contraceptive method. However, knowledge about all the methods, which is a prerequisite for informed choice, is only 58%, and only 42.8% use any modern method at all. This is so because counselling and inter-personal communications, so essential for informed choice, are not pursued as an integral part of service delivery by the health workers.

Communications and counselling services are essential to address myths and misconceptions that abound as also to address method-related problems that inevitably lead to discontinuation of contraceptive use. Women need to be treated with greater respect, and empowered to make informed choices by educating them about the various methods and related side-affects. Follow-up care, particularly in the event of method related complications, is also crucial.

Alongside, it is important to improve the availability of quality contraceptives as in their absence no communication effort can be successful. Social franchising of services through local practitioners, community based service providers, and social marketing through corporates are being tried out in the country under various programmes.

Why is it that fewer couples opt for male sterilization?
Over a period of time, the population programme in India has become women-centric, a sea change from the days when vasectomy or male sterilization was the dominant method. Of the couples opting for a permanent method of contraception, as many as 67.3% chose vasectomy in 1963. This increased to 75% during 1976-1977 but dropped steeply to 21.4% in 1980-81, 6.2% in 1990-91 and 2.3% in 2000-2001.

The drop is directly attributed to excesses committed when a target drive mindlessly pushed vasectomies. The development and promotion of laparoscopic techniques in female sterilization had also made it easier for women to undergo the procedure.

Though equally easy, non-scalpel vasectomy is not being preferred due to various myths and misconceptions. Fear of loss of libido and strength, method failure, and an attitude that makes birth control as the responsibility of the woman explain in large part the poor acceptance of the method.

Apart from increasing access to male sterilization services by making them available on a regular basis at the level of the primary health centre, there is a need to strengthen communication support to the programme at the field level and at the macro level through mass media campaigns.

If people prefer a particular method over others what is wrong in promoting that method on a large scale?
The contraceptive needs of couples vary depending on their life situation. For instance, a newly married couple may need a spacing method while a couple completing their family size may opt for a permanent method. Also, the needs of a lactating mother are different from a woman who has infrequent sex. Logically, it is not possible for people to opt for any particular method on a large scale. Ideally, women and men of varying age groups and family situations should have the option to pick and choose from a variety of methods available.

But if one method is preferred over all the others, it is often due to poor information and knowledge about other options, limited access to services, cost factors or myths and misconceptions.

Often, it also reflects aggressive promotion of a particular method by service providers concerned about meeting programme targets. A case in point is sterilization, which is irreversible, needs limited follow up and therefore tends to get promoted over other methods. This should not be construed to automatically mean that sterilization is that most preferred method.

Promoting a single or few methods limits contraceptive choice to only women in certain life situations. Thus, the excessive emphasis on female sterilization in India means that only those women who have attained their desired family size are able to use contraception. For sustained decline in fertility rates, it is imperative that we have a more balanced "method mix".

Why do some groups oppose the introduction of injectable contraceptives in India?
New contraceptive technologies such as the hormonal injectables and implants are invasive, longer acting, provider-controlled and have a high potential for abuse when they are targeted at women in developing countries. Besides, injectables also have higher associated health risks that cannot be easily addressed with the poor health infrastructure in India. So, while the usage may spread with ease, it may simultaneously breed a new set of health problems for which the woman may have nowhere to go.

Most Indian women have poor health status and poor awareness levels, and when this segment receives invasive technology, the results can be disastrous. Screening and follow-up is the key to effective use of these technologies. Since these two cannot be ensured in a system which is hard pressed for infrastructure and human resources, many argue that it is best to keep out such methods, particularly from the public health service system. Injectable contraceptives are not a part of the public sector health and family welfare programme in India but are available in the market.

Copyright © 2007 - Jansankhya Sthirata Kosh       
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