Shillong: This year, in April, the long impending and inevitable future finally knocked on India’s door. A report by the United Nations declared the country would dethrone China as the world’s most populous country by the middle of the year. The cacophony, concern and clamour arising out of the 142.86 crore figure found a faint silver lining in the dipping fertility rate which stands at 2.0 births per woman. But Meghalaya is an outlier, with its fertility rate as high as 2.9 children per woman.
In the towns and villages of the state, women carrying babies in makeshift cloth slings are a common sight. In rural areas, it’s easy to run into groups of women, with babies on their backs and surrounded by a toddler or two. It is as if India’s ambitious family planning outcomes have sidestepped Meghalaya. Led by poverty and lack of education, the combination of matrilineal society, philandering fathers and the dominance of Christianity has ballooned into a full-blown fertility crisis. The fifth edition of the National Family Health Survey (NFHS) 2019-20 shows the state is second only to Bihar when it comes to the total fertility rate (TFR).
“There’s no conversation about family planning because big families are what they (people of Meghalaya) have seen all their lives,” said a professor, who didn’t want to be named. The northeastern state, one of the poorest in the country, stands at a precarious junction. Its largely tribal population — traditionally used to having large families — is expected to undergo a behavioural change and adopt the concept of family planning. But it is running out of time.
Some religious organisations don’t promote family planning. According to their beliefs, we shouldn’t stop the blessing that’s being given to us – said a doctor, speaking on the condition of anonymity.
It needs to triumph over the alarming figures and battle crippling socio-economic factors to have any chance at having a healthy, educated and empowered population.
Demands of modern life and the effects of education have brought down the TFR in urban pockets of Meghalaya to 1.6. However, the picture in the hinterlands, where more than 78 per cent of the households reside, is alarming. NFHS data shows the fertility rate in rural areas is soaring at 3.3. A senior official of the state’s health department, who didn’t want to be named, pointed out that the actual TFR is worse than what the NHFS data reflects. “It’s not 2.9, it’s around 3.5 which is close to 4,” he said.
In a largely Christian society where children are considered “a gift from God”, the department is at the eye of the storm, trying to battle a problem that stems from a vicious cycle of population anxiety, gender inequality, poverty and poor education.
How bad is the situation
At a local dispensary in the capital Shillong’s Rynjah locality, which houses many migrants and low-income residents, two pregnant domestic workers, Anusha Kharpor and Baritun Khangkrom arrive for their monthly checkup. Their spouses are daily wage labourers.
Kharpor dropped out of school when she was in Class 6, and got married at 17. Now at 38, she was expecting her fourth child. Her first two children, now 18 and 16, also dropped out of school in Class 6.
Theirs is a textbook story of a generation whose potential was lost to lack of education and poverty. The more disturbing trend is that their children are staring at a future no different than what their mothers are living.
“Having four children is a lot, but at least they don’t feel left alone. But I don’t want any more children because my family is not financially secure,” she said.
Khangkrom, 33, didn’t study beyond Class 3, got married at 16 years and is now pregnant with her sixth kid.
“My husband and I came to Shillong for work. All my kids are in the village with my mother. I don’t think I can afford to have any more kids,” she said.
They were informed about family planning measures but didn’t take the message seriously.
This nonchalance has created a palpable sense of urgency among doctors, consultants and senior health officials involved in the family planning programme.
The people of Meghalaya — including local health workers — inevitably bring up the state’s ‘small tribal population’ in conversations about population. The state is predominantly populated by three tribes – Khasi, Jaintia and Garo.
The total population is somewhere between 35-37 lakh, according to the health department. And according to the 2011 census, 86 per cent of the state’s population are tribals.
“The demographic change that took place in neighbouring Tripura, where the tribal population was overtaken by the Bengali community, is a fear that plays in the minds of the Meghalaya’s tribes,” the professor said.
The health department maintains an exhaustive online registry of the number of pregnant women in the state. According to it, there were 40,000 pregnant women in the state in late July. A considerable percentage of them were high-risk pregnancies — 10 per cent were teenage pregnancies, 11 per cent were women above 35 years and 12 per cent were anaemic.
A high acceptance of cohabitation from a younger age combined with low rates of education and the religious discouragement of contraception and abortion leads to a high incidence of teen pregnancies.
“We see that 20 per cent of them (teenagers, women above 35 years) are not supposed to be pregnant [these two groups fall outside the ideal childbearing age],” the senior health official said.
He said nearly 83,000 children are born in the state every year and around 60,000 students graduate in an academic year. The state is not equipped to handle the growing population, and its basket of employment opportunities is limited.
In my study, there were mothers who had up to 14 children. They said we are healthy; we have no health problems, we are okay – Nandaris Marwein, professor of public health.
But these staggering numbers didn’t arise in isolation. As per Census 2011, Meghalaya had clocked the highest decadal growth rate among states between 2001-2011 at 27.9 per cent. The Union Territory of Puducherry recorded the highest overall number at 28.1 per cent and the national average was 17.7 per cent.
Health experts call it a ‘population explosion’.
