I am a social demographer interested in population and fertility trends. As I am a faculty member based in a school of public health, I have an interest in social interventions that influence fertility levels, including marriage, abortion, and contraception. Most of my recent work has been based in Sub-Saharan African countries but I have an enduring interest in the population and fertility dynamics of South Asian countries as well. I largely collect and analyse survey data, whether of women of reproductive age, health facilities or clients.

Getting family planning care right at the societal level is a challenge for many countries, including the United States. Globally sexual and reproductive rights are often politicised and remain contentious even as contraceptive use becomes widespread. India faces several major challenges in family planning, the first of which is the prominence of female sterilisation as the most used contraceptive method and one promoted by the government. Although other methods are available (condoms, pills, IUDs [intrauterine devices, or the coil] and recently injectables), female sterilisation accounts for three quarters of contraceptive use. As a result, a second challenge is expanding contraceptive method choice, including vasectomy. Even though India has a history of providing the latter in the late 1970s, today while slightly over one third of married women are using female sterilisation, fewer than 0.5 percent report their spouses having a vasectomy. Other than condoms, there is relatively little use of other methods, especially for spacing births. A third family planning challenge for India is ensuring equity in couples having informed choice for all family planning decisions, whether to prevent unintended pregnancies or to achieve desired ones. Presently the more privileged segments of society enjoy access to such information and means.

Two areas come to mind, firstly Indias progressive record in legislation on elective termination of pregnancy since 1971, amended further in 2002 and, secondly, the transition in norms around family size to where the average women of childbearing age now has just over two births (2.2) and wants just under two births (1.8). Given there are nearly 370 million Indian women of reproductive age today and each has a mother who likely had two or more times that number of births, this transformation of fertility across just two generations is quite profound. Womens capacity to manage their reproduction has definitely improved. Regarding access to safe abortion, there is still progress to be made but the MTP [Medical Termination of Pregnancy] Act in 1971 preceded the legalisation of abortion in the US by two years. It is easier today for low-income couples to obtain medical abortion pills discreetly from private health providers in India than in the US. I suspect that with more constrained choice of contraceptive methods in Indialargely condoms and female sterilisationsome women have felt it necessary to seek out abortions to end unintended pregnancies as a consequence.

Certainly the Government of Indias national family welfare program, which is the oldest in the world, and implemented through the states has had a major impact on couples fertility levels, through the promotion of female contraceptive sterilisation use. While by no means perfect, the governments universal primary education scheme, along with parents own investments in private schooling for their children, has led to a dramatic reduction in the proportion of women under age twenty with no schooling. In 2015, the National Family Health Survey of nearly 700,000 households found 31.0 percent of females with no schooling compared to 41.5 percent ten years before. For female welfare, education and access to birth control are powerful drivers of empowerment.

I have brought in two colleagues into this conversation. We are collaborating on analyses of the National Family Health Survey data from 1992-93 to 2015-16 Dr. Abhishek Singh and Dr. Kaushalendra Kumar from the International Institute for Population Sciences in Mumbai. They note several government programmes, such as Beti Bachao Beti Padhao, Sukanya Samridhi Yojana and Pradhan Mantri Jan Dhan Yojana which have particularly targeted the girl child and women. BBBP focuses on states and districts in northern India where the child sex ratio at birth is very imbalanced (in favour of males) and seeks to raise awareness of gender equity. SSY encourages parents savings for young daughters education and marriage expenses. PMJDY has helped open bank accounts with no minimum deposits required to enable females and males to access modern-day financial services more readily. While these are all relatively recent initiatives under Prime Minister Modi, they have the potential to significantly improve educational opportunities for girls and women (and thus their employability) and transform their resource base. It will take time before the full impact of these schemes can be appreciated but they are steps in the right direction.

Imbalanced sex ratios, in the sense of more boys than girls being born over what is naturally expected, is a problem in China, South Korea, Taiwan and other places in Asia, although not to the extent as is observed in India. Social norms around male roles in society sustain the desire of couples to ensure a male heir among their offspring. Patriarchal customs can protect land ownership with only males having property rights. At the same time social norms evolve around female roles, such as high dowries commanded to marry daughters off, which lowers the value of females and enhance that of males.

Paradoxically, as Indias fertility rates reach replacement level (2.1 births per woman on average), the demand for sons appears to be increasing. It also appears to be strongest for first births and among the better educated females and wealthier couples. The challenge here is to reduce felt pressures by couples to bear sons and also expand opportunities to females to achieve economically and politically on par with males.

This is a very difficult situation to enforce because private conversations of couples around foetal sex are impossible to monitor and health providers are not permitted to facilitate any type of prenatal sex selection decisions of clients. While authorities will need to persist in enforcement where possible, the eventual solution requires a social re-valuation of sons and daughters until parity in gender value is achieved. The norms around son preference are changing and vary geographically across India; but private decisions can still aggregate up to revealing concentrated imbalances in sex ratios at birth at the national level.

