It is generally claimed that India has always adopted the “cafeteria approach” and continues to do so. Though this implies that all available methods of contraception are offered to the people with the choice left to them, in actual practice it is found that each method of contraception has received varying emphasis at different times.
These method have included the rhythm method, the diaphragm and jelly method, foam tablets, the condom, the intrauterine device (IUD), male and female sterilization and, in more recent times, the contraceptive pill.
Though induced abortion, in the strictest sense of the term, cannot be included in this list, it has also become important in recent times because of the Medical Termination of Pregnancy Act of 1971.
The Rhythm Method:
When India initiated the family planning programme, the Government requested the World Health. Organisation in 1951 to provide an expert on Planned Parenthood to set up a pilot study of the rhythm or the safe-period method.
It was thought that if this method was successful on a large scale, it would provide a simple method of solving the problem of family planning in India.
Though the Government is often blamed for selecting the rhythm method, which is often known as “the un safest method” of family planning, it must be appreciated that, at that time, little or nothing was known about the attitudes of the people to the idea of conception control and, therefore, the selection of a method which was in keeping with the traditions, culture and mores of the people was justified.
The idea of controlled sex-life was well accepted, at least among the Hindus, who formed the majority in the population, for certain auspicious and inauspicious days were prohibited for sex and there were long periods of abstinence following childbirth.
Hence, the rhythm method was expected to face the least opposition from the people. This method, moreover, had the added advantage of not involving any expenditure.
An important consideration in the choice of this method was the fact that it fitted well with the Gandhian ideals, to which the then Minister of Health, Rajkumari Amrit Kaur, strongly subscribed.
It was, therefore, not surprising that the Government of India informed the WHO that it was “definitely for the moment unwilling to consider any other type of family planning.”
The results of the Rhythm Project, both in urban areas (Lodi Colony, New Delhi) and rural areas (Ramanagram, Mysore), indicated once for all that it was not suitable for large-scale application. The method can be used only it fairly accurate records of menstrual cycles are maintained, so that fertile and infertile days can be calculated.
As may well be imagined, the maintenance of such records was not easy in rural India, where high rates of illiteracy were common. Moreover, as most women do not menstruate with any regularity, it was difficult to practice the rhythm method correctly. The psychological and cultural barriers, too, were difficult to overcome.
In the urban study area, of the 231 women who were advised to practice the rhythm method, 114 (49.35 per cent) reported non- use of this method, 90 (38.96 per cent) reported its partial use, and only 27 (11.69 per cent) reported its regular use.
In the rural study area, only 112 women were advised to practice the rhythm method. Of these 82 (73.21 per cent) were following the method either regularly or irregularly at the time of the report.
The most heartening finding of this project was that 70.0 per cent of the 1,088 couples interviewed in the rural areas expressed a desire to learn a family planning method, indicating that family planning was not unacceptable to the Indian people. The stage was, therefore, set for a large-scale programme with modern scientific contraceptives.
Diaphragm and Jelly Method:
After experimenting with the rhythm method, the Indian family planning programme fell back on the diaphragm and jelly method, which fitted well with the western model for family planning service adopted by India.
This method was known to have had a wide acceptability in the West, but was soon found to be unsuitable for India, despite the fact that it was highly effective if used correctly and regularly.
This method required the services of a doctor to fit the women with the correct diaphragm and called for a certain degree of sophistication on le part of the woman to learn how to use the method correctly.
Regularity of use, however, could be ensured only if the woman was highly motivated, and this involved repeated use of the diaphragm. It also required some privacy as well as storage facilities.
Some experimentation with foam tablets was carried out because this method is simple, cheap, and harmless. The other two conditions for an ideal contraceptive were, however, not fulfilled by foam tablets: they were not very effective, for the climatic conditions of the country were not found to be suitable for their use, and they were aesthetically unacceptable to many couples.
Even before the official family planning programme was launched, female sterilisation was known to enjoy some popularity, specially, in urban areas where institutional deliveries took place.
It is evident from the figures of the sex-wise break-up of sterilisation operations from 1956 to 1995-96 (See Table 14.3) that, up to 1959, female sterilisations were more in number than male sterilisations.
After 1960, however, the percentage of vasectomies to the total sterilisation increased, and till 1972-73, this percentage continued to be higher than that of female sterilisations. The highest percentage was reached in 1967-68, when 89.6 per cent of the total sterilisations were vasectomies.