“We are a population of over 30 lakh now. If our TFR continues like this, in 10 years time, we will be more than 60 lakh. Our land and resources are not going to expand. Where are you going to absorb the population?” said Dr Mary Debbarman, a reproductive and child healthcare consultant who is part of the state’s National Health Mission.
The cascading impact of the high fertility rate isn’t just causing unemployment woes. It’s giving birth to a generation of malnourished children, with stunting being one of the most prominent effects. And Meghalaya is showing no signs of improvement. According to NFHS data, the number of children suffering from stunting has increased from 43.8 in 2015-16 to 46.5 per cent in 2019-21.
A health expert said children in the state aren’t deprived of carbohydrates, so they don’t look emaciated — malnourishment most often manifests as stunting. “They [parents] aren’t able to understand that having more children without the resources to bring them up is detrimental to the child’s health,” the expert said.
Short height is all intergenerational and happening for the last few decades because poverty has been high, they added.
Thirty-six-year-old Bessmora and her month-old baby girl arrive at Rynjah’s local dispensary for immunisation.
Less than 5 feet tall, the Khasi woman showed all signs of stunted growth. The 36-year-old domestic worker had also brought her first child, a five-year-old boy in his school uniform, to the dispensary.
She was tired of her philandering husband and had a planned pregnancy. Now, with a daughter to continue her bloodline, she had a birth control device inserted in her uterus.
“I have nothing, so I decided to accumulate some money before having my second child. Now, I’m done with men. I will raise the kids on my own,” she said.
Bessmora knows having fewer children is the only way her kids can have a shot at escaping a destiny of poverty and poor health. The health department will have to mould every mother into a Bessmora for Meghalaya to be able to offer a better alternative to its future generations.
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Fighting the battle
The health department’s doctors, auxiliary nurses and midwives (ANMs) and Accredited Social Health Activists (ASHAs) routinely counsel pregnant and newborn mothers about family planning options. But to bring about behavioural change in a tribal society, the government has to tailor its policies around their beliefs. The department is changing its language and rhetoric to communicate with them. It doesn’t tell people to stop having children — a message sure to backfire. Instead, efforts are being made to convey that pregnancies must be planned. “We don’t use the words ‘family planning’ at the community planning level. We don’t discuss this in the meetings as well. The phrase we use is planning of family,” said Dr Keshav Sharma, a state public health consultant who works with NHM.
The way to achieve this is by introducing birth spacing — a concept which recommends a gap of three years before conceiving the next child.
Is religion a contributing factor?
Christians constitute nearly 75 per cent of Meghalaya’s population. The state’s main denominations are Catholic, Presbyterian and Baptist, with the former being the largest.
The church believes children are “blessings” one shouldn’t stop receiving. This has played a large role in shaping the state’s approach to family planning. Doctors, especially during their postings in remote areas, have run into clergy urging them to not speak about certain contraceptive measures.
“Some religious organisations don’t promote family planning. According to their beliefs, we shouldn’t stop the blessing that’s being given to us,” said a doctor on the condition of anonymity.
Caught in the push-and-pull of birth control and Christianity the medical community is wary of its language and cautious to not ruffle the feathers of any religious institutions.
Donie Pearlin Syiem, senior medical and health officer at a primary health care centre in Pomlum village said nuns in a remote village in the South West Khasi Hills told her to avoid talking about birth control methods such as a copper IUD or tubectomy and stick to “natural” methods of contraception. “In remote areas, it’s still a taboo. Even the other Christian faiths, don’t want to talk about it. It’s a closed-door discussion,” she said.
The Roman Catholic Archdiocese of Shillong is firm in its stand — children are the gifts of God. “We receive them as they come,” said Father Richard M Majaw, the vicar general of the church. The message, however, comes with a rider. Catholic parents need to be told about responsible parenthood.
“Children who are born need care and proper upbringing,” he said, adding the church offers marriage counselling and holds parents meeting in that direction.
The Church washes off any responsibility beyond this. In the past, the health department made attempts to reach out to churches of various denominations but it was met with discouraging responses. They shut officials out with the statement – having kids is a personal matter on which the church doesn’t speak.
In an overwhelmingly religious society, rejection of contraceptives is not the only barrier to family planning. Medical practitioners and health experts point to the low availability of medical abortion services. “When a teenager becomes pregnant, no one offers them the option to medically terminate the pregnancy. The counsellors usually talk in a way like having MTP is so dangerous and having a child and giving it up for adoption is safer,” said a professor, on the condition of anonymity.
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Patriarchy in a matrilineal society
But there’s a silver lining in the dark cloud of family planning that hangs over Meghalaya — the desire to have a girl child. In stark contrast to the rest of India, the matrilineal nature of the state means that every household needs a girl to carry forward the family name. Inheritance of property is also carried forth through the female line. But patriarchy robs women of any form of discernible power. It shows up in the form of polygamy. At 6.1 per cent, the state has the highest level of such relationships. A consequence of this is the rising number of single mothers. Though there is no official data, a study conducted for the period of 2016-2018 by the Meghalaya State Commission for Women titled Exploratory Study on the Socio-Economic Status and Problems of Single Mothers in Meghalaya, stated the prevalence of single motherhood could range up to 15 per cent or more of the total population of women who have ever married or become mothers.
