Family Planning: A burden on Indian Women

Capstone Health Women

Women in India alone carry the responsibility of contraception in India, even if it sometimes comes with a health warning.

Alka, 35, decided to get sterilized along with the c-section when she had her second child. The process is called ‘postpartum sterilisation’ and is generally considered to be safe. However for Alka, the decision was more of a situational need.

Alka works as a professor in Mainpuri, a small town near Agra in Uttar Pradesh. Due to overwhelming responsibilities of work as well family, she had to take a hasty decision of postpartum sterilization.

“I could have waited for a few months after the c-section to get sterilised but with a new baby and work, I wouldn’t have had the time. It is better to get it done at once.” Many women like Alka share the whole burden of family planning themselves, without any contribution from their husbands.

India’s population amounts for 17.7% of the world’s population, making it the second most populated country in the world, according to the latest United Nations data. For years, India has been trying to battle the ‘population problem’. There have been innumerable schemes launched by the central government, as well as many state governments have also launched programmes to assist population control.

However, as much as there is a need for family planning and effective contraception in India, it is also important that this responsibility is shared equally by both men and women. But the reality is much different in the country.

Methods of contraception used in India (in percentage) | Source: UN survey

Aakriti Pandey, 29, lives in Kanpur with her husband and six-month-old son. Soon after the birth of their first child, the couple decided that they needed spacing before the other child.

“I never gave it much thought. Being a woman, I guess I felt the responsibility of family planning is on me. I referred to my gynaecologist and she gave me birth control pills,” said Aakiriti.

Deepak Pandey, Aakriti’s husband also shared the same view as her. “We never discussed it properly. We knew that we needed spacing before another child and without much discussion she (his wife) consulted her doctor. I wouldn’t mind contributing more in the process personally but it just never crossed our mind.”

Health issues often accompany contraceptives:

Soon after she started the prescription, Aakriti started feeling nausea, headaches and depression which are commonly known side effects of the birth-control pills. She said, “The doctor had told me this before I started taking the pills. She said that I might feel signs of depression but it got way too overwhelming after sometime, especially with a baby to take care of. I couldn’t sleep and was nauseous for months before my body could adapt to the hormones. I think we underestimate how severe the side effects of the pills can be for women.”

Oral Contraceptive Pills (OCPs) are very commonly associated with depression in women. A Danish study has revealed that when compared to non-users, those who took the pill were more likely to receive a prescription for antidepressants at a later stage, or to be diagnosed with depression in a hospital. However, these side effects are very common and often ignored by women and medical professionals. 

Dr. Poonam Pandey, who is a gynaecologist, explained how a harmless oral pill can have severe negative effects on women’s health. “Oral pills aren’t exactly harmful for women. They can even reduce the risk of many reproductive disorders amongst women such as endometriosis or cysts. But they can really mess up with the hormone cycle if not taken correctly and under good supervision. The problem starts when sometimes women do not consult doctors before starting a course… There can be several reasons behind that. Maybe there are financial reasons; maybe they have an urgent need for contraception… There are also a lot of stigmas around family planning and women often do not seek professional help.”

Dr. Pandey added that due to the poor conditions of the government medical sector in some parts of the country, the chances of uterine infections among women increase. This can be due to poorly performed medical procedures while performing sterilization or inserting IUDs.

According to the recent NFHS report, 36.3% of the women undergo sterilization while only 0.2% of men in India undergo sterilization. This is despite the fact that vasectomy is simpler, safer, easier, and less expensive than female sterilization, according to the experts. A report by BBC revealed how because of poor healthcare conditions in the country, the sterilization process becomes fatal for many women. 

The report highlights how in November 2014, 13 out of 83 women died in a government ‘sterilization camp’ in Bilaspur, Chhattisgarh due to unhygienic and poorly planned medical procedures in the camp. Many of the women developed severe surgical infection.

Uterine infection amongst women is on a rise owing to poor and unhygienic medical procedures | Credit: Saumyangi Yadav

Even the government policies and aids majorly focus on contraceptive methods for women instead of men.

Dr. Chandrika, Deputy Director of the Family Planning Programme in Karnataka, informed that presently, the only family planning policies that the state government has for men include either barrier methods (condoms) or surgical methods (vasectomy). “For men, we provide surgical facilities at all the Community Health Centres. We have also trained the professionals for that… Earlier we used to conduct awareness activities for male sterilisation every quarterly in all the taluks. We also identified the beneficiaries that way and motivated them to get sterilised. However, due to the pandemic, that hasn’t been happening for past two years.”

