India’s healthcare workers struggle to promote birth control in rural districts with booming fertility rates

With India on course to become the country with the highest population in the world, healthcare workers are battling to promote birth control to families in rural areas

Zamerun Nisha, 33, holds her newborn baby on the maternity ward of a community health centre in the state of Bihar, India (Reuters)

Pratima Kumari, a government health worker in the eastern Indian state of Bihar, sets off on her mini scooter every morning, criss-crossing vast corn fields and pineapple orchards to visit villages and meet young married couples.

She offers condoms and birth control pills for free in the Kishanganj district, and talks to the couples about birth control and the benefits of having just two children.

But it’s mostly been a losing battle in Kishanganj, which has the highest fertility rate of any district in India, itself soon to be the world’s most populous nation.

“The minute I tell couples to use condoms or suggest permanent birth control, they ignore it or just change the topic,” Kumari says.

Community mobiliser Pratima Kumari outside a house in Duadangi village (Reuters)

A nurse takes care of a newborn baby at a hospital in Kishanganj district (Reuters)

Kishanganj and Bihar are exceptions in India, which has for decades attempted to control its population growth.

The national fertility rate, or the number of children a woman has on average, fell to 2.0 in 2019-21, just below the replacement rate of 2.1, official data shows.

But Bihar, one of India’s least developed states, had the highest fertility rate, at 2.98. State health officials estimate Kishanganj’s fertility rate to be around 4.8 or 4.9.

Successive state governments have been aware of the problem, particularly in Kishanganj, and have introduced programmes designed to curb population growth.

Women wait outside the operating theatre in a community health centre in Kishanganj (Reuters)

Besides the free distribution of condoms and birth control pills, the state pays 3,000 Indian rupees (£29.50) to women who undergo sterilisation, and 4,000 rupees to men. Health workers who encourage people to be sterilised are paid 500 rupees per surgery.

Yet the results have been poor.

Fear of sterilisation

“I talk to women while they are experiencing labour pain and nudge them to undergo sterilisation immediately after delivery,” says Parvati Rajak, a medical officer in one of Kishanganj’s seven government health centres.

“But the final choice is always made by the family,” she says, minutes after helping a woman to deliver her fifth child.

Jahan Sheikh, a mother of four and pregnant for the fifth time, says she is not in favour of sterilisation. Sheikh says her mother-in-law told her it was good to have at least five children as they would help on the farm and at home.

“I don’t know, but getting a sterilisation operation makes me nervous. What if there are problems after the surgery? Who will take care of my kids?” she asks.

A 2021 report by the Bihar planning and development department said that the state had a sterilisation target of 871,307 people in 2020, but managed to sterilise just 401,693 (46 per cent).

Men sit next to a board in Belwa village displaying information about the different family planning methods available (Reuters)

Men refused to undergo sterilisation as they thought the procedure would harm their masculinity, health workers said.

In Kishanganj, only 0.2 per cent of the male population was sterilised, while 22.8 per cent of the female population was, the state government report said.

Just minutes after giving birth to her fifth child at a government clinic in Kishanganj, Zamerun, the wife of a mason, says she will try to secure permission from her husband to undergo sterilisation before going home.

Zamerun Nisha gives birth to her fifth child on the labour ward (Reuters)

Nisha is lifted onto a hospital bed after undergoing sterilisation surgery on the same day as giving birth (Reuters)

“My body cannot take this pressure of having babies any more,” she says. “I have been lucky to survive each time.”

Her husband later agrees to allow Zamerun to be sterilised.

Children for work

Of the 14 women interviewed for this report, eight say their families expect them to have at least five children. Sons are preferred.

“For the fourth time I have had a girl... now I will wait for a few years before I try to have a boy,” says Chandani Devi, 36, as she tries to fight back tears in a hospital ward after her delivery.

Her newborn daughter is lying next to her, and nurses are helping her to feed the weak baby.

Senior government officials say they face an uphill task.

Chandani Devi rests as her mother, Ranjana, holds her newborn daughter (Reuters)

“We are doing our best, but in a democracy one can only do this much ... We cannot dictate rules on family planning,” says Tejashwi Yadav, Bihar’s deputy chief minister, who holds the health portfolio and has eight siblings.

Sanjay Kumar Pansari, director of the Bihar government’s Directorate of Economics and Statistics, says the state’s fertility rate is slowly showing signs of decline.

“The state government’s focus is to ensure that policy interventions percolate to the ground, [and that] its mechanisms, such as free sterilisation, temporary birth control instruments, are used actively,” Pansari says.

“The problem is people shy away from using them, and we need to continuously remind them about it.”

Reuters