Chapter 1

Introduction

The problem

The present study is an attempt to understand the differentials in the

contraceptive acceptance among young married couples of Lucknow
belonging to different socio-economic groups. It also

tries to identify the major factors which influence practice of family

planning methods among couples. This is an exploratory study and
tries to revisit the concept of “family planning” during

the period 2018-2020 in Lucknow using sociological lens, this study

is qualitative in nature.

The sociological concept deployed for the understanding of the

factors influencing family planning

acceptance in the present study has been based on Anthony Giddens

concept of “duality of structure”.

The studies done in past on the topic of family planning were limited
in nature. Most of the studiesfocused only on quantitative aspects,
moreover, the bulk of research done in recent past for this topic was
conducted by scholars belonging to medical or para medical
branches.The field wasconfined to rural areas in most of the studies
and family planning has always been looked as something that needs
to be studied in rural communities and major respondents for most
studies were “women”. As pointed out by Arna Seal, in her study, the
topic of family planning is usually confined to rural areas with very
few researchers focusing on urban areas, (Seal, 2000) in

Negotiating Intimacies: Sexualities, Birth Control, and Poor

Households, the researcherchose to study this process in the context
of urban working class women. The issue of birth control is often

viewed as a raging “problem” in rural India. But does it always make

sense to dichotomize problems of the rural and urban in terms of
residence? Policy planners often fail to consider these

complexities while implementing their strategies. For instance, the

KAP survey showed that on the average, the number of children born
by Indian women was much greater than the women’s

desired family size. (Seal, A. 2000).

Policy makers ascribed this difference between the desired and actual
family size to women’s lack of access to effective contraceptive. On
the basis of this understanding, the markets in less developed
countries were swamped with contraceptives for women’s use. In the
long run,however, fertility rates remained high because, in fact, there
was and is more to the issue than mere access. (Seal, A. 2000)

Hence, this study attempts to bridge this gap and also try to overcome
these limitations, an attempt has been made tounderstand the practices
of family planning in the context of present scenario.
Perspective of gynecologists as service providers of family planning
has also been taken into

consideration.The findings of the present study can provide empirical

understanding on the topic.

These findings can also be helpful for policy development.

Relevant Review of Literature

Important studies and research in the field of “family planning”

conducted during the past have been reviewed below to have a better
insight of the present research problem. This also helped in

making this study distinct from the previous studies and also to find
new insights which were missing in the previous studies. For better
understanding, this chapter has been organized under few subheadings
that lists the studies conducted in a particular geographical areas, i.e.
World,South East Asian countries, India, Uttar Pradesh and Lucknow

World Perspective

Although the modern contraceptive prevalence rate (mCPR) has

continued to increase in the majority of LAC (Latin American
countries), substantial disparities in access for marginalized

groups remain. On average, mCPR is 20% lower among indigenous

women than the general population, 5% lower among uninsured
women than insured, and 7% lower among the poorest women than
the wealthiest. Among the poorest quintile of women, insured women
had an mCPR 16.5 percentage points higher than that of uninsured
women, suggesting that expansion of insurance coverage is associated
with increased family planning access and use. In the high- and

upper-middle-income countries we reviewed, all modern

contraceptive methods are typically available through the social health
insurance schemes that cover a majority of the population.

However, in low- and lower-middle-income countries, despite free

provision of most family planning services in public health facilities,
stock-outs and implicit rationing present substantial barriers that
prevent clients from accessing their preferred method or force them to
pay out of pocket.(Thomas Fagan, 2017)Leveraging UHC-oriented
schemes to sustain and further increase family planning progress will

require that governments take deliberate steps to (1) target poor and
informal sector populations, (2) include family planning in benefits
packages, (3) ensure sufficient financing for family

planning, and (4) reduce nonfinancial barriers to access. Through

these steps, countries can increase financial protection for family
planning and better ensure the right to health of poor and

marginalized populations. (Thomas Fagan, 2017)

Knowledge of specific methods and source of family planning among

men is encouragingly high.
Well over 90 percent of the men interviewed mentioned of a method
of family planning. However, this knowledge is heavily biased
towards female based methods, especially the pill, IUD,

Injections and female sterilization. Of course this is understandable

given that most methods popularized by the family planning
programme in Kenya are female based.(Otieno, 1999)

Men may be ready to accept vasectomy, and other hitherto

controversial methods only if they are appropriately and directly
introduced to the idea. When information come to a man through his

wife or partner, he may feel that he is being forced to accept the

method. Surely for many men,vasectomy may not appear to be an
attractive option, and to decide on it , they need to undergo a

well-structured counselling programme. They need to be well

informed of the benefits of the operation. (Otieno, 1999)

Attitude toward family planning is also adequately favourable, at least

from the general outlook.

A great majority of men reported that they approve of family

planning. Whether this high approval is genuine still remain suspect.
But a look at the ever use and current use level suggests that this

approval must have been subject to certain pertinent conditions which

the interviews did not probe further to unearth. (Otieno, 1999)
Against the background of high knowledge and favourable attitude,
one would naturally expect equally high levels of use or practice of
family planning. The fact that high knowledge and positive

attitude have not been translated into practice implies that there could
be a hitch that the programme has not discussed addressed. There is a
large discrepancy between family planning knowledge and attitude on
one hand, and practice on the other hand. Practice here is the ultimate

interest of the family planning programme, because it is the one that

will eventually impact on fertility, yet it is the most difficult to
achieve since it requires a commitment based on consensus

from two individuals. Even among men who had tried using some
methods, the drop-out rate was alarmingly high, almost by half for
most methods. This large gap that exists between knowledgeand use
of family planning methods is a clear indication that sociocultural
constraints to family planning, though weakening, are still a strong
force to contend with (Gule, 1994). (Otieno, 1999)

South East Asia Perspective

China’s total fertility rate (TFR) has been below replacement level
since the 1990s and below 1.5 since the 2000s. To address the issue of
low fertility and rapid aging, the Chinese government replaced the
strict one-child family planning policy with the selective two-child
family planning policy in 2013 and then the comprehensive two-child
family planning policy in 2015. However, a strong baby boom did not
ensue, and births hit a record low in 2018. It is thus vital to
understand fertility motivation among younger generations of women.
Collecting qualitative data in a small city in the Yangtze Delta, we
found that the high costs of current practices of child raising and

education are prominent factors in women’s mind-sets, and that

bilateral family support, including but not limited to help with
finances and care, is the cornerstone of this expensive, modern child

raising model. A complex, bilateral family model has gradually grown

out of the patriarchal system. Grandparents on both sides collaborate
with the mother at different times of the day and in different stages of
children’s development. A familial relay race of child care reduces the

mother’s work-family conflicts. The sustainability of mosaic

familism, the gendered intergenerational collaboration following
bilateral family lines, is questionable, particularly when

raising children comes into conflict with caring for the elderly. It was
suggested that future policies pay sufficient attention to the needs of
women who are embedded in the bilateral extended family.(Ji, 2020)

Majority of women had heard about family planning methods.

However, few had practiced them,which results in high unmet need
among married Tharu women of Dang district in Nepal. The gap

between knowledge and practice regarding family planning needs

serious attention from the concerned authority to be addressed. The
contraceptive prevalence rate of Dang district will be
doubled if those women with unmet need also used any method of
family planning. In this context,this study concerns the need for the
policy maker, government officials, and program managers to

focus on strategic behavior communication program regarding

reproductive health including family planning among tribal
communities like Tharus. (Bhattarai, 2018)Indian Perspective

Reproduction is always simultaneously a physiological as well as a

social act. This slippage between society and biology is what enabled
reproduction to be such a potent site for reformist efforts, and this
slippage is what gives the category of reproduction an analytic
purchase for scholarly work. Histories of fertility and contraception
have largely been made to serve as the pre modern antithesis to a fully
“modern” future, and in the process, Indian women have been cast as

agents of backwardness and as culprits in the quest to attribute

responsibility for national poverty.(Hodges, 2016)

Implication of any public policy largely depends on the conceptual

model of the policy, as it pass through diverse socio-economic and
cultural context. In February 2000, the government of India

adopted the National Population Policy 2000. This policy was labeled
as ‘weak on many counts’as population is not integrated with health,
it has population stabilisation rather than the health and wellbeing of
the population as a goal, and so on. Yet a positive feature of the
policy is that it resolutely affirms the “commitment of the government
towards voluntary and informed choice and consent of citizens while
availing of reproductive health care services, and continuation of the

target free approach in administering family planning services”. (Rao

M. , Population Policies : States Approve Coercive Measures, 2001)

India experiences a lot of constraints in implementing policies, owing

to the complexities arising out of the heterogeneity and diversity of
the population, this pose a major challenge to the process of
development in India, especially in the field of social change. Thus, it
is unjust to compare India with a country like China which has a one
party communist rule and can impose on its people one child policy
and achieve considerable success without much popular revolt, which
is highly unlikely in India as the policy makers have to keep in mind
the complexity and diversity of the Indian population and the
imposition of the political philosophy which operates in India.

Population of India witnessed a very slow growth till 1920 owing to

the huge number of fatalities from famines, wars and epidemics. The
population began to increase from 1921, mostly because of
improvement in health and sanitation condition which was taken care
of by then provincial governments. Population increased by more than
10 percent in a decade with 1931 census enumerating a population of
279 million.The history of Family Planning in India can be traced
back in the 1920’s when a group of Indian Intellectuals and civil
servants visited England for higher education and for training for
posts in Indian Civil Services. Over there, they were exposed to
Malthusian theories and to the establishment of Neo-Malthusian
league in England and elsewhere in Europe. They became aware

of the positive checks likely to operate on a population increasing

beyond its means of subsistence.

The Indians who visited England became keenly committed to the

idea of birth control as a means of regulating population growth and
formed the Neo Malthusian League in Madras in July 1929

wherein they started the Madras Birth Control Bulletin.

Neo Malthusian Leagues were being formed in many other cities

including Bombay (Mumbai) and Poona (Pune). But, a strong action
on birth control seems to have started in Bombay, not as a

means of regulating the population, but as a method of liberating

women from the wheels of childbearing, preventing unwanted births
and reducing the hazards to the life and health of pregnant women
who were willing to expose themselves to the cruel and primitive
methods of induced abortions to avoid additional children.(Srinivasan,
2001)

The unsung hero of Family Planning Programme in India is a man

who is not from a social science or medical science background but
from mathematics background. Professor R.D. Karve a lecturer
in Mathematics in a Bombay College made his life mission to
improve the status of women by advocating widow remarriage and
adopting artificial methods of family planning. He was

completely devoted to this cause and published several books in

English and in Marathi on birth control. Professor Karve is
responsible for the huge improvement in the status of women in

Maharashtra.

However, the fruits of the efforts made by Neo- Malthusian league in

Madras and Professor Karve in Maharashtra could not reach the
masses as Mahatma Gandhi, father of the nation and a highly

influential public figure of those days completely opposed to the idea

of introducing artificial methods of birth control. He argued that
sexual abstinence was the only ethical mean of birth

control. He advocated celibacy too. Gandhi regarded sexual

relationship between couples only for the divine act of procreation.

The British rulers too, were not keen in advocating birth control
practices in India as they had adopted a policy of non-interference in
Indian social matters, as far as possible, did not take any

measures which could be considered as an intrusion in Indian

traditions, customs, values and beliefs.A view which was prevalent
among the followers of Gandhian ideology that using artificial family
planning methods especially at a regular basis, is immoral and
unethical pervades the psyche of a considerable section of the Indian
society. The hesitancy seems to be more in the use of spacing

methods that require repetitive action on the part of the couple than
adoption of a one-time permanent method such as sterilization. This
view is of utmost importance as the Indian data of

Family Planning methods suggest that the highest number of users are
adopting female sterilizations as the only means of ending
reproductive career. As 37.3% of the respondents

accepted female sterilization as a method of family planning (NHFS

2016).

Despite of the unwilling attitude of British rulers and of Mahatma

Gandhi, the intellectuals lead by the Neo Malthusian league and the
convincing argument of Professor Karve for protecting the

health of women, the Governmnet of princely state of Mysore under

the leadership of the Maharaja, officially sanctioned the opening of
family planning clinics in 1930. Only two clinics

started immediately, one at Vanivilas Hospital, Bangalore and the

second one at Cheluvamba Hospital in Mysore. (Srinivasan, 2001)

This clearly shows that awareness regarding birth control was made
available much earlier in southern states of India like, Tamil Nadu,
Karnataka etc. as compared to northern states. Hence
the figures bring out the striking contrast between north and south.
Total Fertility Rate of Tamil Nadu being 1.6, Karnataka 1.8 and 1.7 of
Kerala and Andhra Pradesh respectively and that of UttarPradesh
being 3.1 and Bihar 3.3 children per woman (NFHS 2016). The
success of our National Population Policy will lie in our ability to
bridge the gap between north and south. (Bose, 2000)

The Family Planning Association of India was formed in 1949 in

Bombay, Professor Karve being one of its founding members. In 1951
India included family planning in the first five year plan and

since then it’s been one of the major Public programmes sponsored by
Government of India. In 1977, it was renamed as Family Welfare
instead of Family Planning as it expanded its services and

later it was adopted under the Reproductive and Child Health

services, Ministry of Health.Theoretically, family planning does not
stand alone but is a part of a social system and a system

of ideology. Family planning is associated with a number of values

and attitude orientation.

The phrase “value of children” usually refers to positive functions i.e.

satisfaction derived from having children, but dysfunction i.e. costs
are also essential ingredient of the above concept.A theoretical model
demonstrates possible association between alienation variables and
efforts to control fertility among couples of various socio economic
groups. Under this theoretical framework it has been explained that
meaninglessness, powerlessness, normlessness and social

isolation dimensions of alienation would correlate positively with

number of children.

Successful family planning is associated with rational decision

making, a sense of mastery over the outcome of events, a positive
judgment of the normative order and the perception of social

relations as integrative and supportive. These variables may explain

the mechanism as to how larger proportion of couples accept family
planning among educated and socially advanced people.

In contrast, unwanted pregnancies and maximized fertility should, in

theory at least be associated with aimlessness and drift fatalistic
resignation, low regard for the normative order and a sense of

personal anonymity.

For those high in powerlessness, fertility seems likely to constitute an

occurrence, a chance happening, an unmanaged event. One of the
fundamental principles of Sociology is that when many members of a
society face a recurrent common problem with important social
consequences they tend to develop a normative solution for it. This
solution, a set of rules for behavior in a particular situation, becomes
part of the culture, and the society indoctrinates its members to
conform more or less closely to the norms by explicit or implicit
rewards and punishment. (Freedman,1968)

Explanation for “planning a family” with calculating pros and cons

can also be looked at from “rational choice” perspective of Friedman
(Ritzer, 2011).The basic principles of rational choice theory are
derived from neo-classical economics. Based on a variety of different
models, Friedman and Hechter have put together what they describe
as a “skeletal” model of rational choice theory.

The focus is in rational choice theory is on actors. Actors are seen as

being purposive or as having intentionality. That is, actors have ends
or goals towards which their actions are aimed. Actors are

also seen as having preferences (or values, utilities).

Rational choice theory is unconcerned with what these preferences, or

their sources are. Of importance is the fact that action is undertaken to
achieve objectives that are consistent with an

actor’s preference hierarchy. Although rational choice theory starts

with actor’s purpose or intentions, it must take into consideration at
least two major constraints on action. The first is the scarcity of
resources. Actors have different resources as well as differential
access to other resources. For those with lots of resources, the
achievement of ends may be relatively easy.

However, for those with few, if any, resources, the attainment of ends
may be difficult or impossible. Related to scarcity of resources is the
idea of Opportunity costs. In pursuing a given end, actors must keep
an eye on the costs of forgoing their next most attractive action. An
actor may choose not to pursue the most highly valued end if her
resources are negligible if as a result the chances of achieving.(Ritzer,
2011)

Durkheim (1950), who was generally responsible for the theory in

sociology, emphasized the importance of macro-level social
processes, structures, norms, and values external to individuals

that integrated them into the larger society and shaped their behavior.
People were depicted as constrained in exercising free will by the
social order. Durkheim's (1951) only work that had a direct
application to medical sociology was his theory of suicide in which
the act of taking one's life was determined by the individual's ties to
his or her community or society. Indirectly,Durkheim (1964) also
influenced the study of planning for a family in noting the transition
from mechanical to organic social solidarity, with its emphasis upon
specialization.

