Family Planning in Asia and the Pacific - International Council on ...

IntroductionThe use of contraceptive methods <strong>in</strong> India <strong>in</strong>creased from13 per cent <strong>in</strong> 1971 to 56 per cent <strong>in</strong> 2005/06, <strong>and</strong> fertilitydecl<strong>in</strong>ed from about 6 births per woman <strong>in</strong> <strong>the</strong> 1960s <strong>and</strong>1970s to about 2.7 births <strong>in</strong> 2004. This decl<strong>in</strong>e of morethan 3 births per woman represents about 85 per centof <strong>the</strong> decl<strong>in</strong>e required to reach replacement fertility: 2.1births per woman. The rise <strong>in</strong> contraceptive use <strong>and</strong> <strong>the</strong>pace of fertility decl<strong>in</strong>e, however, has not been uniformthroughout <strong>the</strong> country. Progress at <strong>the</strong> national levelmasks important differentials among subgroups of <strong>the</strong>population. For example, <strong>the</strong> gap <strong>in</strong> contraceptive use <strong>and</strong>fertility between <strong>the</strong> sou<strong>the</strong>rn <strong>and</strong> <strong>the</strong> nor<strong>the</strong>rn states ofIndia observed <strong>in</strong> <strong>the</strong> 1970s cont<strong>in</strong>ues to exist. Fertility <strong>in</strong>six major states is at or below <strong>the</strong> replacement level <strong>and</strong> itis close to <strong>the</strong> replacement level <strong>in</strong> ano<strong>the</strong>r four states. It is<strong>in</strong> four nor<strong>the</strong>rn states only that fertility is more than threebirths per woman (IIPS, 2007). There are o<strong>the</strong>r disparities<strong>in</strong> contraceptive use <strong>and</strong> fertility between <strong>the</strong> poor <strong>and</strong> <strong>the</strong>rich, <strong>and</strong> between <strong>the</strong> educated <strong>and</strong> <strong>the</strong> uneducated. While<strong>the</strong> country has also made tremendous progress <strong>in</strong> termsof economic growth, <strong>the</strong>se disparities <strong>in</strong> contraceptive use<strong>and</strong> fertility have important implications for <strong>the</strong> futureof <strong>the</strong> country. The purpose of this study is to review <strong>the</strong>current status of <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong> India,to document <strong>the</strong> persist<strong>in</strong>g <strong>in</strong>equalities <strong>in</strong> contraceptiveuse <strong>and</strong> fertility <strong>and</strong> to assess <strong>the</strong> factors responsible forregional <strong>in</strong>equalities.The fertility behaviour of couples is <strong>in</strong>fluenced by <strong>the</strong>irown characteristics <strong>and</strong> <strong>the</strong>ir residential environment: aparticular country; a state, or a district with<strong>in</strong> a country;<strong>and</strong> urban or rural areas with<strong>in</strong> a district. It is difficultto summarize this vast literature. However, at <strong>the</strong> risk ofoversimplification, it can be said that couples have childrenbecause <strong>the</strong>y want or need <strong>the</strong>m. Some prefer large familiesto ensure security <strong>in</strong> old age, to secure additional assistance<strong>in</strong> domestic <strong>and</strong> agricultural activities, or to support <strong>the</strong>upbr<strong>in</strong>g<strong>in</strong>g of o<strong>the</strong>r sibl<strong>in</strong>gs. This implies that couplesprefer large families to enhance <strong>the</strong>ir own well-be<strong>in</strong>g now<strong>and</strong> later <strong>in</strong> life. A shift <strong>in</strong> value from this self-<strong>in</strong>terest to<strong>the</strong> well-be<strong>in</strong>g of children is believed to <strong>in</strong>itiate tradeoffsbetween <strong>the</strong> quantity <strong>and</strong> quality of children <strong>and</strong> between<strong>the</strong> cost <strong>and</strong> benefits of children. These tradeoffs lead to adesire for smaller families. This shift <strong>in</strong> th<strong>in</strong>k<strong>in</strong>g is facilitatedby a couple’s education, diffusion of ideas through massmedia, contact with o<strong>the</strong>r families benefit<strong>in</strong>g from smallerfamilies <strong>and</strong> <strong>the</strong> macro-level conditions to which <strong>the</strong>y areexposed.Factors such as education do not affect fertility directly.Their <strong>in</strong>fluence on fertility is transmitted through fourma<strong>in</strong> proximate determ<strong>in</strong>ants: marriage, post-partumamenorrhoea <strong>and</strong> abst<strong>in</strong>ence, abortion <strong>and</strong> use ofcontraception (Bongaarts, 1978). Age at marriage risesslowly <strong>and</strong> its fertility-<strong>in</strong>hibit<strong>in</strong>g effect is usually cancelledout by <strong>the</strong> fertility-enhanc<strong>in</strong>g effect of reductions <strong>in</strong>post-partum amenorrhoea <strong>and</strong> abst<strong>in</strong>ence associatedwith modernization. While <strong>the</strong> use of abortion servicessuppresses fertility, its availability is limited <strong>in</strong> manysocieties. In brief, fertility is ma<strong>in</strong>ly determ<strong>in</strong>ed by <strong>the</strong>use of contraception. In recogniz<strong>in</strong>g this fact, develop<strong>in</strong>gcountries <strong>in</strong>itiated family plann<strong>in</strong>g programmes that offerservices <strong>and</strong> <strong>in</strong>formation about contraceptive methods tocouples who wanted to regulate <strong>the</strong>ir fertility.The demographic literature <strong>and</strong> <strong>in</strong>ternational populationconferences have focused on how <strong>the</strong> fertility transition willoccur: through <strong>in</strong>vestment <strong>in</strong> family plann<strong>in</strong>g programmesor dependence on economic development. Some arguedthat economic development would ultimately lead tofertility decl<strong>in</strong>e as it did <strong>in</strong> North America <strong>and</strong> WesternEurope. O<strong>the</strong>rs argued that family plann<strong>in</strong>g programmeswould decrease fertility even <strong>in</strong> poorer sett<strong>in</strong>gs as seen <strong>in</strong>Bangladesh <strong>and</strong> Ghana (Phillips et al., 1988, Debpuur etal., 2002). These two oppos<strong>in</strong>g positions were evident at<strong>the</strong> 1974 <strong>and</strong> 1984 <strong>in</strong>ternational population conferences.At <strong>the</strong> World Population Conference <strong>in</strong> Bucharest <strong>in</strong> 1974,develop<strong>in</strong>g countries argued for “development” be<strong>in</strong>g <strong>the</strong>best contraceptive, whereas developed countries argued for<strong>the</strong> importance of family plann<strong>in</strong>g programmes. By <strong>the</strong> timeof <strong>the</strong> <strong>International</strong> Conference on Population <strong>in</strong> MexicoCity <strong>in</strong> 1984 <strong>the</strong> two sides had switched <strong>the</strong>ir positions.Many studies conducted prior to <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD) <strong>in</strong>Cairo <strong>in</strong> 1994, however, <strong>in</strong>dicated that <strong>the</strong> best resultswould be obta<strong>in</strong>ed by a good family plann<strong>in</strong>g programmeimplemented under conditions of a good social sett<strong>in</strong>g (forexample, see Bongaarts et al., 1990; Ja<strong>in</strong>, 1985; Cutright,1983; Mauld<strong>in</strong> <strong>and</strong> Berelson, 1978; <strong>and</strong> Freedman <strong>and</strong>Berelson, 1976). This was also reflected <strong>in</strong> <strong>the</strong> discourse of<strong>the</strong> 1994 conference.The ma<strong>in</strong> message imbedded <strong>in</strong> <strong>the</strong> ICPD Programmeof Action <strong>in</strong>cluded two elements: provide contraceptivemethods with<strong>in</strong> <strong>the</strong> context of reproductive health <strong>and</strong>advance women’s equality <strong>in</strong> education, health <strong>and</strong> economicopportunities. With<strong>in</strong> <strong>the</strong> context of fertility transition,<strong>the</strong>se two recommended actions are consistent with <strong>the</strong>reduction of unwanted fertility through <strong>the</strong> provision ofcontraceptive services <strong>and</strong> reduction of wanted fertility,with improvements <strong>in</strong> equality <strong>in</strong> education, health <strong>and</strong>economic conditions (for a comparison of populationpolicies pre- <strong>and</strong> post-ICPD, see Ja<strong>in</strong>, 1998a; <strong>and</strong> for <strong>the</strong>evolution of population policies <strong>and</strong> <strong>the</strong> role of differentactors, see Ja<strong>in</strong> 1998b).The deliberations with<strong>in</strong> countries on population issueshas affected <strong>the</strong> <strong>in</strong>ternational discourse. At <strong>the</strong> same time<strong>the</strong> outcome of <strong>the</strong> <strong>in</strong>ternational conferences <strong>in</strong>fluencedpopulation policies <strong>and</strong> programmes <strong>in</strong> develop<strong>in</strong>g129