The influence of reproductive autonomy on social and economic health of India

Aligning with the theme of World Contraception Day, 2023 “The Power of Options,” India successfully introduced newer contraceptive this year and expanded the basket of contraceptive choices under its National Family Planning Programme. On the backdrop of a much celebrated G20 tenure of India and the landmark passing of a women’s reservation bill by Indian parliament. Dr Vandana Dabla, Advisor– Monitoring, Evaluation & Research and Dr Abhijeet Pathak, Chief of Party & Country Lead- Family Planning, Gender and Youth, Jhpiego India share some insights into India’s efforts in the domain of family planning and how the contraceptive choices enable people to take control over their reproductive health- in service of their economic and educational aspirations specifically from India’s women and young people

India’s commitment towards universalizing equitable healthcare is well known, as evident from the largest universal healthcare program in the world (PMJAY) and the largest school health & wellness program in the world. But these large programs related to medical and tertiary care should not let us forget the country’s systematic efforts in the field of reproductive health and family planning (FP). In 1952, India became the first country in the world to launch a nation-wide Family Planning Program- which then was limited to 5 contraceptive options: three spacing methods [combined oral contraceptive pills, condoms, and intrauterine devices (IUDs)] and two limiting methods (male and female sterilization) – with an undue and unfair focus on the later. Since then – India has achieved a sub-replacement level fertility and is now pivoted its FP program to one that addresses the needs of its young people, its women – as an instrument of unlocking their potential and in service of the economic aspirations of the country and its people. Having made remarkable commitments in the London FP summit (FP 2020)- and more remarkably – having achieved them; FP2030 commitments made by India in 2022 are equally ambitious and as a part of that 2023 marked a significant step with the introduction of Single Rod Sub-dermal Implants (referred as implant in this article) and the new sub-cutaneous DMPA injectable; which was on the backs of a similar introduction of reversible methods in 2017-18 ( DMPA IM and the local Indian made- non steroidal weekly pill was introduced in the public system as part of Mission Parivaar Vikas )  

For long, the National FP program of India was oft criticized for its excessive focus on numbers and its treatment of its clients, its target driven and prescription-based approach – but the last 5-6 years have changed that completely. The launch of new methods – which are reversible in nature – points to the progressive thinking that now prevails in the policy-makers, who no longer perceive Family Planning only as something that helps reduce the number of children born to a couple – but actually now see FP as a way of unlocking the potential of human capital in India. Reversible methods such as those 4 introduced in the last 5 years by GoI – are used to delay first births, space subsequent births and even used by those who do not want more children. Newer methods such as Implants are adding choice to the “Long Acting” category of contraceptives where India only had IUDs.  These introductions in Mission parivaar vikas – were also accompanied by demand side interventions such as a design innovation to meet newly weds (called nayi pehel kit is designed as a gift for newly weds and triggers a conversation with the ASHA), newer IEC campaigns which do not contain health based messaging but focus on themselves such as educational attainment, financial freedom and even pleasure and companionship as entry points to give messages on contraception. All these evidences hints at a more matured national FP program of India; and is now empowering young men and women to have children when they want in keeping with their life plans and plans for education, livelihoods and economic situations.

India has also been monitoring its progress through indicators such as – unmet need for FP- through National Family Health Survey (NFHS) for last three decades. Initiated in early 1990s, the first NFHS was conducted in 1992-93. Since then, country has successfully completed NFHS-2 in 1998-99, NFHS-3 in 2005-06, and NFHS 4 in 2015-2016. The fifth round of NFHS fieldwork was conducted in two phases; one from 17 June 2019 to 30 January 2020 and phase two from 2 January 2020 to 30 April 2021.

And we are seeing results. NFHS5 revealed a massive jump in contraceptive prevalence driven mostly by reversible methods. Just the DMPA IM introduction is estimated to have caused a jump of 0.8 per cent in the countries mCPR value. Although the significant reduction in the unmet need by more than 50 per cent over the past three decades (19.5 per cent in NFHS 1 to 9.4 per cent in NFHS 5) has clearly established the unwavering commitment of the program towards its goal; the unmet need among the young population (age 15-29 years) has always been more than the national average. As this young population moves through their reproductive health, it is important to now move from a Youth-friendly program to a youth -responsive one; from a gender sensitive program to a gender transformative one.

India is at the cusp of this change -rising  age at marriage, higher levels of women’s education, increasing wealth index, media exposure, digital inclusion at a rate never seen before in the world coupled with financial inclusion of women; couples reporting health care decision making together without influence of others, saturation of knowledge about family planning methods, and reducing inter-personal violence with an increasing  young demographic profile, which is aspirational and interested in quick economic mobility are all factors that will help India take the next big leap in its FP indicators. The caution is that India requires a more intensive and strategic lens to explore the intersectionality of gender and its program and the overlapping space of youth and reproductive policy. 

These increasing choices will not just reduce the maternal and perinetal morbidity and mortality among women of reproductive age, the resultant increased reproductive autonomy among these women- is what India is banking on for the reduction of in its gender inequities , increase in workplace participation by women , increase in their economic contributions and savings all of which will contribute to the stated goal of a 5 trillion Indian economy by 2025.  Reproductive autonomy is critical in empowering women to control their lives, reproductive health and pursue their educational and career aspirations.

Of course, there are still glaring blind spots such as the private sector which is the largest source of reversible contraception for young people; or the role of men and traditional method use (NFHS5 reports that traditional methods are the fastest growing FP method in India) as well as strategic use of its million strong front line workforce; even the provider biases in a system as medicalised as India  – are all challenges that the National FP program is now working on.  It is important to work on these issues to ensure that the oldest FP program in the world, demonstrates how without coercion, a country can transition from a fertility focused program led by fears of population; to a  truly gender transformative and youth responsive program being driven by the aspirations of its demographic dividend, in service of not just health but an impact that is intersectional, towards educated, empowered and economically strong families leading India into a decade it can rightfully call its own .