I suspect the public is quite aware of gender preferences and discriminations against females. It will be important for social influencers, whether in government or civil society, to promote gender equality and neutralise longstanding opinions about the lesser rights and value of females. One transformative source of influence on public beliefs and opinions is mass media, particularly television and film and their associated celebrities. Positive modelling of the value of females and their lifelong contributions can gradually and permanently alter peoples beliefs and behaviors. India has tremendously talented actors, actresses and film producers who could appeal to the social conscience with strong visuals, story lines and re-balance gender preferences. This and continuing education of each generation can correct misguided thinking and actions.

It is very difficult to estimate the number of abortions, both unsafe and safe, in most countries. A recent study estimates nearly sixteen million abortions in 2015 with only one-fourth happening in public health facilities. Another study in nine Indian states suggests that as many as two thirds of induced abortions are unsafe. There are a number of reasons why unsafe abortions appear commonplace the sheer number of them given unplanned pregnancies resulting from unprotected sex, the legal status of abortions and relatively easy access to abortion means outside of the public sector, and the modest levels of contraceptive use for birth spacing, driven primarily by use of condoms, which have high failure rates. If a woman is not ready for permanent contraception and has limited knowledge of and access to other birth control methods, she is likely to experience an unplanned pregnancy and seek resolution with an abortion. Medical abortion pills are readily available from pharmacies and other private retailers. However, unless proper counselling and monitoring of the use of pills are provided, which often are not, such access is considered unsafe.

Lastly, even though a legal procedure, induced abortion often carries social stigma. Females are embarrassed to report seeking and terminating a pregnancy which means they often resort to informal abortion care or unsafe means.

I think the apparent rise needs to be first examined in terms of whether it is voluntary or involuntary childlessness that is increasing. Possibly it is both. Infertility has as its causes both male and female factorssemen quality, uterine structural issues from pelvic inflammatory disease, exposure to environmental chemicals and toxins and stress for example. A first challenge is to properly measure the prevalence of these conditions in males and females by which careful analyses can be conducted to determine the patterns and causes.

I am not knowledgeable enough about the Indian governments approaches but certainly a comprehensive national family planning program will address couples reproductive intentions, whether to space, limit or have desired births. This includes addressing infertility issues. Denmarks public health system, for example, supports assisted reproduction services (in vitro fertilisation) for women irrespective of marital status and sexual orientation and the proportion of births assisted with IVF is rising.

I would say yes. One finds few countries in the world, particularly with populations as large as Indias, where permanent contraception occupies such a prominent role as a means of birth control. Female sterilisation is favoured in Central America and China, but women there also use other methods. While female sterilisation is a terminal use status for many Indian women, they appear not to access other contraceptive choices as readily if they wish to space births. Striking is the extent to which female sterilisation has become the birth control option for less educated and low-income women.

The governments Family Welfare program has recently introduced two spacing methods Chayya, a once a week oral contraceptive pill, and Antara, a three-month injectable contraceptive. These offer protection against unplanned pregnancies to breastfeeding women and require minimal attention to use. These help complement the other government-sponsored methods. In addition, the government has been promoting immediate postpartum IUD insertions so that women can leave the birth facility protected with a highly effective method. With major surveys such as the National Family Health Survey conducted every few years, it will be possible to monitor the uptake of the new methods and observe how the family planning intentions of couples are being realised.

Nearly one in every five women on this planet is Indian (seventeen percent). Each of them deserves to be born a wanted daughter, be educated, live a healthy productive life and be a contributing member of society. India should not squander this human resource, which can potentially help accelerate the countrys future economic growth.

Amy O. Tsui, PhD is a Professor in the Department of Population, Family and Reproductive Health of Johns Hopkins Bloomberg School of Public Health and a senior scholar of the Bill & Melinda Gates Institute for Population and Reproductive Health.

Her research interests include family planning, fertility, and related health issues in developing countries and her current research is on the effects of various family planning and health service delivery models on contraceptive, fertility, and sexual health outcomes in sub-Saharan African and other low-income countries. She obtained an MA degree from the University of Hawaii in 1972 and her PhD from the University of Chicago in 1977. Among her honours are the Champion of Public Health award from the Tulane School of Public Health and Tropical Medicine, 2005; the AMTRA Award, JHSPH, 2006-07; the Golden Apple Award, JHSPH, 2009; and the Carl S. Schulz Lifetime Achievement Award, Population, Reproductive and Sexual Health Section from the American Public Health Association, November 2010.

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The challenge of getting family planning right: Professor Amy O. Tsui on sexual and reproductive health in India - Hyderus Cyf