Volume 27, Number 2, June 2001
Prevention of Unwanted Births in India Would Result In Replacement Fertility
Women in India can expect to have nearly three births if current rates of fertility hold. Should women have only wanted births, however, India's total fertility rate (TFR) would drop by 25%, to replacement level (2.1 lifetime births). According to the 1998-1999 National Family Health Survey (NFHS-2),1 while nearly one-half (48%) of currently married women aged 15-49 practice contraception, one method--female sterilization--predominates, accounting for 71% of all use.
The sample for the 1998-1999 NFHS-2 in India, whose population crossed the one billion mark in May 2000, includes more than 90,000 ever-married women aged 15-49. The majority are Hindu (82%), live in rural areas (74%), had not worked in the year before the survey (61%) and are illiterate (58%). At the time of the survey, 94% were married. The survey provides data on castes, tribes or classes the government has designated as socially and economically deserving of protection--18% of the sample belong to an especially disadvantaged caste, 9% to a similarly disadvantaged tribe and 32% to still other underprivileged classes (designated as "other backward classes"). The remainder (39%) are in middle and higher castes or do not belong to any caste or tribe.
Although the median age at first marriage has been rising in India, it has reached only 16.7 years for women aged 20-49--more than one year below the country's legal minimum marriageable age (18 years). Because the traditional custom of gauna, in which a husband and wife delay moving in together following their formal marriage, is still followed in some parts of the country, the median age at first cohabitation (17.4 years) is almost one year later than the age at first marriage. Among women aged 25-49, urban women are two years older than rural women when they first move in with their husband (18.6 vs. 16.6), and high school graduates are more than five years older than illiterate women when they do so (21.5 vs. 16.0).
Fertility and Fertility Preferences
For the three years preceding the 1998- 1999 survey, the TFR in India was 2.9 lifetime births per woman. This represents a 16% decline from the rate (3.4 lifetime births) recorded in the 1992-1993 National Family Health Survey. The overall TFR masks large differences between states. State TFRs range from below-replacement fertility of 1.8 births in Goa and 2.0 in Kerala to 4.0 in Uttar Pradesh and 4.6 in Meghalaya.
Overall TFRs vary comparatively less by urban or rural residence (a difference of 0.8 births) than by education (a difference of 1.5 births between the least- and most-educated women in the sample). Moreover, by the end of their reproductive years, Muslim women can expect to have more births (3.6) than either Hindu (2.8) or Christian women (2.4).
These differentials in total fertility are echoed in differentials in the median age at first birth. While 25-49-year-old women overall have their first birth at age 19.4, those living in urban areas are 1.6 years older at their first birth than are rural women (20.6 vs. 19.0). High school graduates are 4.8 years older than illiterate women when they first give birth (23.3 vs. 18.5), and women with a high standard of living have their first baby nearly three years later than do women with a low standard of living (21.2 vs. 18.5).
The national TFR of 2.9 is fairly close to the mean number of children that Indian women consider ideal--2.7. This ideal family includes proportionately more boys than girls--that is, 1.4 sons, one daughter and 0.3 children of either sex. Although 78% of the births occurring in the three years preceding the survey were wanted at the time of conception, 12% were wanted later and 9% were not wanted at all. The proportion of unwanted births was highest among 40-49-year-olds (42%) and among women who already had at least four children (25%). The total wanted fertility rate, which represents the level of childbearing that would result if all unwanted births could be prevented, is 2.1 lifetime births, or 25% fewer than the actual TFR.
Overall, only 30% of women want to have another child (15% want one within two years, 13% want one within a longer period of time and 2% are undecided about the timing), and 28% are still fecund and do not want any more children. An additional 36% have been sterilized or are protected from further childbearing by their partner's vasectomy.
Although the proportion of women wanting at least one son (85%) and the proportion wanting at least one daughter (80%) are similar, son preference still plays a prominent role in Indian women's fertility preferences. For example, among women with two living children, the proportion wanting more children is far greater among those with two daughters (53%) than among those with two sons (17%) or those with one son and one daughter (24%). Women who do not have a daughter are twice as likely to want to stop childbearing as are those who do not have a son (41% vs. 20%). Moreover, when asked the preferred sex of their next child, the proportion preferring a boy was more than four times that preferring a girl (47% vs. 11%). Twenty-eight percent of women said that it does not matter; the remaining 15% left it "up to God."