Every year, the Union Ministry of Health and Family Welfare conducts a 14-day long programme called ‘Vasectomy Fortnight’. “In the first seven days we have the ‘awareness week’ where we have awareness activities. The second week is the ‘service week’ where we conduct surgery on the beneficiaries,” Dr Chandrika added.

Even so, when it comes to family planning policies for men, it is mostly limited to awareness programmes. On the other hand, the government has several different programmes for women. “For women we have OCPs like MALA-N and Chhaya pills, which are distributed free of cost to the beneficiaries. We also focus on injectable contraceptives, IUDs as well as surgical methods for women.”

One such initiative of providing injectable contraceptives called ‘Antara Programme’ was started under the National Health Mission by the government back in 2016.  These contraceptives are distributed free of cost and administered door to door in several states of India by Accredited Social Health Activists (ASHA). 

However, medical professionals say that many women have been complaining about side effects due to the Antara injections. “Many women have been complaining about severe pain in their lower abdomen and irregular or prolonged menstruation after being administered the Antara injections by the government,” said Dr. Poonam Pandey.

When asked about this, Dr. Chandrika, Deputy Director of the Family Planning Programme, said, “It is just a myth. These are hormonal injectables. Women’s bodies take time to get used to these changes and that is why they face these side effects. Sometimes it can take months to adjust to the hormonal changes in body.”

Dr. Chandrika agreed that in a few cases the side effects can be more severe. “Many women develop Amenorrhea (absence of monthly menstrual periods) temporarily after getting administered the injectables. However, I consider this as a blessing in disguise. You see, a huge number of women are anaemic in India. So Amenorrhea is actually correcting their anaemia.”

Almost every other form of contraception has known side effects on women’s body and mental health. A report reveals that roughly one in every 1,176 women on the pill is at risk of developing a blood clot in any given year. In the same article it is explained how for many women, getting an IUD inserted could be extremely painful. Reports also reveal that even when performed correctly and in hygienic circumstances, tubal ligation remains riskier and more invasive than vasectomy. Despite these facts, female contraceptives are much more accepted and popular in India.

As UN data shows, only methods that has seen decline in the number of users from 1994 to 2019 is male sterilization (from 43 million to 16 million) | Credit: Saumyangi Yadav

To ensure that the side effects of various contraceptive methods are minimised, it is important to take several health conditions of women in consideration. That is the approach that is followed in Foundation of Reproductive Health Services (FRHS), an NGO based in New Delhi which aims at providing safe contraceptive options to women living in rural and underprivileged areas.

Mansi Rawat, Programme Officer at FRHS, told, “We follow what we call a ‘9-step approach’ in our organisation. Before administering any kind of pills or injective, we do a full body check-up of the person, identify any kind of underlying health issue, and then choose the suitable method. We also take several other factors such as age, diet, etc. I think public medical sector also needs to follow these pre-necessities in order to minimise any kind of risk that comes with contraceptives.”

There is not just one reason behind the fact that men are unwilling to contribute more in the family. It is a combination of multiple social and psychological reasons that contribute to this mentality.

Sanjeev Chowdhary (name changed), 72, shared his feelings about the same. “I think what happened during the emergency in 1975 is still in the back of a lot of men’s minds, especially men my age… It is like a trauma that everyone remembers in the back of their head. Of course, it is just my opinion and there are a lot of other factors that contribute to the fact.”

During the emergency in India under Prime Minister Indira Gandhi which lasted for 21 months from 1975 to 1977, civil liberties were suspended. Sanjeev Gandhi, the Prime Minister’s son carried out a mass forced sterilization campaign which still remains a controversial topic. According to a report by BBC, this campaign is often called a “gruesome campaign” to sterilize poor men. There were reports of police forcing and dragging the men in several villages to get surgery.

The dark history of male sterilization in India | Credit: Saumyangi Yadav

Even many women in India feel that the responsibility of family planning should not be shared by men. Dr. Chandrika explained that many women feel that pregnancy and contraception is their role. “Not only that but many in Indian culture, women consider their husbands as their gods. They wouldn’t let anything happen to their husband’s bodies or put them in any kind of risk. That is why very often it is a conscious decision of the woman to take the entire burden on her.”

