India’s high fertility: The myths and the reality

This article by Shailaja Chandra attempts to uncover widespread assumptions about women’s fertility, contraception and the role that religion plays in birth control. The good news is that 44 per cent of the population living in 21 states and union territories of India has already achieved replacement levels of fertility. Kerala and Tamil Nadu achieved this more than a score of years ago. This post is part of the Wikiprogress series on measuring progress on gender equality.

Population stabilisation efforts in the rest of the country are of relatively recent origin but none-the-less commendable. The added good news is that the increase in contraceptive prevalence has been larger and faster among illiterate and uneducated women than those with schooling.

According to the International Institute of Population Sciences (EPW Arokiasamy 2009), more than two fifths of the reduction in Total Fertility Rate country-wide is attributable to illiterate women. The study calls it “remarkable demographic behaviour which has given significant direct health benefits to women and children — almost equal to what educational improvement has done for progress in human development.”

Now some disappointments: States which continue to lag behind are the same — Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand, Chattisgarh and Rajasthan — some 284 problem districts account for nearly half India’s population and 60 per cent of the yearly births countrywide.

Among 18 to 24-year-old couples the contraceptive prevalence rate is not even 19 per cent. In many districts it is as low as 10 per cent. According to NFHS -3 and the latest Annual Health Survey, in Bihar more than half the women in the child bearing group are not using any family planning method.

Ideally one should wait for the unravelling of the 2011 Census data and the results of NFHS- 4 to see the extent of improvement but both reports are expected only in a year or two.

Even so, lessons that existing reports provide will only get updated — certainly not set aside.

In India, female sterilisation continues to be the most dominant method of birth control even though women overwhelmingly favour non-invasive options. In the absence of tools that do not depend on partner-co-operation (condoms) or adherence to rigid regimens (pills), a poor woman confronts the prospect of an unwanted pregnancies every month, until somebody agrees to escort her for an operation. The policy question is whether by facilitating more acceptable birth control options one can accelerate fertility regulation and in the process improve health outcomes for women (and newborns).

That brings one to a widespread myth relating to the practice of contraception by religion. Professor P.M. Kulkarni at JNU who has researched differentials in population growth among Hindus and Muslims (using NFHS data) says that all religious communities have experienced substantial fertility decline and contraceptive practice has been well accepted by all. Within religious faiths, 85 per cent of Hindu women would like to limit the family to two children whereas in the case of Muslim women, the figure is 66 per cent.

Even so, fertility levels among the poor, be it Hindus or Muslims are not so widely different and have in fact narrowed considerably. he difference in births boils down to less than one child per woman. “This,” says Kulkarni “belies the general belief that Muslim women are barred from using contraceptives.” The belief that religion and religious fiats discourage contraception among Muslims is not borne out by statistics.

An even more significant aspect of his analysis of NFHS data shows that the unmet need for family planning is one and a half times more among Muslim women than Hindu women.

In terms of contraceptive use, Muslim women’s use of the pill is almost twice that of Hindu women and the use of IUD is also higher compared to Hindu women. Two things can be concluded:

First that among the rural poor, the difference in fertility between Hindus and Muslims is not as marked as is usually supposed.

Second: there is a perceptible difference in the preferred method of contraception: Muslim women seem to be more open to the use of it.

This leads one to ask what might be the trends in Muslim dominated countries like Bangladesh, Indonesia and Iran which have achieved high levels of contraceptive use.

According to the UN Economic & Social Affairs Population Division’s Contraceptive Use by Method (2012,) in Bangladesh the use of the pill is more than 25 per cent. Women also use IUDs and injectables in sizeable measure. In the case of Indonesia injectables are the preferred choice, followed by pill use. The use of condoms is comparatively small. Iranian women seem to rely hugely on the pill but they also use IUDs in high proportion.

To sum up, the focus of the reproductive health programme has appropriately been on the laggard districts -  mostly in the Hindi belt. But reduction in fertility has to be pursued by meeting the unmet demand for specific contraceptive choices and not by depending predominantly on sterilizing women. This requires three approaches: first by encouraging spacing among 18 to 24-year-olds; second improving access to contraceptive choices for women who are averse to sterilization. Finally what other countries have done to great advantage needs a re-look. In China, 40 per cent of the women rely on IUCDs. In India more and more women with children have begun opting for IUDs but access needs to increase manifold because the device gives a 3 to 10 year protection against pregnancy and can be reversed at will. Finally, latest research on the safety of injectables needs to be investigated afresh, looking at international best practices.

