It was the cusp of winter and summer in Jhalawar- February 2018. I was looking forward to the field trip this time, especially after the long hiatus. The country side is always refreshing. New ideas come to mind effortlessly, and one feels completely rejuvenated. It is also a good time to take stock of strategies/activities that the government is implementing or we, as an organization are supporting. More often than not, it is gratifying to know that your efforts are in the right direction, while sometimes it makes you sit up and question whether things are really going the way you had envisaged.
I was visiting a Village Health and Nutrition Day[1] (VHND) at an Anganwadi Centre (AWC) in Khanpur block of Jhalawar. The Auxiliary Nurse Mid-wife (ANM) was carrying out her routine activities like immunization, ante natal care, etc. Intermittently, young children below 6 years were being weighed. Little babies, oblivious of what was coming cooed and giggled in their mothers’ arms until a sharp needle was thrust in their tiny bodies. Then came the shrilling cries, which were silenced soon after the mothers put them to their breasts. Mothers who came for the first time did not know the trick to calm their children. However, the ANM was quick to advise.
Visit to the AWC, for the women beneficiaries, who attended the VHND, seemed like an outing. All of them were dressed in their fineries, replete with accessories and make-up- kohl, lipstick and in some cases even rouge! At the fag end of the session, a young woman came in to ask for medicines for her child who had fever. Let’s call her Raveena[2]. The ANM asked the child’s age and gave two tablets with precise instructions for use. As soon as Raveena left, the ANM proudly mentioned that she was able to convince the young woman to undergo sterilization as she already has three children.
I had noticed Raveena- she was fair with light eyes- uncommon in this part of Rajasthan. She did not appear to be more that 22-23 years old. And, she was sterilised. I asked the AWW about her age. The response was a lot of other information but her age. Apparently, Raveena had a child marriage. When she came of age, her parents married her off to a much older man for money, in May 2013. She had her first child in May 2014, the second one in September 2015 and the third one in July 2017. The ANM thought that at this rate she would get pregnant again (as her youngest was weaning). Hence, the best option would be to convince her for a permanent method. And Raveena relented.
Though the government of India offers a basket of contraceptive choices (the most recent entrant being the injectable contraceptive), data shows that couples prefer permanent methods (sterilization) over temporary methods. It is largely female sterilisation (36%) while male sterilisation is almost nil (0.3%). Reasons range from fear of losing virility to inability to do strenuous work, even when the procedure for males is much simpler (without anaesthesia) and quicker. The recuperating time is also much less in case of males.
In villages, the primary responsibility to promote contraceptives rests with the ANM and ASHA. They are incentivised for uptake of contraceptive methods which is skewed towards permanent method and long acting methods (IUD- Intra Uterine Devices- primarily for spacing between children). So, the natural tendency is to promote the method that gets higher incentive. Similarly, the beneficiaries are also offered cash incentives for undergoing sterilization. The incentives for men are double of what a woman receives. Yet the numbers tell adifferent story. A general rule followed is that only couples who have completed their family should be counselled for adopting a permanent method and only if the last child is above a certain age. This is to enable the couple to have children if something untoward happened.
The following day was earmarked for data integration between the three front line workers – ASHA, ANM and AWW of a village in Pirawa block of Jhalawar. I started probing the ANM about the age of women who have been recently sterilized. She said that young women are choosing this method even after one child- given that it is a boy. They do not prefer other methods and their husbands refuse to use any protection- temporary or permanent. I asked her what she thought about the trend- very young women getting sterilized. “Madam, I have three villages in my jurisdiction. In each of these villages, I have a case where the woman had got sterilised after the first child and all three of them have lost their only child. One was less than a year old, who fell into the well. The other two were bitten by snake- a toddler and a seven-year-old. I got to refer all of them for reversal procedure. All these women are in their early-to-mid-twenties.”
Adoption of contraception, especially by women, is empowering as we all know. It enables them to be in control. However, it seems that it is also important to choose the right method at the right age. Else, it may be disempowering. In our effort to increase uptake of family planning methods, we must not lose sight of long term socio-economic effects on the woman and her family. Let’s take Raveena’s case. What if, God forbid, something happened to her husband? She would find it difficult to remarry. Or if she lost a child? The eldest one is not even four. In other cases, what if the reversal surgery is unsuccessful? Will the couple reconcile to being childless for life or would the husband remarry (and leave this woman)? What happens to the woman- no one would want to marry her given that she cannot have children? Will she have the wherewithal to fight the situation and take care of herself? It is agonising to even imagine what such women might have to go through.
This, to me is a peculiar situation- all stakeholders- beneficiary, service provider, beneficiary’s spouse and family and the government, all seem to have taken a step in the right direction without realising the risks involved. We need to watch closely and prevent such a situation to arise. We need to begin early- delay the age of marriage, delay the first pregnancy, encourage use of long acting methods to space children and/ or till they are of a certain age and then propose a permanent method, if needed at all. The workers at the village level need to be reoriented accordingly so that their interactions range from unmarried adolescents to their parents to couples who have completed their families.
Last, but not the least. We often tend to ignore the needs of men- their queries need to be addressed. They need to be motivated too- preferably by men who have undergone the procedure themselves. Our approach needs to be more inclusive of men. A mechanism to involve fathers and husbands needs to be devised to have a more effective family planning program.
[1] VHND is a pre-fixed day of the month when the ANM provides mother and child health services at the AWC of the village. Beneficiaries are identified by ASHA during home visits through the month.
[2] Not her real name.
Priyadarshini Roy was Director-Programs with the Antara Foundation
Disclaimer: The article has been written in personal capacity, and the views and opinions expressed are those of the author