Kolkata: The use of family planning methods has decreased in five districts of West Bengal in the last five years, while the state overall increased slightly by 3%, according to the latest National Family Health Survey (NFHS-5). This indicates a lack of knowledge of family planning methods in these five districts and implementation gaps at the grassroots level in the family planning programme.

Between 2015 and 2020, Bankura recorded a 19.6% decrease in any family planning methods, which is the highest decrease in the state, followed by Purulia (18%) and Purba Medinipur (16%). Of all modern methods, female sterilisation is the most used method in the country, but Purulia recorded an 11.7% decrease in female sterilisation followed by Paschim Medinipur (6.8%) and Nadia (6.7%). Another modern contraception method is the usage of pills which has also declined in the same period. 7.2% decrease recorded in Purba Medinipur followed by Nadia (4%) and Bankura (3.1%).

Bankura recorded highest decline in family planning service followed by Purulia and Purba Medinipur in last five years.

Family planning focused programmes mainly implemented through the deployment of ASHA workers in rural communities. Their job includes raising awareness, bring behavioural changes, developed community participation and enabled empowerment at the grassroots level.

However, an ASHA worker in Nadia’s Hanskhali block explained that as they receive performance-based incentives for promoting universal immunisation, referral, and escort services for the Reproductive & Child Health (RCH) and other healthcare programmes, they sometimes were underpaid.

In the state, ASHA workers get Rs 3,500 salary per month and additional incentives ranging between Rs 1,500-2,000. “We are responding to COVID-19 cases for the past one year, and we act as the first port for any health-related demands of deprived sections of the population who find it difficult to access health services. We cannot reach everyone at a time because we have to work with a large population. Convincing them to take family planning service is a difficult task for us,” said a worker.  

A woman in her 30s from the same block responded that she had never heard of any modern family planning methods other than condoms and female sterilization. “I never used any method except condoms. We tried it often after having our second child but never think of female sterilisation,” she said. She thinks it is a personal choice of a couple to take family planning service or not, but she confirmed that she never heard about any alternative methods from ASHA workers in her village. 

She also claimed that a woman could get sterilised if she already has a son, which highlighted a strong preference for sons in society.

Deputy Chief Medical Health Officer of Nadia Dr Atasi Mondal claimed family planning services were hindered due to the current pandemic situation. “We are working with limited resources, and our target was to increase female sterilisation last year. Even a few of our staff got training for ligation, but we could not start due to pandemic,” said Mondal. She expressed optimism to cope with the declining use of contraceptive methods in the district once the situation gets normal.

A former ASHA trainer from the state who wished to be anonymous said that there was always a crisis of health workers in villages. “It is not a new thing to have fewer ASHA workers than required. The most important thing they (ASHA workers) hardly talk about family planning methods among women. There is no mechanism to constantly monitor their work. In my experience, I found ‘one size fits all’ strategy won’t work. ASHA workers need to give more focus on family planning methods at PHC level.” 

According to NFHS-5 survey Purba Medinipur recorded highest prevalence of child marriage (57.6%) while Paschim Medinipur recorded highest teen pregnancies (25%). Both have direct connection with declining family planning and poor child health.

According to NFHS-5, the percentage of health workers who talked to female non-users and users of family planning methods in the Bankura district has reduced by 4% and 7%, which indicated the implementation gap. She further highlighted misconceptions about the side effects of injectable contraceptives among women, which also restricted the acceptance of family planning service among the marginalised community. “We need more block specific grassroots level strategies and monitoring system to implement successful family planning programmes,” she asserted.

Comparing data of the NFHS-5 with the NFHS-4 survey, Namrata Karamchandrani, Director of Anahat for Change Foundation, flagged some areas of concern. “Low level of family planning will lead to unintended pregnancies and lower spacing of birth thereby affecting the health of the newborns. Marginalised families will be economically overburdened with more and more births, and fail to take care of the newborns. This will increase cases of diarrhoea, respiratory infections and malnutrition in children and further pushing up the rate of child deaths.”

She thinks more childbirths will affect the reproductive health of women and will also reduce women employment rate, thereby impacting women empowerment. She, therefore, urged to continue to plug implementation gaps in the family planning programme at the grassroots level.

