Tuesday, Jun 06, 2023

Family Planning: An Unequal Burden On Women

Gender Bias

Family Planning: An Unequal Burden On Women

National Family Health Surveys unequivocally demonstrate that the onus of adopting family planning measures is always on women

 Patriarchal attitudes and misconceptions about masculinity
Patriarchal attitudes and misconceptions about masculinity

Rajni Murmu was 17 years old when she got married and was pregnant within the next three months. A college student at the time, the underage bride did not want to become a mother just yet. Medical termination of pregnancy, however, was not an option since her family believed that aborting the first child meant she wouldn’t bear children anymore. “I later found out it’s not true. My family also assured me that they would help raise the kid. They did not. At 19, I was forced to become a full-time mother to a sick child,” says Murmu, a resident of Madhupur in Jharkhand. One day, in those initial months, tired of the baby’s incessant crying, Murmu asked her husband to hold the baby. “He did not. So I chose not to hold the baby either. Why is it only my job to raise him? That was the first time my husband hit me,” Murmu remembers.

A former sociology professor and social activist, Murmu states that after the first child, she had at least six abortion procedures. “I did not want any more children and my husband was fine with it because I was young and he knew there was time,” says Murmu. “I asked my husband to get sterilized, but he refused as he felt his ability to have sex would be affected. He would often force me or emotionally coerce me to have sex. But he refused to get any contraception, meaning I kept getting pregnant,” she adds. Murmu relied on contraceptive pills, but they did not always work and had multiple side effects.

By the time Murmu’s second child was born, the repeated abortions and improperly conducted home deliveries via midwives (Murmu’s father objected to hospital deliveries), Murmu’s uterus was damaged. Her in-laws and family refused to allow her to get her uterus removed. Repeated sex, which doctors had prohibited, also meant that her uterus remained vulnerable to injury.

It was only after Murmu divorced her husband for domestic violence and became financially independent that she could finally have some control over her own body. “The first thing I did was to get my uterus removed,” Murmu recalls. Today, Murmu leads a healthier life and has not been experiencing the blackouts and fevers that were so common in those married years. The emotional scars, however, remain.

The basket of measures for women when considering contraceptive choices is more, while measures for men are limited to sterilisation or condoms.

Murmu’s story is a nuanced reminder of how little control women have over their own bodies and sexual rights in India, despite being the sole onus bearers of the country’s family planning policies. Recent data from the National Family Health Survey (NFHS) unequivocally demonstrates that adopting family planning measures is a woman’s burden and states that have effectively controlled their population have done so at the cost of women. The data shows how family planning techniques used on women are the ones that have been successful with female sterilisation far outnumbering male sterilisation as the preferred medium of contraception. Male sterilisation and the usage of condoms are still not common practice in India. Despite the State’s extensive advocacy of condom use, there is a noticeable reduction in its use.

Resistance to Condoms and Vasectomy

According to NFHS 5, only 9.5 per cent of men in India use condoms. The data also shows that there is no dearth of awareness. The use of condom remains very low despite the fact that 82 per cent of men are aware that consistent use of condoms can reduce the chance of HIV.

States with good population records also fare poorly when it comes to contraception equality. Take, for example, the states that achieved an impressive scale of population control. The total fertility rate of Kerala (the number of children per woman) is 1.8, which is less than the national average. Kerala is one of the states with the lowest crude birth rate (annual number of births per 1,000 population) which is only 13.5 per cent. The national average is 19.7 per cent. But its status as the state that achieved the highest scores in population control was gained at the cost of women. The rate of female sterilisation is 46.6 per cent, according to the NFHS 5. Meanwhile, only 0.1 per cent of men undergo sterilisation in Kerala. Despite the fact that 84.5 per cent of men in Kerala have the knowledge that condoms will prevent HIV, only 3.4 per cent use them.

