Every year, World Population Day (11 July) serves as a rallying point for strengthening the demand for access to contraceptives for women and girls, worldwide. Being able to control one’s fertility, is undoubtedly one of the most significant aspects of women’s control over their own destinies. Family planning and gender equality go hand in hand. For instance in India, data shows that districts with the highest contraceptive use, are also the ones which show reduction in child marriage and violence, and increase in women’s literacy. Sadly, however, a lack of control over fertility is a reality for a large number of women and girls today, and this is rooted squarely in patriarchal social norms which dictate that decisions related to when and how many children to have be taken by men in the household, and this is a significant barrier that women are left to negotiate. It is estimated that there are 214 million women in developing countries who want to time, space or prevent a pregnancy, but are not using modern contraception. The situation is especially dire in the global south, particularly in Sub-Saharan Africa and Southern Asia which account for 39% of all women in developing regions who want to avoid pregnancy and 57% of women with an unmet need for modern contraception. This underscores the importance of strengthening family planning and contraceptive services, especially in developing countries.
Much like all issues related to women’s sexuality and reproduction, family planning and access to contraceptives are also deeply political. While in several countries women are struggling against right wing politico-religious forces to gain access to birth control, others in countries like India face a dual burden; that of trying to negotiate contraceptive use in their intimate relationships on the one hand, and of having contraceptives thrust upon them in the interest of “controlling population” on the other. It is worthwhile to recall that the origins of several family planning programs today are rooted in Malthusian anxiety of “over-population”. In India for instance, the family planning program began in the 1950s, with a population control perspective and there is a dark history of the use of population control during the emergency between 1976-1977, when forced and coerced vasectomies were carried out rampantly. There is, therefore, an aspect of “reproductive wrongs” that deserves our attention.
The International Conference on Population and Development (ICPD), held in Cairo in 1994, signified a shift in the discourse of women’s reproductive health in many ways, one of them being the move from target-based population control to that of reproductive rights and women’s empowerment. It made a call for moving beyond narrowly focused population programmes to look at family planning within a paradigm of reproductive rights. Countries like India, following the Cairo Conference, realigned their policies to promote a “target-free” approach to promote voluntary uptake of contraceptives. Yet, on the ground, targets continue to drive health workers to use pressure tactics in order to achieve their “quotas” even today. Access to safe abortion services may even be made conditional upon acceptance of family planning. Monetary incentives for providers and motivators, although clearly unethical, do not raise any eyebrows (In September 2016, the Government of India announced a new scheme to accelerate access to family planning services in 145 high-priority districts “within a rights-based framework”, but stipulated increases in incentives to not just acceptors of specific methods, but also motivators and providers!). Even as India commits to a rights-based approach to family planning, the government is instituting policies that restrict entitlements like maternity benefits only to one child. Quality of care is abysmally poor, with women being herded into camps to be sterilized. Not long ago, in 2014, 13 women lost their lives after undergoing sterilization operations under hazardous conditions at a camp in the state of Chhattisgarh. While their deaths managed to gain some global attention, several other women who suffer morbidities due to poorly performed sterilization procedures and IUD insertions, continue to suffer in silence.
International agencies and partnerships like FP2020 repeatedly affirm that it is voluntary contraception and family planning which they advocate, but how are these platforms ensuring that this is being adhered to on the ground? Are policies and programmes being examined to ensure that they are free from coercion? With quality of care being such a big concern in India (and many other countries), are social audits being instituted to ensure that quality guidelines are adhered to? Is quality of care being addressed, not in the context of ensuring compliance to contraceptive use, but in the context of rights violations? As we move forward from the Family Planning Summit in London, it is worthwhile to re-examine how we understand and address the challenges that women face in accessing contraception. It is a reality that women need and want contraceptive services, and health systems must be able to provide them. But perhaps we also need to be conscious and aware of alternate grassroots realities, so that what we see as an advancement of reproductive rights does not become a source of injustice for others. This is only possible if family planning programs are monitored closely for quality and governments made accountable for violations. Civil society activists within countries like India are relentlessly drawing attention to these problems and it is time that these voices are amplified at global platforms, to pressurize governments into addressing and preventing violations that women are subject to in the name of reproductive choice.
*The title of this viewpoint borrows from the title of Betsy Hartmann’s book ‘Reproductive Rights and Wrongs’ (1995), which examines the global politics of population control.