10328705 Melanie Pescud

Fertility and Birth Control in India An Investigative Review

This essay shall investigate and review the topic of fertility and birth control in India. This subject is of particular importance today as the Indian population is rapidly increasing to a state of over-population. There is a need to slow the growth of the population. As the population continues to grow there will be over-crowding, a limiting of resources and the quality of life will decline. The obvious manner in which to accomplish this is to educate and make available the necessary and appropriate contraceptive methods to the Indian population. This is a difficult task in that there are several factors that affect the successful implementation of a population control strategy. These include the education levels of the population, religious constraints, cultural barriers and economical constraints. Current contraceptive methods available are not proving effective as they are being inconsistently and incorrectly used by a large majority of the population or no birth control is being used at all. It is important for greater access and information to be provided to the men and women of India so that they may be used effectively. There is also a niche to be filled for the relatively new immunological birth control vaccines being developed to be introduced as a population control strategy. New and old methods of birth control shall be discussed and conclusions shall be made as to the fertility of Indian people today and into the future.

The Republic of India is a country in South Central Asia which comprises the major part of the Indian subcontinent. India covers a land area of 3.3 million square kilometers and its coastline stretches 7600 kilometers (Embassy of India 2005). It is the seventh largest

10328705 Melanie Pescud country by geographical area. India is bordered by Pakistan, the Republic of China, Nepal, Bhutan, Bangladesh, Myanmar and Afghanistan. India is a sovereign socialist secular democratic republic (Wikipedia 2005).

India has the tenth largest economy in the world (Wikipedia 2005). A quarter of Indians live below the poverty line. These people have a level of income below which they cannot afford to purchase all the resources required to live.

According to the Embassy of India, the 2001 Census accounted for a population of 1027 million people living in the country. India is the worlds second most populous country (Wikipedia 2005). India occupies 2.4 percent of the worlds land area, yet it supports over 15 percent of the worlds population. In 2005 the population growth rate is estimated to be 1.4 percent (Wikipedia 2005). Almost 40 percent of Indians are younger than 15 years of age and the average age of Indians is 26 years old (Wikipedia 2005).

India has a birth rate of 22.32 per 1000 people. The death rate is 8.28 people per 1000. The total fertility rate is estimated in 2005 to be 2.78 children per woman (Wikipedia 2005). The sex ratio at birth is 1.05 males to every female and for the total population this ratio is 1.07 males per every female. Life expectancy at birth is 63.57 for males and 65.16 for females (Wikipedia 2005).

Life expectancy increases are contributing to the population explosion. The HIV problem India is experiencing is cause for concern in that it will significantly contribute to the

10328705 Melanie Pescud decline in quality of life for those affected by it (Eberstadt 2004). Currently in India there is a HIV positive population of between 5 and 8 million. The prevalence of HIV is 3 to 4 percent of the total population in India. This is important in that barrier methods of contraception should be used correctly by those infected with this disease to curb the growing numbers of people infected with HIV.

Generally in nature there is a slight imbalance on the sex ratios at birth, with a slight bias in favour of boys. Generally there are 103 to 105 boys born for every 100 girls (Eberstadt 2004). In India however there is an unnatural excess of boys. Son preference in India remains extremely strong. With declining fertility and the widespread use of ultrasound Indias sex ratio differential is on the increase. In the 2001 census sex ratios ranged across India from 108 to 126 boys for every 100 girls (Eberstadt 2004).

India is multi-ethnic and multi-religious. The majority of the population is Hindu, over 80 percent of Indians in fact. Despite this, India is home to one of the worlds largest Muslim populations (Embassy of India 2005). There are over 120 million Muslims living in India. Members of many other religions also reside in the country.

Hindu women are more likely to use family planning methods than Muslim women according to an Indian national survey (Balasubramanian 1984). The same survey also found that 17 percent of Hindu women compared to 13 percent of Muslim women had used contraception at all in their lives. Sterilization rates are higher amongst Hindu females compared to Muslim women. This contributes to the higher fertility amongst

10328705 Melanie Pescud Muslims compared to Hindus. Both religions are pro-natalist. They do differ however in regards to their beliefs concerning marriage, reproductive behaviour and fertility control (Balasubramanian 1984). These beliefs have an effect on age at marriage, marriage stability and contraceptive use, which influence fertility. For example, Islamic beliefs, in contrast to Hindu beliefs, support polygamy, allow for easy divorce in case of infertility, and allow widows to remarry. The risk of pregnancy for Muslims is increased as a result of these beliefs. The education levels of the Indian population also constrain the control of fertility.

