The same is reflected in the 2030 Agenda for Sustainable Development Goals under target 3.7: by 2030, ensure universal access to sexual and reproductive health-care services, family planning information and education, and the integration of reproductive health into national strategies and programmes.

Conventionally, the role of contraception is attributed to only ensuring the rights of adults to decide freely and responsibly on the number and spacing of their children. The World Health Organization (WHO) emphasizes three roles of family planning: assistance in timing, spacing, and limiting of births.

The denotation is that family planning helps the couple or partners to plan a birth at the right time when they are ready, assists them in planning adequate space between marriage and the first birth and between two births, and supports limiting the desired number of children.

Along with the WHO, several individual researchers have further stressed the role of family planning in the prevention of reproductive tract infections (RTIs) and sexually transmitted diseases (STDs). However, with reduced birth rates, global and local public and private donor spending on contraception research and development, supplies, and related health care is shrinking significantly.

Unmet need for family planning

Despite India reaching replacement-level birth rates (i.e., on an average of two children per woman), the ‘unmet need for family planning’ (defined as fecund and sexually active women who don’t want any more children or want to delay the next child but do not have access to contraception) is still high in women.

Population scientists report that a substantial share of the decline in birth rates is attributable to a rise in age at marriage and access to abortions. The latest National Family Health Survey (2019–21) suggests a considerable state-wise variation in the unmet need for family planning.

Figure 1 shows the highest and lowest unmet needs noted in Meghalaya (27%) and Andhra Pradesh (4.7%), respectively. In the larger states, such as Bihar and Uttar Pradesh, the unmet need for family planning is very high. It indicates that a large number of populations in these states want to use family planning but don’t have access to it.

Unfinished agenda for family planning

The agenda for family planning is not yet finished. Specifically, the agenda of family planning does not end with the decline in birth rates and reaching the replacement level of fertility. The agenda was to enhance access to and use of contraceptives with a rights-based approach and expand choices and safety.

Gender equity in contraceptive choices and use is a critical concern where contraceptive use and its side-effect burden is disproportionately borne by women. Except for male condoms, men’s role in other types of contraceptive use has reduced significantly. Male sterilization has been disappearing in India. Further, the research and development in the manufacturing of contraception is heavily skewed toward female contraception rather than male contraception.

Figure 1: Unmet need for family planning among the women aged 15–49 years across the states and Union territories in India, National Family Health Survey, 2019–21:

The new agenda: Family planning for happiness and prosperity

The new agenda for family planning relies on its role in promoting happiness and prosperity, besides population stabilization and enhancing women’s and human rights. With increasing access to education, postponement of marriages, and an increase in life expectancy, there are new emerging concerns that include contraceptive knowledge, supplies and coverage for unconventional target groups such as adolescents and older adults.

India also has one of the highest adolescent pregnancies in married populations, while we don’t have much evidence on contraception use, pregnancies and abortions in unmarried populations and older adults owing to a lack of data collection rather than their nonexistence.

However, the emergency contraceptive and abortion pill sales data give some hint that there is a considerable hidden burden in India as well. Access to contraception knowledge and coverage for older adults to ensure their sexual rights is also not on the mainstream policy agenda. With increasing life spans in the populations, sexual health and the concerns and rights of older adults also assume importance.

Concluding remarks

Unintended births have a greater chance of being undernourished, receiving less care and education, and having a higher chance of mortality. Couples with unintended births, sexual and reproductive tract infections, or contraceptive-led side effects have a greater chance of having work-family conflicts, intimate partner violence, and lower socio-economic status.

Unmarried partners with accidental pregnancies and sexual tract infections have a lower chance of acquiring greater human capital, skills, and successful labor markets and also have a greater chance of suffering from mental health issues.

Promotion of contraception choices, knowledge, use, and safety for all eligible and desired individuals is critical for expanding happiness, well-being, and prosperity in the country through quality human capital creation, greater labor market participations and avoiding undesired public spending.

It does not only ensure population stabilization but also prevents mistimed pregnancies, education and job market drop-outs, and reduces health risks. It helps build gender and social equity by reducing unwanted motherhood penalties for women, especially those from deprived social groups.

In particular, promoting healthy communication between partners and eliminating stigma around family planning to improve reproductive and sexual health outcomes have demonstrated an impact on making equitable and joint decisions to reach fertility intentions, sexual, emotional and mental health and achieve desired socio-economic outcomes for individuals, families, and society.

Finally, public spending on research for developing gender-sensitive contraceptive method choices to involve more men, increase supply and services, and provide information is essential to achieving family planning-led happiness and prosperity for the country.

*Srinivas Goli is associate professor, International Institute for Population Sciences (IIPS), Mumbai, India. Md Juel Rana is Assistant Professor, Govind Ballabh Pant Social Science Institute, Prayagraj. Declaimer: Opinions expressed are solely the authors’ personal views and do not reflect the opinions and beliefs of the affiliated organizations.

Courtesy: CounterView

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While this medical method of abortion (MMA) has a success rate of 95%-98% if administered properly and before nine weeks of gestation, the study found that the lack of medical supervision has resulted in a significant number of botched abortions in India.

Incomplete abortions after the use of pills caused 65% of complications in women seeking post- abortion care in Assam, 59% in UP and 51% in Bihar, stated the report. The method was legalised in India by amending MTP act in 2002 to strengthen access to safe abortions up to seven weeks and it is still considered one of the safest and most effective measures.