However, presently in India, all the government schemes mainly focus on contraceptives for women.

A scheme for delivery of Oral Contraceptive Pills at the doorstep of beneficiaries by ASHA with a minimal charge is also available. The brand “MALA-N” is available free of cost at all public healthcare facilities. There are several other such initiatives under the Family Planning Programme of National Health Mission (NHM); most of them solely focus on female contraceptive methods, burdening the women with the role of contraception.

What experts say?

Sky social is an organization based in Bhopal, Madhya Pradesh working for gender mainstreaming, child rights and prevention of gender-based violence across the state. Srishti Pragat, the Founder and Chairperson of Sky Social, said, “We have noticed this disparity while implementing policies about menstruation and all as well. These conversations are done at the community level with women only, and men and boys are almost never involved. The reason we felt is that because pregnancy is related to woman’s body, it is ultimately considered to be her responsibility. Any conversation about sexual and reproductive health of women only involves the female community.”

“When government organizes meetings to discuss sexual and reproductive health in Anganwadis, husbands usually just drop women there and leave. Even these ASHA workers are mostly women only. Men are almost never involved in the while process of policy making or implementation when it comes to family planning, which should be changed,” added Pragat.

Paati P. is a gender activist and researcher, currently working as a consultant in gender at JSW Foundation in Delhi. She shared her insights about why there is such disparity in the family planning policies by the government.

“The major perception that goes around women is that they are supposed to take care of children and the family. Even though now, from past few decades, many women have started to come out of these gender roles and recognise than they are more than just the roles they were assigned by the society. But we still haven’t reached a stage where these roles can totally be disposed off… For example, if you notice the kind of promises that politicians make to rural women around elections, you would notice that they are mostly mother-child related policies or free sewing machines to women so they can get employment without even going out of the house or free LPG cylinders to women. Very few campaigns motivate or help these women to step out of their house and contribute to the society. If the election campaigns are like this, I can only imagine how government policies for family planning will be,” she said.

However, Mansi Rawat from FRHS has a contrasting view on this. She said, “It is not like there aren’t enough male contraceptive methods available in the country. Of course, Vasectomy is there to begin with. It is cheaper than other surgical methods. But there are non-surgical methods available too. The actual problem is that men do not take an active part in the process. The government does not need to focus on creating new contraceptives but on debunking the myth and stigma that is present around the whole family planning process.”

Paati P. believes that rigid gender roles, patriarchy and toxic masculinity are the main factors due to which men are unwilling to contribute to the process of family planning.

“Men in India are always conditioned to believe that they only have to go out and support the family financially while women have to take care of the family and children… Because of toxic masculinity, it is believed that if a man is very involved in raising kids or taking care of the family, he is not man enough or he is too soft. Because of these reasons men are still hesitant to take part in the process of family planning and contraception,” she added.

Dr. Poonam Pandey, gynaecologist, also agrees with this. “Most men just are not as involved in the process. Maybe it is true to some extent that there are more contraceptive methods available to women, oral pills for instance. But there are enough methods available to men to take off some burden from the women.”

Government policies primarily focus on women contraceptive methods. For men, condoms (barrier methods) are the most popular form of contraception | Credit: Saumyangi Yadav

To resolve the disparity that is present, it is very important to first tackle the stigma around the process of family planning. Paati P., gender activist, believes that it is important to spread awareness amongst men. “Though not all but a large section of women have started letting go of the rigid gender roles. They have started to go out of their houses and support their families and themselves financially. However, very few men have been able to come out of these gender roles. It is important for them to understand that contributing in childcare and pregnancy does not make them less manly. We, as women also need to talk to men more about these topics of family planning, household, pregnancy, etc.”

Women also need to speak up more about these issues rather than just taking everything that is being forced on them, added Paati P. “I know it is a matter of choice sometimes but still then, it is important that women have conversations with their peers, with other women and question the norms that have been present in the society for so long.”

A recent report revealed that a Birth Control Pill for men, which was developed by researchers from the University of Minnesota, is expected to start human trials this year. However, even if the trials succeed, it is difficult to predict how much time it would take for such pills to gain popularity and acceptance in India.


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