Education levels can be indicated by looking at the literacy levels of India and also comparing it to other countries. According to UNESCO 2002 the adult literacy rate, which is people over the age of 15 was 59 percent in India. Therefore contraceptive choice for people in India will not always be the same in all countries or appropriate. This is compared to Nepal at 44 percent, Iraq at 58 percent, The Philippines at 96 percent and Hungary at 99 percent.

In the Thare district of Maharashtra State, India, 77.5 percent of the males are literate and 57.8 percent of females are literate according to the Census of India in 1991.

For contraceptive use to be effective the type to be used must be understood adequately. For example, some people cannot count to 20 and it would be impractical to use contraceptives that require counting days of the cycle. With this in mind the various methods of contraception shall be explored further.

10328705 Melanie Pescud Women in India have been limited in their pursuits for obtaining their reproductive intentions and health needs (Ravindran 2001). There is an obvious unmet need in India for effective family planning. This is based upon women wanting to achieve the following as cited by Bruce and Jain 1994:

a desired pregnancy with a positive outcome the prevention of an unplanned pregnancy terminating an unwanted pregnancy safely achieving the desired interval between two consecutive births preventing any associated reproductive morbidity

The regulation of fertility is more likely to be achieved with the use of modern contraceptive methods. It has been found that those women who had never used a contraceptive only tended to undergo sterilization following one or more induced abortions (Ravindran 2001). The Indian family planning program has focused exclusively on sterilization as the primary method for decreasing fertility levels. This had continued for several decades. Sterilization was usually chosen after a long struggle with poorlytimed and unwanted pregnancies, induced abortions, miscarriages, stillbirths and infant death (Ravindran 2001). Contraception was not usually used in these situations.

According to the National Family Health Survey of 1992 to 1993 the contraceptives used by women who were actually using contraception but were currently having an unwanted or poorly-timed pregnancy were:

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traditional methods 62% condom 33% oral pill 25% intra-uterine device 18% sterilization 1% other modern methods 1%

Of the women who had used sterilization as their first contraceptive method 16.2 percent had previously had an induced abortion. Of these women, 10 percent of women who had used other contraceptive methods before sterilization had previously had an induced abortion (Ravindran 2001).

The median age at sterilization in India was 26 years in 1998 to 1999 and 79 percent of sterilizations occurred before the woman turned 30 (International Institute for Population Sciences 2000). Induced abortion is heavily relied upon to prevent unwanted children and assist with birth spacing.

The use of emergency contraception is also important in restricting the number of pregnancies that would otherwise occur in its absence. A study by Ambardejar et al 2001 was conducted to determine whether multiple courses of emergency contraceptive therapy supplied in advance of need would tempt women using barrier methods to take risks with their more effective ongoing contraceptive methods. It was found that multiple

10328705 Melanie Pescud contraception doses supplied in advance did not tempt condom users to risk unprotected intercourse. Following unprotected intercourse, however, those women with the pills at their direct access did use them more. So it was concluded that it is beneficial for women to receive provision of the emergency contraception in advance.

Knowledge of emergency contraception by health care providers in North India has been found to be inadequate (Rathore et al 2003). Amongst the general population and paramedical workers awareness of emergency contraception is practically non-existent.

The National Family Planning Survey carried out in India in 1995 found that 78 percent of conceptions that occur each year are not planned for and of these, 25 percent are unwanted. This contributes to the 11 million induced abortions annually in India (Rathore et al 2003). It has been estimated that 75 percent of unwanted pregnancies have been prevented each year by the use of emergency contraception (Stewart and Trussel 1992).

There is an enormous amount of pressure put on Indian women by their mothers in law to conceive within the first year of marriage (Barua and Kurz 2001). Many women are not aware of where they can access contraceptive services or they are not permitted by their husbands to use family planning practices. Many women have troubled pregnancies but do not choose to use contraception until they have a daughter, especially after the death/s of previous children (Ravindran 2001). There is a national problem with poor health, poverty, marital disharmony and abuse that are exacerbated by their inability to achieve their desired reproductive intentions.