The report ‘The Incidence of Abortion and Unintended Pregnancies in Six Indian States’, published on November 13, 2018, provides data for Assam, Gujarat, Bihar, Madhya Pradesh Tamil Nadu and Uttar Pradesh, which together account for 45% of women of reproductive age in India. The study was conducted jointly by Indian Institute for Population Sciences, Mumbai, Population Council, New Delhi and New York-based Guttmacher Institute, a research organization that promotes reproductive health and rights globally.

The prime reason for the abortion complications, the study found, was that women did not undergo the stipulated 15-day procedure for termination of pregnancy which requires at least two visits to a health facility.

Of the 7.6 million abortions that took place in 2015 in the six study states, 77% or 5.8 million were carried out through non-facility MMA and Uttar Pradesh alone accounted for 2.6 million.

The guidelines in the Handbook for MMA, issued by the ministry of health and family welfare, require that Mifepristone and Misoprostol, the two-drug regimen used to induce abortion, can only be provided only by a registered medical practitioner or a government hospital. But, the UPAI study found that most women obtained it from informal vendors and chemists. This means that they are not counselled and lack adequate information about the usage and side-effects of these drugs.

More than half of all abortions in India continue to be unsafe, and incomplete abortions have increased from around 30% to over 50% in the last five years, which shows the increase in unsuccessful home medical abortion attempts, IndiaSpend had reported on November 5, 2016.
The new study underlines the importance of abortion as an indicator that reflects a region’s contraceptive behaviour, unintended pregnancies and the type of termination services offered.

‘Abortion numbers are underestimated in India’

While abortion has been legal in India for over five decades, maternal deaths remain an issue: As many as 56% abortions in India are unsafe; 8.5% of all maternal deaths in India are due to unsafe abortion; and 10 women die every day due to this reason, IndiaSpend had reported on November 22, 2017.

The new study is a follow-up of the report published by The Lancet Global Health in December 2017 titled The Incidence of Abortion and Unintended Pregnancy in India, 2015.

The previous report estimated 15.6 million abortions in the country in 2015, of which 73% or 11.5 million were obtained through MMA medication outside health facilities, 22% or 3.4 million occured in health facilities and 5% were done outside facilities using unsafe methods.

But the NFHS-4 survey estimated that a majority of abortions, as many as 52%, were provided in private health facilities, about 20% in public facilities and 26% were performed by women themselves.

“Statistics compiled by the Indian Government on the number of abortions provided in facilities are known to greatly underestimate abortion incidence because the coverage of facility-based services is incomplete and in addition, many abortions occur outside of a facility setting,” the report argues. Hence, the study used data from indirect sources, by conducting a large-scale sample survey of public and private facilities that provide abortion and data on sales of medication abortion drugs.
 
Public health facilities plagued by shortage of trained doctors and stigma

Of all the facility-based abortions in the six states studied, about 13% were performed in private facilities; public facilities accounted for only 5% of abortions. Only Assam registered 15% of induced abortions in public facilities while Bihar, Gujarat and UP lagged behind at 2%, 3% and 4% respectively.

“The state government of Assam had over the last four- five years made a concerted attempt to improve comprehensive abortion care in the public health facilities,” said Vinoj Manning, chief executive officer of Ipas Development Foundation India, an advocacy group that works to prevent unsafe abortions. “They allocated adequate money in their annual health budget and ensured utilisation of the budgets for training and certifying new MBBS providers to provide abortion care at primary and community health centres (PHCs and CHCs).”

Though the medical termination of pregnancy (MTP) Act, 1971 was passed 50 years ago, safe abortion is still not a reality for women in India. Manning puts this down to multiple reasons. “Lack of access to safe abortion for women owing to the paucity of services where it is needed the most – close to their homes/communities – and shortage of legal providers, is one of the core reasons,” he said. “Additionally, many women continue to be unaware about abortion being legal in India, and the knowledge about where, when and how they can access safe services.”

PHCs need to step up abortion services

Barriers to abortions were commonly observed in PHCs, which are essentially the first point of contact to a qualified medical practitioner for those living in rural areas. “PHCs typically have limited capacity to offer the service, and across the six study states, only a small proportion do so (3–14%)”, the report said. Hence the burden of performing abortions shifted to the large public facilities like the public hospital or the community health centres.

“MTP trained doctors are mostly located in the urban area,  while majority of our population live in the rural areas,” Sushanta Banerjee, head of research and evaluation team at Ipas Development Foundation, told IndiaSpend. “We still have high unmet need for safe abortion at PHCs. Even when a PHC doctor is trained on providing abortion services, the community remains unaware of this service.”

Although there is a provision for one gynaecologist in every CHC, there is a 76.3% shortfall of obstetricians and gynaecologists compared to their requirement at CHCs, IndiaSpend had reported on November 22, 2017.

Why women end up looking for informal, dangerous abortion services

Public and private health facilities denied women abortion beyond the prescribed 20-week  gestational period, as per the study. As many as 29% of public hospitals in Bihar and 63% in Assam provided second trimester abortions, the study showed. But in Gujarat and Tamil Nadu, CHCs and PHCs did not provide second trimester abortions which made women look to informal methods of termination.

The report also states that 54-87% of facilities in the six study states had turned away at least one woman seeking termination of pregnancy. The reasons cited by facilities included shortage of staff, lack of supplies or for not having consent from their husbands or a family member which are not legal grounds for denying abortions.

To ensure that women do not buy MMA pills from informal vendors, Banerjee recommended improved abortion services at all levels of public health facilities. “There is also an urgent need to move from medical doctors to mid-level providers, including nurse and midwives,” he said. “Over reliance on medical doctors will restrict the access and will influence to women to go to informal providers.”

Courtesy: India Spend

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