The narrow streets around Masjid Chowk in the heart of Mushahari block in Muzaffarpur district of Bihar lead to a nondescript ‘basti’ inhabited by poor Muslim families, most of whom are engaged in fashioning colourful lac bangles to make ends meet. Those who are not involved in this traditional trade work as daily wagers or autorickshaw drivers. Incomes are paltry and the burden of running households falls on the frail shoulders of local women.
Take Mehmooda Khatoon. She is 26 but looks as if she has already spent a lifetime in struggle. Up at 5 am she sends off her husband, an autorickshaw driver, to work by 6 am after which she wakes up her three children. The eldest, a boy, has to be dressed for school even as the younger two – a four-year-old daughter and a toddler – vie for her attention. Mornings melt away in chaos but Mehmooda not only attends to the trio patiently she ensures that all the household chores are done.
Although Mehmooda seems to be in control of her life, she has a few regrets, particularly over the fact that she became a mother very young. “I didn’t know how to prevent pregnancy and within a space of two years I was mother to two,” she says. Only later, a neighbour told Mehmooda, who is illiterate, about the oral contraceptive pill. By then, she had three children to raise. “In these tough times, with our meagre income, it’s a strain to provide for so many children. I want them to study well. So when I found myself pregnant for the fourth time I decided to visit a private clinic in the area to get a safe abortion, and followed it up with a sterlisation about a year ago,” she reveals.
Like Mehmooda, Shameeda, who is in her early-thirties, had no idea about contraception. Although she had heard about the condom from a married sister she was hesitant to ask her husband to use one. “We can’t talk freely with our ‘shohar’ on these matters,” she says. Within eight years, she gave birth to five daughters. This visibly anaemic woman, who has never been to school, has now undergone sterlisation to control her family size. Shameeda’s and Mehmooda’s situation underlines a phenomenon known as “unmet need” for family planning. Unmet need is the percentage of women who want to avoid a pregnancy but are not using any kind of contraception.
The National Family Health Survey (NFHS)-III data reveals that in India nearly 13 per cent of currently married women fall in this category. In fact, the United Nations Population Fund (UNFPA) pegs the country’s unmet need at 28 million, accounting for over 10 per cent of the global unmet need. Pregnant or amenorrheic women too come in this category if their current or most recent pregnancy was unwanted or mistimed and they were not using contraception. The NFHS-III shows that younger women (15-24 years) have a greater unmet need for spacing than for limiting even as the total unmet need varies from state to state. For instance, it’s 8.5 per cent in Andhra Pradesh (District Level Health Survey – III), 19.6 per cent in Rajasthan and as high as 37 per cent in Bihar.
Addressing unmet need can be one of the crucial ways to empower women and ensure family well-being. In 2006, it was added to the fifth Millennium Development Goal (MDG) as an indicator for tracking progress on improving maternal health because family planning can effectively decrease maternal mortality by reducing the number of pregnancies, abortions and high-risk births.
But pushing down the numbers has been challenging. Particularly for a state like Bihar, from where Shameeda and Mehmooda hail. Says Sanjay Kumar, Bihar’s Executive Director of the State Health Society, “Bihar has the highest unmet need for family planning in the country at 37 per cent.” This means that one-in-three or four women here has an unmet need for spacing and limiting methods. In fact, as per Bihar’s Annual Health Survey 2010-11, 35 of the 37 districts reported less than 50 per cent usage of any contraception.
Consequently, the state’s Total Fertility Rate (TFR) is 3.7, which means that every married couple on an average has a minimum of three children. Low levels of education, under-age marriages and gender disparity combined with factors like poor health infrastructure and service availability, and a family planning programme centred on female sterilisation, has ensured that women here find it difficult to take control of their own fertility.
Kumar emphasises female literacy, “Data shows that the TFR of women who have had 12 years of education, whether in Bihar or the rest of the country is the same – 1.6. But when one looks at illiterate women, their TFR in Bihar is 4.5 as compared to 3.4 elsewhere. So there is a strong correlation between the two.”
Patriarchal attitudes add to the problem. Strong son preference compels many Indian women to bear children until they have a son. Divya, 26, from Naungaon, a tiny village in Dharampur block of Himachal Pradesh’s mountainous Solan district, fell into this trap. The young woman has four children – three daughters and a son. Lack of information on contraception led to her becoming a mother of a daughter immediately after her marriage at 16. Another three children followed, leaving her with little time or energy. She says, “At 26, I am a mother of four. If I had known about contraception I could have ensured adequate spacing between my children. It would have given me an opportunity to take care of them and myself properly.”
After Divya had her first daughter, her mother advised her to go in for another – she was only 18 then. “She told me that if it was a son then I could complete my family. My second child was also a daughter. I would have been okay with two children but in our society women have to produce a son,” she says. The fear is they would be deserted by their husbands if they did not have a son. Divya is now considering going in for sterilisation.
In a state like Himachal, where the TFR, at 1.8, is already well below the replacement level of 2.1, the District Level Health Survey III (2007-08) puts the total unmet need for contraception at 14 per cent. This figure has increased by two per cent since the last DLHS-II. It also indicates that the use of modern spacing methods is relatively poor – a fact confirmed from Divya’s account.
Says Subhash Mendhapurkar, Director, SUTRA, a non-government organisation working on women’s issues, “If one looks at the NFHS and DLHS data, the percentage of unmet need has increased. Yet, the only procedure being stressed is sterilization, which still forms the bulk of the family planning procedures done in Himachal.” Along with Population Foundation of India (PFI), SUTRA is working on ensuring reproductive rights of women, including advocacy of adoption of non-terminal methods of family planning.
Mendhapurkar believes that it is time for a shift in strategy. “I see great possibility in the Intra Uterine Contraceptive Device (IUCD) because it’s a reversible method. The female condom is another alternative.” Adds Sanjay Kumar, “Why should a 24-year-old woman go in for a permanent method in any case? In Bihar, we are planning to concentrate on IUDC, as it is acceptable across faiths. In Araria and Kishanganj districts where there is a sizeable minority population, women inquire about IUCD services.”
Ultimately, it is about expanding women’s choices. If a woman wants has access to modern contraception, she is certainly in better control of her body, her life. As Rekha Masilamani, well-known reproductive rights activist, puts it, “No talk of women’s empowerment can be done without ensuring women’s right to contraception.”