In the work of George Herbert Mead (1934) and Herbert Blumer

(1969). Symbolic interaction maintained that social reality is
constructed on a micro level by individuals interacting with one

another on the basis of shared symbolic meanings. Human beings

were seen to possess the capacity to think, define situations, and
construct their behavior on the basis of their definitions and
interpretations. ``It is the position of symbolic interaction,'' states
Blumer (1969:55), ``that the social action of the actor is constructed
by him [or her]; it is not a mere release of activity brought about by
the play of initiating factors on his [or her] organization.'' Social life
was therefore produced by interacting agents choosing their own
behavior and acting accordingly, not by large-scale social processes
and structures channeling behavior down option-less pathways.

(Cockerham, 2001) As evident in the practice of decision making

regarding family planning from a study conducted in Odisha it was
indicated that decisions to stop having children are primarily

economic. In all cases, whether poor and non-poor, financial burden

was cited as the main reason for not wanting a large number of
children. In many cases, respondents stated that to have children

is joint spousal decision making. As expected, joint decision is more

among respondents with higher levels of education and respondents
belonging to non-poor households. Only one sixth of respondent’s
decision about family size changes in the hypothetical circumstances
of a rise in family income and government provision of free education
and free ration to all children. Thissuggests that the poor and the non-
poor are firm on their decision and there is little change in decision in
relation to income and cost factors. From the field study it is also
evidenced that regardless of their own family sizes, most respondents
made declarations along the lines of "a small family is a good family"
and could support this statement with various problems associated
with large families. While some of the problems mentioned were tied
to personal experience or observation of others, the majority of men
repeated standardized lists including various potential

expenses on children and the inability to "raise good human beings" if

one has many children.

However, they reported that there is a pressure to stop childbearing

because of personal economic hardship. Besides, majority of the
respondents including both poor and non-poor, however, view

raising their children as "proper human beings" to be a moral duty

which takes precedence in their own eyes. This requires education,
food, clothing and medical treatment as well as a mother's

attention. They indicated that it is not possible to fulfill this duty when
one would have many children. Thus, those who do not plan their
families are regarded by some as irresponsible parents

and become the subject of gossip (Sahoo, 2014)

The gender and development (GAD) perspective takes a more holistic

approach towards development. The proponents of this view argue
that marginalization from the development process is not the only
reason for women’s subordibation (Anand, 1984). Rather, the
phenomenon is ascribable to a variety of gender- related factors and
patterns of economic growth systematically producing sharp class
differences and social hierarchies.Also, the approach tries to avoid
androcentric and ethnocentric assumptions underlying development
models. Thus, GAD proponents study third world women within their
specific historic and socioeconomic contexts.

((Seal, 2000)

Explanations of fertility behavior and particularly of fertility

regulation and decline have long been discussed in literature. While
some of the biological explanation put forth earlier are no longer

taken seriously, the social, cultural, economic and political factors

have been extensively debated.

Effort is made to see whether one or a combination of these

explanations applies to the Indian fertility transition. The discussion
here is based on the three essential conditions for fertility decline

specified by Coale (1973) these are: Fertility must be within the

calculus of conscious choice, reduced family size must be
advantageous and efficient techniques of fertility regulation must be

available.(Kulkarni, 2011)In the past, childbearing was taken as

natural. For believers, it was given or granted (or blessed)

by God, and for others something that was not up to one’s choice. In
some surveys of early 1950’sin parts of India, question that tried to
elicit family size desires were not answered or no specific
number was stated by many. Bust recent surveys show that specific
response to such question has become nearly universal. Numerical
answers on ideal family size were given by 90,93 and 98% of

women of reproductive ages in the three rounds of the NFHS carried

out in 1992-93,1998-99 and 2005-6 respectively. Over time,
awareness of contraception has become universal; 96,99, 99% in

three successive rounds of the NFHS respectively. (Kulkarni, 2011)

From sociological point of view, the resistance to the small family

norm is rooted in the traditional ideas governing marriage and family
in Hindu society. Marriage is a social obligation to a Hindu.

Its main purpose is to perpetuate the family traditions as well as

continue the group through progeny. In the four fold scheme of the
asarams that envisages the Hindu way of life, the life of a

house holder (grihasta), comes around the age of 20-25, since a boy is
initiated into a 12 year studentship (brahmacharya) between the ages
of 8-12. Our mores and folkways are attuned to this

ideal, which sets a high value on children and encourages a large

family. As regards a woman, maturity is supposed to be her first
concern, it is the ‘central fact’ in her life. Sterility is

inauspicious. Child is the ‘central fact’ in her life. A child brings

status to a woman since it bestows on her the role of mother besides
that of wife. A young girl is socialized in such a manner that she
not only considers childlessness inauspicious but positively looks
forward to establishing emotional links with a child of her own soon
after marriage. The feeling becomes intense in two

situations: One, where the general death rate is very high which
means widowhood is a quick possibility; and the other where
remarriage of a widow is impossible. It is possible that both the

situations co- exist. A childless woman if widowed, especially in

early life, will have to ruin her

life in loneliness without any object upon which her impulses can be
centered. A woman with

many children is therefore considered very fortunate. In keeping with

this attitude, failure to bring

forth a child soon after marriage becomes a serious domestic concern.

Ceremonies are performed

to invoke the Gods so that a girl may be saved from bareness. These
psychological and social

forces are reflected in the fact that the interval between the age of
consummation of marriage and

first pregnancy is generally low. It is, as we know, undesirable that a

fresh conception should
follow soon after a foetal outcome, but it happens. A foetal outcome
causes great physical and

mental strain, compared to a live birth. Physicians therefore advise

that a woman who has had anabortion or a miscarriage should not be
burdened with the load of a fresh pregnancy till her womb

regains strength. But very few people in India consult a qualified

physician and among those who

consult, only a few care to follow medical advice. It does not require
the professional advice of a

physician to know what must be the physical and mental state of a

woman who has lost her child

prematurely. Indeed common people know that it is this woman who

needs more rest than the one

who has delivered a full term baby. But what is practiced is different
from what is thought to be

desirable. A woman who bears a full term baby is looked after with
sympathy and care; she is

given compulsory rest and is often exempted to a great extend from

the drudgery of domestic work,

especially in the early days. Moreover cohabitation is often postponed

till her health is regained to
menstruate. (Pathare, 1966)

The mother of a boy is often by habit – given preferential treatment.

In most cultures a son is more

welcome than a daughter. Instances are abundant in Hindu mythology

to show the pride of place

of male children. Dhritrashtra had 100 children and they were all
males, the Kauravas. Kunti’s five

children were all males, the Pandavas. In ancient Sparta a father of

three or four sons received

rewards from the state. A son, expecially as the first born brings
prosperity to his parents. He is a

potential earner and therefore an asset to his parents. It is he who

saves them from hell. A son is

also needed to perform religious ceremonies like shrada, and by

continuing the family sradha (he)

becomes himself indispensable ; hence procreation was regarded as

the repayment of a debt to the

mames of a family. Common folk in Maharashtra have a saying;

“Even if a son kicks his mother

she would go to heaven, but a woman who has only daughters goes to
hell, taking 42 kulas with
her. (Pathare, 1966)

Professor Kapadia writes “the frustration which makes the young wife
reckless reveals the tyranny

of the husband and his kin… The husband can tyrannize his wife in
various ways and for various

reasons. If he does not like her or if he is attached to someone else, he

may force to end her life to

make way for a second marriage. Dowry and other related customs
provide a good handle to a

husband and his kin for humiliating, depressing and even beating the
woman. Oppression of the

daughter-in-law by her husband’s kin is frequent and can be

extremely vexatious. For the most

part the wife is motivated. It is she who is brought to the clinic and
told about birth control. It

would thus mean that she is somehow solely held responsible for all
the children that she bears.

Finally when a woman is persuaded to accept contraception, we face

the reality that is almost
always her husband who decides whether birth control has to be
adopted or not. As we know hiscooperation is of paramount
importance in putting the idea of contraception into practice. (Pathare,

R. 1966)

The issue of couple’s preferences for family size becomes irrelevant if

there is compulsion by the

state in the matter of fertility. In the past, high fertility was expected
by the society and the family

and couples were pressurized to adopt it. On the other hand fertility
outside marriage was socially
disapproved in many societies, and continues to be so in India. Similarly, in the Neo-
Malthusian
atmosphere of the 1960’s and 1970’s, some compulsion in birth control was suggested.
China did

adopt this route after 1970, and it was contemplated in the Indian programme as well,
though not

actually introduced. Yet there have been pressures on couples to adopt birth control often

sterilization. This practice culminated in the emergency period intensification, but after the

resultant backlash policy makers and workers have been wary of such steps. Not that some
amount

of pressure is not applied but overall this has not been strong after 1977. Further with
abandoning

of the target strategy by the Indian programme, such pressures have

eased. The decisions of
couples, thus, are primarily their own. Some influences of parents and
elderly do persist, but with
greater nucleus on, these have weakened. Over time, fertility behavior
moves from social and

family controls to deliberate individual control as noted by Srinivas

(1972)

Coale’s third point relates to the availability of efficient means of

contraception. This condition is

met quite well in India thanks to the government programme. The

family planning programme

made contraceptives availiable from many outlets, publicity was

given to these and the supply to

couples has been free.

Family planning contributed to fertility decline in a major way, from

the beginning, family

planning methods in the country were skewed towards sterilization of

woman. This was because

the government chose the cheaper action of sterilization rather the

more expensive one of teaching

the know-how of the use of spacing methods of contraception, despite

successive years of

economic growth.
Subramanya Swamy (1974) gives similar arguments for economic
and developmental reasons. He

says that the number of children desired by a couple are basically

conditioned by economic reasons

and therefore, with the development the couples decision to have less
number of children.

He further concludes that a sharp decline in the birth rate in India in

the future is inevitable, but it

will be autonomous and not induce by the impractical family

campaign of the Governmnet.Majumdar (1947) further states that
fertility in all the countries has been found to be negatively

correlated with social status, the poorer sections over produce, the
richer sections do not produce

their due share of progeny, so that there is a differential fertility. The

type of economy also

contributes to population growth. The tribes who take to agriculture

and settle in the plains have

larger family size and faster growth rate. The capitalistic economy by
starting big industries and

leading to urbanization led to rapid population growth in Europe

which was much faster than in
Asia at same time.

Mandelbaum (1974) says that women of poor families have more

children due to two reasons

 Because more of their children die in infancy, they need more

children to have one

surviving child.

 Since the children die in infancy, the lactation and ovulation

periods before becoming

fecund again are shorter.

Contrary to the belief that primitive tribal people used natural

methods for birth control, Baiga

tribe of Madhya Pradesh although a primitive tribe, are quite aware

about the terminal method as

well as spacing methods, but are unaware of natural methods like

Rhythm/Safe periods, abstinence

and withdrawal. Tubectomy is most preferred among the tribe, despite

tribal women having

90.33% illiteracy.(Jyoti Jharia, 2013)

Female sterilization is the world’s most popular contraceptive

method. In India, female
sterilization has been the mainstay of National Family Welfare
Program accounting for 84% of

prevalence among married women.(Neena Malhotra, 2007) Female

Sterilization is the most widely

known method of contraceptive in India. Education of mother is

significantly related with the total

number of living children in family. Thus, improving literacy level

may prove beneficial in

controlling population growth.(Bhawna Puwar, 2012)

Exposure to Family Planning messages differ by religion, in a study

among Hindu, Sikh and

Muslim women, Sikh women were more likely to be exposed to

Family Planning messages in

general and from almost all media sources, than Hindu or Muslim
women, 68.6% of Sikh women

say they have heard or seen a family planning message through

media, compared with 48.4% of

Muslim women and 46.6% of Hindu women. Muslim women are

more likely than Hindu women
to have heard or seen a Family Planning add on television whereas
Hindu women are more likelyto have had exposure from each of the
other media sources. The proportion of Muslim couples

having positive attitude towards Family Planning was lower than that
of Hindus and Sikh.(Kumar,

2011)

In rural India access to contraceptive services and supplies are not

primary limiting factors in

women’s use of reversible modern methods, a range of temporary

Family Planning methods are

available free of charge at Health centers. Women felt that when they
had no other option, they

found ways to obtain Medical Termination of Pregnancy (MTP) and

tubectomy services in nearby

district.(Mary Ann Kirkconnel, 2008)

Women in rural areas of Tamil Nadu are eager to accept sterilization,

this attitude is not an outcome

of their having become “modernized” leaving tradition behind, but is

a manifestation of their way

of using cultural categories as a resource to advance their goals which

is to gain prestige as it is
culturally defused. Cultural conception may be contested but they are
nevertheless challenged

according to certain widely accepted principles. Cultural norms

determine what can be contested

in the first place and how. In the matter of sterilization “culture” has
to do with conceptions of

personhood; what is to be a women. Moreover culture determines

power relations and the forms

of action that asymmetrically situated actor may choose for advancing

their goals. A young

mother’s decision to seek sterilization against the wishes of her

mother-in- law becomes

intelligible when a women’s life cycle and their sense of personhood

are taken into account. The

popularity of female sterilization in rural Andhra Pradesh is shown to

be intelligible if the symbolic

value of a young mother’s reproductive capacity is understood in

terms of familial power relations.

Through sterilization, young mothers can symbolically push their

influential mother-in-law
towards older age, thus increasing their own relative prestige and they
can strive to control the

ambiguity surrounding their reproductive function.(Saavala, 2000)

As early as 1956, cash incentive schemes were introduced in states

such as Tamil Nadu to increase

contraceptive use levels. It was argued that economic incentive may

induce illiterate rural couples

to use temporary methods, while couples may succumb to material

inducement to use temporary

method. The evaluation of this programme found that the contact

person component of the

programme has a significant effect on contraceptive use even after

three year of discontinuation of

the programme. Thus the usefulness of an interaction based approach

towards family planning

programme providing personal support along with education and

communication for achieveinglong term changes in contraceptive
behavior. Contact person approach has clear advantages over

incentive programme in the long run.(T.S. Sunil, 1999)

Sterilization regret among married women is independently associated

with the sex composition
of children, experience of child loss and region of residence. Women
who had been sterilized at

age 30 or older had lower odds of reporting sterilization regret than

women who had been sterilized

before 25 years of age.(Abhishekh Singh, 2012). Age less than 30

years was the strongest factor

of regret as women less than 30 years of age are 1.8 times more likely
to regret sterilization.

Women under 30 years need greater counseling as compared to older

women.(Neena Malhotra,

2007)

Women who had only daughters are more likely to regret sterilization
than women who had only

sons. Among women who had recent sterilization, the odds of

experiencing regret were higher

among women having only daughters than those having only sons.
And among women who had

undergone sterilization six or more years earlier, the odds of reporting

sterilization regret were

elevated among those who had only sons compared with those who
have combination of sons and
daughters. Indian women perceive that while sons may take care of
their economic needs,

daughters will look after them when they are old. Women who
experienced child loss were more

likely to regret sterilization than those who did not. Women residing
in high fertility regions were

significantly less likely to regret sterilization than women residing in

less fertility

regions.(Abhishekh Singh, 2012) Regret of post sterilization was less

when husbands were

involved in decision making. Women undergoing interval sterilization

were less likely to regret in

comparison to those who had the procedure concurrent with caesarean

section.(Neena Malhotra,

2007)

Unmet need for a family planning is defined as the proportion of

married women of reproductive

age who are not using any method but would likely to postpone the
next pregnancy. Thus unmet

need for family planning is a discrepancy between expressed fertility

goal and contraceptive
practice. The unmet need is because of little incentive for programme
manager or grass root health

workers to promote contraceptive methods for spacing.(Amit Kumar,

2013) Unmet need has a

considerable socio demographic significance; its root causes are still

largely unknown.

Demographic and social factors are assumed to be the underlying

determinants of unmet need for

family planning. Wealth index and unmet need of family planning

have a statistically highsignificance. Women in the poor and middle
wealth index groups have nearly 42-44% of higher

likelihood of unmet need as compared to women in the high wealth

index group. Women with

exposure to media have a positive impact on unmet need for family

planning.(Sherien Raj T, 2013)

The topic of family planning is usually confined to rural areas with

very few researchers focusing

on urban areas, (Seal, 2000) in Negotiating Intimacies: Sexualities,

Birth Control, and Poor

Households, the researcherchose to study this process in the context

of urban working class
women. The issue of birth control is often viewed as a raging
“problem” in rural India. But does it

always make sense to dichotomize problems of the rural and urban in

terms of residence?