According to NFHS-5, the overall percentage of child marriage in the state is 42%, same as NFHS-4, and 16% have already begun childbearing among 15-19 years age young women. Nadia is one of the child marriage prevalent districts which recorded 39.9% child marriage and 15.1% teen pregnancies in the last five years.

While speaking to the district coordinator of CHILDLINE Nadia, he didn’t want to comment on this and claimed that there is no data available regarding the high prevalence of child marriage in the district. According to NFHS-5, Purba Medinipur recorded the highest prevalence of child marriage 57.6% in the state which is 17.6% higher than NFHS-4 and 22% teen pregnancies which is 8% higher than the overall state. Paschim Medinipur recorded 55.7% child marriage followed by Bankura 45.7%. These data correlate that low acceptance of family planning service, early marriage and teen pregnancies has a direct relation with high-risk pregnancies and child mortality.

Sarada Giri, District Child Protection Officer (DCPO) of Purba Medinipur admitted the fact that the district observed more early marriage despite having an 87% literacy rate which is first in literacy in comparison to other districts of the state. “We need more strategies to combat this menace. Most of these early marriages happened due to love affairs through the use of social media and the internet. These girls either by choice or trapped and eloped with boys. We are focusing on more sensitisation of parents and safe use of mobile phones but facing challenges due to the current pandemic. As the schools are closed over one year, we could not organise awareness campaign or formal sensitisation that would also make these girls vulnerable.”

Even the low conviction rate is also contributing to the high prevalence of early marriage in the district. “Earlier there was zero conviction rate in child marriage in the district but in last two years I registered 10 FIRs and legal action has been taken but the legal process should be fast to ensure justice on time,” she added.

The choice of family-planning method varied from place to place based on the population’s socio-cultural factors and economic status. There was a visible rural-urban disparity in adopting family-planning methods in the state.

In urban areas, the use of condoms, a modern method of contraception, was 10.1%, whereas it was 5.7% in rural areas. But overall, female sterilisation was the most common method of contraception in West Bengal. The proportion of male sterilisation was much smaller, with less than one per cent of married couples choosing it, which shows low acceptance of male sterilisation and condoms that reflect limited male engagement in family planning.

According to NFHS-5, 0.1% of male choose sterilization as a family planning method while 34% of men age 15-49 years in the state agree that contraception is women’s business and a man should not have to worry about it. Photo: Tanmoy Bhaduri

Admitting the fact that family planning has decreased in Purba Medinipur Dr Bibhas Roy, Chief Medical Officer of Health (CMOH) of the district says, “We targeted to increase male sterilisation to diversify the contraception method and launched several campaigns to increase male participation. We got a better response while organising awareness meets with male members, but it didn’t create an impact. The reason behind our failure is that a few communities in the district have social and religious taboo regarding male sterilisation. However, we are trying to implement new strategies to increase male participation in family planning service.”

Purvi Tanwani, Gender Equity Fellow at Swedish Institute said, “While conducting awareness sessions in rural areas, I have received a lot of queries regarding SRH services, maternal health, antenatal and post-natal care of mothers, disorders like PCOD/PCOS etc. This goes on to prove that information and knowledge related to various aspects of Sexual Reproductive Health do not reach these women from responsible sources. One of the reasons can be the overburdening of community healthcare workers like ASHAs with other health-related activities. It leads to negligence in maternal and child health care and proper disbursal of resources and information.”

She further explained that although West Bengal’s total fertility rate (TFR) 1.6 children per woman, there are areas of concern that need attention. “So, even as we celebrate India’s progress towards achieving population stabilisation, we must continue to plug implementation gaps in the country’s family planning programme at the grassroots level. In West Bengal, the district health and family welfare department must remain focused on delivering high-quality family planning services to those who need them. Simultaneously, we need more male-specific family planning campaigns to engage males in the family planning process which can bring about a wider awareness of the role of men in the family planning system and the need for them to take more responsibilities and support their partner to sustain the growth of the system,” Purvi added.

The author is a Kolkata-based independent journalist. He can be reached @tanmoy_pj

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