Contraceptives, but not for singles
As a community resource person (CRP) couple in Chakpahar village in the Morwa block of Samasthipur district in Bihar, Sanjay Giri, 30 and his wife Sunita Devi, 28, have the challenging task of visiting young couples from conservative rural communities to discuss new family planning methods to delay having their first child and have the second one after a gap of three years.
In a community where women get married young and there is pressure on the newly-weds, especially women, to prove their fertility and give birth to a son immediately after marriage, discussions around contraception are often dismissed as new-fangled notions promoted by city folk with no understanding of rural cultural practices.
“Almost all women get married by the age of 20 and have their first child by 21. Women are disempowered unless they have at least two children and at least one son. If they don’t have a child in the first two years, she risks being declared “barren” and being sent back home so her husband can remarry,” said Dr Narottam Pradhan, technical director, Project Concern International (India), which runs the JEEVika technical support programme using CRP couples like the Giris to increase the use of spacing methods of family planning since December 2017.
After mapping households and identifying married couples in the reproductive age of 15-49 years, CRP couples begin visiting homes to discuss methods to improve family well-being. “Instead of contraception, we focus on ‘khushaal parivar’ (prosperous family) and begin by talking to the family elders about poverty alleviation, health and nutrition over four or five visits. Once they accept us, we talk to the family and the young couple about how having fewer children lowers poverty by keeping the land undivided, keeps children healthy and reduces household expenses. It’s only then that we tell them about the many contraception options available free to delay and space birth,” said Sunita, who is a mother of three. “I didn’t know better, no one told me about these things,” she said. The couple earns ₹1,400 each every month for counselling families.
With India hosting Partner’s Forum on The Partnership for Maternal, Newborn and Child Health in New Delhi on December 12-13 to accelerate multisectoral community-oriented innovations and best practices for best results, the spotlight is on projects like JEEVika CRP couple counselling. Data from Project Concern International India’s pilot in Morwa block from December 2017-May 2018 showed couple counselling increased the use of modern methods of family planning from 6.18% to 14.63%.
“The availability of modern methods of contraception is not an issue and the environment is enabled, but hesitation exists. Male hesitation is higher, if someone mentions contraception, they laugh and turn away,” said Dr Pradhan.
Fertility decline has been the slowest in Bihar, which is the third-most populated state with a population of 110 million. Bihar is the only state in the country where couples on average continue to have more than three children, which had led the state’s total fertility rate (TFR) —the average number of births a woman has in her lifetime – stay at a high 3.4, according to National Family Health Survey-4, 2016. India’s TFR is 2.2, with the urban India and 18 states having fertility rates below the replacement level of 2.1, which is when the population stops growing.
India’s 253 million adolescents, who now account for more than one-fifth of the population, are still not included in discussions about sexual and reproductive health and rights. “I once asked Asha didi (village health worker) why some unmarried women have children and some don’t, and she complained to my mother that I was shameless,” said Beena Rai, 15, from Shankarpatti village in Patna.
“We don’t talk about contraception with unmarried girls and boys, these things don’t happen in our village,” said Sunita Prasad, an Asha from Behrohkhra village in the Tajpur block of Samisthipur in Bihar.
Soni Kumari, 45, herself a JEEVika couple counsellor, was too embarrassed to discuss family planning with her 20-year-old daughter Rupam Kumari, who got married in October.
The age at which a woman gives birth affects her health and the health of her child. “One in three babies are born to adolescent girls, who are not physically ready for childbirth,” said Dr Jaideep Malhotra, president, Federation of Obstetric and Gynaecological Societies of India.
In India, 42% of under-5 deaths occur in children born to mothers under 20 years old, compared to 33% for children born to 20-29 years old mothers, according to National Family Health Survey-4 (2015-16).