10328705 Melanie Pescud The responsibility of men in the use of contraception is lacking and proving to be a barrier to birth control. Condoms were introduced in the late 1950s as a reversible barrier method in India by the National Family Welfare program. Vasectomy was the only other method available but it is permanent. Male sterilization is chosen by 6 percent of couples opting for a contraceptive as opposed to 40 percent for female sterilization (Balaiah et al 1999).

Male attitudes to family planning can often be negative and women are powerless to motivate their husbands into using condoms for example, let alone female contraceptives. A study by Zachariah 1990 found that 40 percent of women from Southern India were not using any contraception because their husbands objected to their doing so.

Mens knowledge of contraceptive methods is lacking behind females, which itself is limited. Men most commonly knew of female sterilization followed by male sterilization and knowledge of the other available contraceptives was even more limited (Balaiah et al 1999). In this study of 3072 men only 40 percent of men reported having access to information on contraceptives. Only 16.2 percent of the men had tried condoms. Men who chose not to use contraception cited wanting another child (the majority of men desired three or more children) and lack of access to information and services as reason not to use contraception.

Men were often uneducated when it came to facts about vasectomy. A large proportion of men believed that vasectomy would affect their physical strength adversely and reduce

10328705 Melanie Pescud their sexual potency (Balaiah et al 1999). These were the main reasons behind placing sterilization as the womans responsibility. Once again, education and access to contraceptive methods is lacking in the male population of India and contributing to the ineffective control of pregnancies. It is appropriate now to describe the new birth control methods being developed to fill a large niche amongst the Indian population.

There is an important need for effective reversible contraception as the current methods are not proving effective. This is the result of incorrect use and lack of information and education on the available contraceptives. To solve this problem and control population growth, greater information on contraceptives is necessary. There is also a niche to be filled for new contraceptives such as the immunological contraceptives being developed.

Vaccines against fertility are relatively new in the area of contraception. They allow the reproductive process to be intercepted by using immune effectors that enable pregnancy to be avoided through a number of pathways (Raghupathy and Talwar 1992).

Pregnancy can be prevented by the inactivation of a hormone that is essential to a successful pregnancy, or counteracting a gamete antigen responsible for the development of gametes as well as fertilization. There are many potential vaccines for birth control possible.

Human chorionic gonadotrophin vaccines can be used as birth control as this hormone is crucial in the establishment and maintenance of pregnancy in the early stages. Phase I

10328705 Melanie Pescud trials began in India in 1976 and Phase II trials commenced in 1990 (Raghupathy and Talwar 1992). The vaccine works by producing antibodies against hCG. The block to fertility is reversible and women in the Indian trials were able to conceive when treatment was ceased.

In a trial by the International Centre for Genetic Engineering and Biotechnology, Delhi, India it was found that only 60 to 80 percent of trial patients developed antibody titres high enough over a long enough time period to prevent pregnancy using HSD-hCG. At monthly intervals three injections were required for primary immunization as well as follow up boosters. Also monthly antibody titre checks were necessary. The trials and follow up study showed that the vaccine was safe, effective and reversible (Kumar 1998).

Gonadotrophin releasing hormone vaccine works through the production of antibodies for this hormone that render both men and women infertile. GnRH is essential in stimulating the release of follicle stimulating hormone and luteinising hormone. The downside is that it can lead to a loss of libido and cause anatomical and behavioural changes. It can also cause target organs such as the prostate to atrophy (Raghupathy and Talwar 1992).

In the Phase I trials of the hCG vaccine some of the subjects did not react with a clear anti-hCG response following secondary vaccination. The restoration of the antibody responses was facilitated by immunization with the same gonadotrophin subunit linked to an alternative carrier. This vaccine is referred to as carrier-induced suppression (Raghupathy and Talwar 1992).

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Anti-sperm antibodies can prevent penetration of the zona pellucida and prevent the acrosome reaction. In guinea pig animal models there was a 100 percent block to fertility (Raghupathy and Talwar 1992). Vaccines that prevent the zona pellucida from being traversed are being developed. Anti-zona antibodies are capable of preventing fertilization of oocytes, inhibiting sperm attachment and penetration.

