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Reuters
Reuters
Health
By Rupam Jain

How India's birth control battle falters in rural district

A nurse holds the feet of a newborn baby after it was delivered at the labour ward of a community health centre in Bahadurganj subdivision of Kishanganj district in the state of Bihar, India, March 21, 2023. India's fertility rate, fell to 2.0 in 2019-21, but State health officials estimate Kishanganj's fertility rate at 4.8 or 4.9, creating a population growth problem that the state is trying to curb with the distribution of condoms and birth control pills, as well as the paying 3,000 Indian rupees ($36.50) to women who get sterilised, 4,000 rupees to men, and 500 rupees per surgery to the health workers who perform them. "I talk to women while they are experiencing labour pain and nudge them to undergo sterilisation immediately after delivery," said Parvati Rajak, a medical officer in one of Kishanganj's seven government health centres. "But the final choice is always made by the family." REUTERS/Anushree Fadnavis

Pratima Kumari, a government health worker in the eastern Indian state of Bihar, sets off on her mini scooter every morning, crisscrossing 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.

Mati Hasda, 40, who has seven kids, cooks food as she talks with one of her sons, at their house in Duadangi village, Bahadurganj subdivision of Kishanganj district, Bihar, India, March 21, 2023. India's fertility rate, fell to 2.0 in 2019-21, but State health officials estimate Kishanganj's fertility rate at 4.8 or 4.9, creating a population growth problem that the state is trying to curb with the distribution of condoms and birth control pills, as well as the paying 3,000 Indian rupees ($36.50) to women who get sterilised, 4,000 rupees to men, and 500 rupees per surgery to the health workers who perform them. "The state government's focus is to ensure that policy interventions percolate to the ground, its mechanisms such as free sterilisation, temporary birth control instruments are used actively," said Sanjay Kumar Pansari, director in the Bihar government's Directorate of Economics and Statistics. REUTERS/Anushree Fadnavis

But it's mostly been a losing battle in Kishanganj, which has the highest fertility rate of any district in India, 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 told Reuters.

Kishanganj, and Bihar, are exceptions in India, which has over decades controlled its population growth.

Masera Khatun, 37, who is pregnant with her sixth child, sits outside her house at Duadangi village in the Bahadurganj subdivision of Kishanganj district, Bihar, India, March 21, 2023. India's fertility rate fell to 2.0 in 2019-21, but State health officials estimate Kishanganj's fertility rate at 4.8 or 4.9, creating a population growth problem that the state is trying to curb with the distribution of condoms and birth control pills, as well as the paying 3,000 Indian rupees ($36.50) to women who get sterilised, 4,000 rupees to men, and 500 rupees per surgery to the health workers who perform them. "The state government's focus is to ensure that policy interventions percolate to the ground, its mechanisms such as free sterilisation, temporary birth control instruments are used actively," said Sanjay Kumar Pansari, director in the Bihar government's Directorate of Economics and Statistics. REUTERS/Anushree Fadnavis

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 of 2.98. State health officials estimate Kishanganj's fertility rate at 4.8 or 4.9.

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

A baby is seen at the neonatal intensive care unit of a hospital in the Kishanganj district, Bihar, India, March 20, 2023. India's fertility rate, fell to 2.0 in 2019-21, but State health officials estimate Kishangan''s fertility rate at 4.8 or 4.9, creating a population growth problem that the state is trying to curb with the distribution of condoms and birth control pills, as well as the paying 3,000 Indian rupees ($36.50) to women who get sterilised, 4,000 rupees to men, and 500 rupees per surgery to the health workers who perform them. "I talk to women while they are experiencing labour pain and nudge them to undergo sterilisation immediately after delivery," said Parvati Rajak, a medical officer in one of Kishanganj's seven government health centres. "But the final choice is always made by the family." REUTERS/Anushree Fadnavis

Besides the free distribution of condoms and birth control pills, the state pays 3,000 Indian rupees ($36.50) to women who get sterilised and 4,000 rupees to men. Health workers who get people sterilised are paid 500 rupees per surgery.

Yet the results have been poor.

FEAR OF STERILISATION

Women wait outside the operation theatre of a community health centre in Bahadurganj subdivision of Kishanganj district, Bihar, India, March 21, 2023. India's fertility rate fell to 2.0 in 2019-21, but State health officials estimate Kishanganj's fertility rate at 4.8 or 4.9, creating a population growth problem that the state is trying to curb with the distribution of condoms and birth control pills, as well as paying 3,000 Indian rupees ($36.50) to women who get sterilised, 4,000 rupees to men, and 500 rupees per surgery to the health workers who perform them. "The state government's focus is to ensure that policy interventions percolate to the ground, its mechanisms such as free sterilisation, temporary birth control instruments are used actively," said Sanjay Kumar Pansari, director in the Bihar government's Directorate of Economics and Statistics. REUTERS/Anushree Fadnavis

"I talk to women while they are experiencing labour pain and nudge them to undergo sterilisation immediately after delivery," said 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 said, minutes after helping a woman deliver her fifth child.

Jahan Sheikh, a mother of four and pregnant for the fifth time, said she was not in favour of sterilisation.

Sheikh said her mother-in-law told her it was good to have at least five children as they would help in 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 asked.

A 2021 Bihar planning and development department report said the state had a sterilisation target of 871,307 people in 2020 but managed just 401,693 or 46%.

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

In Kishanganj, only 0.2% of the male population was sterilised while it was 22.8% for the female population, 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, said she would try to secure permission from her husband to undergo sterilisation before leaving for home.

"My body cannot take this pressure of having babies anymore," she told Reuters. "I have been lucky to survive each time."

Her husband later said he had agreed, and Zamerun was sterilised.

CHILDREN FOR WORK

Reuters spoke with 14 women and six government medical officers for this report and eight of the 14 women said their families expected 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," said Chandani Devi, 36, as she tried to fight back tears in a hospital ward after her delivery.

Her newborn girl was lying next to her and nurses were helping her feed the weak baby.

Senior government officials said they faced an uphill task.

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

Sanjay Kumar Pansari, director in the Bihar government's Directorate of Economics and Statistics, said 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, its mechanisms such as free sterilisation, temporary birth control instruments are used actively," Pansari told Reuters.

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

($1 = 82.1900 Indian rupees)

(Reporting by Rupam Jain in Kishanganj, Editing by YP Rajesh and Raju Gopalakrishnan)

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