Instead of lamenting over irresponsible parenthood, the focus needs to target the unmet needs of specific population cohorts to empower women with what they need the most - liberty to decide when to have the next child or not to have one. Without being subjected to an operation.

Religion is not the issue --- women’s freedom to decide about pregnancy and childbirth is.

- Shailaja Chandra

This blog originally appeared on Shailaja Chandra's blog, here

Abstinence doesn’t do the trick

This blog, written by Wikichild co-ordinator Melinda Deleuze, discusses the negative impact that adolescent pregnancies can have on the child, the mother and all of society. It is a contribution to the last day of the Wikiprogress spotlight on the Wikigender Network.

When I was 16 years old, I had one week of sex education required by my American high school. However, my state’s curriculum revolved around abstinence as the preferred means of birth control, along with fear as the method to encourage restraint until marriage. In my class, at least one girl, aged 15, already had an abortion before taking the course, and one boy, also aged 15, was a father. The course provided too little, too late. YES, abstinence has a 100% success rate. YES, it is the best way to avoid catching a sexually transmitted infection. NO, I’m not surprised that the US ranks second to last among the rich countries for number of teen births: 36 per 1,000 births among 15-19 year old girls (read more in this blog). 

Rich countries vs. the US in teen births (per 1,000 15-19 years old)

*Legend: In the lefthand graph, the UNICEF 

colors  represent the first, second and third 

Data from UNICEF's 11th Report Card and KIDS COUNT Data Book. 

tiers of countries' ranking. In the graph on the right, the colors match states with the country tiers. In this case,  the darkest blue indicates the 21 states which have a higher rate of teen births than the lowest ranking country (i.e. Bulgaria).

This year’s UN World Population Day focused on adolescent pregnancies, a persistent occurrence in both developing and developed countries. Around 16 million adolescent girls aged 15 to 19 give birth each year, according to the WHO. While there may be varying opinions on this issue, the fact is that adolescent pregnancies gravely affect the teen mother, the child and the rest of society (i.e. you and me). Despite misleading perceptions, these consequences can occur among married and unmarried adolescents in developed and developing countries for both intended and unintended pregnancies.

 How does it affect the well-being of the child?

The immediate health of children born to adolescent mothers is at risk, and the younger the mother, the higher the risk. This WHO Report states that “in low- and middle-income countries, stillbirths and death in the first week and first month of life are 50% higher among babies born to mothers younger than 20 years than those born to mothers aged 20–29 years.” Also, babies born to adolescent mothers are more likely to be pre-term, have a lower birth weight and have asphyxia, which all increase the baby’s chance of death or future health problems. Substance abuse during pregnancy is higher among adolescent girls, which contributes to a higher percentage of low birth-weight babies and infant mortality, along with other health issues.

How does it affect the well-being of the young mother?

First of all, the health of young mothers is severely compromised, as pregnant teenagers face double the risk of dying from pregnancy-related complications relative to women in their 20s.* This UNFA report summary states that “across developing countries, complications from pregnancy and unsafe abortion are the leading cause of death for girls aged 15-19.” The younger the mother, the more she is at risk of maternal complications, death and disability, including obstetric fistula. Up to 65% of women with obstetric fistula developed this during adolescence, says this WHO Report. Additionally, adolescent pregnancies are at higher risk for sexually transmitted diseases. Younger girls are less likely to practice safe sex and make up 64% of all new infections among young people worldwide, states this UNFPA factsheet.

Additionally, adolescent pregnancy contends with secondary education. In developed countries, motherhood during adolescent years increases girls’ chances of dropping out of school. In the United States, teen mothers are 10% less likely to obtain a high school diploma, as shown in this UNFPA report summary. Whereas in developing countries, the longer girls remain in school, the less likely they are to become pregnant in their teens. In Timor-Leste, for example, total fertility rates vary from 6 to1 ratio births per woman with no education to only 2 to 9 ratio births for women with secondary schooling or above, as indicated in this Women Deliver background paper. Delaying childbearing also increases chances of obtaining a higher income and better careers, among with other aspects of well-being, such as mental and psychological.

How does it affect the overall well-being of society?

Adolescent pregnancies concern us all as they negatively impact the development of a society. This UNFPA report summary states that “investing in family planning helps reduce poverty, improve health, promote gender equality, enable adolescents to finish their schooling and increase labour force participation.” In the UN Secretary-General Ban Ki-moon’s message for this year’s World Population Day, he stated that “when we devote attention and resources to the education, health and well-being of adolescent girls, they will become an even greater force for positive change in society that will have an impact for generations to come.”

