Unmet need for family planning was added to the fifth Millennium Development Goal (MDG) in 2006 as an indicator for tracking progress on improving maternal health. Family planning has an important role to play in achieving the MDGs and ensuring that health is within reach for all people. But the health indicators of Madhya Pradesh show the path lagging far behind to achieve MDG with 13.1% of total unmet needs for family planning.
Contraception: Contraception is the deliberate prevention of the conception of offspring by any of various means. In general, birth control or contraception is anything that prevents a woman from becoming pregnant. The choice of contraceptive methods by couples for fertility control is one of the central issue concerning the reproductive rights & reproductive rights of women. Reproductive health addresses the reproductive processes, functions and system at all stages of life.
Reproductive Health: Reproductive health as defined by WHO is a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.
Unmet Needs of Family Planning: According to DHS (Demographic and Health Survey), a woman has an unmet need for contraception if she is fecund, sexually active and not using any contraceptive method, and does not want a child for at least two years. The concept of unmet need points to the gap between some women's reproductive intentions and their contraceptive behaviors.
Unmet need for quality reproductive health services is a grave violation of reproductive health rights, particularly of women & girl. Disparities in unmet need violate women’s and men’s fundamental human right to control their own fertility and choose the number and timing of their children.
Unmet need for contraception can lead to unintended pregnancies, which pose risks for women, their families, and societies. DLHS-3 [District Level Household & Facility Survey, DLHS-3; 2007-08 Ministry of Health & Family Welfare,Govt. of India] presents the grim portrait of government’s efforts to satisfy the family planning needs of fecund couples of 15-49 years of age. In Madhya Pradesh only 56.2% of currently married people under the reproductive age group of 15-49 years are using any method of contraception for controlling the fertility. The state has total unmet needs of 13.1%. Scrutinize of the prevailing circumstances of unmet needs of family planning is more terrifying in some of the districts in the state. For example the total unmet needs in Satna & Sidhi districts are as high as 30.5% & 31.4% respectively. Even Jhabua, Raisen, Chhattarpur & Sheopur district are having more than 25% currently married couples(15-49 years) having unmet needs of family planning.
"Unmet need" estimates include only married women of reproductive age & excludes unmarried girls, who are sexual activity (and therefore risk of pregnancy) varies greatly and is not measured. Unmarried youth who are sexually active represent a large and growing segment of the population.
Unmet need does not necessarily mean that family planning services are not available. It may also mean that lack of information about contraception, or that the quality of the services on offer does not inspire the necessary confidence, or that women themselves have little say in the matter. Cultural and family barriers to family planning also influence a couple’s decision to use contraception. Effective family planning programs should promote wider knowledge about the range of contraceptive methods and their proper uses.
“No Contraception”
Gayatri (24 years) was married around two & half years back with Thanedar Adivasi in Jhalar (the core village of Panna Tiger Reserve). Gayatri gave birth to a baby boy in the very first year of her marriage. And now when her first child is just one & half year old, she is 8 months pregnant for second time. Gayatri has become very anemic due to consecutive pregnancy. But Gayati & Thanedar do not have any knowledge about any contraceptive techniques. The only method they know about is the total abstinence. In fact this only method known by every couple for spacing & limiting their family in Jhalar Village.
But abstinence is not the solution to the unmet needs of family planning. It hampers the reproductive rights of couples. And this not the case in Jhalar only. But in number villages in Madhya Pradesh even young couples are ignorant about the FP methods.
Family Planning Needs for Spacing & Limiting: Needs of family planning methods of contraception can be needs either for spacing or for limiting the size of family. Unmet needs for spacing in Madhya Pradesh 5.5% & unmet needs for limiting is 7.6%.Spacing method of family planning is more popular because the couple can further plan to have child birth just by withdrawing the use of contraceptives. Spacing would naturally help reduce the momentum of population growth. It also ensures better maternal and child health, which in turn leads to better survival of children and so, diminishes the desire for larger families.
Among the spacing methods of contraception, Condoms are highly effective as it helps to prevent both pregnancy and sexually transmitted diseases (STDs). While the state government claims 87.6% achievement in addressing service needs of condom users & 68.7% for IUD users during 2007-08. But unfortunately as per DLHS-3, in Madhya Pradesh it is shocking that only 4.6% are currently using condoms as a family planning method. The situation is more critical in rural areas with only 2.5 current uses of condoms by married couples of 15-49 years age. This means about 95% of currently married population are at risk for getting infected with STDs. In rural areas of 31 districts has less than 3% use of condoms by the currently married couples under child bearing age. Even the two most developed districts of the state namely, Indore & Bhopal are just having 9.2% & 11.8% condom.
The rate of using an intrauterine device (IUD) 0.5% is almost equivalent to the use of Emergency Contraceptive (0.4%) which is used after unprotected sex to prevent pregnancy. But both of these methods do not provide any protection against STDs.
Sterilization is a permanent method of family planning used for limiting the size of the family. In Madhya Pradesh the population programme has become women-centric as female sterilization is far more common than male sterilization. In the state whereas the female sterilization accounts for 45%, the average percentage of Vasectomy is only about 0.8%. The percentage of couple choosing vasectomy as family planning method in Morena & Sheopur is zero; while the rate of female sterilization in these district is above 35%.Even the data of Department of Public health & Family welfare exposed that out of the total sterilization done in 2007-08 & 2008-09(April 08-Jan 09) 93% sterilization was done to female & only 6.5% were the male sterilization. This indicates that though equally easy, non-scalpel & less invasive and is often done in the doctor's; vasectomy (male sterilization) is not being preferred due to various myths and misconceptions. Fear of loss of libido and strength, method failure, and an attitude that makes birth control as the responsibility of the woman explain in large part the poor acceptance of the method. On the other hand it also indicates that no ample efforts have been made to promote male sterilization, a very effective way for population stabilization.