In 1973- 74 and 1974-75, however, these percentages were 42.8 and 45.3 respectively. This decrease may be attributed mainly to the fact that the vasectomy camp approach was abandoned after 1972-73, In 1975-76 this percentage was 53.9 and in 1976-77, the height of the period of the emergency, three-fourths of the sterilisations were done on men.
The popularity of vasectomy reached low ebb in the year 1976-77 when less than one-fifth of the sterilisations were done on men. In the year 1978-79, there was some improvement with 26.3 per cent of the sterilisation being vasectomies.
However, since 1980-81 this percentage has been declining, with only 13.4 per cent of the sterilisations done in 1984-85 being vasectomies. This position has since not changed with only 8.2 per cent of the sterilisations done in 1989-90 being vasectomies.
The popularity of vasectomy has declined even further, with only 1.9 per cent of the sterilisations done in 1996-97 being vasectomies.
A major breakthrough in contraceptive technology occurred when the intrauterine device, known as the Lippes Loop, was accepted, after some experimentation as the answer to the family planning problem not only of India but all developing countries.
This method was cheap, simple, effective, and its most attractive feature was that its use involved only one action and was reversible. This had great relevance in a developing country like India, where motivation for family planning was not very strong.
The Lippes Loop was, therefore, brought into the Indian family planning programme in 1965, with a great deal of publicity and high expectations.
These high expectations were initially fulfilled beyond the wildest hopes of even the most optimistic administrator, with women queuing up for IUD insertions.
The IUD programme, however soon, crashed, for women once again were queuing up, but this time for the removal of the IUD. While in the period from January 1965 to March 1966 and in 1966-1967, 812,713, and 909,726 women respectively accepted the IUD, the figures for 1972-73 and 1973-74 were 354,624 and 371,594 respectively.
Since 1974-1975 however, the IUD programme has started picking up again, probably because of the introduction of a new type of IUD, the Copper, and in 1984-85 25.6 lakhs IUD insertions were done. In 1989-90, the figure stood at 49.4 lakhs. By 1995-96, the figure had gradually gone up to 685.1 lakhs, but fell to 568.1 lakhs in 1996-97.
The reasons for the chequered career of the IUD in India are not difficult to find. The programme, which started with such promise, got into disrepute mainly because of the inadequate preparation, before it was launched, in terms of training of personnel and provision of facilities to handle side effects like bleeding, pain, etc., and because of the absence of efficient follow-up services.
The incomplete knowledge about the IUD led to several rumours about it. The United Nations Advisory Mission, which carried out an evaluation of the Indian family planning programme in 1969, analysed the reasons for the rapid decline in IUD acceptances and rightly pointed out: “The step from limited pilot studies to the use of the IUD on a large scale within the programme was thus taken rapidly and with insufficient preparations.”
But the Mission also reiterated that “the IUD remains the only known, inexpensive reversible method of clinical contraception.”
It, therefore, recommended that the IUD programme in India should be rehabilitated, and efforts should be made to retain the staff, ensure better dissemination of information to the public and particularly to individual clients, effect a careful screening of clients to exclude all those with contradictions, and pursue a thorough follow-up of cases permitting continuous evaluation of the programme, analysis of problems and corrective measures at short notice.”
The Condom, now known as Nirodh in India, is presently distributed all over the country through three schemes: (i) The Commercial Distribution Scheme, (ii) The Free Supply Scheme and (iii) The Depot Holders Scheme.
The Commercial Distribution Scheme, launched in September 1968, involves the marketing of Nirodh through the regular network of salesmen, distributors, wholesalers and retailers of the twelve marketing companies including Brooke Bond, Hindustan Lever, ITC, Indian Oil Corporation, Lipton, Tata Oil Mills and Union Carbide.
This scheme utilises modern marketing techniques and attempts to create a demand for Nirodh and then meets this demand by making Nirodh widely and conveniently available throughout the country along with such daily items of consumption as tea, cigarettes, soap, kerosene, etc.
Till 1973-74, Nirodhs were available at 15 paise for 3 pieces. In 1974-75, this price was raised to 25 paise. This Scheme has made good progress over the years despite the steep fall in its use in 1974-75 because of increased prices and reduced funds available for promotional publicity.
It has been observed: “Market research carried out independently by Operations Research Group, Baroda, has shown that consumer purchase of Nirodh is growing more rapidly in medium and smaller towns and rural areas than in cities, thereby achieving one of the objectives of the programme.”