Most demographic studies are also geared along these lines ignoring
in the process (Dyson and

Crook 1948) pointed out class differences within the urban and rural
populations. Also, continuous

focus on rural population problems and the low birth rate in urban
regions vis- a –vis rural India

often undermines the fact that urban slums and pavement dwellers
and the most marginalized socio

economic classes in urban India tend to have high fertility rates

comparable to high fertility groups

in the villages. (Michaelson 1981, Lebra et all 1984; Basu 1992).

Within a particular region (urban or rural) social class may affect

differentially the life chances of

different groups of women in terms of access to contraception,

income and so on. It is important

to learn about the birth control and sexual experience of urban slum-
dwelling women because of
what it reveals about women’s agency in this crucial, most important,
most intimate aspect of their

lives.(Seal, 2000)

Woman are not in control of their own fertility- it is more likely that
men are – and so the resulting

‘inability’ to influence one of the most fundamental aspects of

biological function can have

profound effects on both physical and mental health (Doyal,1995).

India’s National Family Planning programme launched in 1951 has

been largely female centric in

that women have to take the major responsibility for effective birth
control use. Women, therefore

are considered reproductive agents, who, if made to accept birth

control, can assuage the threat of

India’s growing numbers.

This pattern is in line with the global trend in development policies

which offered an interesting

anomaly to poor women in the Third world since the fifties.

Female sterilization has been the pervasive and growing form of birth
control in India. This is so
despite criticism from scholars and practitioners regarding its relative
inefficacy in relation to otherbirth control method. First, in
comparison to vasectomy, the male sterilization method, female

sterilization whether it is tubectomy or laproscopic sterilization is

more expensive and hazardous

to health. Second, since it is terminal and irreversible it is not the most

effective method choice in

a society where the survival rate of children is still low.

For instance, a women in the sample lost her second child after having
undergone sterilization.

She regretted her decision and constantly blamed herself. Thirdly,

sterilization becomes an option

for woman, only after they has a specified number of children.

Consequently, it prevents birth

spacing and leads to deterioration of mother’s health and population

growth. A female centric

contraceptive culture, thus, places the onus of contraception on

women without being sensitized

to their life situations.

Besides underscoring the ‘insensitivity’ of family planning

programmes, studies have questioned
the effectiveness of women centered family planning practices in
highly patriarchal milieus where

women’s low family status may be a deterrent to fertility control.

(Seal, A. 2000).

Policy planners often fail to consider these complexities while

implementing their stratigies. For

instance, the KAP survey showed that on the average, the number of
children born by Indian

women was much greater than the women’s desired family size.
(Seal, A. 2000).

Policy makers ascribed this difference between the desired and actual
family size to women’s lack

of access to effective contraceptive. On the basis of this

understanding, the markets in less

developed countries were swamped with contraceptives for women’s

use. In the long run,

however, fertility rates remained high because, in fact, there was and
is more to the issue than mere

access. (Seal, A. 2000).

Overall, then, the preference of the Indian Family Planning

Programme draws two main types of
criticism. One, adhering to the modernization school, critiques the
centrist bureaucratic model of

the programme as an expression of a tradition-bound soft state unable

to adapt to the efficacy ethic

of contemporary times. The other source of criticism, Marxist in its

proclivities, asserts that much

more than the operation of the programme itself, it is its quality that
needs restructuring. These

critics contend that the failure of the family planning programme is

due in large part to its anti-

natal ideology which professes to ‘control’ birth and consequently

imposes governmental policies

on people instead of giving them viable chance to determine their

reproductive behavior. Indeed,

the Marxist critics suggest that the programme only pays lip services
to providing a variety of

methods. In reality, choices are restricted by inadequate facilities and

information, preventingusage of reversible methods, specifically
terminal, irreversible methods by the government. (Seal,

A. 2000).
The evaluation of the family planning programme performance,
however, is not within our

purview. Rather, the aim has been to furnish a general impression

about constraint faced by the

women in getting the information about and services for birth control
methods offered by the

programme. Within that framework it will suffice to say that these

women are also effected and

constrained by the dynamics of extant family planning services.

Additionally, the programme’s

orientation serve to further exacerbate the gender politics in

contraceptive usage. (Seal, A. 2000).

Women’s agency in the negotiation of intimacy seems to be severely

constrained by the limits of

their physical environment and compounded by the gender dynamics

of spousal roles.

One of the primary concerns in this research was to focus on

processes related to reproduction

instead of outcomes of reproduction per se. Examining only

quantifiable elements like numbers of
children or use of birth control does not necessarily render a full
picture of women’s reproductive

decisions take shape. (Seal, A. 2000).

Development policies pertaining to population control are, for the

most part blind to the intricacies

of poor women’s circumstances. Family Planning Programme tends to

objectify women as

‘clients’. In the process, women’s daily struggle for survival as wives,

mothers, sexual partners,

income-earners and home makers and so on are over looked. (Seal, A.

2000).

Consequently, family planning programmes introduce and popularize

female-centered, terminal

and outcome-oriented birth control methods which do not ultimately

help to alleviate the situation

of women or contain population growth. Rather, in some instances,

they serve to perpetuate a

women’s gender subordination. That is why a focus on processes,

rather than outcome is crucial.

Two areas elemental in processes leading to reproductive outcomes

were explored. These relate to
women’s sexual and birth control negotiations with their husbands.

Conjugal dynamics during intercourse and negotiations pertaining to

birth control suggest that

women’s birth control choices (or lack there of) may not necessarily
reflect decisions of a ‘couple’.

In fact patterns of differential conjugal dynamics during intercourse

questions certain assumptions

of mainstream demographic research. The latter postulates data

collection on ovulation, fecundity,

coital frequency and risk of conception (for couples without

contraceptives) for family planning

programme management. (Seal, A. 2000).Treating these factors as

objective biological and physical phenomenon. The presumption is
that

knowledge of ovulation intervals, fecund periods, frequency of coitus,

unprotected eligible couples

(wife and husband within 15-45 years) will adequately help shape
planned contraceptive

intervention through family planning programme to limit family size.

(Seal, A. 2000).

Uttar Pradesh Perspective

Various theories developed in the past relating to the determinants of
contraceptive acceptance

indicate that change in the world wide level of contraceptive use is a

dramatic example of the

diffusion of an innovation. The steps leading to a decision to adopt a

contraceptive method are

described in a number of socio-psychological models which generally

include the stages of

becoming aware, becoming informed evaluating, making a trial and

finally adopting the

innovation. The theory of diffusion and adoption shows that

adaptation of a method rises sharply

as information is diffused rapidly through many channels. (Rastogy,

2017)

Applying the notion of agency to their subjects of enquiry, the authors

find that neither

the Jat nor the Sheikh women showed any evidence of being active
agents in controlling

their own fertility.(Jeffery, 1997)

The demographic approach to empowering women consists of putting

them through
’modem’ institutions, the most important being formal schooling. An
underlying assumption

is that these institutions are taken to mean the same everywhere and
evoke the same

attitudes from those whose lives they affect (Jeffery, 1997). Exploring
the place of schooling in

women’s lives in the two villages, the authors note that the Muslim
girls of Qaziwala must

negotiate a difficult terrain (spatially and otherwise), to access any

form of education. The

location of schools disadvantages the minority/subordinate groups and

makes for low use

of these facilities. This in turn reduced their potential presence in

junior and higher secondary

schools, since the latter were situated in areas dominated by the

majority community.

The madrasa schools were really no alternative since they excluded all
girls who attained

puberty. The record of Jat girls’ attendance in schools was only

marginally better. However,
overall, the key advantage educated girls were considered to enjoy,
and the reason most

women gave for wanting their daughters to be schooled, was

enhancement of their marriage

chances; it was feared that unschooled girls would be hard to marry

into a good house.

From a demographic perspective, the authors found that: (a) the most
clear differencebetween the schooled and unschooled women was in
the choice of contraceptive method;

(b) there was no evidence to suggest that schooled women have better
relationships in their

households than unschooled women; (c) female schooling in Nangal

was linked to low

fertility among Jats ’less because independent-minded women were

insisting, against the

views of their in-laws, that they wanted small families and more
because their in-laws had

already reached that conclusion’ (Jeffery, 1997).

Rejecting the use of religion as an explanatory variable in

understanding demographic
change, the authors argue that the fertility of the Sheikhs can be
understood much more in

terms of their marginalised position as a minority group within Indian

society rather than

as a response to any ’essential’ feature of Islam. Jats seem to have

controlled their fertility

better mainly because of ’specific kinship practices that have affected

inheritance patterns

for at least 100 years, and [their] local dominance at the district level
(and more widely)

that has allowed them to manipulate political resources (schools,

clinics, employment and

advancements) in their own interests’ (Jeffery, 1997).

Thus, the explanation for the differential demographic regimes of the

Sheikhs and Jats has

to be sought not in the intrinsic messages of religion per se but in the

intersections between

religion and political economy-an economy where the Jats of Nangal

experienced a different

environment with far less risk than that of the Sheikhs of Qaziwala.
This enmeshing
of different factors to produce a specific demographic outcome has
led the authors to question

the ’Cairo consensus’, namely, that girls’ schooling leads to

empowerment, and that

schooling or empowerment will inevitably lead to lower fertility.

(Jeffery, 1997)

All past and present data do indeed find that the highest fertility rates
are to be found among the

poor, the rural and the less educated. In the latest 2015-16 round of
NFHS, the total fertility rate

(TFR) for village India was 2.4 compared to 1.8 for urban India; 3.2
for the lowest wealth quintile

and 1.5 for the highest wealth quintile. 2.26 for scheduled castes
compared to 1.93 for non

SC/ST/OBC groups. This means that our efforts to impose a two-child

norm in this country will

disproportionately target the rural, the poor, the less educated and the
socially most disadvantaged.

It becomes highly important to acknowledge the precariousness of

their lives, high poverty,
illiteracy and lack of opportunity that tilts their cost-benefit calculus
in the direction of children

being the source of security – to protect them in times of crises, in old

age, in conflict and in natural

disaster (Basu A. M., 2020)Lucknow Perspective

The study conducted in the urban slums of Lucknow (Mohan, 2020).

The perception of married

males regarding family planning was accessed. It was observed that

female sterilization technique

was considered as the most effective terminal method of family

planning by the respondents. Only

30.46% of the respondents (or their spouses) were currently utilizing

any family planning method.

The reason of low utilization could be due to low knowledge about

different methods of birth

control especially NSV. Majority of the respondents perceived socio-

cultural barriers as the most

important cause for low acceptance of NSV. Majority (35.9%) of the

respondents had the

perception that NSV leads to decrease in physical strength while 35%

stated that due to the
availability of other family planning methods NSV is less needed.
Educational status of the

respondent was found to be the most important predictor for

perceiving the socio-cultural barriers.

These myths and misconceptions could be removed only by educating

the community regarding

family planning methods especially NSV. The findings of this study

will help the policy makers

to formulate the plan and policies to increase the use of family

planning methods especially NSV,

which will ultimately help to reduce the problem of population

growth

Although, India has achieved a great success in the Family Planning

Program and has managed to

reduce the TFR from 5.9 in 1960 to 2.3 in 2016 (NHFS 2016) despite
this, it faces a lot of

shortcomings. The programme still limits itself to population

stabalisation and not much emphasis

is given on overall well being of the individual. Fortunately, few

changes can be seen in the
Governmnet’s policy where role of both the partners in planning for a
family has been addressed.

It has been observed that the website of Family Planning Programme

https://humdo.nhp.gov.in/

has undergone a paradigm shift from focusing “Hum Do Humare Do”

to “Jodi Zimmedar Jo Plan

Kare Pariwar” emphasizing the role of both the partners in planning

for a family. Moreover, the

logo of the programme too has undergone a transformation, where

there is a caricature of one child

with a couple without indicating the gender of the child. All these are
few positive steps taken by

the Governmnet in promoting birth control. Another area where focus

needs to be shifted is the

overall reproductive career of the couple. The focus is usually in tune

with the Neo Malthusian

thought of reducing the population but the need of the hour is to

include measures which would

help the couple to initiate their reproductive career. The state should
start fertility clinics in all the
public hospitals so as to make fertility choices available to masses at a
subsidized price. Barring

few Governmnet hospitals, fertility treatment or Assisted

Reproductive Techniques (ART) aresolely in the hands of private
clinics which charge exorbitantly and hence limits its services only

to people belonging to the upper section of the society.

Given this overall scenario of health among women, the package of

reproductive health appears to

miss the woods for the trees. It also constitutes a waste of resources
that ought to be used for

strengthening primary health care. We have today in our country a

dominant ideology that seeks

to reinforce a dark tradition of Indian womanhood: that of sacrifice.

Macroeconomic reforms,

which are eroding the necessary conditions for women’s health, are
complementing this. As is,

perhaps, health policy, with its focus on women as merely

reproductive beings.(Rao M. , Family

Planning Programme : Paradigm Shift in strategy, 2000)

RESEARCH QUESTIONS
India was the first country in the world to have launched a National
Programme for Family

Planning in 1952. With its historic initiation in 1952, the Family

Planning Programme has

undergone transformation in terms of policy and actual programme

implementation. There

occurred a gradual shift from clinical approach to the reproductive

child health approach and

further, the National Population Policy (NPP) in 2000 brought a

holistic and a target free approach

which helped in the reduction of fertility. Over the years, the

programme has been expanded to

reach every nook and corner of the country and has penetrated the
Primary Health Centres and Sub

Centres in rural areas, Urban Family Welfare Centers and Post-

partum Centers in the urban areas.

Technological advances, improved quality and coverage for

healthcare have resulted in a rapid fall

in the Crude Birth Rate (CBR), Total Fertility Rate (TFR) and growth
rate (2011 Census showed
the steepest decline in the decadal growth rate.) The objectives,
strategies and activities of the

Family Planning division are designed and operate towards achieving

the family welfare goals and

objectives stated in various policy documents (NPP: National

Population Policy 2000, NHP:

National Health Policy 2002 and NRHM: National Rural Health

Mission) and to honour the

commitments of the Government of India (including ICPD:

International Conference on

Population and Development, MDG: Millennium Development

Goals, Sustainable Development

Goals-SDG, FP-2020 summit and others). (NHM,2018)

The proposed study looks at the knowledge, attitudes and practice of

family planning programme

along with the role of gynecologists in disseminating and providing

the services of family planningamong young married couples of
Lucknow.. It is interested specifically in finding answers to the

following general questions:

-To what extent are men participate in accepting Family Planning?

- What is the role of gynecologists in providing family planning
services?

- What are the new trends in accepting family planning practices

amongst young married couples

of Lucknow?

Objectives of the study

The study has been designed to explore the socio-economic,

demographic and cultural

determinants of family planning acceptance among different segments

of young married

population of Uttar Pradesh, Lucknow with the major objectives as

described below –

 To understand aspiration towards family planning.

 To analyze the role of “men” in accepting family planning practices

 To observe the role of “gynecologists” in imparting family

planning knowledge and

services”

Universe and selection of the areas of the study.

Keeping in view the paucity of time and limited resources, two
important medical institutions were

selected where young married women between the reproductive age

group of 15-49 years could

easily be found. The universe of the study remains Lucknow (urban)

city, Uttar Pradesh, India.

Under this universe these two medical institution, one located in

Rajendra Nagar and the other

located in Chowk were selected for this study.

Tools and techniques for Data Collection

The study is mainly based on the data collected through interviews

with the selected 328 currently

married women in the reproductive age group of 15-49 years of age.

These interviews were

performed through structured interview schedules. The schedule

covers socio- economic and

demographic details, knowledge and attitude towards family planning

methods, decision making

and aspiration towards family planning and reproductive healthData

was obtained through various sources. For secondary sources- census
reports, National
Family Health Survey etc.

Primary Data was collected through in depth interviews, Focused

group discussions and

observation method as well as discussions with medical practitioners

was done.

Sociologists combining several methods in a single piece of research,

using each to supplement

and check on the other, this process is known as triangulation.

Norman Denzin (1970) actually

distinguished four types of triangulation. Data triangulation occurs

when data are collected at

different times and perhaps uses different sampling strategies within

the same research project.

The other forms of triangulation are Investigator triangulation,

Theoretical triangulation and

Methodological triangulation.