Health Implications of Unmet Needs of Family Planning: These unmet needs results in unintended pregnancies which leads to unsafe abortion. It's a sad reality that 8% of all maternal deaths in India are caused due to unsafe abortions The state has maternal mortality ratio of 379/100000 live births. This means that out of 379 maternal deaths about 30 maternal deaths in Madhya Pradesh occur due to unsafe abortion. Unsafe abortion damaging the health and fertility of thousands and causing an estimated 15,000 preventable deaths in India.” Further the risk associated with the unmet needs of family planning may result into incidence of reproductive tract infection & sexually transmitted diseases including HIV/AIDs. Women are more prone to these diseases to biological factors associated with that. Figures compiled by MPSACS show that 91.7 percent of the reported HIV/AIDS patients in Madhya Pradesh acquire the virus through sexual transmission.
The unmet needs of family planning results in high fertility rate. High fertility is responsible not only for population growth but it also deteriorates the health of women. Anemia of different grade is prevalent among 58% women under reproductive age of 15-49 years in the state. Population momentum can be checked to a great extent by spacing births & limiting the size of family & increased use contraceptives by sexually active people.
Thus family planning reduces maternal mortality in three ways. It prevents pregnancies that are unwanted and hence more likely to end in unsafe abortions, which contribute to one in eight maternal deaths. Finally, it reduces the proportion of births that are at greater risk of complications because of the mother’s age, parity, or birth spacing. Family planning can also slow the spread of HIV/AIDS. Condoms simultaneously prevent HIV transmission and unwanted pregnancy.
Loopholes & Steps for Inclusion: The main reason cited by family welfare program for loop holes & failure of family planning programme is pervasiveness of mass illiteracy is also one of the major causes of failure of family planning programmes in many districts. For example Jhabua, Sidhi, Satna with only 25.7%, 36% & 51.6% female literacy respectively & the use of any contraceptive method by currently married couple is less than 50% & the unmet needs are higher than 30%.
But this is cannot be justifiable reason for malfunctioning of the department. They cannot linger on till the people become educated to meet out family planning needs of the people. And also literacy is not an obligatory need use of contraception. It is frequently barbed out said that the social customs, traditions & social outlook averts the use of contraceptive methods. But even if is true what endeavor have been done for the behavioral change is still a big concern.
Behavioral Change Communication (BCC) though a very important component of Eleventh Five Year plan, with the provision of Rs.1890.02 has been made for BCC / IEC in 2008-09. In spite of that in the name of the BCC only activity commenced is sticking out the posters or wall painting. These wall paintings, posters or hoardings alone cannot bring about instant changes in the social outlook regarding contraception established since longer. The behaviour change communication program includes activities for inclusion of only married couples under reproductive age for promotion of contraceptive usage.
Also the analysis the budget for family planning program for 2007-08 & 2008-09 reveals that family planning budget for 2008-09 constitutes only 1.76% of total RCH-II budget for a year & it shows declining trend as it has deceased to Rs. 346.06 lacs from Rs. 386.45 lacs in 2007-08.
Use of contraception is not just a need but is the reproductive right of the people. But the family planning program in the state is still lacking right based approach for inclusion of more & more reproductive population. No attempt has been made for community need assessment regarding informed & preferred choices of contraceptives and efforts for intensive inclusion.
Challenges Remain
Family planning programs face continuing challenges in their efforts to address unmet need.
- Discontinued use of contraception. There are high rates of discontinuation of contraceptive use in the state. Often, discontinuation results from insufficient counseling, lack of follow-up services, or lack of suitable alternative contraceptives.
- Improvement of service delivery methods. Programs must continue to improve their methods of reaching client populations, especially younger adults. Much of the need for contraception among this group is to space births. Ambiguity in service delivery system needs to be checked immediately.
- Inclusion of Unmarried Youth. A large section of youth who are sexually active are still excluded from the family planning programmes in the state is still a big challenge to be met out.
Approaches Required
Family Planning Program should ensure the availability of contraceptives appropriate to their age, reproductive intentions or health needs & even the informed/preferred choices of the people under reproductive age.
The quality of family planning services can be judged on six key dimensions: the choice of contraceptive methods, information given to clients, the technical competence of providers, interpersonal relations between providers and clients, follow-up and continuity of services, and the constellation of services offered. Good-quality services not only attract new clients but can also help prevent contraceptive discontinuation.
Behavioral change is required not only escalating the practice of contraceptive use but is also vital for promoting male involvement & concern. It also needs to emphasize to bring attitudinal changes on the part of service provider. “Male Involvement” should be understood in a much broader sense than male contraception, and should refer to all organizational activities aimed at men as a discrete group which have the objective of increasing the acceptability and prevalence of family-planning practice of either sex.
Hence the emphasize should be on the proper implementation & promotion of Family welfare programmes to increased & intensive coverage for maintaining good reproductive health of its population. Family planning programs typically incorporate educational components to help women choose appropriate methods & bringing positive behavioral changes. Programs should accentuate appropriate counseling and involvement of male partners in decision-making to reduce discontinued contraception. Family planning program should not hamper the reproductive rights but on the other hand it should promote positive trend for behavioral change.
Seema Jain |
