Why Family Planning must be key priority in Budget 2017

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Just this month, a woman died and five others were critical after a surgery at a family planning health camp in Maharashtra’s Yavatmal district went horribly wrong.

The woman who died was just 36 years old. The death, according to reports, occurred because the government doctor at the Primary Health Centre cut the intestine instead of the fallopian tube while operating on her.

The tragedy brings home the critical gaps in India’s family planning programs especially in large parts of rural India. Given this, it is important that the government prioritizes family planning in the upcoming Budget to ensure that young couples are offered information about, and given access to FP options.

In 2015, the Health Ministry announced some welcome measures in this regard, like expanding the basket of contraceptive choices and ensuring their availability in district hospitals. There are now three spacing methods of contraception in the government FP program – Centchroman, Progestin Only Pills, and injectable contraceptive – offering greater choice and independence to users.

But India is still way short of the commitments it has made under FP2020. At the 2012 London summit, the country had promised to provide FP services to an extra 48 million new users by 2020.

The progress report in 2015-16 shows just how far we are from that goal. Less than eight million extra users have been catered to until July 2016. To meet the targeted numbers, the government has to allocate more resources towards meeting the FP needs of the population.

Census 2011 showed that over 10 crore girls in India get married before they are 18 years old. Young couples, across communities, come under great pressure to have a baby within a year of marriage. Many of them want to delay babies but don’t have the information or access to do so.

Expanding contraceptive choices for men and women while important is not sufficient by itself. They have to be empowered about exercising these choices and this has to be done through sustained community awareness campaigns by the government, civil society and other stakeholders. This needs extra staff on the ground and therefore more funds. The budgetary allocations to health and FP need to be substantially hiked.

India spends just 1.3% of its GDP on healthcare, a figure far lower than countries like Bangladesh, Brazil, Russia and China. Even Afghanistan and Nepal allocate more. Budget 2017 needs to address this shortfall.

Family Planning is a Rights Issue

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Starting January 25, thousands of activists and experts from around the globe will gather at Bali, Indonesia, for the 2016 International Conference on Family Planning. It’s an opportunity to take stock of goals that have been met with, and for countries to evaluate how to boost workforces and tweak their approaches toward achieving the new Sustainable Development Goals.

India has a lot to feel proud about. Its population growth rate has dropped considerably – from a near 22% in 1991-2000 to 17.6% in 2001-11. With a fertility rate of 2.3, we are now just 0.2 points away from reaching the replacement level. And the good news is that nearly 60% of our population lives in states where replacement fertility is already reached or will soon meet the target.

That’s the good news. There is plenty however to be done when it comes to how we approach family planning at the policy level. On this count, India lags far behind countries like Sri Lanka and Bangladesh which is surprising given that w were the first country, globally, to have a government-backed family planning program.

For one, India still reports the highest unmet need for contraception worldwide at 21%. In Bihar it is 31% among women between 15-19 years and 33% between 20-24 years. Maternal and neo-natal mortality is five times higher among girls who conceive before they hit the age of 20. They are also more likely to experience spontaneous abortions, infections and anemia.

This is largely because on the ground the emphasis on female sterilisation remains extraordinarily high. According to UN data, in India, over 37% of women between 15-49 years use sterilization as a method of contraception. Only 3.1% use a pill and 5.2% rely on condoms.

“The rights perspective on family planning is missing at the policy level and it is high time that this changed”, says Dr Pranita Acharya, gender, poverty and HIV/AIDS specialist at the International Centre of Research on Women. “It is the right of couples to decide when and how many children to have. This is only briefly touched upon at the policy level and forgotten on the ground”.

Other contraceptive choices require counseling and careful monitoring – an investment that most states find burdensome. Sterilisation, on the other hand, is a one-time, gunshot intervention. The result is that many women have been sterilized even before they need it.

There is a near complete lack of awareness when it comes to contraceptive choices among married adolescent girls and newly married couples. Filling this gap is critical given that India accounts for 17% of maternal deaths, worldwide. Educating newly married couples about various contraceptive methods could help prevent many more such deaths.

It is also important to involve men in family planning matters believes Sushma Shende, Program Director, Maternal and Newborn Health, at NGO SNEHA. This will help couples make better informed and collective decisions.

“Considering the socio-economic set-up of the areas in which we work, it is difficult for women to take decisions with respect to FP”, says Shende. “Her husband and mother-in-law play an important role in decisions regarding child bearing and family planning. Moreover, the pressures of bearing and rearing the child is considered to be the responsibility of women so increased awareness amongst the men will make them more supportive and help address misconceptions or fear”.

Family planning in Dharavi

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A vasectomy surgery is the end of “manhood”. A Copper-T can prick the body, rust inside the body, or ride up to the chest. Condoms give no “satisfaction”. Oral contraceptive pills can cause weight gain.

These are the the notions and misconceptions that SNEHA team working on the Family Planning programme has to deal with and dispel effectively. The Family Planning unit of SNEHA has been working hard in Rajiv Gandhi Nagar, Dharavi to dispel these misconceptions and notions since 2011 and have induced behavioral changes in many women and men in the area. As per SNEHA estimates, as much as 46% of the population has an unmet need for family planning.

For instance, Karishma, 30, (name changed) was reluctant to use any form of contraception, till she conceived again. She already had two children. She then approached a SNEHA community organiser who helped her get an abortion at Family Planning Association of India (FPAI) at nominal rates. The incident motivated her to get Copper-T fixed to avoid pregnancy for five years.

Social exclusion and lack of information limit access to services such as family planning which are crucial for reducing unwanted pregnancies, saving lives, reducing poverty and slowing population growth. A woman’s ability to control her fertility directly impacts the quality of her life and that of her children. Access to family planning can reduce the number of maternal deaths and child deaths.

“Instead of sermonising to the community to have less children, we have adopted a different approach. We tell them that having fewer children, it is easier to feed and educate them. We tell them that their families can be better and healthier,”said the programme coordinator, Family Planning, SNEHA.

SNEHA has adopted the Peer-educator model, whereby women from the community have been roped in to educate the other members and also provide contraceptive such as condoms, oral contraceptive pills and other services at the doorstep. SNEHA also gives the community information about safe abortion practices, post-partum family planning, spacing between two children and using methods of contraception by choice and mutual decision making. It has also strengthened the referral system to service providers such as municipal hospitals, and FPAI.

Some of our peer educators have made good choices and have fewer children. They help demonstrate the benefits of family planning in the community,”said Bapat.

There is also intervention by way of events and campaigns, group meetings, and home visits. Women who avail of SNEHA services and referrals to FPA agree to speak in group meetings that help in motivating other members of the community.

SNEHA also involves men in the project, a neglected target group of most family planning interventions. Men are important to target becuase usually they make all the decisions regarding family planning. To effectively deal with men in the area, SNEHA hired a male community organiser who conducts group meetings with men and is able to engage with men in the area well.

For instance, a SNEHA personnel were counselling a man who was in a live-in relationship with a woman. When the girlfriend recently got pregnant, SNEHA personnel helped her get an abortion and also helped the man understand the importance of using contraception to avoid such unwanted pregnancies.

“It is important not to judge such people and provide intervention whenever necessary,”said the programme co-ordinator.