Perhaps the only thing worth paying attention to in the TFR story is that the overall decline has been championed and led by Muslim women. Clearly inclusion and education for minorities (and all people) can have positive development outcomes.
By Varna Sri Raman
While there has been widespread celebration about India reaching our Total Fertility Rate (TFR) goals — there are enough and more reasons in the NHFS 5 data to demonstrate that we should be worried about the worsening health outcomes, for women in particular. The TFR is the average number of children born per woman at which a population exactly replaces itself from one generation to the next without migration. There is actually very little to celebrate. India now has five states which are well and truly above replacement levels – these are Bihar, Jharkhand, Uttar Pradesh, Meghalaya and Manipur.
Since India started its population control program in 1950s, Uttar Pradesh and Bihar have been India’s most populous and most fertile states. Nothing much has therefore changed – if India’s overall TFR has fallen it has little to do with the success of population control efforts where they were most needed. The longer-term outcomes and benefits of a falling TFR have had more to do with gains for women in states that were already doing well on the TFR front. So how and why has India’s population programme continued to fail in Jharkhand-Bihar (erstwhile Bihar) and Uttar Pradesh?
Lack of improvement in TFR
Table after table in the data of NHFS-5 shows that awareness of contraception among women and even availability of contraception is not a problem per se, however the use of contraception is abysmally low. The answer has to do with investments in education and agency/bodily autonomy for women in these states. Here are some more statistics that are worth looking at from the NHFS which are as misleading as the national-level TFR, because the devil is in state-level details, in a union/federation of states like India.
For instance, the rate of underage marriage has fallen marginally (not statistically significantly which means the reduction could be an artefact of sampling or data collection) at a national level, but the rate has increased in Punjab, West Bengal, Manipur, Tripura and Assam all states with historically high levels of child marriage.
Even if one wanted to celebrate the TFR story and we really do need good news in this country – what does the data show? 66.3 per cent women who are employed use a modern contraceptive method, compared with 53.4 per cent women who are not employed, and contraceptive use increases in communities and regions that have seen more socioeconomic progress.
Employment to contraceptives
The data also shows that the “unmet need for family planning methods” is highest among the lowest wealth quintile (11.4 per cent) and lowest among the highest wealth quintile (8.6 per cent), it also tells us rather unambiguously that the use of modern contraceptives also increases with income from 50.7 per cent women in the lowest wealth quintile to 58.7 per cent women in the highest quintile.
India’s Periodic Labour Force Survey (PLFS) data shows that participation of women in the labour force is declining. Women’s withdrawal from workforce can potentially affect the use of contraceptives among population. Women from economically backward classes and states with poor record of facilities, rights, social norm regimes and social environment are also least likely to be able to access and use modern contraceptives. NHFS also tells us that Bihar, Uttar Pradesh, Rajasthan, and Jharkhand have less than 18 per cent of women paid for their work and no more than 50 per cent women in these states have access to phones. Getting paid and having access to phones, as many studies suggest facilitate autonomy for women – both of over their bodies and their lives by facilitating access to contraceptive use, financial services and support networks.
Falling health indicators for Indian women
Meanwhile, the Sex Ratio at Birth (the number of girls born for every 1000 boys) for children born in the last five years is below 950 for seven states and is below 900 in three states, viz., Goa: 838, Himachal Pradesh: 875, and Telangana: 894, the largest decline has been in Goa (from 966 to 838. A look beneath the national TFR rate story and you find, for instance – that the onus of family planning is still on women. Earlier it was through methods like Copper-T and now through female sterlisation practices as shown through latest NFHS data. It shows that burden of family planning disproportionately falls on women.
Domestic violence against women is highest in Karnataka at 48 per cent, followed by Bihar, Telangana, Manipur and Tamil Nadu. Three of every five women in India are anaemic (57 per cent of all women aged 15-49 years) and this has gotten worse over time. Iron deficiencies are problematic not just for instrumental reasons (reasons that affect maternity and a foetus) but also for women and their own health and well-being.
Inclusion and education
The NHFS also shows a rise in health and nutritional disorders for women, more when compared to men, 24 per cent of women and 22.9 per cent of men were found to be overweight or obese (BMI ≥25.0 kg/m2), which is 4 per cent higher than in 2015-16.
Further the NFHS shows that the average out of pocket expenditure (OOPE) on a delivery in a public health facility increased in more than half of the surveyed states. Meanwhile the use of hygienic menstrual materials for periods is at 59 per cent in Bihar and at 66 per cent in Assam and Gujarat. Water and Sanitation outcomes are also poor and affect women disproportionately. We now know that nearly one in five households in India practise open defecation despite the PMs declaration that India is now ODF free nearly two years ago.
Perhaps the only thing worth paying attention to in the TFR story is that the overall decline has been championed and led by Muslim women. Clearly inclusion and education for minorities (and all people) can have positive development outcomes. We just need to actually get started on development work, instead of patting ourselves on the back on account of a broader secular demographic trends.
Varna Sri Raman is a researcher based in New Delhi. She worked with the Research and Knowledge Building team at Oxfam India.
Image: Hippopx, licensed to use under Creative Commons Zero – CC0
