India has made significant strides in family planning in terms of greatly reducing population growth. However, it would be a mistake to view this achievement in isolation. The pertinent question is where it sits within the broader context of women’s reproductive health. The issue is not just the number of children a woman bears, but if she has the freedom of choice in terms of “if, when and how" to have a baby.

Total fertility rate (TFR) is the average number of children a woman will have over her childbearing years (15-49). India’s TFR has more than halved over the last four decades to 2.2 in 2015-16 (all data cited here is from government sources, except where stated). Replacement-level TFR (2.1) means each generation exactly replaces itself. If TFR is less than 2.1, a population begins to shrink. Twenty-three of India’s states and Union territories are already below this level. United Nations projects India’s population to reach 1.66 billion by 2050, then stabilize and steadily fall.

Family planning starts with the “if"—the fundamental decision whether to have a child. The “when" involves the timing of first childbirth as well as the time (“spacing") between successive childbirths. Early childbirth increases fertility and, therefore, the chances are that another baby will follow soon. The risk of premature delivery and low birthweight babies increases largely when conception is within six months of a previous birth. Many Indian states rate poorly in terms of the “if and when".

Last year, I met Champa, 20, in a remote north Indian hamlet. Champa was married at 16 and had two children by 19, both girls. With one child severely malnourished, she was expecting her third, her family hoping for a boy. There are millions of disempowered women like Champa across rural India. The choices of “if and when" were all made for Champa by her in-laws and husband. She had very little say.

My previous column explained why educating girls sets off a virtuous chain reaction. Higher literacy leads to delayed marriage, fewer and heathier children, and a corresponding reduction in poverty. The national figure for median age at first birth among women is 21. This varies by education—compare Kerala with female literacy of 97.9% and TFR 1.6, against Bihar with female literacy of 49.6% and TFR 3.4. Bihar and other northern states with huge population shares, but dismal social outcomes, need to step up.

Effective front-line delivery can impact the “if" and “when". Government health workers in villages are often inadequately trained in women’s reproductive health. Proper counselling of couples on available options and side effects, and regular follow-up on continued use is crucial. Alongside primary healthcare, access to good health facilities and skilled manpower are needed to tackle family planning. There is a 74% shortfall, nationally, in obstetricians and gynaecologists in community health centres. India’s unmet need for family planning (proportion of women wanting to postpone or stop childbearing, but not using contraceptives) is 12.9%, which increases to 22% for younger married women within the ages 15-24. This unmet need leads to unwanted pregnancies and unsafe abortions.

The “how" of family planning alludes to the basket of contraception methods readily available to the couple. India’s modern contraceptive prevalence rate (mCPR) is 47.8%, of which an astounding 36% is female sterilization. Contraception through condoms is 5.6%, oral pills 4.1%, intrauterine devices (IUDs) 1.5% and male sterilization 0.3%. Female sterilization has been the mainstay of India’s TFR reduction so far. Holistic family planning necessitates greater choice and availability of non-terminal methods.

Bangladesh reduced its TFR from over 7 in the early 1970s to near replacement-level today, and offers several lessons. Its mCPR is 54.1%, comprising 27% oral pills, 12.4% injectables, 6.4% condoms, 4.6% female sterilization, 1.2% male sterilization, the remainder being IUDs and implants, according to the Bangladesh Demographic and Health Survey 2014. Apart from its broad health and women-centric approach to family planning, Bangladesh ensured sufficient options, access and availability. India only recently launched newer options such as injectables, and has much ground to cover.

Several measures are needed to assure good reproductive health nationally. Girls have to be educated, and married late. Front-line workers need adequate training in reproductive health choices that they can communicate with both men and women. Facilities need to be strengthened in terms of infrastructure, equipment and manpower. There must be easy accessibility of all contraceptives approved in India’s national health plan.

India has made big strides in reducing population growth, but much more needs to be done to assure good reproductive health nationally.

Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok

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