Sample Size

As mentioned above, Lucknow district has been selected for the

present study. Within Lucknow,
two hospitals namely, Rajendra Nagar hospital, a private hospital run
by a popular gynecologist,

Dr. Sunita Chandra and Queen Mary Hospital, a part of King George
Medical College were

selected for the study. Based on their approachability and huge

footfalls, they were selected.

The sample size of 328 respondents, combined from both the above
institute were selected based

on purposive sampling.

The sample size of 328 was decided based on a formula –

The sample size (n) is calculated according to the formula: n = [z2 * p

* (1 - p) / e2] / [1 + (z2 *

p * (1 - p) / (e2 * N))]

Here, N = 2198 was decided based on the past six months record of
the clinic, where 2198

married women aged 15-49 years visited the clinic.

Where: z = 1.96 for a confidence level (α) of 95%, p = proportion

(expressed as a decimal), N =

population size, e = margin of error.

z = 1.96, p = 0.5, N = 2198, e = 0.05n = [1.962 * 0.5 * (1 - 0.5) /
0.052] / [1 + (1.962 * 0.5 * (1 - 0.5) / (0.052 * 2198))]

n = 384.16 / 1.1748 = 327.007

n ≈ 328

The sample size (with finite population correction) is equal to 328

This means 328 or more measurements/surveys are needed to have a

confidence level of 95% that

the real value is within ±5% of the measured/surveyed value.

Methods for Data Analysis

This is an exploratory study, qualitative in nature and data obtained

for this study is analyzed using

statistical tools and content analysis. The nine chapters gives a vivid
description of the field

observation, quantitative results of data collected through interview

schedule. The major primary

sources were interview schedules, non-participant observation and

discussion with gynecologists.

Further, secondary data of National Family Health Survey IV were

used to validate the findings

of the study.
The data collected through the field work were arranged, coded and
tabulated according to

predetermined coding and tabulation plans.

Organization of the chapters.

This study contains nine chapters. The first chapter Introduction is

introductory in nature and

introduces the topic of research i.e. “family planning” in detail and

also describes the methodology

used to conduct this research, it contains the research design,

sampling method, tools used to data

collection etc. The second chapter “The Setting :Family Planning

Programme In India” is a

detailed chapter which explains comprehensively the accomplishment

of Ministry of Health and

Family Welfare with regard to Family Planning Programme in the

recent past. It also elaborates

the achievement of various bodies like Population Fund of India

(PFI), Population Council etc.The third chapter i.e. “Reflections from
the field” as the name suggest, this chapter is based on

the observation made during the field visits, it describes the physical
infrastructure of the field
along with other observations made all the review of the studies
which have been done on this

topic before. The fourth chapter “Understanding acceptance of

family planning methods

through the lens of Gynecologists”, this chapter consists of the

interaction made with doctors

and they are the primary health providers and in urban area women
consult them for all their needs

regarding delaying, spacing or ending their reproductive career. The

fifth chapter “Socio

Economic and Demographic details”describes the socio economic

background of the

respondents. The sixth chapter “Knowledge and attitude towards

family planning methods”

analyses the level of knowledge and the respondent’s attitude towards

family planning. The

seventh chapter “Decision making and aspiration towards family

planning methods” gives an

elaborate description of the respondent’s agency in making decisions

and their aspiration towards
having a family. The eighth chapter “Reproductive Health”discusses
the condition and

knowledge of reproductive health as understood by the respondent.

The ninth chapter “Findings

and Conclusion” lists down the major findings of the study and
provide provides a conclusion for the entire research.

Chapter 2

The Setting

India – Family Planning Programme and practices

History of Family Planning in India

The history of Family Planning in India can be traced back in the 1920’s when a group of
Indian

Intellectuals and civil servants visited England for higher education and for training for posts
in

Indian Civil Services. Over there, they were exposed to Malthusian theories and to the

establishment of Neo-Malthusian league in England and elsewhere in Europe. They became

aware of the positive checks likely to operate on a population increasing beyond its means of
subsistence. The Indians who visited England became keenly committed to the idea of birth

control as a means of regulating population growth and formed the Neo Malthusian League in

Madras in July 1929 wherein they started the Madras Birth Control Bulletin.

Neo Malthusian Leagues were being formed in many other cities including Bombay
(Mumbai)

and Poona (Pune). But, a strong action on birth control seems to have started in Bombay, not
as a

means of regulating the population, but as a method of liberating women from the wheels of

childbearing, preventing unwanted births and reducing the hazards to the life and health of

pregnant women who were willing to expose themselves to the cruel and primitive methods
of

induced abortions to avoid additional children.(Srinivasan, 2001)

The unsung hero of Family Planning Programme in India is a man who is not from a social

science or medical science background but from mathematics background. Professor R.D.
Karve

a lecturer in Mathematics in a Bombay College made his life mission to improve the status of

women by advocating widow remarriage and adopting artificial methods of family planning.
He

was completely devoted to this cause and published several books in English and in Marathi
on

birth control. Professor Karve is responsible for the huge improvement in the status of
women in

Maharashtra.

However, the fruits of the efforts made by Neo- Malthusian league in Madras and Professor
Karve in Maharashtra could not reach the masses as Mahatma Gandhi, father of the nation
and a

highly influential public figure of those days completely opposed to the idea of
introducingartificial methods of birth control. He argued that sexual abstinence was the only
ethical mean of

birth control. He advocated celibacy too. Gandhi regarded sexual relationship between
couples

only for the divine act of procreation.

The British rulers too, were not keen in advocating birth control practices in India as they had

adopted a policy of non-interference in Indian social matters, as far as possible, did not take
any

measures which could be considered as an intrusion in Indian traditions, customs, values and

beliefs.

A view which was prevalent among the followers of Gandhian ideology that using artificial

family planning methods especially at a regular basis, is immoral and unethical pervades the

psyche of a considerable section of the Indian society. The hesitancy seems to be more in the
use

of spacing methods that require repetitive action on the part of the couple than adoption of a
one-

time permanent method such as sterilization. This view is of utmost importance as the Indian

data of Family Planning methods suggest that the highest number of users are adopting
female

sterilizations as the only means of ending reproductive career. As 37.3% of the respondents

accepted female sterilization as a method of family planning (NHFS 2016).

Despite of the unwilling attitude of British rulers and of Mahatma Gandhi, the intellectuals
lead

by the Neo Malthusian league and the convincing argument of Professor Karve for protecting
the

health of women, the Governmnet of princely state of Mysore under the leadership of the

Maharaja, officially sanctioned the opening of family planning clinics in 1930. Only two
clinics

started immediately, one at Vanivilas Hospital, Bangalore and the second one at Cheluvamba

Hospital in Mysore. (Srinivasan, 2001)

This clearly shows that awareness regarding birth control was made available much earlier in

southern states of India like, Tamil Nadu, Karnataka etc. as compared to northern states.
Hence

the figures bring out the striking contrast between north and south. Total Fertility Rate of
Tamil

Nadu being 1.6, Karnataka 1.8 and 1.7 of Kerala and Andhra Pradesh respectively and that of

Uttar Pradesh being 3.1 and Bihar 3.3 children per woman (NFHS 2016). The success of our

National Population Policy will lie in our ability to bridge the gap between north and south.

(Bose, 2000)

The Family Planning Association of India was formed in 1949 in Bombay, Professor Karve

being one of its founding members. In 1951 India included family planning in the first five
yearplan and since then it’s been one of the major Public programmes sponsored by
Government of

India. In 1977, it was renamed as Family Welfare instead of Family Planning as it expanded
its
services and later it was adopted under the Reproductive and Child Health services, Ministry
of

Health.

India was the first country in the world to have launched a National Programme for Family

Planning in 1952. With its historic initiation in 1952, the Family Planning Programme has

undergone transformation in terms of policy and actual programme implementation. There

occurred a gradual shift from clinical approach to the reproductive child health approach and

further, the National Population Policy (NPP) in 2000 brought a holistic and a target free

approach which helped in the reduction of fertility. Over the years, the programme has been

expanded to reach every nook and corner of the country and has penetrated the Primary
Health

Centres and Sub Centres in rural areas, Urban Family Welfare Centers and Post-partum
Centers

in the urban areas. Technological advances, improved quality and coverage for healthcare
have

resulted in a rapid fall in the Crude Birth Rate (CBR), Total Fertility Rate (TFR) and growth
rate

(2011 Census showed the steepest decline in the decadal growth rate.) The objectives,
strategies

and activities of the Family Planning division are designed and operate towards achieving the

family welfare goals and objectives stated in various policy documents (NPP: National

Population Policy 2000, NHP: National Health Policy 2002 and NRHM: National Rural
Health

Mission) and to honour the commitments of the Government of India (including ICPD:
International Conference on Population and Development, MDG: Millennium Development

Goals, Sustainable Development Goals-SDG, FP-2020 summit and others).

Human beings have always made attempt to plan their families. The practices adopted are
rooted

in their beliefs, social philosophy, social situation and perceived needs. Methods to control
birth

and to induce abortion were there in Ancient India. Use of herbs by tribal communities in
India

includes those with properties to prevent conception in female.

As on 1st March, 2011 India’s population stood at 1.21 billion comprising of 623.72

million (51.54%) males and 586.47 million (48.46%) females. India, which accounts for

world’s 17.5 percent population, is the second most populous country in the world next only

to China (19.4%). ( Family Welfare Statistics in India, 2011)

India set the goal of population stabilization in the very first Five- Year Plan (1951-1956)
which

was formulated soon after India attained independence in 1947. In spite of completing 11
FiveYear Plans, the goal of population stabilization remains distant. The population continues
to grow

at a faster rate than anticipated by policy makers. India is the first country in the world to
officially

promote family planning in 1952 with the expressed desire for a lower rate of population
growth

and stabilize the population at a level consistent with the requirements of the national
economy.
The ground work for the policy was worked out between1931 and 1951.Family Planning is
not

merely the use of contraception for limited family size. Rather it is a mode of planning family
size

as per requirement of time and space. According to WHO Expert Committee (1971) ‘the
family

planning is a way of thinking and living that is adopted voluntarily, upon the basis of
knowledge,

attitude and responsible decisions by individuals and couples, in order to promote the health
and

welfare of the family group and thus contribute effectively to the social development of a
country.’

CONTEMPORARY STATUS OF FAMILY PLANNING PROGRAMME

Year 2010-11 recorded 34.9 million total family planning acceptors at national level.
Comprising

of 5.0 million Sterilizations, 5.6 million IUD insertions, 16.0 million condom usersand 8.3
million

O.P. users as against 35.6 million total family planning acceptors in 2009-10.

The proportion of tubectomy operations to total sterilizations was 95.6 percent in 2010-11 A
total

of 50.09 Lakh sterilizations were performed in the country during 2010-11.

As a measure to encourage people to adopt permanent method of Family Planning, Ministry

of

Health and Family Welfare has been implementing a Centrally Sponsored Scheme since 1981
to
compensate the acceptors of sterilization for the loss of wages for the day on which he/she
attended

the medical facility for undergoing sterilization. This compensation or monetary incentive is
Rs.

1500 for acceptors of Vasectomy and Rs. 1000 for acceptors of tubectomy in High Focus
States.i

In India, female 4tabilizing4n is being done by Minilap tubectomy and Laparoscopic tubal
ligation.

Though both methods are equally safe and effective, a trained Gynaecologist or surgeon is
required

for lap. Sterilisation, whereas minilap can be performed by a trained MBBS doctor. It has
been

also observed that states providing minilap tubectomy on a regular basis throughout the year
have

achieved replacement fertility levels, states like Kerala, Karnataka, Tamil Nadu and Andhra

Pradesh. In order to meet the high unmet need in female strilisation, it is imperative to have
trained

service provider for minilap tubectomy at the peripheral health facilities so as to provide
regular

fixed day services throughout the year.An estimated 75% of all contraceptive users (84% of
those who use a modern contraceptive

method) in India rely on female sterilization, while vasectomy is used by just 2% of

contracepting

couplesii. For many women, female sterilization is the first and the only contraceptive method
they
use. The median age at sterilization is 25.7 years; this, however, varies from a low of 23.6
years in

Andhra Pradesh in southern India to 30.5 years in Manipur in eastern India

. In 2001, an estimated 15.8% of currently-married Indian women of reproductive age had an

unmet need for contraception, i.e. they desired to space or limit pregnancies but were not
using

contraceptive methods to do so. The contraceptive prevalence rate of reversible methods has

remained low; while supplies of reversible contraceptives are available free of charge to
women

in some areas, demand has been weak.

The sterilization operations, mainly among females were being performed in some hospitals
in

India for a long time. The sub- committee of Health Panel Planning Commission, in April
1951

recommended provision of facilities for sterilization, along with advice on contraceptive on

medical, social and economic grounds. The first Five Year Plan document while launching
the

policy on family planning did not refer to surgical methods of birth control on social and
economic

grounds. In 1958, Tamil Nadu took the initiative to introduce sterilization operations in males
and

females as their official policy, on the basis of the Planning Commissions Health Panel Sub

Committee recommendations and watched the reaction; Maharashtra soon followed Tamil
Nadu
policy. Gradually, the sterilization operation facility was introduced on increasing scales as
one of

the important methods of birth control in almost all states.

The method, for all practical purposes being irreversible it was considered that for ensuring
marital

harmony both husband and wife should consult each other before deciding the adoption of

sterilization method. The regulatory measures, therefore, included written consent of both
husband

and wife. Ministry of Health letter of 20th April 1960 offering 100% central assistance for

sterilization facilities specifically stated that “Sterilization should be voluntary with consent
of the

couple and following consideration should be taken into account in effecting sterilization.

a) The number of living children and their sex.

b) Ages of husband and wife.

c) Socio-economic prospects of the couple.

d) Emotional and mental attitude.

e) Their preparedness for permanent birth limitation Family Planning / Family Welfare
Programme (FWP) by the Government of India

This is a centrally sponsored programme, for which 100% help is provided by the Central to all the
states

of the country. The main strategies for the successful implementation of the FWP programme are:

FWP is integrated with other health services.

Emphasis is in the rural areas

Adopting terminal methods to create a gap between the birth of 2 children

Door-to-door campaigns to encourage families to accept the small family norm

Encouraging education for both boys and girls

Encouragement of breast feeding

Proper marriageable adopted (21 years for men and 18 years for women)

Minimum Needs Programme launched to raise the standard of living of the people.

Monetary incentives given to poor people to adopt family planning measures.

Creating widespread awareness of family planning through television, radio, news papers,

puppet shows etc.

Family planning is not confined to only birth control or contraception. It is important as whole for the

improvement of the family’s economic condition and for better health of the mother and her children.

First of all, family planning highlights the importance of spacing births, at least 2 years apart from one

another. According to medical science, giving birth within a gap of more than 5 years or less than 2
years

has a seriously affect the health of both the mother and the child.

Giving birth involves costs and with an increase in the number of children in a family, more medical
costs

of pregnancy and birth are involved, along with incurring high costs of bringing up and rearing the

children. It’s the duty of the parents to provide food, clothing, shelter, education to their children.
Family

planning, if adopted, has an effective impact on stabilizing the financial condition of any family.

The initiatives taken by the Government in implementing the Family Planning Programme have

significant impact on the country as a whole. India was the first country in the world to establish a

government family planning program way back in 1952. According to 2011 Family Welfare
Programme,
some major achievements are as follows:

 Awareness of one or more methods of contraception.

 Increase in contraceptives use over the years. Knowledge of female sterilization, which is
considered to the most safest and popular method of

modern family planning.

 Increase in the use of condoms.

 Increased knowledge about contraceptive pills.

 Fertility rate low among educated women.

 Fertility rate low among higher income groups.

Year 2010-11 recorded 34.9 million total family planning acceptors at national level. Comprising of
5.0

million Sterilizations, 5.6 million IUD insertions, 16.0 million condom users and 8.3 million O.P.
users as

against 35.6 million total family planning acceptors in 2009-10.

The proportion of tubectomy operations to total sterilizations was 95.6 percent in 2010-11 A total of

50.09 Lakh sterilizations were performed in the country during 2010-11.

As a measure to encourage people to adopt permanent method of Family Planning, Ministry

of

Health and Family Welfare has been implementing a Centrally Sponsored Scheme since 1981
to

compensate the acceptors of sterilization for the loss of wages for the day on which he/she
attended

the medical facility for undergoing sterilization. This compensation or monetary incentive is
Rs.
1500 for acceptors of Vasectomy and Rs. 1000 for acceptors of tubectomy in High Focus
States.

