One of the underplayed success stories in India has been its steady and natural move towards population stabilisation. The Census data makes clear that the population growth rate has declined from 24.7 per cent in 1971-81 to 17.7 per cent in 2001-2011. This decline has been witnessed across regions and communities.
Although some data is yet to come in, the National Family Health Survey-5 shows that 19 of the 17 states and 5 Union Territories have managed to get their Total Fertility Rate (TFR) – the average number of children born per woman – to less than 2.1. This number 2.1 is critical because it is the level at which a population exactly replaces itself from one generation to the next. At a seminar organised last week by the Population Foundation of India on this new data, demographer K.S. James, director of the International Institute for Population Sciences, IIPS, the organisation that executes the NFHS, termed this a “remarkable development”.
But the pandemic has pushed back some of the gains. According to a report, Covid-19 limited access to contraceptives for 26 million couples in India. According to an analysis by the Foundation for Reproductive Health Services India, the lockdown is likely to have resulted in an additional 2.4 million unintended pregnancies. Another study showed that approximately 2 million women had restricted access to abortion services in 2020.
Evidence from past epidemics has shown that emergency responses lead to the diversion of resources from routine healthcare services towards containing and responding to outbreaks. These re-allocations have constrained limited access to sexual and reproductive health services, such as safe institutional deliveries, contraceptives, and pre- and post-natal healthcare.
A similar phenomenon has been witnessed as a consequence of the Covid-19 pandemic. The near- and long-term implications of limited availability of essential health services, including sexual and reproductive health services, could be severe. According to estimates by the Guttmacher Institute, a 10 per cent decline in the use of reversible contraceptive methods in low and middle-income countries due to reduced access to services would result in an additional 49 million women with an unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year. UNICEF has estimated that India would have the highest number of forecast births (at 20 million) in the nine-month span from when Covid-19 was declared a pandemic.
Results from a three-state study commissioned by the Population Foundation of India (PFI) to assess the impact of Covid-19 on young people — particularly young women and girls — have yielded results that merit deep concern. Findings suggest that the fear of being infected kept many from accessing services at health facilities and led to resistance in interacting with frontline health workers — the Accredited Social Health Activists and the Auxillary Nurse Midwife (ASHAs and ANMs) — on family planning during their home visits. Young people in three of our largest states — Uttar Pradesh, Bihar and Rajasthan — reported an unmet need for reproductive health services and sanitary pads during the lockdown. While contraceptives were available at the district level, limited access to public transport prevented frontline workers from collecting supplies for delivery.
Dr Soumya Swaminathan, Chief Scientist at WHO, stated emphatically in the course of the 15th Tata Memorial Oration hosted by Population Foundation of India in October, that even in countries that dealt comparatively well with the pandemic, women ended up shouldering an inordinate amount of the burden of the pandemic. This is something we have also been consistently noticing in findings from all our studies and assessments. India has not been an exception where women have had a rough time, whether it is handling the after-effects of the lockdown, the increased economic losses for working women, or the burden of care-giving compounded by the challenge of managing their own health.
Women are the health response system
It comes as no surprise that women constitute an overwhelming proportion of the health workforce globally and 70 per cent of the world’s frontline health workers. In India too, 3.3 million frontline health workers, comprising ASHAs, ANMs and Anganwadi workers, are women and make up a large part of India’s healthcare system. It is ironic that they find their own health and well-being so severely hurt during challenges wrought upon by Covid-19.
To make sure that we use these experiences as lessons and do not allow what we have learnt to fritter away, certain systemic changes are imperative.
Any public health response must prioritise sexual and reproductive health, including family planning, and treat it as an essential service at all times. It is only if these services are in place that we won’t be blind-sided next time. An agile system that acknowledges that women are at a bigger risk of domestic violence when there are epidemics, would help in dealing better with women’s health issues, both physical and mental. A recognition that women need and deserve more attention and care during stressful periods like this would vastly help society as a whole and not just the women themselves.
In the shadow of the Covid pandemic, a Lancet Citizens’ Commission to ‘Reimagining India’s
Health System’ was launched recently, with the objective to ensure that a comprehensive, inclusive ‘citizen-up’ approach would inform the blueprint that is put in place for accessible and quality universal healthcare for India in the future.
Hope for the future
Population projection for India and States 2011-2036, released in July this year, indicates that the Total Fertility Rate (TFR) is expected to decline from 2.37 during 2011-2015 to 1.73 during 2031-35. The assumption is that the TFR would continue to follow the recent pace of decline. Crude birth rate will decline from 20.1 during 2011-15 to 13.1 during 2031-35 because of falling level of total fertility. There has been an interruption, no doubt, but with a recognition of the problem, an approach to put in place a system that is sensitive to the needs of women, India could continue to be well on course to fully stabilise its population voluntarily.
Poonam Muttreja is the Executive Director of the Population Foundation of India-PFI. Views are personal.