The exhaustive study gives a background on the marriage system within the three tribes, prior to the influence of Christian ideology. In a radical interpretation of the institution, marriage is “regarded as a civil contract” and can be “terminated for a number of reasons, such as adultery, mental health issues, maltreatment, etc”. The “traditional mindset persists even today to a certain extent” despite the prevalence of the Christian faith, resulting in a large number of single mothers who are separated or divorced from, or abandoned by their husbands.
“In our community, since the mother lives with her family and in close proximity to her relatives, we help each other. It’s not just in terms of financial things but also emotional support. Of course, single mothers have hardships but they have the strength of the support system. And there is no taboo attached to being a single mother,” said Nandaris Marwein, professor of public health at Martin Luther Christian University.
Free from any stigma, the matrilineal society empowers women to have children out of wedlock and be single mothers for the sake of continuing their lineage. Nonetheless, divorced or separated women often remarry “hoping to finally get a husband who can ease their burden, but they end up having more children,” the study stated.
Driven by anxiety
Breaking down the factors behind the ever-rising population, the senior health official explained that at the core of it lies a mix of economic, political, and territorial anxieties — all tangled together.
Widespread poverty and a largely agrarian economy drive people to have many babies. The governing principle is they will serve as extra helping hands, provided they make it through the early years.
The political and territorial insecurities are largely rooted in history, going back to the time Meghalaya was carved out of undivided Assam in 1970. A landscape covered by misty clouds and filled with green hills and gushing waterfalls predominantly populated by Khasis, Jaintias and Garos.
The Khasi and Jaintia were allotted 40 per cent reservations in state government jobs while the Garos got 40 per cent – a policy currently undergoing review. Nonetheless, the reservation policy creates perfect conditions for the brewing of political anxieties. Each tribe thinks the other will have a greater representation and have more children of their own to combat this ‘threat’.
The territorial anxieties, the official said, are connected to the general tendency among tribals to be wary of outsiders and be protective of their territory. The presence of non-tribals in the state, which goes back to the time of Meghalaya’s creation, heightened the impulse. There is a prevailing belief that increasing their population will prevent them from being marginalised in their own land. “Fear brings together people. The society thrives on fear psychosis, not on empowerment,” he remarked about the state.
The geographical terrain doesn’t make things any better. The topography has impeded communication between nearly 7,000 villages across Meghalaya. The state’s maternal mortality rate —197 deaths per 1 lakh deliveries as opposed to the national average of 97 per 1 lakh— has failed to stir concern because, at a micro level, the figures boil down to one death in nearly 36 villages.
“Each village is a republic of its own,” the official said.
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Lack of education & poverty
Poverty and lack of education have played a central role in catapulting the fertility rate. Health experts give them more weight than religion. “Why did the urban figures change? It’s all about education,” the professor remarked.
And their solution to control population growth is to keep more girls in school, which they believe “somehow magically affects fertility”.
The NHFS-5 data for Meghalaya proves the hypothesis. The TFR of women with no schooling stood at 4.5 and those under five years of education was 5.1. The number dropped as their years of education increased. For those with five to nine years of formal schooling, the TFR was 3 children per woman. For women who stayed in school for 10-11 years, the number was 1.9 and for those with over 12 years of schooling, it was 1.7.
However, the picture is grim in the hinterlands. Marwein, who has visited over 30 villages and interacted with 800 respondents for a study about the utilisation of healthcare services among pregnant and lactating women, said the regions were plagued by rampant poverty. They have no exposure to the outside world.
“It’s not in their minds to aspire for a good lifestyle. They are happy with what they have,” she said.
Family planning is a recourse that they adopt only when the life of the mother is threatened. “In my study, there were mothers who had up to 14 children. They said we are healthy; we have no health problems, we are okay,” she said.
Despite all the bleak tales, the government measures are bearing results. In March, the state’s chief minister Conrad Sangma informed the Meghalaya assembly that the maternal mortality rate – which is tied to fertility rates — reduced by 53 per cent over the last two years.
The Protection of Children from Sexual Offences Act (POCSO) has also become a roadblock, if not a deterrent for the large number of teen pregnancies the state sees. However, health practitioners noted that people are aware of the legal repercussions and have sought advice to forge dates on a birth certificate to skirt getting booked. But they are optimistic the stringent law will curb the phenomenon.
The state has created awareness in even the most remote villages, but this is just the first step. The hurdle now is making people adopt safe practices, to get villagers to shrug off their aversion to change – all of which are always connected to having poor access to quality education.
During fieldwork, health experts met mothers who knew about contraceptives but weren’t sure where to get them. In the case of men, the challenge was getting them to use it.
“Some of the men that I interacted, they believe that having more children is better. They say we feel guilty if we do family planning because most people hold on strongly to their religious beliefs,” said Marwein.
(Edited by Theres Sudeep)