CURRENT FAMILY PLANNING EFFORTS

Family planning has undergone a paradigm shift and emerged as one of the interventions to
reduce

maternal and infant mortalities and morbidities. It is well-established that the states with high

contraceptive prevalence rate have lower maternal and infant mortalities. Greater investments
in

family planning can thus help mitigate the impact of high population growth by helping
women

achieve the desired family size and avoid unintended and mistimed pregnancies. Further,

contraceptive use can prevent recourse to induced abortion and eliminate most of these
deaths.

Studies show that if the current unmet need for family planning could be fulfilled over the
next 5

years, we can avert 35,000 maternal deaths, 1.2 million infant death, save more than Rs. 4450

crores and saveRs. 6500 crores, if safe abortion services are coupled with increased family

planning services. This strategic direction is the guiding principle in implementation of

family

planning programme in future.Contraceptive services under the National Family Welfare

Programme

The methods available currently in India may be broadly divided into two categories, spacing

methods and permanent methods. There is another method (emergency contraceptive pill) to
be

used in cases of emergency.

Spacing Methods:- These are the reversible methods of contraception to be used by couples
who

wish to have children in future. These include: A. Oral Contraceptive Pills (OCPs)

These are hormonal pills which have to be taken by a woman, preferably at a fixed time,
daily.

The strip also contains additional placebo/iron pills to be consumed during the hormonal pill
free

days. The method may be used by majority of women after screening by a trained provider.

At present, there is a scheme for delivery of OCPs at the doorstep of beneficiaries by ASHA
with

a minimal charge. The brand “MALA-N” is available free of cost at all public healthcare
facilities.

Condoms

These are the barrier methods of contraception which offer the dual protection of preventing

unwanted pregnancies as well as transmission of Reproductive Transmitted

Infection/Sexually

Transmitted Infection (RTI/STI) including HIV. The brand “Nirodh” is available free of cost
at

government health facilities and supplied at the doorstep by the ASHAs for minimal cost.

Intra-Uterine Contraceptive Devices (IUCD)

Copper containing IUCDs are a highly effective method for long term birth spacing.

Should not be used by women with uterine anomalies or women with active PID or those
who are

at increased risk of STI/RTI (women with multiple partners).

The acceptor needs to return for follow up visit after 1, 3 and 6 months of IUCD insertion as
the

expulsion rate is highest in this duration.

Two types: o Cu IUCD 380A (10 yrs) o Cu IUCD 375 (5 yrs)

New approach of method delivery- postpartum IUCD insertion by specially trained providers
to

tap the opportunities offered by institutional deliveries.

Permanent Methods:- These methods may be adopted by any member of the couple and are

generally considered irreversible.

Female Sterilisation

Two techniques:Minilap: Minilaparotomy involves making a small incision in the abdomen.

The fallopian tubes

are brought to the incision to be cut or blocked. Can be performed by a trained MBBS doctor.

Laparoscopic: Laparoscopy involves inserting a long thin tube with a lens in it into the
abdomen

through a small incision. This laparoscope enables the doctor to see and block or cut the
fallopian

tubes in the abdomen. Can be done only by trained and certified MBBS doctor or specialist.

Male Sterilisation

Through a puncture or small incision in the scrotum, the provider locates each of the 2 tubes
that

carries sperm to the penis (vas deferens) and cuts or blocks it by cutting and tying it closed or
by
applying heat or electricity (cautery). The procedure is performed by MBBS doctors trained
in

these. However, the couple needs to use an alternative method of contraception for first three

months after sterilization till no sperms are detected in semen.

Two techniques being used in India:

o Conventional

o Non- Scalpel Vasectomy – no incision, only puncture and hence no stitches

Emergency Contraceptive Pill (ECP)

To be consumed in cases of emergency arising out of unplanned/unprotected intercourse and

The pill should be consumed within 72 hours of the sexual act and should never be
considered a

replacement for a regular contraceptive.

Other Commodities - Pregnancy Testing Kits (PTKs)

Helps to detect pregnancy as early as one week after the missed period, thus providing an
early

opportunity for medical termination of pregnancy, thus saving lives lost to unsafe abortions
and

These are available at the sub-centre level and also carried by ASHA.

Service Delivery Points

All the spacing methods, viz. IUCDs, Oral Contraceptive Pills(OCPs) and Condoms are
available

at the public health facilities beginning from the sub-centre level. Additionally, OCPs
Condoms
and Emergency Contraceptive Pills (since are not skill based services) are available at the
village

level also through trained ASHAsPermanent methods are generally available at primary
health centre level or above. They are

provided by MBBS doctors who have been trained to provide these services. Laparoscopic

sterilization is being offered at CHCs and above level by a specialist gynaecologist/surgeon

only.

The Salient features of the Family Planning Programme

On-going interventions:

More emphasis on spacing methods like IUCD.

Availability of Fixed Day Static Services at all facilities.

Emphasis on minilaptubectomy services because of its logistical simplicity and associated

with

less failure and complication rates.

A rational human resource development plan is in place for provision of IUCD, minilap and
NSV

to empower the facilities (DH, CHC, PHC, SHC) with at least one provider each for each of
the

services and Sub Centres with ANMs trained in IUD insertion.

Ensuring quality care in Family Planning services by establishing Quality Assurance

Accreditation of more private/NGO facilities to increase the provider base for family
planning

services under PPP.

Increasing male participation and promoting Non- Scalpel Vasectomy.

Compensation scheme for sterilization acceptors, under the scheme, Ministry of Health &
Family

Welfare provides compensation for loss of wages to the beneficiary and also to the service
provider

(& team) for conducting sterilizations. The compensation scheme has been enhanced in 11
high

focus States from the year 2014.

‘National Family Planning Indemnity Scheme’ under which clients are indemnified in the

eventualities of deaths, complications and failures following sterilization. The providers/

accredited institutions are indemnified against litigations in those eventualities.

Post-Partum Intra-Uterine Contraceptive Devices(PPIUCD) Incentive for service providers

and

ASHAs.

Ministry of Health & Family Welfare has introduced short term IUCD (5 years effectivity),
Cu

IUCD 375 under the National Family Planning Programme. Training of State level trainers
has

already been completed and process is underway to train service providers up to the sub-
center

level.

A new method of IUCD insertion (postpartum IUCD insertion) has been introduced by the

Government.Promoting post-partum family planning services at district hospitals by

providing for placement

of dedicated family planning counsellors and training of personnel.

Home Delivery of Contraceptives (HDC)

A new scheme was launched to utilize the services of ASHA to deliver contraceptives at the

doorstep of beneficiaries. The scheme was launched in 233 pilot districts of 17 States on 11
July

2011 and later expanded to the entire country from 17th December 2012.

ASHA is charging a nominal amount from beneficiaries for her effort to deliver
contraceptives at

doorstep i.e. Re. 1 for a pack of 3 condoms, Re. 1 for a cycle of OCPs and Rs. 2 for a pack of
one

tablet of ECP.

Ensuring Spacing at Birth (ESB)

Under a new scheme launched by the Government of India, services of ASHAs to be utilised
for

counselling newly married couples to ensure spacing of 2 years after marriage and couples
with 1

child to have spacing of 3 years after the birth of 1st child. The scheme is operational in 18
States

(EAG, North Eastern and Gujarat and Haryana). ASHA would be paid following incentives
under

the scheme:

o Rs. 500/- to ASHA for delaying first child birth by 2 years after marriage;

o Rs. 500/- to ASHA for ensuring spacing of 3 years after the birth of 1st child and

o Rs. 1000/- in case the couple opts for a permanent limiting method up to 2 children only.

Pregnancy Testing Kits (PTKs)

Nishchay: Home based Pregnancy Test Kits (PTKs) was launched under NRHM in 2008
across

the country and was anchored with the Family Planning Division on 24th January, 2012.

The PTKs are being made available at subcenters and to the ASHAs.

The PTKs facilitate the early detection and decision making for the outcomes of pregnancy.

Improving contraceptives supply management up to peripheral facilities. Demand

generationactivities in the form of display of posters, billboards and other audio and video
materials in the

various facilities. Strong political will and advocacy at the highest level, especially in states
with

high fertility rates. New interventions to improve access to contraception

Expansion of basket of choice

o Injectable Depot Medroxyprogesterone Acetate (DMPA): The Drugs Technical Advisory

Board

(DTAB) agreed to the introduction of the injectable contraceptive DMPA in the public health

system under the National Family Planning Programme.

o POP: Under piloting process

o Centchroman: Under programming

Improved Contraceptive Packaging: The packaging for Condoms, OCP and ECP is now
being

improved so as to influence the demand for these commodities.

Planning for improved service delivery through promotion of post-partum family planning
(esp.

through Minilap) and NSV: The detailed programme specifications was shared with States in
August 2015-16. Handholding of the States is being done for improving the static centers for
post-

partum family planning and NSV.

Progress made under Family Planning Programme

Number of IUCDs and sterilisations has remained static in spite of declining CBR and TFR.
There

is a need to sustain momentum to reach the replacement level fertility.

Considering the current efforts to focus on spacing, it is expected that IUCD performance
would

increase in near future.

Promotion of IUCDs as a short and long term spacing method

In 2006, Government of India (GoI) launched “Repositioning IUCD in National Family

Welfare

Programme” with an objective to improve the mixed method in contraceptive services and
has

adopted diverse strategies including advocacy of IUCD at various levels; community

mobilization

for IUCD; capacity building of public health system staff starting from ANMs to provide
quality

IUCD services and intensive IEC activities to dispel myths about IUCD. Currently, increased

emphasis is given to promotion of IUCD insertion as a key spacing method under Family
Planning

programme.

“Alternative Training Methodology in IUCD” using anatomical, simulator pelvic models,

incorporating adult learning principles and humanistic training technique was started in
September

2007 to train service providers in provision of quality IUCD services.Actions taken and
achievements

Hindustan Latex Family Planning Promotion Trust (HLFPPT) has been engaged to support
states

to conduct interval IUCD training and also post training follow-up of trained personnel.
HLFPPT

would also follow-up sample cases of IUCD insertion to ensure retention;

Directive has been issued to the states to notify fixed days/ per week at SHC and PHC level
for

conducting IUCD insertions and

Introduction of Cu-IUCD-375 (5 years effectivity) under the Family Planning Programme.

Increasing provider base for IUCD (through AYUSH practitioners)

It has been approved to train AYUSH doctors in IUCD after a short refresher course/ training
and

AYUSH doctors except Yoga and Naturopathy practitioners are allowed to perform IUCD

insertions at public health facilities after undergoing stipulated training.

Emphasis on Postpartum Family Planning (PPFP) services

In order to capitalize on the opportunity provided by increased institutional deliveries, the

Government of India is focusing on strengthening post-partum FP services;

PPFP services are not being offered uniformly at all levels of health system across different
States

of India resulting in missed opportunities;

Insertion of IUCD during the post-partum period, known as Post-partum Intra-uterine

Contraceptive Device (PPIUCD), is being focused to address the high unmet need of spacing

during post-partum period.

Actions taken and achievements

Strengthening Post-Partum IUCD (PPIUCD) services at high case load facilities:

o Currently the focus is on placement of trained providers for PPIUCD insertion at district
and

sub-district hospital level only, considering the high institutional delivery load at these
facilities.

Total 10,34,894 PPIUCDs have been inserted all across the country since the initiation of the

PPIUCD programme. Approximately 5,90,217 PPIUCD insertions have taken place in 2014-
15 as

against around 3,24,487 in 2013-14.

Appointing dedicated counsellors at high case load facilities:

o RMNCH+A counsellors are being appointed at all high case load facilities to provide
counselling

services in following areas: Post-partum Family Planning (IUCD and Sterilisation);

 Other family planning methods such as condoms, pills etc.;

 Ensuring healthy timing and spacing of pregnancy;

 Mother & baby care;

 Early initiation of breast feeding;

 Immunization and
 Child nutrition.

The posts of 1633 RMNCH+A counselors have been approved across the country (as per the
state

projections) in financial year 2014-15. Of these, 959 positions are filled and counselors are in

place.

Assured delivery of family planning services

Fixed Day Services (FDS) for IUCD insertion: States are facilitated to ensure fixed days
IUCD

insertion services at the level of SC and PHC (at least 2 days in a week).

Fixed Day Static Services in sterilisation at facility level:

Operationalization of FDS has following objectives:

 To make a conscious shift from camp approach to regular routine services;

 To make health facilities self-sufficient in provision of sterilization services and

 To enable clients to avail sterilization services on any given day at their designated health

facility.

Camp approach for sterilization services is continued in those states where operation of
regular

fixed day static services in sterilization takes longer time.

Rational placement of trained providers at the peripheral facilities for provision of regular
family

planning services.

Actions taken and achievements:

In year 2014-15, all the States have shown their commitment to strengthen fixed day family
planning services for both IUCD and sterilisation and it has been included under quarterly
review

mechanism to assess progress made by the States.Recent field visits and review missions to
the States reveal that most of the facilities at the level

of CHC and above have been operationalised for providing FP services on fixed day basis.

Analysis of the data available from HMIS for 2014-15 reveals that:

o Around 36.3% of NSVs are conducted at PHC, 33.2% at CHC level, 29.2% at SDH/DH
level

and 1.2% at State owned institutes;

o Majority of minilap sterilisations (45.4%) are conducted at PHC level followed by 31.5% at
CHC

level. 22.9% of the minilap were conducted at SDH/DH level and 0.2% at State owned
institutes;

o 26.6% laparoscopic sterilisation is conducted at PHCs via camp mode. However, it is

important

to note that majority of laparoscopic sterilisation (45.8%) is conducted at CHC level. 27.1%
of

cases were operated at SDH/DH level and 0.5% at State owned institutes and

o As anticipated around 67.2% of the PPS is reported at DH/ SDH level since majority of

institutional deliveries are conducted at these facilities; however, this needs to increase at
PHC

(12.7%) and CHC (17.6%) level as well.

Public Private Partnership (PPPs)

PPP in family planning services are intended to utilize the reach of private sector in
increasing the
access to family planning services. In order to promote PPP in family planning services,
accredited

private facilities and empanelled private healthcare providers are covered under revised

compensation scheme for sterilization and NFPIS.

Accreditation and empanelment of private health facilities/healthcare providers is

decentralized

to District Quality Assurance Committees (DQAC).

Sterilisation services at private facilities have increased in 2014-15 compared to 2012-2013

:Scheme of home delivery of contraceptives by ASHAs at doorstep of beneficiaries

Community based distribution of contraceptives by involving ASHAs and focused IEC/BCC

efforts are undertaken for enhancing demand and creating awareness on family planning. To

improve access to contraceptives by the eligible couples, services of ASHA are utilised to
deliver

contraceptives at the doorstep of beneficiaries. The scheme has been rolled out in all the
districts

of the country. Under HDC schemes ASHAs are distributing condoms, OCPs and ECPs in all

states of India except Tamil Nadu, Puducherry and Himachal Pradesh where ASHA structure
is

non-existent. Contraceptive distribution in these three states is being done by Anganwadi

Workers

and ANMs.3 independent agencies evaluated the scheme and following points emerged out
of it:

o Majority (62 %) respondents have heard of the scheme from ASHA. In other words, ASHA
has
been communicating on the scheme to the community;

o Nearly, 78 % of those state visited, said that ASHA was able to explain and counsel on the
use

of contraceptives;

o 95% of the women beneficiaries (interviewed) were completely satisfied with the Scheme;

o 65 % of those who procured from ASHA cited easy access as the reason. In other words,
ASHA

is emerging as an important source on account of her easy access;

o Of the respondents who were provided contraceptives by ASHA, 53 % were willing to pay;

o 86% ASHAs believed that the Scheme including payments will be successful in the longer
term;

o 50% of the ASHAs indicated positive community response and o ASHAs feel empowered
and

have expressed confidence in distributing contraceptives to beneficiaries, irrespective of

receiving

any payment by beneficiaries.

Scheme for Ensuring Spacing at Births

As stated above under the scheme, services of ASHAs to be utilised for counselling newly
married

couples to ensure spacing of 2 years after marriage and couples with 1 child to have spacing
of 3

years after the birth of 1st child.The scheme was initially conceived for 18 states, but in later
years

the spacing component of the scheme was rolled out in few other states like West Bengal,
Maharashtra, Andhra Pradesh, Telangana and Daman Diu. Dadar and Nagar Haveli have also

initiated the implementation of the scheme (both spacing and limiting components).

