Stemming the tide
INDIA RHONA GHATE
Nagpur—Three years ago, when the intra- uterine loop was introduced here on a large scale, it seemed that at last a method of birth control had been found that was cheap, reliable, and simple enough for the Indian people. The way seemed open for a rapid reduction of the birth rate. This hope has not been fulfilled. The birth rate is still about forty-one per thousand, and the population is increasing by 13 million every year. So that despite a substantial rise in production since Independence (food pro- duction has increased by over 60 per cent) consumption of food per head has actually gone down. At this rate the population may easily double in the next thirty years and reach 1,000 million. Forecasts of unprecedented famines are not mere scaremongering.
Why has there not been quicker progress? It is not through any lack of enthusiasm on the part of the Government. India has the biggest family planning programme in the world. From the Department of Family Plan- ning in the Central Government down to the primary health centres in the countryside there is an elaborate organisation at every level; and it can now be said that (in theory at least) family planning advice is provided as part of the regular health services all over the country.
Nor is there now any lack of funds. The fourth five-year plan provides £127 millions for family planning, and America has recently pro- mised substantial aid; the loop and other con- traceptives are being manufactured in India in adequate numbers; 10,000 doctors and 15,000 other workers have had special training. Pub- licity is being tackled imaginatively. On a way- side railway station a poster advocating family planning is likely to be the only bright and well-designed object in sight. Cinema newsreels in every regional language carry an injunction to Limit Your Family. 'Family Planning Weeks' and 'Family Planning Camps' are frequently publicised.
Yet even in the towns and cities, where there are now over 1,500 clinics, progress has been slow. I recently visited a clinic in a Central Indian city run by a well-known voluntary organisation. The doctor was there all morning but only th,ree patients came—all three wanting the removal of a loop fitted on a previous visit. This is perhaps an extreme case, but even in the 1,200-bed Government Medical College Hospital the Head of the Department of Ob- stetrics told me the response in their clinic is disappointing. True they fitted 300 loops last year, but this in the second year of the pro- gramme in the biggest hospital in a city of 700,000. Partly it is because the loop has not been found so foolproof as was expected. Though it is reported in other countries to be completely satisfactory in 80 to 90 per cent cases, here only about half have no complaint. The main reasons for this seem to have been over-hasty fitting in unsuitable patients and lack of proper follow-up, but in the meantime each unsuccessful case is a poor advertisement.
No really satisfactory alternative method is yet available. Oral contraceptives are too ex- pensive, and also demand a regularity of use that cannot be relied on here. Older methods are used; but none is really suitable for a poor Indian home with its lack of privacy, and often even of the most rudimentary bathroom.
Disappointment over the loop has made official thinking turn to sterilisation as the best hope, and it is now being advocated for all families with three or more children. The cam- paign has had some success in urban areas, especially in Bombay. The disadvantage of sterilisation, of course, is its permanence. A woman doctor told me she is reluctant to advise a husband to have vasectomy in case his wife dies and he marries again.
The word. 'motivation' is very popular just now in Indian discussions on family planning; and it is indeed the crux of the matter. Railway posters are not enough. With the methods so far available each case has to be persuaded. This means laborious house-to-house visiting by health visitors or social workers, and even then it is a slow task to overcome traditional atti- tudes. Indian society being what it is, an approach through the husband is probably more likely to succeed. In Bombay (where it is claimed that the birth rate has begun to drop) this has been done by approaching men in their working places, especially in the cotton mills.
In the countryside the difficulties are much greater. I went round a village with a group of social workers (in this case a favoured village within easy reach of a town) 'motivating' from mud but to mud hut, followed by a swarm of ragged children who were kept at bay by the threat of a sui (injection). One woman with eight children had been sterilised after her last delivery. She was very happy about it, and her children looked healthy. A woman who had had bleeding after the fitting of a loop had been told by the village busybody that it meant cancer : much time had to be spent on reassur- ing her. A man who was interested had only one surviving son and was therefore not advised vasectomy but a loop for his wife, at which he demurred because he thought it meant an operation. After two hours two women had agreed to 'loops and one man to vasectomy. The doctor would come next time and do it if they had not changed their minds.
We also talked with a grandmother, one of whose sons has had five children and another seven. In each case only two survived. And at least in the countryside this is the main. point —Avery villager feels that he must have as many children as possible so that a few may survive. Dirt, ignorance and poverty combine to make life hazardous. One baby in "ten still dies even before it reaches its first birthday. To tell these people that fewer children will mean healthier children is all very welt. With a radical change in standards it will: but which is the cart and which the horse? It seems there is no short answer. The loop has not worked a miracle. Progress in family planning has been slow because there is as yet no wholly satisfactory method to offer, because staff and resources are not yet reaching the countryside with sufficient impact, and because a rise in economic and social standards must go hand in hand with the birth-control cam- paign.
A start has been made. It is claimed that more than 3 million sterilisations have been performed and more than 2 million loops fitted. But there are 90 million couples now in the reproductive age-group. Dr Chandrasekhar, Minister of State for Family Planning in the Union government, has put it that the aim is to reach these 90 million and reduce the annual birth rate from 41 per thousand to 25 or 20 in the next ten years. It is a stupendous task, bit the only hope is to try.
Previous page