Poor Infrastructure, A sterilisation centre in Kolkata
Poor Infrastructure, A sterilisation centre in Kolkata Photo: Getty Images

Tamil Nadu that recorded impressive CBR (Crude Birth Rate) of 14.2 per cent also shows a similar picture. Successful population control has been achieved at the expense of women. Only 1.8 per cent of men use condoms though 90 per cent of the men know that consistent use of condoms would prevent HIV. The practice of male sterilisation is also abysmally low in Tamil Nadu, which achieved the fastest growth in population decline. Only 0.1 per cent of men go for vasectomy (male sterilisation). Birth control through sterilisation is considered the responsibility of women as 57.8 per cent of women go for the same.

The use of condoms in West Bengal, the state that has a low birth rate (14.9 per cent), is slightly better compared to Kerala and Tamil Nadu. Only 7 per cent of men use condoms, but again male sterilisation is not popular in West Bengal too, which is only 0.1 per cent, while 29.4 per cent of women go for sterilisation. Another south Indian state that achieved a decline in population growth also corroborates this argument that population control is always a woman’s business. Karnataka, which recorded a birth rate of 16.9 per cent, has 57.4 per cent of female sterilisation. Male sterilisation is zero in Karnataka, and only 4.1 per cent of men use condoms.

Who’s to Blame?

While patriarchal attitudes and misconceptions about masculinity and virility often cloud people’s judgment when it comes to opting for contraceptives, it is not always the people to be blamed alone, but the system too.

“The responsibility cannot be put entirely on people,” says Niramala Sudhakaran, retired superintend of the Women and Child Hospital at Thiruvananthapuram Medical College. According to Nirmala, the failure in administering male sterilisation is a systemic error. “There are a number of men who are willing to do it, but the scarcity of trained doctors and facilities in public healthcare systems keeps them away from choosing vasectomy,” she says.

Patriarchal attitudes and misconceptions about masculinity and virility often cloud people’s judgment, but it is not always the people to be blamed, but the system too.

There are a number of misconceptions about male sterilisation as well. According to doctors, people need counselling to address the stigma attached to it. “Some people have wrongly understood that vasectomy would weaken their sexual health and masculinity. There is no system to address such issues,” says a senior gynaecologist working at a government hospital in Kerala.

A recent drive organised by the health department of Kerala to encourage “No Scalpel Vasectomy” validates this argument. The total number of vasectomies conducted in Kerala during 2022-23 was 625, according to the Directorate of Health Service. Of this, 130 had been conducted during the two-week drive organised by the department in 2023. “Vasectomy is a less complicated and a less painful procedure as compared to tubectomy. Still, people are reluctant to go for it because of a lack of awareness. Besides, the incentives provided to the health workers who go to the people to educate them have not been revised for a long time,” says Hariprasad, one of the two doctors in the Kollam district of Kerala, who performs vasectomy. There is a scarcity of trained doctors too according to health workers in Kerala. “There are very few doctors who are trained in doing the procedure, in other words, governments do not give priority for conducting such trainings,” says a doctor.

Moreover, awareness about family planning carried out by healthcare and family welfare service providers tends to stick to generating awareness only among women. Abhinav Pandey, Policy Engagement Office at the Y P Foundation, says that in most cases, frontline workers, ASHA workers and others who campaign on the ground are females and often feel uncomfortable speaking to men about sexual health. Pandey states that most meetings about family planning done by frontline workers in rural and semi urban spaces areas are conducted exclusively for, and among women and there is usually zero messaging for men. “Even the basket of choices for women when considering contraceptive choices is more, while choices for men are limited to sterilisation or condoms,” he adds.

In 2019, Lucknow’s G B Pant Institute of Studies In Rural Development submitted a report to the Ministry of Women And Child Development outlining the reasons why the burden of family planning was unequally borne by women. The study, of which Pandey was an author, notes that about 37 per cent of the male respondents from states like Bihar, Madhya Pradesh, Uttar Pradesh, Rajasthan, Jharkhand, and Chhattisgarh, believe that contraception is a concern for women, not men, out of which majorly are the men belonging to the lowest two quartiles of the wealth index.

The lived experiences of Rajni Murmu and millions of other women nevertheless show that birth control and raising a child should be shared equally between partners. “If more heteronormative fathers were equally involved as the mothers in raising children, perhaps more men would want to choose contraception,” she laughs. At present, the data and the lived experiences of women show that despite advances in family planning, Indian men essentially continue to play little part in either child care or population control.