Celebration of World Population Day & Fortnight (July 11 – 24, 2015)

The event was observed over a month long period, split into an initial fortnight of
mobilization/

sensitization followed by a fortnight of assured family planning service delivery

. o June 27 to July 10, 2015: “Dampati Sampark Pakhwada” or “Mobilisation Fortnight” was

organised and

o July 11 to July 24, 2015 “Jansankhya Sthirtha Pakhwada” or “Population Stabilisation

Fortnight” was organised. A workshop was organized at Vigyan Bhavan on “Vulnerable

Populations in Emergencies” chaired by AS & MD NHM, Ministry of Health & Family

Welfare.

The aim was to motivate and mobilize the nation towards population related issues, especially

during emergencies. Hon’ble Union Minister of Health & Family Welfare, Shri J. P. Nadda

distributing winning prizes in the painting competition to school children in presence of

Hon’bleMinister of State for Health & Family Welfare, Shri Shripad Yesso Naik The
inaugural session of

the workshop also witnessed prize distribution by the Hon’ble Union Minister of Health &
Family

Welfare, Shri J. P. Nadda and Minister of State for Health & Family Welfare Shri Sripad
Yesso

Naik, to school children who had brought laurels to the schools by winning prizes in the
painting

competition organized by Jansankhya Sthirata Kosh. The inaugural session was followed by a
panel discussion which was moderated by AS & MD, Shri C. K. Mishra. In this forum Dr.
Rakesh

Kumar, JS (RCH) & Executive Director- Jansankhya Sthirata Kosh (JSK), Dr. Jagdish
Prasad,

DGHS and other prominent dignitaries presented their views on the subject.

CONTRACEPTIVE IN THE NATIONAL FAMILY WELFARE PROGRAMME

The Department of Health and Family Welfare is responsible for implementation of the
National

Family Welfare Programme by, inter-alia, encouraging the utilization of contraceptives and

distribution of the same to the States/UTs through Free Supply Scheme and Public-Private

Partnership (PPP) under Social Marketing Scheme. Under Free Supply Scheme of
contraceptives,

namely, Condoms, Oral Contraceptive Pills, IntraUterine Device (Cu-T), Emergency

Contraceptive Pills and Tubal Rings are procured and supplied free to the States/UTs. The
channel

for supply of these contraceptives under Free Supply Scheme is Government network
comprising

Sub-Centers, Primary Health Centers, Community Health Centers and Govt. Hospitals, State

AIDS Control Societies throughout the country. Procurement procedures: Orders are placed
on

HLL Life Care Ltd. (a PSUs under the Ministry) for procurement of contraceptives being

manufactured by them as per Govt. instructions. For the remaining quantities, tenders are
solicited

from the firms through Advertised Tender Enquiries for concluding Rate Contracts. Rate
Contracts
are concluded with the manufacturers and supply orders are placed upon them as per their

competitive rates and the capacity to manufacture the items. Quality Assurance:
Manufacturers do

in-house testing of stores before offering them for inspection. At the time of acceptance of
stores,

all the batches are tested in certified lab and thereafter, stores are supplied to the consignees.

Social Marketing Scheme

The National Family Welfare Programme initiated the Social Marketing Programme of
Condoms

in 1968 and that of Oral Pills in 1987. Under the Social Marketing Programme, both
Condoms andOral Pills are made available to the people at highly subsidized rates, through
diverse outlets. The

extent of subsidy ranges from 70% to 85% depending upon the procurement price in a given
year.

Both these contraceptives are distributed through Social Marketing Organizations (SMOs).
The

SMOs are given Deluxe Nirodh condom at Rs.2.00 per packet of 5 pieces and this is sold @
Rs.3/-

per packet of 5 pieces to the consumer. One cycle of Oral Pills, which is required for one
month,

is given to the SMOs @ Re.1.60/- and it is sold to the consumer @ Rs.3/- per strip (cycle)
under

the brand name- “Mala–D”. Under the Social Marketing programme, currently one
Government

brands (Deluxe Nirodh) and twelve different SMOs brands of condoms (i.e. Rakshak, Ustad,
Josh,
Mithun, Style, Thril, Kamagni, Sawan, Milan, Bliss, Ahsaas and KLY-MAX) are sold in the

market. Similarly for Oral Pills, one Government brand (Mala-D) and six SMOs brands of
Pills

(i.e. Arpan, Pearl, Ecroz, Sunehri, Apsara and Khushi) are sold. Based on the
recommendation of

the Working Group on Social Marketing of Contraceptives, SMOs have the flexibility to fix
the

price of branded condoms and OCPs within the range fixed by the Government. 6.6.1.a. Sale
of

Condoms (Quantity in Mpcs) Sl. No Social Marketing Organisation

Centchroman (Oral pills)

Since December 1995, a non-steroidal weekly Oral Contraceptive Pill, Centchroman

(Popularly

known as Saheli&Novex), to prevent pregnancy is also being subsidized under the Social

Marketing Programme. The weekly Oral pill is the result of indigenous research of CDRL,

Lucknow. The pill is now available in the market at Rs.2.00 per tablet. The Government of
India

provides a subsidy of Rs.2.59 per tablet towards product and promotional subsidy.

Copper-T Under the National Family Welfare Programme,

Cu-T-200B was being supplied to the States/UTs. From 2003-04, advanced version of Intra

Uterine Device i.e.Cu-T-380-A has been introduced in the Programme. This Cu-T has longer
life

of placement in the body and thus provides protection from pregnancy for a period of about
10
years. Now the advanced version of IUDs i.e.Cu-T-380A is being procured and supplied to
the

States/UTs. From the year 2012-13 IUD 380A and IUD -375 are procured by this Ministry.
Orders

have been placed for a quantity of 37.62 lakh Copper T-380 and IUD 375 for the current year

2015-16. Central Medical Supplies Society (CMSS) With a view to assure procurement and

distribution of supplies in time, the government has now set up an autonomous agency viz.
Central

Medical Supplies Society (CMSS) whose sole responsibility would be to ensure

uninterrupted

supplies of commodities in the states. This agency would be able to cut the proverbial
bureaucratictape by laying down a firm procurement and distribution system in the country,
thereby

transforming the committed goals into a reality. The indent has been sent to CMSS for
procurement

of balance quantity of contraceptives from private manufacturer for the year

Over the years, social scientists have argued the relationship between demographic change
and

economic outcomes, and it is now well established that improving literacy and economic

conditions for individuals lowers birth rates, while low fertility in turn plays a positive role in

economic growth. Family planning (FP) programmes impact women's health by providing

universal access to sexual and reproductive healthcare services and counselling information.
FP

also has far-reaching benefits which go beyond health, impacting all 17 sustainable
development
goals (SDGs); however, the focus is on goals 1, 3, 5, 8 and 10. FP has been recognized as one
of

the most cost-effective solutions for achieving gender equality and equity (goal 5) by
empowering

women with knowledge and agency to control their bodies and reproductive choices by
accessing

contraceptive methods. A women's access to her chosen family planning method strongly
aligns

with gender equality. Birth spacing can have great implications on health, for instance,
reduction

in malnutrition (goal 2) and long-term good health (goal 3) for the mother and the child 1.
Access

to contraceptives helps in delaying, spacing and limiting pregnancies; lowers healthcare costs
and

ensures that more girls complete their education, enter and stay in the workforce, eventually

creating gender parity at workplace.

Today, the demographic dividend is in India's favour and FP can and should be used to
leverage

it. Longer lives and smaller families lead to more working-age people supporting fewer

dependents. This reduces costs and increases the country's wealth, economic growth (goal 8)
and

productivity of the people. Ultimately, these result in reduction in poverty (goal 1) and
inequalities

(goal 10) leading to the achievement of the SDGs through a multiplier effect.
Research shows that adequate attention to family planning in countries with high birth rates
can

not only reduce poverty and hunger but also avert 32 per cent of maternal and nearly 10 per
cent

of childhood deaths, respectively. There would be additional significant contributions to

women's

empowerment, access to education and long-term environmental sustainability. The United

States

Agency for International Development (USAID) estimates that ‘every dollar invested in
family

planning saves four dollars in other health and development areas, including maternal health,

immunization, malaria, education, water and sanitation. Thus, investing in family planning is
themost intelligent step that a nation like India can take to improve the overall socio-
economic fabric

of the society and reap high returns on investments and drive the country's growth.

With over half of its population in the reproductive age group and 68.84 per cent of India's

population residing in villages, opportunities are plenty but so are the challenges. It is still an

unrealized dream of the healthcare system to be able to reach the last mile, especially women

belonging to scheduled castes and tribes (SC and ST) in distant and remote parts of the
country.

As a result, the mortality among these groups is high. Scheduled tribes in India have the
highest

total fertility rate (3.12), followed by SC (2.92), other backward class (OBC) (2.75) and other

social groups (2.35). Contraceptive use is the lowest among women from ST (48%) followed
by
OBC (54%) and SC (55%) while female sterilization is the highest among women from OBC

(40%) followed by SC (38%), ST (35%) and other social groups (61.8%). There is an urgent
need

for universal and equitable access to quality health services including contraceptive methods.

Favorable policy environment to meet high unmet need for contraception

An estimate done by the Ministry of Health and Family Welfare (MoHFW), Government of
India,

states that if the current unmet need for family planning is met over the next five years, India
could

avert 35000 maternal deaths and 12 lakh infant deaths.If safe abortion services could be
ensured

along with increase in family planning, the nation could save approximately USD 65000
million.

Yet, the fourth National Family Health Survey (NFHS-4)states that almost 13 per cent of
women

have an unmet need for family planning including a six per cent unmet need for spacing
methods.

The consistency in these numbers since the NFHS-3 in 2005-2006 suggests that despite
increasing

efforts to create awareness on the subject, there is an existing gap between a woman's desired

fertility and her ability to access family planning methods and services.

There is a direct correlation between the number of contraceptive options available and the

willingness of people to use them. As shown in Fig. 1A, it has been estimated that the
addition of
one method available to at least half of the population correlates to an increase in use of
modern

contraceptives by 4-8 percentage points. Fig. 1A shows a projection of the rise of modern

contraceptive prevalence rate (mCPR) in India, based on the trends observed by Ross and

Stover10 and using the current mCPR of 47.8 for India (from NFHS 4) as the base
value.Source : NFHS IV

Fig. 1

Effect of number of contraceptive methods on modern contraceptive prevalence rate

(mCPR). (A) The graphic is a projection of the rise in modern contraceptive prevalence rate

(mCPR) in India with every additional contraceptive method. This estimation is based on the

mCPR of 47.8 from the National Family Health Survey 4 (NFHS-4). (B) Evidence on

contraceptive method mix in developing countries South/South-East Asia. The mCPR has
been

represented on a scale of 100 percentage points to depict the distribution of contraceptive

method

mix for each country.

Expanding the basket of contraceptive choices led to an increase in overall contraceptive

prevalence in Matlab, Bangladesh, where household provision of injectable contraceptives in

1977

led to an increase in contraceptive prevalence from 7 to 20 per cent. As of 2015, injectable

and

pills together accounted for about 73 per cent of the modern contraceptive usage in
Bangladesh,
which has an mCPR of 55.6 per cent. In addition to Bangladesh, Fig. 1B shows the mCPR of
other

neighbouring South East Asian countries such as Bhutan, Indonesia, Nepal and Sri Lanka
where

the availability of seven (or more) contraceptive methods corresponds with a higher mCPR.
India,

with five available methods of contraception (as of 2015), recorded the lowest mCPR among
these

countries.

In India, efforts have been made over the years by the government to create a favourable
policy

environment for family planning, in the form of several important policy and programmatic

decisions. At the London Summit on Family Planning held in 2012, the Government of India
made

a global commitment to provide family planning services to an additional 48 million new

users by2020. According to the FP 2020 country action plan 2016, the government aims at
focusing on

mCPR, keeping in mind the current annual mCPR increase rate of one per cent as compared
to the

2.35 per cent annual increase required to reach the FP2020 goals for India. As a signatory of
the

SDGs in 2015, India has committed itself to achieving good health and well-being (goal 3) as
well

as gender equality (goal 5) by 2030.

In 2015, the announcement of the introduction of three new contraceptive methods -

injectable
contraceptive, centchroman and progestin only pills by the government of India indicated a
much-

needed shift from the terminal method of female sterilization, which accounted for two-thirds
of

contraceptive use in India until 2015-2016, to more modern limiting methods of

contraception.

Introduction of new contraceptive methods has always been marred by controversies

surrounding

their efficacy, side effects and safety. Consistent efforts need to be made to educate not just
the

users but also the service providers in every aspect surrounding a newly introduced method
so that

their capacities are strengthened. The users will also benefit from the strengthening of service

providers; they will have better, more accurate access to information surrounding various

contraceptive options, enabling them to make more informed choices. The third and equally

important partner is the media. Greater efforts need to be made by both the government and
civil

society organizations to educate media to promote unbiased reporting and avoid creating
panic on

introduction of new methods.

Like any medical solution, contraceptive methods can also have side effects but it is
imperative to

note that the ability to access the available range of contraceptive choices is every woman's

reproductive right. Implementation of pilot programmes is of utmost significance and

relevance to
generate further evidence on the efficacy of various contraceptives in different contexts. This

enables a better understanding of the impediments in introduction as well as sustained usage

of

new contraceptives. To prevent early discontinuation and also dispel-related myths and

misconceptions, women will need proper counselling on the usage and side effects of

contraceptives.

Empowering community health workers to ensure better quality of care

India has close to 900,000 Accredited Social Health Activists (ASHAs) who are the access
point

for meeting the health needs and demands of the remotest sections of the population,
especially

women and children. In addition to the ASHAs, other community health workers such as
theauxiliary nurse midwife (ANM), reproductive, maternal, new born, child and adolescent
health

(RMNCH) counsellors and adolescent health counsellors are crucial in covering for the
shortage

of specialized healthcare providers in the country. Capacity building of community health

workers

can be of significance in reaching the last mile. The training of frontline workers has to be
technical

and beyond; there needs to be greater emphasis on trainings around community mobilization
and

counselling for contraceptive technologies, addressing myths and misconceptions prevailing

in the

communities regarding modern methods of contraception.

Quality of care (QoC), consisting of its crucial components such as access to contraceptive
choices,

quality counselling services, information and follow ups, can ensure that the unmet need of

millions of women across the country is met, and there is an accelerated reduction in fertility.

Efficient responsiveness to users not only creates demand but also ensures return of the
clients,

ensuring long-term effectiveness and sustainability of the programme. To ensure that quality

services reach the last mile, services need to be geographically convenient. And finally,
quality

services cannot be provided in the absence of adequate infrastructure and competent and
unbiased

service providers and frontline workers.

The landmark verdict in the Devika Biswas versus Union of India case in 2016 made a
number of

recommendations to ensure a diligent functioning of the Quality Assurance Committees at the

State and district levels. The judgment took cognizance of “The Robbed of Choice and
Dignity”

report of the multiorganizational fact-finding mission led by Population Foundation of India

(PFI)

on the sterilization deaths in Bilaspur, Chhattisgarh in November 2014. It also directed the
State

and Union government to move away from a fixed target-based approach for family planning.
And

finally, it made specific recommendations to the government to improve the quality of

services
being provided under the family planning programme. This was a significant move to
advance

women's reproductive rights and choices in the last several decades and ensures a promising
way

forward for family planning in India.

Recognizing family planning as a human rights issue

Women's health goes beyond providing technical solutions or increasing the availability of

contraceptive methods. Of tremendous significance is a woman's agency, choice and access

to

quality reproductive services. Access to quality family planning is not only a human right; it
isextremely important for individual and societal well-being, and for the nation's
development as a

whole.

Addressing critical indicators such as child marriage and early pregnancy

Child marriage violates the basic rights of children and especially the right to enjoy a free and

joyful childhood. India is among the countries with the highest number of girls married
before the

age of 18. Early marriage is typically followed by immediate childbearing. A systematic

review of

23 programmes from Africa, Bangladesh, Nepal and India conducted by PFI showed that
social

pressure to prove fertility, insufficient knowledge on contraceptives and limited decision-

making

power among women were the main reasons for the high levels of early pregnancy. The
country
needs policies in place that empower women, rather than those that restrict access to
contraception.

