Gaya: If it were up to her, Saroja Devi, 23, would not have had three children. But it is not up to her. Her husband opposed contraceptives and surgical sterilisation, and she does not, she confessed, dare defy him.

Saroja Devi’s predicament is shared by many women across Gaya, a district in southern Bihar, according to an IndiaSpend survey that studied the persistent failure of family planning in India’s most fertile state by children per woman. More than 90% of women discussed family planning with their husbands, but only 18% of them had a say in the final decision, we found.

In Gaya, the southern district of Bihar where Saroja Devi lives, the unmet need for family planning among married women was 36.5% in 2017, our survey of 900 women conducted between December 2017 and April 2018 found. This was 24 percentage points higher than India’s average unmet need in 2015-16-- 12.9%. Bihar’s overall unmet need for family planning is 21.2%, the third highest in India.

At 3.4, Bihar reports India’s country’s highest fertility rate, but if all the women in the state were to only have the number of children they wanted, this rate would have been 2.5 children per woman, according to the 2015-16 National Family Health Survey (NHFS-4).

Unmet need reveals the gap between a woman’s reproductive intentions and her contraceptive behaviour. The gap could be caused by lack of access to contraceptives, but it could also reflect cultural, social and religious beliefs that forbid contraception or do not allow women to take independent decisions about family planning.

In this, the second and concluding part of our series on the failure of family planning measures in Bihar, India’s third most populous state, we look at the reasons for the unmet need for contraception. In the first part, we concluded that although 94% of sexually active women aged 15-49 knew of at least one of the eight contraceptive methods in existence, only one in five (20.1%) were currently using any.

Women with no education and from the poorest families had the highest total unmet need in Bihar--40.1% and 40.6% respectively, according to a NHFS-4 fact-sheet. Sexually active women between 35 and 39 years of age had the highest unmet need--42.5%. About 12.5% of total births occurred among teenaged women, the third highest number in this category in India.

Decision-making is mostly a male prerogative

Typically, lower family sizes and desired fertility are observed among women with higher levels of autonomy, IndiaSpend reported in April 2017. Higher rates of contraceptive prevalence were recorded among women with greater interpersonal control and lower rates of child mortality were observed among women with more decision-making powers.

We found that in 4.8% cases of married women surveyed, husbands alone make decisions regarding modern contraceptive use, 18% of women said they alone make the choice. These women showed a preference for the contraceptive pill.

More than half of surveyed women (50.2%) who were between ages 15-19 had one living child before using their first contraceptive. Irrespective of level of education, maximum percentage of women used their first contraceptive after having their first child.

Also, in some cases of unwanted pregnancies, women tend to undergo abortions under bad conditions without the required care, resulting in serious health issues to them.

Most unmet demand among women with four children

One in three women in Bihar has had an unplanned child, according to a 2018 paper by the Asian Development Research Institute. And only one in three married women had access to family planning services. The state’s health department failed to provide contraception to nearly 4 million couples in Bihar, according to a March 2018 report in The Times of India.

Of the total unmet need, 9.6% was for spacing, as per NFHS-4. However, the United Nations Family Planning data put Bihar’s figures at 41%, the highest among all Indian states.

Two in every five uneducated women surveyed by IndiaSpend reported an unmet need for family planning. Among married women who had or didn’t have children at the time of the survey, the unmet need was highest among those who had four (41%).

Among rural married women in Gaya, 36.5% expressed an unmet need for family planning in 2015-16. This is an increase by close to five percentage points from 31.9% in 2012-13. There was a 15-percentage-point increase in unmet need for spacing--from 11% in 2012-13, to 27.6% in 2015-16.

Amongst married women in Gaya aged 15-49 years, total unmet need for family planning was 36.5% in 2017, an increase from 32.6% over ten years. More rural women (37.9%) needed family planning assistance than urban (29.1%) and did not get it.

Access to contraception

In our survey across Gaya, we found that 75% of women who used supply-based contraception felt that government family planning services were available at all times of the day in 2017. Among women who used contraceptives, 51.5% travelled less than 30 minutes to access them.

Of all the women in Gaya using modern contraceptives--pharmacies were the main source for contraceptives such as the copper tube, the intrauterine device, the contraceptive pill and other modern methods--53.5% preferred to buy them at pharmacies; 18.5% purchased them from a health centre. Seven of 10 rural women bought modern contraceptives at a pharmacy; and urban women showed a preference (37%) for health centres.

Women in the 15-44 age group preferred buying contraceptives from a pharmacy, while more than one in three women 45 years of age chose hospitals.

More than three in five uneducated women (62.5%) opted for pharmacies, but as education levels rose, the preference moved to hospitals or health centres. The preference for pharmacies continued till the age of 49, beyond which women were shown to prefer visiting hospitals to buy their contraceptives.

Injectables and sterilisation

The Bihar government in July 2018 introduced Antara, an injectable contraceptive which could block pregnancy for up to three months. Pregnancy can occur 7-10 months after the last dose of the contraceptive, as per this government pamphlet.

Given free, it was made available to every health centre in the state. But these contraceptives are controversial--they have been linked to health issues including osteoporosis, breast cancer, and delayed return of fertility, IndiaSpend reported in October 2017.

In 2017-18, 257 women in Gaya received their first dose of the Antara contraceptive while 161 received their fourth dose, according to the latest Health Information Management System data.

More than 50% of women who underwent sterilisation did it through a government hospital, while 25% chose private facilities.

Ever since the deaths of 13 women in Chhattisgarh in 2014 during sterilisations performed under unsanitary conditions, importance has been placed on conducting hygienic sterilisations. Gaya has not reported any deaths in the aftermath of female sterilisations in Gaya in 2017-18, but there were 35 cases of post-surgery complications, as per the latest data available on the Health Management Information System, a digital initiative of the ministry of health and family welfare to support the planning procedure for health facilities.

Less than 30 minutes to reach contraceptive source

One in two women in Gaya who were using supply-based contraceptives said that they had to travel less than 30 minutes to reach their source of contraceptives, while 32% said it took them between 30 and 59 minutes. Only 3.3% of women said it took them 2-3 hours to reach their contraceptive supplier.

This is the concluding part of our two-part series on Bihar’s population crisis. You can read the first part here.

(Das is a programme policy manager at the International Growth Centre India. He has a Master of Research degree in social policy from the London School of Economics and an MA in development studies from the Institute of Development Studies at the University of Sussex.)

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Kumar Das