According to a 1974-75 Government report of the Family Planning Programme, there were four lakh retail outlets for Nirodh throughout the country. During 1983-84, a scheme was started to place funds at the disposal of the companies for the purpose of demand creation.
This scheme has helped to increase the sales of Nirodh. Involvement of voluntary organisations/societies for the sale of condoms under their own brand name has also increased sales.
The importance of the condom has increased in recent times due to its usefulness in the prevention of HIV/AIDS as well as other sexually transmitted diseases.
Free supplies of Nirodh are available at all family welfare planning centres and sub-centres in the country. Under the Depot Holders Schemes, introduced in 1981, Health Guides and Multipurpose workers are provided with Nirodh for distribution and can be sold at 5 paise for a pack of 6 pieces. This amount is retained as an incentive by those who run the scheme.
Condoms are also commercially distributed through the Social Marketing Scheme under the brand named, Sawan, Bliss and Masti the first two by Parivar Sewa Sanstha and the last by Population Services International (India).
The Government of India has been extremely cautious about including the pill in its armoury of contraceptive weapons, despite the fact that oral contraceptives have been one of the most popular methods of family planning all over the world.
Since the 1950s attempts have been made to develop such pills indigenously. The pill programme was initially started with a few of Pill Project Centres with the objective of assessing its efficiency and effectiveness as well as the complications that may arise out of its use by Indian women.
The Pill Project was later extended to Urban Family Welfare Planning Centres at all district headquarters and towns and became a part of family planning services offered by the Central Government Health Schemes by the armed forces, the Railways, the Employees State Insurance Scheme, and a few primary health centres in each district.
In 1974, the pill programme was extended to all urban family welfare planning centres and those primary health centres which would be in a position to monitor its progress and continuing use by women.
In a sense, these developments arose out of the recommendations of the Second United Nations Advisory Mission (1969), which had advised that oral contraception should be introduced in the Indian family planning programme on a large-scale, subject to continued checks for its medical and social acceptability and its effectiveness.
The Mission had also emphasised the importance of rigorous pre- treatment procedures and later supervision and follow-up checks on all pill users.
At present, attempts are being made to expand the oral pills programme, under which certain categories of paramedical personnel will be authorised to distribute pills free of cost with the condition that the client must be examined by a doctor within three months.
Social marketing of oral pills which was launched in November 1987, under the brand name Mala-D and Mala-N is available through the free distribution scheme. Oral contraceptive pills are also being marketed under brand names ECROZ, Pearl, Choice and Moti.
Though abortion is not considered by the Government of India as a family planning method, it needs to be considered along with other methods of family planning for a widespread acceptance of abortions is known to have a dramatic impact on birth rates.
It is also important to consider this aspect of abortion which finally led to the enactment of the Medical Termination of Pregnancy Act in 1971. The law became effective from April 1972.
The Medical Termination of Pregnancy Act, 1971, framed mainly on the recommendations of the Committee appointed by the Central Family Planning Board, Ministry of Health, Government of India, under the chairmanship of Shri Shantilal Shah, allowed termination of pregnancy on the following grounds: (i) When the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health; (ii) When there is a substantial risk that if the child is born, it would suffer from such physical or mental abnormalities as to be seriously handicapped. Explanation
(a) Where any pregnancy is alleged by the pregnant woman to have been caused by rape, the anguish caused by such pregnancy shall be presumed to constitute and a grave injury to the mental health of the pregnant woman.
(b) Where any pregnancy occurs as a result of failure of any device or method used by any married woman or her husband for the purpose of limiting the number of children, the anguish caused by such unwanted pregnancy may be presumed to constitute a grave injury to the mental health of the pregnant woman.
It was also laid down that, for all women below the age of eighteen and all women of unsound mind, the termination could take place only with the consent of her guardian. In all other cases, the consent of only the pregnant woman herself is required for the termination of pregnancy.
Though the Government of India did not include abortion among family planning methods, it referred to the Medical Termination of Pregnancy Act as a piece of social legislation of great importance, and its potentiality for supplementing the family planning programme was never overlooked.
Attempts are continuously made to induce all women seeking abortion to accept suitable methods of family planning with a reasonable amount of success. Up to March 1989, 6,291 approved institutions perform such abortions.
In March 1977, this figure was only 2,072. Sin April 1972 up to March 1990, a total of 16.98 million terminations of pregnancy has been done under the Act. By the end of March 1989, 14,292 doctors were trained under the programme.