I’m grateful that the World Population Day addressed adolescent pregrancy. While we often talk about maternal and infant mortality rates, as well as low birth-weight babies, we overlook at times this major proponent. I hope that there can be more open conversations with teens in order to overcome some of the obstacles to preventing teen pregnancies. And believe me, teaching abstinence just doesn't do the trick.

Melinda Deleuze

* Gennari, Pamela, J. 2013. “Adolescent Pregnancy in Developing Countries.” International Journal of Childbirth Education 28:57

The U.S. versus the rich world in child well-being

This blog, written by Wikichild coordinator Melinda George, is a comparison between the recently published 2013 KIDS COUNT Data Book on America's child well-being with UNICEF's 11th Report card on rich countries' child well-being. This blog is a part of the Wikiprogress Series on its well-being and progress networks.

Since last week’s launch of the Annie E. Casey Foundation’s 2013 KIDS COUNT Data Book, discussions about America’s child well-being, particularly concerning each states’ rankings, have been a hot topic. (For those of you who missed the highlights, read more here.) The Data Book examine trends of 16 indicators pertaining to 4 dimensions (economic well-being; education; health; and family and community). 

In April 2013, the United Nations Children’s Fund (UNICEF) Innocenti office of research launched its 11^th Report Card on child well-being in rich countries. This report ranks the world’s 29 advanced economies in terms of their overall well-being, using 26 internationally comparable indicators separated into 5 dimensions (material; education; health and safety; behaviors and risks; housing and environment).

According to this UNICEF study, the U.S. was ranked 26^th out of 29 in overall child well-being and was on the lower end for most dimensions and indicators. The Data Book recognises that when the data was disaggregated, the results were strikingly different, particularly the education data for the lowest-income students.

So, how do America’s states and races compare to 

the well-being of children in other advanced economies?

Between these two studies, there are 3 shared indicators (low-birthweight babies; child and youth mortality; teen births) and a 4^th indicator where the observed age range differs by one year (teens not in education, employment or training; i.e. NEET rate). 

I've aligned the state and race data* with the rich countries implementing UNICEF's 3 color system**, showing the first, second and third tiers. I also added a 4th color (the darkest) to indicate the states which are off the country charts. 

Low-birthweight babies

(% born below 2.5 kilograms or 5.5 pounds)

Regarding the percentage of babies born below 2.5 kilograms, Alaska is comparable to Norway, Idaho to Belgium, Georgia to Greece, and Mississippi is off the charts. A majority of the states are in the bottom third of the advanced countries. However, Hispanics and non-Hispanic Whites are in the middle, closer to Germany, while African Americans (at 13.2%) have a much higher percentage of babies below 2.5 grams than the average in Greece (around 9.5%). 

Child and youth mortality rate

(deaths per 100,000 among 1-19 year-olds)

We see the same trend in child and youth mortality rates as we did in the low birthweight percentages. The majority of states are in the bottom third of advanced countries' rates, with only 5 states in the top two-thirds. However, the Asian and Pacific Islanders in the U.S. have the same rate as Sweden and the Netherlands.

Teen births

(per 1,000 15-19 year olds) 

Since the United States has the second highest number of teen births next to Bulgaria, it is not surprising that 21 out of 50 states are off the charts. There are no states in the top two-thirds of the rich countries; however, the Asian and Pacific Islanders are in the middle third, with the same number of teen births (11 births per 1,000 15-19 year-olds) as Greece and the Czech Republic.

NEET rate

Percentage of 15-19 or 16-19 year olds not in education, employment or training 

The percentage of teens in the United States neither attending school nor working varies a lot between the states. In comparing with the advanced country rankings, most states were in the bottom third, and 13 states were in the middle third. Also, Vermont and Wyoming have rather low percentages (4%) and are comparable to Germany. When the U.S. data is disaggregated by race, it also is more evenly spread, covering all three tiers of the advanced countries. American Indians have the lowest percentage (15%), only slightly lower than Bulgaria's percentage. I must note that the UNICEF study observed teens 15 to 19 years old, while KIDS COUNT observed only 16 to 19 year olds in its study.

It’s unfortunate that there were not more shared indicators among the two studies and most of the shared indicators were related to children's health. While the KIDS COUNT data is most likely very relevant to local policy-making, it cannot be compared internationally.