Contraceptive Knowledge and Use
Almost all (99%) currently married women in India know of a modern method of contraception. The most widely known methods are female sterilization (98%) and vasectomy (89%). The three modern spacing methods asked about--the pill, IUD and condom--are known by 71-80% of women. Only 49% know of at least one traditional method.
Almost one-half (48%) of currently married 15-49-year-olds were using a method of contraception at the time of the survey, and 55% had used one at some time in their lives. The national contraceptive prevalence rate hides wide differences in state prevalence rates, which range from 20% for women in Meghalaya to 68% for women in Himachal Pradesh. State contraceptive-use patterns do not always follow state fertility patterns, largely because contraceptive use is only one of the factors that affect fertility. For example, Goa has a contraceptive prevalence rate of 48% (the same as the national average), even though it has the lowest TFR in the country (in part because of the relatively high age at first marriage in Goa, 23 years).
Female sterilization dominates contraceptive use in India and is used by 34% of currently married women, accounting for 71% of all use. The next most popular methods are the condom or rhythm (used by 3% each) and the pill, the IUD or the partner's vasectomy (2% each). (Reliance on vasectomy has declined over time, as only 2% of all sterilizations performed within the nine years before the survey were male procedures, compared with 10% of all sterilizations performed 10 or more years prior to the survey.)
The median age at female sterilization in India is 25.7 years. Muslim women are much less likely to be sterilized than are either Hindu or Christian women (20% vs. 36-37%). In addition, women who have not finished middle school are far more likely than high school graduates to be sterilized (41% vs. 26%).
In line with the dominance of female sterilization in India's method mix, the most important sources of modern methods are government and municipal hospitals (46%). Overall, 76% of modern-method users obtain their method from a public provider, 17% from a private provider and the remaining 5% from other sources, such as nonspecialized shops.
Overall, 16% of currently married Indian women are categorized as having an unmet need for family planning,* with equal proportions of that need for methods to limit births (8%) and for methods to space births (8%). If India's unmet need for contraception were met, overall prevalence would reach 64%, an increase of one-third.
Maternal and Child Health
Although both infant and child mortality have been declining steadily, in the 10-year period preceding the survey, 73 of every 1,000 babies died before their first birthday, and 101 died before they were five years old. The mortality rate among children younger than five is 70% higher in rural than in urban areas, and 29% higher among Hindus than among Muslims (mostly because Muslims are more likely to live in urban areas). Rates of child mortality also fall precipitously with increasing education--i.e., from 123 child deaths per 1,000 among babies born to illiterate women to 37 per 1,000 among those born to high school graduates.
The mothers of 34% of the babies born in the three years preceding the survey had had no prenatal check-ups; the main reasons were that such check-ups were considered unnecessary (60%) or too costly (15%), and because the family would not grant the woman permission to have them (9%). Among women who did have a prenatal check-up, the median number was 2.8. Overall, most Indian women (53%) gave birth in their own home, while 17% did so in private health facilities, 16% in public health facilities and 12% in their parents' home.
Sexual and Reproductive Health
Responses to a module on reproductive health indicate that 36% of ever-married women experienced abnormal vaginal discharges or symptoms of a urinary tract infection in the three months preceding the survey. Overall, 39% reported at least one reproductive health problem. Sixty-six percent of women with a reproductive health problem, however, did not seek any advice or treatment for it.
Knowledge of AIDS is quite low in India, which, because of its size, currently is among the two countries with the most HIV-infected people in the world. Only 40% of ever-married women had ever heard of AIDS. Of women who know of the syndrome, 33% could not mention any way of avoiding it; another 40%, however, believed that AIDS can be prevented by having sex with only one partner, 30% by using clean needles or avoiding injections, and 25% by avoiding sex with prostitutes. Just 20% mentioned condoms as a way of avoiding AIDS.
The majority of Indian women (56%) agree with at least one reason that would justify a husband beating his wife. The most commonly endorsed reasons are that the wife neglects the home or the children (40%), that she goes out without telling her husband (37%), that she shows disrespect for her in-laws (34%), that she is suspected of being unfaithful (33%) and that she does not cook food properly (25%). In terms of experience, 21% admit to ever having been beaten or physically mistreated at age 15 or older (90% by their husband), with 11% having been abused within the past year.
1. International Institute for Population Sciences (IIPS) and ORC Macro, India: National Family Health Survey (NFHS-2), 1998-1999, Mumbai, India: IIPS, 2000.
*Unmet need is the proportion of married women who are fecund and at risk of pregnancy--and who do not want any more children or want to wait at least two years before having another child--but are not using any contraceptive method.