Driven by male reluctance, contraceptive use falls, population surges

Over the eight years to 2016, as India’s population surged, the use of contraceptives declined almost 35 per cent, even as abortions and use of emergency pills — both with health hazards and side effects — doubled.

Despite a 14 per cent percentage-point rise in literacy in the decade to 2011, hazardous birth-control measures of the last resort are becoming the first choice among both poorer and wealthier, better-educated Indians.

The result is that the country’s population, now estimated at 1.32 billion, is expected to surpass China’s in the next six years and reach 1.7 billion by 2050, even as millions of women die from unsafe abortions.

While condom use declined 52 per cent over eight years and vasectomies fell 73 per cent — indicating greater reluctance among men to use birth control — the use of oral birth-control pills fell 30 per cent, Health Ministry data showed.

Compared to 300,000 men who agreed to vasectomies in 2008-09, more than 5.5 million women agreed to use intrauterine contraceptive device (IUCDs) to avoid pregnancy the same year. Over the years, the number of women resorting to these devices has remained steady.

‘People think that women should undergo everything,’ said Nozer Sheriar, deputy secretary general of the Federation of Obstetric and Gynaecological Societies of India (FOGSI).

The government is trying to expand contraceptive choice and use, Health Minister J.P. Nadda — referring to the forthcoming launch of controversial injectable contraceptives for women in the public health system — said in January 2017. Greater contraceptive use allows births to be spaced better and reduces the chances of accidental pregnancies and population rise.

Does the use of conventional contraceptives correlate with literacy rate? That is not clear. Indeed, there is some evidence that the opposite is true.

For instance, Karnataka’s literacy rate (75.6 per cent) is higher than than the national average of 74 per cent. Yet the state is among the top five of those that reported the highest drop in vasectomies, IUCDs and oral-pill use.

In Bihar, with a 73 per cent male-literacy rate (overall 64 per cent), the use of oral pills rose four times and the use of condoms doubled between 2008 and 2016. In Kerala, where 96 per cent of men are literate, condom use dropped 42 per cent.

While Indian men believe that condoms reduce sexual pleasure and vasectomies rob them of their manhood, women have concerns about the health impacts of IUCDs and oral pills, said Umesh Kulkarni, part of the training team of Ipas, an NGO that tries to prevent death and disability from unsafe abortions.

Over a decade to 2016, in 10 of 14 states surveyed as part of the National Family Health Survey, 2015-16, use of any modern method of family planning among women of childbearing age (15 to 49) decreased six per cent, despite a greater awareness of birth-control methods and an improvement in family planning services.

So, why is contraceptive use falling? The government’s ‘aggressive approach’ — with doctors in public-health centres given targets and incentives for vasectomies and IUCD insertions and government school teachers offered pay rises to push these family planning methods — is counter-productive, said Ipas’ Kulkarni, a medical doctor.

The growing reluctance to undergo vasectomies could be an echo of the wariness created by the hardsell. While 290,000 Indian men chose this permanent contraceptive in 2008-09, the figure for 2015-16 was less than 80,000.

Information, education and communication about male sterilisation is inadequate, said experts, not only in society at large but in the public-health system. The fall in use of condoms could reflect these inadequacies.

Condoms are a better option than other oral-contraceptive methods, but men are not keen to use them. Though 660 million condoms were distributed nationwide in 2008-09, that figure fell to 320 million in 2015-16. Andhra Pradesh and Madhya Pradesh recorded the highest falls of 83 per cent and 79 per cent, respectively.

Over the same eight-year period, the use of oral pills by women came down by 30 per cent. Tamil Nadu and Kerala recorded the highest falls.

As contraceptive-usage declined, sales of emergency contraceptive pills that check pregnancies rose 100 per cent over the eight years in question. While a million emergency pills were sold nationwide in 2008-09, the figure rose to two million in 2015-16.

As the name suggests, the emergency contraceptive pill should only be used when conventional contraceptives fail or after an unexpected sexual encounter takes place. If used often, these pills can disrupt a woman’s menstrual cycle, cause intermittent bleeding, and, possibly, infertility, said Ipas’ Kulkarni.

In 2007-08, no more than 8,958 emergency pills were sold in Haryana, the state with the lowest sex ratio. Eight years later, the number had risen to 128,000, a 13-fold rise. The number of vasectomies, IUCD insertions and condoms sold in the state dipped 34 per cent, 30 per cent and 32 per cent, respectively, over the same period.

The sale of emergency pills rose significantly in Bihar (1,305 per cent), Uttarakhand (724 per cent) and Jharkhand (383 per cent). In Tamil Nadu, where over-the-counter sales of these pills were banned in 2006, consumption more than doubled over these eight years.

When all else fails, Indians turn to abortions, in larger numbers than ever — as many as 2,500 abortions were carried out every day in 2016, doubling from eight years ago.

Compared with less than a million reported annual abortions, India logged sales of 11 million units of popular abortion medicines, mifepristone and misoprostol. More than 10 million women are estimated to secretly undergo abortions every year.

Abortions were illegal until the Medical Termination of Pregnancy Act (MTP Act), 1971, kicked in. Yet, 46 years later, abortion is still considered taboo, rarely discussed but clearly used by women to end unwanted pregnancies.

Quacks are often their choice for help with abortions. Wrongly done procedures by quacks were the third-leading cause of maternal deaths in India, Sheriar said.

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