The Data Book recognises childhood obesity as a growing problem; however, the KIDS COUNT index regrettably does not include an indicator for childhood obesity as there is no 50-state data source available. In the 11^th Report Card, the U.S. is almost off-the-charts for its childhood obesity rate in comparison with other rich countries. Comparable data is crucial in order to highlight the problem areas, share best practices, and tackle America’s childhood obesity. 

When considering America's improvements and declines in child well-being, we should look across states, across races and across other advanced economies to get a better understanding of what success looks like. I hope that policy-makers will do the same when deciding where efforts should be spent.

*The data concerning the U.S. is available online at www.datacenter.kidscount.org. 

**The countries with grey bars have data for fewer than 75% of the total number of indicators used in the UNICEF study.

Melinda Deleuze

A Promising Future for Child Nutrition?

This ProgBlog article by Robbie Lawrence, Wikichild Coordinator, is part of the Wikiprogress Health Series.

"In June, the Prime Minister will host the Nutrition and Growth event ahead of the G8; we hope Mr Cameron takes this timely opportunity to pledge significant investment in nutrition programmes and show real leadership in improving children’s futures, as well as those of their communities and their countries.” David Bull, UNICEF UK

Wikichild is currently focusing on nutrition as part of the wider Wikiprogress spotlight on health this month. On Monday, UNICEF released ‘Improving Child Nutrition: The achievable imperative for global progress’ which reports that significant advances have been made in the fight against stunting – the long term effect of hunger and malnutrition. Citing successes in eleven countries - Ethiopia, Haiti, India, Nepal, Peru, Rwanda, the Democratic Republic of the Congo, Sri Lanka, Kyrgyzstan, Tanzania and Vietnam, the report shows that stunting and other forms of undernutrition can be brought down by improved understanding of the problem and the implementation of practical measures that target pregnant mothers and children in the first two years of their life.

According to UNICEF, one in four of all children suffer from stunting because they haven’t had the right nutrients in the critical 1,000-day window following conception. Malnutrition, through lack of both macronutrients and certain micronutrients has long-term negative impacts on brain and nerve development and function, including mental activity, and the acquisition of skills needed to interact well socially. This impairment is often reflected in lower IQs and poorer performance at school (Save the Children). The damage done to a child’s body and brain by stunting is irreversible. It brings down performance at school and later at work, and heightens children’s risk of dying from infectious diseases.

‘Improving Child Nutrition’ builds on UNICEF’s earlier report ‘Tracking Progress on Child and Material’ by highlighting new developments and showing that attempts to improve nutrition programs are working. An estimated 80 per cent of the world’s stunted children live in just 14 countries spanning across Africa and Asia, and by working in communities within these nations, UNICEF and other organizations have reduced stunting by applying a series of steps including, improving women’s diet, early and exclusive breastfeeding and providing minerals and appropriate food to new mothers.

These programs all have common elements: political commitment, national policies and the presence of trained community workers to deliver information and aid. To use two examples of their success; we can look at Ethiopia, where stunting has been cut from 57 percent to 44 percent in the first decade of this century through the implementation of a national nutrition program, and at the Maharashtra state in India where the percentage of stunted children fell from 39 percent in 2005 to 23 percent in 2012 due to the support of frontline workers. 

Such progress is undoubtedly promising, and presents a unique opportunity for future global frameworks to further alleviate the problem of undernutrition. UNICEF itself acknowledges that there is still a great amount of work to be done if the World Health Assembly’s new global target of reducing the number of stunted children under the age of five by forty percent by 2025 is to be achieved. 

More recently, inequality has been a hot topic on the Wikichild, Wikiprogress and Wikigender platforms so we are well versed in the hidden realties that large, all encompassing goals such as this can mask, but it is encouraging that new approaches are targeting individual countries and communities, allowing accurate data systems to be developed that can describe and monitor changes in the circumstances of different population groups.

Furthermore, tools like the Hunger and Nutrition Commitment Index (released last week) provide greater transparency and public accountability by measuring what governments achieve, and where they fail, in addressing hunger and undernutrition. Even Duncan Green has commended the HANCI, stating that ‘it could become one of the more useful annual league tables’, as it forces governments to be ‘slapped’ if they underperform. 

Nutrition should remain at the center of the global development agenda leading up to Post 2015. The evidence laid out in UNICEF’s report and the momentum generated by their successes shows that improving child and maternal nutrition is an achievable necessity for global progress.

Robbie Lawrence

Wikichild Coordinator