There are other candidate immunogens that researchers are focusing on. These include FSH, inhibin, riboflavin carrier protein and progesterone.

Problems arise in the Indian situation as to the length of time immunity is sustained for as well as the numbers of vaccine administrations necessary and which vaccines are most suitable. There is a need for more trials to be conducted.

There is a great lack of knowledge amongst the Indian population of the contraceptive methods available and a lack of education surrounding the correct usage of those methods adopted to control the birth rate. The awareness of the population can be increased through health educators, mass media, and by providing information in appropriate educational settings. Door to door visits from educators have also been suggested as viable options for increasing knowledge of available contraceptives and increasing the access to birth control. The relatively new immunological contraceptive vaccines being developed are promising additions to the already numerous birth control methods available. They will hopefully create a new niche in the contraceptive needs area where

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10328705 Melanie Pescud other methods have not been successful. It is necessary to account for the cultural and religious constraints that limit a couples choice of contraception. Of course these decisions will come down to the choice of the individuals and couples but they should be assisted with the provision of resources and education so as to ensure the best choice is made when deciding to commence an effective method of birth control. With regard to the high levels of poverty in India it is also important that contraceptives are affordable to all people possibly through subsidies by the government.

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10328705 Melanie Pescud Bibliography

Ambardekar, S., Blanchard, K., Coyaji, K., Ellertson, C., Hedley, A. and Trussell, J., 2001, Emergency contraception: randomized comparison of advance provision and information only, Obstetrics and Gynaecology, vol. 98, pp. 570-575.

Balaiah, D., Ghule, M., Hazari, K., Juneja, H., Naik, D. and Parida, R., 1999, Contraceptive knowledge, attitudes and practices of men in rural Maharashtra, Advances in Contraception, vol. 15, pp. 217-234.

Balasubramanian, K., 1984, Hindu-Muslim differentials in fertility and population growth in India, Artha Vijnana: Journal of the Institute of Politics and Economics, vol. 26, pp. 189-216.

Barua, A. and Kurz, K., 2001, Reproductive health-seeking by married adolescent girls in Maharashtra, India, Reproductive Health Matters, vol. 9, pp. 53-62.

Bruce, A. and Jain, A., 1994, A reproductive health approach to the objectives and assessment of family planning programs, in Population Policies Reconsidered: Health, Empowerment and Rights, Cambridge, Harvard Centre for Population and Development Studies.

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10328705 Melanie Pescud Census of India, 1991, Provisional Population Totals, Registrar General and Census Commissioner, India.

Eberstadt, N., 2004, Power and population in Asia, Policy Review, no. 123, pp. 1-21, http://www.policyreview.org, accessed 21/09/05.

Embassy of India 2005, India: a dynamic democracy, http://www.indianembassy.org/dydemo/indiaprofile/profile.htm, accessed 11/09/05.

International Institute for Population Sciences, ORC Macro, 2000, National Family Health Survey, 1998-1999, India, Mumbai.

Kumar, S., 1998, Research into anti-fertility vaccine continues despite protests, The Lancet, vol. 352, pp. 1528.

Raghupathy, R. and Talwar, G., 1992, Vaccines against fertility, Current Opinion in Immunology, vol. 4, pp. 597-602.

Rathore, A.M., Sachdeva, J. and Tripathi, R., 2003, Emergency contraception: knowledge, attitude, and practices among health care providers in North India, Obstetrics and Gynaecology, vol. 28, pp. 142-146.

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10328705 Melanie Pescud Ravindran, T., 2001, Unmet need for reproductive health in India, Reproductive Health Matters, vol. 9, pp. 105-113.

Stewart, F. and Trussel, J., 1992, The effectiveness of post-coital hormonal contraception, Family Planning Perspectives, vol. 24, pp. 262-263.

United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute for Statistics 2002, Education and Literacy, http://www.earthtrends.wri.org accessed 12/09/05.

Wikipedia Internet Encyclopedia 2005, India, http://en.wikipedia.org/wiki/India accessed 11/09/05.

Zachariah, K., 1990, Some comments on the demographic transition in Kerala, Demography India, vol. 19, pp. 183-188.

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