According to NFHS-4, eight per cent women between 15 and 19 yr of age were either already

mothers or pregnant. NFHS-4 data also reveals that between 2005-2006 and 2015-2016, the

percentage of women (between 20 and 24 yr) married before 18 yr of age dropped by 21 per
cent,

while there was a 12 per cent decrease in the percentage of men married before the age of 21.

While these figures depict a positive trend, one cannot ignore the fact that over one out of
four

(27% of girls) were married before the age of 18.

The government and civil society organizations should continue to work on the issue of child

marriage by adopting different strategies including, but not limited to, raising awareness,

behaviour change communication (BCC), community participation, conducting

empowerment

programmes for adolescents and not merely offering cash incentives.

Easy access to safe abortion services for women

The World Health Organization has stated that ‘every eight minutes a woman in a developing

nation will die of complications arising from an unsafe abortion’. An estimated 15.6 million

abortions occur annually in India. Only five per cent of abortions in India occur in public
health

facilities, which are the primary access point for healthcare for poor and rural women. Unsafe

abortions account for 14.5 per cent of all maternal deaths globally and are most common in

developing countries in Africa, Latin America and South and Southeast Asia, with restrictive
abortion laws, while the unmet need continues to be high. Such abortions are preventable
byensuring access to quality family planning, safe abortion and counselling services as well
as by

providing comprehensive sex education.

The social stigma surrounding abortion compels women to resort to unsafe abortion methods
at

the hands of unqualified service providers. In the Indian context, a study conducted in Bihar
and

Jharkhand found that abortion providers in both the public and private sectors favoured
offering

abortion and counselling services to married rather than unmarried women. The same study

pointed out that only 31 per cent of all participating providers agreed that all women
regardless of

marital status should receive information on contraception on request. This act of restricting

abortion services to women based on their marital status highlights the prejudice of providers

against unmarried women and leads to high instances of unsafe abortions in the country.

The Medical Termination of Pregnancy Act (MTP), 1971 intends to provide safe and easily

accessible abortion services to women with unwanted pregnancies on the approval of a

medical

practitioner, provided the pregnancy is within 20 wk gestation. In India, unsafe abortion is

routinely performed by unregistered medical practitioners without any medical training as

well as

by women who prefer to self-medicate themselves. Such practices often lead to severe health

complications. According to International Centre for Research on Women, 59 per cent of

women
in Madhya Pradesh surveyed revealed that they had an abortion because they did not want
any

more children. In addition, 22 per cent confessed using abortion as a proxy to contraception
and

as a means of birth spacing.

To improve access to safe abortion services, a draft amendment bill to the MTP Act, 2014 has
been

proposed by the Ministry of Health and Welfare, which allows abortion between 20 and 24
wk if

the pregnancy involves risk to the mother and child or has been caused by rape. It would also
allow

Ayurveda and Unani practitioners to carry out medical abortions. While increasing the time
limit

is in line with the technological advancements and would give the couple adequate time to
decide,

it can also lead to an increase in sex-selective abortions in the country.

Finally, there is a paradox when it comes to men's attitude towards abortion which needs to
be

acknowledged and addressed. Men need to be more involved in every dimension of sexual
and

reproductive health and family planning, right from being users of contraception to being

supportive partners to their significant other as she makes a crucial decision about
abortion.Enhanced male engagement in family planning

In many parts of the world including India, family planning is largely viewed as a women's
issue.
A disproportionate burden for the use of contraception falls on Indian women. Female
sterilization

accounts for more than 75 per cent of the overall modern contraceptive use in India . In
contrast,

India's neighbouring countries such as Bangladesh, Bhutan, Indonesia, Nepal and Sri Lanka

exhibit a more balanced method mix scenario which subsequently translates into a higher
mCPR .

As per NFHS-4 data, the two methods of contraception available to men - vasectomy and
condoms

- cumulatively account for about 12 per cent of the overall mCPR suggesting that women are
the

driving force behind the family planning vehicle in India, and 40.2 per cent men think it is a

woman's responsibility to avoid getting pregnant. Most family planning programmes focus on

women as primary contraceptive users while men are viewed as supportive partners, despite

evidence depicting interest from male users to existing programming. There needs to be
greater

recognition of the fact that decision-making on contraceptive use is the shared responsibility
of

men and women and programmes should cater to men as FP users. Family planning
initiatives

should address beliefs, myths and misconceptions surrounding contraceptive services as well
as

other barriers that refrain active male participation. The family planning programmes should

restructure their communication methods and strategies in a manner that includes men as both

enablers and beneficiaries, hence making them responsible partners.

It is also important to reach men and adolescent boys as users not just in family planning

programmes but also in government policies and guidelines as well as in research to create
more

male contraceptive options.

Addressing the sexual and reproductive needs of the youth

Youth (15-34 yr) account for 34.8 per cent of the total Indian population, of which an
enormous

number still do not have access to contraceptives.

According to a 2006-2007 subnational youth survey in India, while most youth had heard of

contraception and HIV/AIDS, there was lack of detailed information and awareness. While
95 per

cent of youth had heard of at least one modern method of contraception, accurate knowledge
ofeven one non-terminal method was considerably low among young women, with only 49
per cent

reporting positive knowledge Likewise, while 91 per cent of young men and 73 per cent of
young

women reported having heard about HIV/AIDS, only 45 per cent of young men and 28 per
cent of

young women had comprehensive awareness of HIV. The recently released findings of the

UDAYA study in the States of Uttar Pradesh and Bihar by the Population Council revealed
low

levels of knowledge regarding sexual and reproductive health across all adolescents. In both
States,

among older adolescents (15-19 yr), slightly less than a quarter of unmarried boys and girls
and
one in two married girls knew that a girl could become pregnant even when she had sex for
the

first time. Correct knowledge of oral and emergency contraceptives was considerably low
across

all adolescent groups in both States which indicated an urgent need to improve awareness,

strengthen service deliveries and evaluate outreach strategies.

In its 2016 report, the Lancet Commission acknowledged the ‘triple dividend’ of investing in

adolescents: ‘for adolescents now, for their future adult lives, and for their children’.
According to

an estimate by the Guttmacher Institute, 38 million of the 252 million adolescent girls aged
15 to

19 years in developing countries are sexually active and do not wish to be pregnant over the
next

two years. These adolescents include a staggering 23 million with an unmet need for modern

contraception. It is more important now than ever to make a shift from one-size-fits-all
approaches

and cater to the needs of married and unmarried adolescents.

Increased investment in family planning

The National Health Policy 2017 talks of increasing public spending to 2.5 per cent of the
GDP,

which is a welcome sign. However, much higher health allocations are necessary to take
forward

the nation's family planning agenda in favour of reproductive health and rights. The
Government's
newly launched Mission Parivar Vikas Programme focuses on improving access to
contraceptives

and family planning services in 145 high fertility districts in seven States. In addition to
higher

health allocations, the government needs to ensure efficient and complete utilization of funds

already allocated to family planning activities.

India spent 85 per cent of its total expenditure on family planning on female sterilization with
95.7

per cent of this money going towards compensation, 1.45 per cent on spacing methods and 13
percent on family planning-related activities such as procurement of equipment,
transportation,

Information Education and Communication (IEC) and staff expenses in 2016-17 4. According
to

our analysis of the National Health Mission (NHM) Financial Management Report, the total

budget available for family planning activities under the NHM was ₹12220 million in India
during

2016-2017. Of the total money for family planning, 64 per cent was directed for providing
terminal

or limiting methods, nine per cent towards ASHA incentives for FP activities, 5.3 per cent for

training, 5.5 per cent for procurement of equipment, 3.7 per cent for spacing methods and 3.6
per

cent towards BCC/IEC activities for family planning (Fig. 2). The total spending was ₹7415

million indicating that only 60.7 per cent of the total money available for family planning
activities
was spent during 2016-2017. Of the total expenditure for FP activities, 68 per cent was spent
on

terminal or limiting methods of which compensation for female sterilization constituted 92.7
per

cent; 13.3 per cent was incurred for ASHA incentives, 3.7 per cent was incurred for spacing

methods of which incentives to providers for post partum intrauterine contraceptive device

(PPIUCD) insertion constituted 73.2 per cent and compensation for intrauterine contraceptive

device (IUCD) insertion at health facilities constituted 14.2 per cent, 2.8 per cent on
interpersonal

communication (IPC)/BCC activities and two per cent was spent for training.Source:
Population Council of India

Fig. 2

Allocation, expenditure and utilization of FP budget 2016-2017. POL, petroleum oil and lubricants;

RMNCH, reproductive, maternal, newborn, child, health; FP, family planning; bcc, behaviour change

communication; IEC, Information, Education and Communication; IUCD, intrauterine contraceptive

device.

Investing in behaviour change communication (BCC)

The above mentioned numbers suggest that although family planning programmes in India
have

made significant progress, the budgetary spending and allocation is still skewed towards
terminal

methods, with inadequate emphasis on training of service providers and investment in

BCC/IPC.

The issues surrounding family planning and sexual and reproductive health emerge from
deep-
seated social norms, which cannot be uprooted overnight. It is imperative to strategize
effectively

to work with communities to influence social norms.Social and Behaviour Change

Communication (SBCC) can address sociocultural norms such as

sex selection, early marriage, unwanted pregnancies, domestic violence and gender
inequality.

PFI's transmedia edutainment intervention, Main Kuch Bhi Kar Sakti Hoon - I, (A Woman,
Can

Achieve Anything, MKBKSH) is one such example. PFI's experience with MKBKSH Season
1

and 2 shows that entertainment education (EE) initiatives have tremendous reach and
potential to

change the knowledge, perception and behaviour among viewers.

In addition to SBCC, interpersonal/spousal communication has the potential to significantly

improve family planning use and continuation. In countries with high fertility rates and unmet

need, men have often been considered unsupportive partners as far as family planning is

considered suggesting lack of adequate spousal communication. SBCC is a key avenue in the

existing communication within the family planning programme in a country like India where

frontline workers reach populations where other media cannot reach. It is the time to not just

increase investments in health and family planning but to fully utilize the currently available

budget and rearrange the existing allocations in favour of reversible contraceptive methods
and

SBCC to challenge and change existing sociocultural norms.

The success of India's family planning programme is shouldered by researchers,
policymakers,

service providers and users, who will need to do their part to ensure equitable access to
quality

family planning services. The praxis of family planning is simple and the availability of a
basket

of contraceptive choices can play a crucial role in stabilizing population growth. An effective
and

successful family planning programme requires a shared vision among key stakeholders,
which

include the government, civil society organizations and private providers. These stakeholders

should ensure that the sexual and reproductive needs of youth and adolescents in the country
are

fulfilled. In addition, greater male participation as active partners and responsibility bearers
can

certainly ensure increased use of contraception. The time to act is now. And this should begin
with

a concerted effort from everyone to empower women, expand family planning choices and
strive

for greater gender equality so that every individual can lead a dignified life.
CHAPTER 3
REFLECTIONS FROM THE FIELD
Study Area

This study is conducted in Lucknow, Uttar Pradesh, India.

Lucknow is the capital of the Indian state of Uttar Pradesh and is also the administrative
headquarters of the eponymous District and Division. It is the largest city in Uttar Pradesh,
the
eleventh most populous city and the twelfth most populous urban agglomeration of India.
Lucknow has always been known as a multicultural city that flourished as a North Indian
cultural
and artistic hub, and the seat of power of Nawabs in the 18th and 19th centuries. It continues
to be
an important centre of governance, administration, education, commerce, aerospace, finance,
pharmaceuticals, technology, design, culture, tourism, music and poetry.
The city stands at an elevation of approximately 123 metres (404 ft) above sea level.
Lucknow
district covers an area of 2,528 square kilometres (976 sq mi). Bounded on the east by
Barabanki,
on the west by Unnao, on the south by Raebareli and in the north by Sitapur and Hardoi,
Lucknow
sits on the northwestern shore of the Gomti River. Hindi is the main language of the city
and Urdu is also widely spoken. Lucknow is the centre of Shia Islam in India with the highest
Shia
Muslim population in India.
Historically, the capital of Awadh was controlled by the Delhi Sultanate which then came
under
the Mughal rule. It was later transferred to the Nawabs of Awadh. In 1856, the British East
India
Company abolished local rule and took complete control of the city along with the rest of
Awadh
and, in 1857, transferred it to the British Raj. Along with the rest of India, Lucknow became
independent from Britain on 15 August 1947. It has been listed the 17th fastest growing city
in
India and 74th in the world.
Lucknow, along with Agra and Varanasi, is in the Uttar Pradesh Heritage Arc, a chain of
survey
triangulations created by the Government Of Uttar Pradesh to boost tourism in the state.
Uttar Pradesh is one of the states in India whose Total Fertility Rate (TFR) is 3.1 which is
above
the national TFR of 2.2 (NFHS, 2016).
Around 18% of married women or 1 in 5 women in Uttar Pradesh, willing to give space
between births, do not have access to family planning methods according to a survey
conducted
by TSU.The survey done in 25 districts of the state by technical support unit (TSU) stated
that 7% of
women in the state are at risk of becoming pregnant but are not using any contraception. The
unmet
need for family planning among younger women (15-24 years) is 23%.
Family planning allows couples to attain their desired family size. It is a key health
intervention
that can improve family health and reduce maternal and infant deaths. Proper birth spacing of
2
years results in healthier mothers and babies.
By reducing rate of unintended pregnancies, family planning also reduces the need for unsafe
abortions. Every 12 minutes a woman in India dies from pregnancy or childbirth-related
complications.
According to the ministry of health & family welfare, if the current unmet need for family
planning
could be fulfilled within the next five years, the country could avert 35,000 maternal deaths
and
12 lakh infant deaths.
Women and men are equally responsible for family planning, yet the burden falls
disproportionately on women.
Female sterilization in India remains the preferred method of contraception (36% of married
women aged 15-49 years), while male sterilization is extremely low (0.3%).
In 2015-16 only 3,101 men underwent vasectomy while 2,49,613 women had got tubectomy
done
in UP. The figures in 2016-17 were not enthusiastic as only 8,219 men got vasectomy done as
compared to 2,86,107 women who opted for tubectomy, revealed data from family planning
department.
Sources of Data and Selection of the Respondents
This study is based on primary data collected through field work. Both Primary as well as
secondary data was used in this study.
Data is collected through data triangulation, which involves considering data from at least
three
different sources to help ensure more dimension to the data (Saldaña, J., & Omasta,
M. ,2016).
Data triangulation also referred as data sources triangulation depicts the use of multiple data
sources in the same study for validation purposes. According to (Denzin, 1978), there are
threetypes of data triangulation; namely, time, space and person. These types of data
triangulation come
as the result of the idea that the robustness of data can vary based on the time data were
collected,
people involved in the data collection process and the setting from which the data were
collected
(Begley, 1996). The sources for primary data were respondents i.e. married woman between
age
group of 15-49 years, gynecologists and non-participant and quasi participant observation.
With
the help of interview schedule data was collected from the respondents. Telephonic and face
to
face interviews were used to collect information from gynecologists. A sample size of 328
young
married woman, belonging to different social strata of the society were selected amongst two
medical institution which includes a private maternity clinic and a state run hospital for
women.
Purposive sampling, involving married women aged between 15- 49 years were selected.
Woman
belonging to this particular age were selected because this age bracket is considered as
“reproductive age” by a W.H.O. report of 2006.(WHO, 2006) This age group falls in between
major changes in woman’s lifetime from menarche to menstruation.
Keeping in view the paucity of time and limited resources, two important medical institutions
were
selected where young married women between the reproductive age group of 15-49 years
could
easily be found. The universe of the study remains Lucknow (urban) city, Uttar Pradesh,
India.
Under this universe these two medical institution, one located in Rajendra Nagar and the
other
located in Chowk were selected for this study.
The study is mainly based on the data collected through interviews with the selected 328
currently
married women in the reproductive age group of 15-49 years of age. These interviews were
performed through structured interview schedules. The schedule covers socio- economic and
demographic details, knowledge and attitude towards family planning methods, decision
making
and aspiration towards family planning and reproductive health
Data was obtained through various sources. For secondary sources- census reports, National
Family Health Survey etc.
Primary Data was collected through in depth interviews, Focused group discussions and
observation method as well as discussions with medical practitioners was done.
Sociologists combining several methods in a single piece of research, using each to
supplement
and check on the other, this process is known as triangulation. Norman Denzin (1970)
actually
distinguished four types of triangulation. Data triangulation occurs when data are collected
atdifferent times and perhaps uses different sampling strategies within the same research
project.
The other forms of triangulation are Investigator triangulation, Theoretical triangulation and
Methodological triangulation.
Relevance of the Study
The Family Planning Programme was launched by the government in 1951 and even after 63
years
the population of our country continues to grow at a high rate. The country's headcount is
almost
equal to the combined population of the United States of America (USA), Indonesia, Brazil,
Pakistan, Bangladesh and Japan -- all put together.
According to the findings of NFHS 4 (2015-2016), the use of contraceptives has declined by
3%
in the last 10 years. In 2005- 2006 it stood at 56.3% and in the latest report of 2015-2016 it
went
down to 53.5%. whereas in Uttar Pradesh, which has a Total Fertility Rate of 3.1, the use of
contraceptives increased slightly, from 43.6% in 2005-2006 NFHS data to 45.5 % in 2015-
2016
NFHS 4 data.
Sterilization was started in 1958 in India and became a huge success as a permanent method
of
family planning as it was centrally sponsored, involved monetary incentives and because very
few
other methods which were temporary in nature were available. As an irreversible procedure
tubectomy and vasectomy possess threats to the reproductive rights of an individual, still in
India
tubectomy is highly accepted by women. Previous studies in the areas of family planning and
tubectomy were limited in understanding the statistical and demographic trends of
sterilization and
did not focus much on sociological aspects like culture, family setting, occupation of the
women
etc. with most of them focusing on rural areas or in states with high fertility so there is a need
to
understand the relevance of this procedure and the government’s Family Planning
Programme at
present in an urban setting. Thus this study aims to understand the sociological reasons
behind
acceptance of various family practices by young married couples residing in Lucknow.
For the purpose of collecting primary data by using the techniques of interview schedule and
participant/non participant observation, I narrowed down upon two medical institutions
particularly concerning with women’s health. These spaces facilitated easy identification of
women in the reproductive age bracket of 15-49 years. It reflected the attitude of active
acceptors
of family planning methods. I choose to conduct my fieldwork in these two places as both
these
institutions are well established and experience huge footfalls. Permission was granted
toadminister interview schedule and non-participant observation in the private institution and
also
Unfortunately, my request to collect data from Queen’s Mary Hospital, a public health
institution
was not accepted by the authorities and hence I used quasi participant observation and visited
the
institution frequently disguising either as a patient or as an attendant to a patient to collect
data.
My access to both these institutions was limited to the outpatient department (OPD).
Field details –
1. A Maternity Clinic and Nursing Home located at Rajendra Nagar, Lucknow. (Private
Institution)
Photograph of Dr. Sunita Chandra's ClinicMap location of Dr. Sunita Chandra’s Clinic
SOURCE: GOOGLE MAPS
2. Queen’s Mary Hospital (part of CSMMU, Lucknow) (Public Health Institution.)
QUEEN MARRY HOSPITALMap Location of Queen Marys Hospital, Chowk
SOURCE:GOOGLE MAPS
I made visits to both these fields during the following dates-
Time period – 18th March 2018- 7th May 2018
19th August 2019-30th August 2019
23rd October 2019- 30th November 2019
On the basis of my field work I have made certain observations, these observations are
categorized under four areas –1. Physical infrastructure of the institution.
2. Woman as “clients” in these institutions.
3. The “gendered nature” and “power relations” between patient and doctor.
4. Role of “Husbands” during their visits to Gynecologists.
1. Physical Infrastructure of the institution
I started my observation with the outer structure or space of the institution concerned and
made
an attempt to decode the meanings of what these spaces or structures meant using a
sociological
understanding.
 A Maternity Clinic and Nursing Home located at Rajendra Nagar, Aishbagh, Lucknow.
Private Institution.
This nursing home is located in a very prominent location close to the main Charbagh
railway station in Lucknow and has a history of more than 25 years of existence. It is run
by a renowned Gynecologist of the city and is very popular in the area. I learnt about the
popularity of the clinic by a “rickshaw puller” who took me there and was full of praises
about the doctor. During my frequent visits to the clinic, most of the e-rickshaw or rickshaw
puller helped me in establishing the idea of this clinic being a “renowned” or popular one
by a mere fact that I never had to give directions nor mention the name of the clinic when
hiring a rickshaw from my home in charbagh, “Jajja baccha aspatal, rajendra nagar wala,
Dr.____ wala” were sufficient keywords to reach my destination.
It is located inside a lane, quite close to the main road of Aishbagh area. The sign board
can be easily located from far, the roads are broad and approachable for any four wheeler
or large vehichles like ambulance. The clinic is surrounded by multiple shops selling allied
items/services related to a maternity clinic like pharmacies, General Shops, Xerox shops,
even shops helping people in getting a “birth certificate” made along with providing
assistance for various other government schemes like Sukanya Samridhhi Yojana, some
LIC schemes for children particularly girl child. All these gives an idea of the kind of
services that are associated with reproduction and how a market has emerged out of
it.Reproduction is physiological process which has its own material and non-material culture.
Presence of these services in the surrounding of any maternity center or hospital further
strengthen the culture of birth and how it gets reproduced with time in various ways in
different time and space.
From outside the clinic resembled an old, huge bungalow which has been converted into a
nursing home for all practical purposes. Existence of ramps indicated an easy access to
stretchers, which is an essential for a place like this. A common public toilet was located
close to the entrance and was well maintained and had easy access. The building had
multiple floors, the ground floor was the OPD and all the other floors were used as OTs
and rooms for the patient. My access was limited to the OPD section alone. The ground
floor resembled like a huge living room/ hall of a bungalow, partition were made using
aluminum fabrication to divide the floor further into various sections. A small reception
area was located right in front of the entrance of the OPD, towards its right side was the
main chamber of the Gynecologist, towards left was a counseling room and a space was
also dedicated to a small pharmacy functioning inside the OPD located within the waiting
area of the institution.
The waiting room during OPD hours is filled with patients along with someone
accompanying them. There was hardly any patient who visited alone. The accompanying
person was either the husband of the patient or a close kin of the same gender, usually of a
same or higher age group.
Queen’s Mary Hospital (part of KGMU, Lucknow) (Public Health Institution.)
The Department for Obstetrics and Gynecology of King George’s Medical University,
Lucknow
is located in a separate building known as “Queen’s Mary Hospital” in the old city. This
building
is a separate unit located opposite to the main entrance of KGMU. The old building of the
hospital
has been renovated partially and is mix of both the modern architecture and of the British
colonial
architecture. The HOD’s cabin and the corridors leading to other cabins, resemble the
colonial
architecture with high roofs, huge windows, and broad stairways. A huge crowd awaits every
day
in front of the building to have access to public health. One has to pass by a huge crowd in
order
to get inside the building. Only females are allowed inside, this is followed very strictly,
males get
entry only if required. There is a person standing at the entrance makes sure that only females
getan entry. On reaching inside, there is a small registration window where patients have to
fill in the
details and have to pay Rs.1 for their OPD ticket which is valid up to 15 days. The general
OPD
is located on the right side and a new department for Artificial Reproductive Technique is
located
on the left side. The OPD is further categorized under various units, all these units are located
in
the ground floor of OPD. OPD resembles a huge hall surrounded with different rooms, the
various
units are emergency and gynecology OPD room no. 1,2,3, Antenatal OPD room no.4,5,
Family
Planning OPD Room No.13, there are some specialty clinics too, functioning regularly like,
infertility clinic, oncology clinic, immunization clinic, postnatal clinic etc. The family
planning
clinic is held daily and involves counselling and provisions of all contraceptive devices.
Tetanus
immunization of all pregnant women is also done. Post-partum IUCD, use of new
contrcaeptives
like Chhaya and Antara is also promoted here.
Woman as “clients” in these institutions.
On entering the clinic, the first point of contact was the receptionist who enquires about the
purpose
of visit, for a fresh patient she gives a form asking for basic details to be filled by patients like
name, age, religion, marital status, address, contact number, blood group etc. She then
records
current height the and weight of the patient by asking them to stand on weighing scale and
then
collects the consultation fee and gives them a patient number. Further, patients are sent for a
primary examination by a junior health professional who records their medical history and
writes
her remarks based on it. Later, this sheet is passed to the senior gynecologist who gives the
final
verdict by examining the patient and explains them their medical condition and the course of
action
which is required. After the interaction with the doctor, patients are further introduced to
another
female health worker who helps the patient in understanding their exact medical condition in
a
much simpler, lay men language and also clarifies their doubts, if any.
It was observed that women were treated in a very inorganic fashion and their entire
interaction
with the staff at the clinic was highly objective. This scenario is not particular to a maternity
center
alone but can be found in any other health setup. The health industry today, reduces health to
any
“physical infirmity” alone and does not take into account the emotional and social well-being
of
the patients, which is highlighted in the WHO’s definition of health,”state of complete
physical,
mental and social well-being and not merely the absence of disease or
infirmity”
.Unfortunately, mental and social well-being is not given the importance it deserveswhen it
comes to public health in India. The noble health profession is more like a service provider
in any other industry”. Extremely sensitive issues that women have related to their
reproductive
health is seen as mere “physical ailment” to the staff and this could be sensed with the first
point
of contact and the junior doctor’s rough voice tone and impatience while they takes a
preliminary
examination of the patient. Sometimes, woman hesitate to share details regarding her body,
which
is something that is extremely personal to her and has to be shared in public in front of many
health
professionals and “strangers” as well who are either accompanying a patient or are patient
themselves, sitting inside the doctors chamber.
The woman visiting this clinic mostly wore traditional attire in accordance with their
religious
belief. Muslim women mostly wore burqa and other in salwar kameez or saree. Husbands
who
accompanied their wives mostly stayed outside the main waiting area and entered as soon as
the
doctor called their wives for consultation. The woman interacted with fellow patients and
indulged
in small informal talks. Since it took a long time for each patient’s turn to come, such small
gestures
allowed them to pass their time.
Queen Mary Hospital, a public health institution, where I went in as a quasi-participant
observer
made the following observations. After the registration, the patients are usually asked to wait
in
the waiting hall, where a nurse takes their registration slip and guide them to the room where
they
had to consult a doctor. The room no. 2, i.e. the gynecology OPD had 2 senior resident
doctors,
who were carefully examining the patients and writing their prescriptions with senior doctors
taking rounds. The entire hall is usually full with ladies. Women felt comfortable while
discussing
their issues openly as the entire room has only woman present. Woman belonging to various
socio
economic background visited the hospital, but majority of them were from lower middle class
or
poor section of the society. Woman belonging to the most marginalized section had little or
no
clue about their body and its processes. It becomes very difficult for the doctors to take their
medical history because as simple things like year of their birth, details about menstruation
cycle
are completely unknown to these women. Lack of formal education and limited awareness is
a
reason for such ignorance. As the public health institutions charges little or no fee, it becomes
easy
place for access for woman of most marginalized section, but their limited or no awareness of
their
bodily functions act as barrier in providing adequate health services. While interacting with a
doctor, I learnt that they try avoid giving contraceptive pills or any form of medication for
familyplanning to the illiterate woman as they fail to count the days as to when and how
many tablets are
to be taken. There is a huge unmet need too, but it is not because of non-availability of
methods of
contraception alone, but it is because of the limited knowledge that woman have about these
methods.
The “gendered nature” and “power relations” between patient and doctor.
On entering the main chamber, the doctors was surrounded by 2-3 patients and few patients
waiting
for their physical examination to be done behind the curtains. The cycle of patients entering
the
chamber is like a process where one patient goes out, two patient enters, on entering one
patient
stands near the door and the other sits on the chair next to the patient already waiting for their
turn
as the patient sitting on the examination stool kept right next to the doctor is getting attended
by
the doctor. One can feel a sense of achievement when the staff calls out their name to get
inside,
it is like getting an “entry” to a holy place! The entire process of registration and then waiting
to
get attended is itself an experience.
Finally when the patient gets to sit on the examination stool, the doctor asks various questions
to
the patient in order to get an accurate medical history of the patient. There were many woman
with
blank faces and were clueless about their own bodily functions like their last menstrual cycle,
if
any irregularities experienced in the cycle etc. which shows the awareness level of woman.
The
woman were mostly very hesitant in talking about their problem, for a very personal event
like
pregnancy or planning for a family, which is a very sensitive area and is extremely personal
requires more of elements like comfort, private space with polite communication. But in the
clinic
there were 3-4 patients present in front of the doctor with 2-3 patients lying inside the
examination
room waiting to get examined. Sometimes, the woman felt hesitant in discussing about her
issue
in the presence of strangers who were non medical staff. Sometimes in the room, husbands of
other
patients were also present, presence of the other gender, further made them uncomfortable.
Sometimes, while dealing a sensitive issue like infertility of a couple, the men too faced an
embarrassing moment, when other patients stared at the couple with uncomfortable looks. For
the
medical institution, these woman were reduced to “mere” clients who came to seek a service.
This
highly objective, inorganic atmosphere of the clinic acted as a barrier for a woman in
expressing
her concerns to the doctor. The patriarchal societal structure of North India itself socializes a
woman to become submissive and compliant. Woman easily “obeyed” the advices given by
theGynecologists and never questioned or raised any doubts. They mostly nod their heads to
the
advice of the gynecologist, this reflected the gendered nature of patient and doctor
relationship.
There is a paucity of qualified gynecologists, in the entire clinic only one doctor was a
qualified
gynaecologist, others were either nursing staff or doctors having a degree in alternative
medicines
like Ayurveda, Unani etc. The gynecologist herself confessed that she is overworked and this
is
visible in her interaction with the patients as she gets irritated easily and fails to empathize
with
the patients.
In the public health institution, i.e. Queen Mary’s Hospital, the dynamics of patient doctor
relationship is quite different compared to the private clinic. Since it is a public health space
and a
part of medical university, there is dedicated department solely to gynecology and obstetrics,
which is visible by presence of ample amount of specialists, senior doctors, senior residents
etc. It
is a non-profit making body which takes minimum fee for consultation attracts patients from
all
socio economic backgrounds, particularly from poorer sections of our society. The OPD has
many
senior resident doctors attending the patients and doing primary examination, they are
watched by
senior doctors and hence are very careful in diagnosing the condition. This structure often
benefits
the patients as they get a thorough check-up. Senior residents show best of their behavior as
they
are being watched by their professors. Apart from the power relation between doctors and
patients,
there also exists a power relation between doctors themselves in a public health space,
particularly
a medical college.
Role of “Husbands” during their visits to Gynecologists.
In this clinic, I noticed that most woman were accompanied by their husbands, especially
those
woman who were either expecting or planning their families. The patriarchal superiority of
husbands and their superiority over their wives were clearly visible, the unequal power
relations
were captured very well during my visits. On entering, the men usually initiates the enquiry
at the
reception counter, followed by inputs given by woman, later men “looks” and selects for
place for
the woman to sit and then they went out to stand outside the clinic to interact with other men.
On
being called out the woman signals their husbands to come inside. In one such, while I was
asking
woman whether they would like to volunteer for the study, I approached a couple, who got
married
recently. The lady agreed to contribute to the study and i took her inside a “counselling
room”which had been allotted to me to collect data and interact with the patients. After
sometime her
husband came in searching for her and took her back to the waiting area, after waiting for few
minutes I went the the waiting area looking for my respondent, she came and whispered in
my ears
that she cannot come with me as her husband is “not allowing” her share the details. This
clearly
showed the kind of control men have over woman even today. In another case, while I was
observing the doctor-patient relation inside the main chamber, a muslim couple were siting,
with
the wife completely covered in “burqua” the husband was responding to most of the
questions,
the wife was slowly whispering the responses and husband was telling them aloud to the
doctor.
Similarly, when the doctor advices about some contraception like insertion of a Copper T or
IUD,
the first reaction of the woman is either they will look towards their husband if he is present
or
pushes the decision for future and tells the doctor that she will ask her husband and then
decide.
This “authoritative” position that men hold in patriarchy gets reinforced and reproduced
within
these spaces.
Although, men were not allowed inside the OPD of the public health facility, but their role
was
still visible when it comes to decision making by woman for her own “body”. When the
doctor
advices to insert an IUD or get sterilized, they mostly could not agree with the doctors
decision
and had to push it for the next visit as they needed time to consult their husband’s or family.
This
shows the weak agency of woman towards her own physiological needs. After a
“professional”
advice, another “authoritative” permission had to be granted for further procedure.