Strand organiser: Mhairi Gibson, University College London
State population policies in India: evolution and provision of family planning services by them
C. Bhattacharya
London School of Economics
A population policy, whether pro-natalist or anti-natalist, is defined to address three elements of a population, namely, fertility, mortality, and migration. Anti-natalist population policies had been employing provision of family planning as the primary method to reduce birth rate and slow population growth. In 1994, the Cairo conference played a significant role in advancing the reproductive health (RH) approach in the population and development field. This new approach concentrates in quality of care instead of increased coverage therefore leading to a paradigm shift from addressing population control from the aggregate level to focussing on RH needs of individuals. Subsequently, most signatory countries to the Cairo conference are in the process of integrating Programme of Action recommendations by integrating RH care in their already existing family planning programmes.
Due to the federal nature of the political structure of the country, until 1998, the Government of India at the Centre was fully responsible for policy planning and funding and it was the States that have been implementing these policies. Therefore, the policies originating from the States is a new development in the history of Indian policy-making scene. This paper explores the reasons behind the adoption of these policies. It also examines the changes in the family planning programme due to these policies. The analysis is based on three policy themes. They are discontinuation of use of demographic targets, incentives and disincentives; expansion of the range of family planning methods; and the involvement of the local self governments, the Panchayati Raj Institutions in the family planning programme. These are three of the indicators of measuring quality of care as espoused by Judith Bruce in 1990. However, before the implementation of the Reproductive Child Health project in 1997, as part of the World Bank's review of the Indian family welfare programme, Merrick (1996) prescribed them as reproductive health strategies for the country at the national level. Due to their relevance and appropriateness they need to be addressed at the State-level also.
By virtue of being one of the oldest policy initiatives to influence fertility behaviour in a country of significant demographic impact, the Indian population policy and the family planning programme have been closely examined and analysed in population and development literature over the last four decades. However, studies on the recent development of adoption of population policies by the states remains limited though a beginning has been made. Much of the existing evidence of state-level population policies has become available only recently and a good deal of it remains restricted on official documents. The studies that have looked at the states with population policies (Sen and Ramachandran 2001, Visaria 2001) have stopped at criticizing the use of incentives and disincentives as family planning strategies by these States and how that is diverging from the objectives of the National Population Policy 2000. However none of the studies have analyzed these policies in-depth nor have they ventured to find out the rationale behind the use of these family planning strategies. Thus a gap of knowledge exists on the cause of emergence of the state population policies, and the extent to which that could be explained based on the implementation of RH approach, strategic planning used by these states, and the change in the Centre-State relationship.
The research conducted is qualitative in nature. Case study is chosen as a strategy to find in depth knowledge about the research topics. So the most appropriate multiple research methods employed are in-depth semi-structured interviews and documentary analysis. Madhya Pradesh (MP), a policy state was chosen as a case study to be compared with West Bengal (WB), a non-policy State. The fieldwork was conducted for nine months. The three study sites were MP, WB and Delhi. In Delhi, I visited the Union government offices, academic and research institutes. Within each case study states, I visited 2 districts, and 2 blocks in each district. Then in each block I covered one health centre and one Panchayati Raj office. As a result I conducted over 130 interviews. The sampling decisions with regard to the choice of the states and interviewees were made based on purposive sampling.
The preliminary analysis of the data shows that the adoption of state policies was due to availability of financial and technical assistance from the Policy Project funded by USAID. Moreover, no significant impact of policies can be found on family planning service provision. Whatever changes have taken place are part of the changes in the national family planning programme and they are independent of the adoption of the policies. Involvement of Panchayati Raj Institution varies from state to state - depends on duration of their presence and support from ruling political party in that state. Proof of use of demographic targets can be found at the district levels. "The district level targets are given by increasing 10-20% of the last year's achievement" (Deputy Director, MP).Finally in some states the elected representatives of the Panchayati Raj Institutions are being disqualified based on 2-child nor so that they can act as role models. "I have details from the Assembly where more than 500-600 PRI members have been disqualified" (Deputy Director, MP).
This paper thus examines a new development in the Indian population policy scenario. It also shows how India being a signatory to the Cairo conference is moving away from its commitment.
Email: c.bhattacharya@lse.ac.uk
Gail Grant
University of Southampton
Background
Until 1991 Estonia was a republic of the Soviet Union and in common with other former Soviet and Eastern European States, Estonia has been experiencing 'transition' since independence. This has involved not just political and economic change, but also impacts on reproductive health.
Data and Methods
As part of a wider study into abortion and contraception in Estonia, key informant interviews and focus group discussions were conducted in Estonia during 2003. Estonians and Russians, both men and women, were invited to participate in focus group discussions. In addition, national politicians, service providers and other local experts were interviewed. The data collected were then analysed using the qualitative data analysis software Atlas.ti version 5.0.
Results
Results suggest that transition has been a painful experience for some inhabitants of Estonia. Young adults express wariness of having children when they feel insecure about the future, especially in terms of employment opportunities and living costs. Although the provision of sex education has improved drastically, some young people have missed out, sometimes because of non-attendance at school. Attitudes to contraception are positive, but fears concerning the safety of hormonal methods remain. Views concerning abortion remain liberal, but abortion is not treated lightly. Respondents are aware of the situation pertaining to sexually transmitted infections, especially the issue of HIV, and are well informed about risk factors and methods of prevention.
Email: gpg@soton.ac.uk
Changes in reproductive and lifestyle variables among first- and second- generation Bangladeshi migrants in London: Implications for breast cancer risk.
Alejandra Nunez-de la Mora, Dora A. Napolitano and Gillian R. Bentley.
University College London
Data extracted from socio-economic, dietary and lifestyle questionnaires, supplemented by hormonal data, were used to analyse how a series of physiological and behavioural variables implicated in breast cancer risk have changed among generations of Bangladeshi women living in London. Contrasts between first and second generation migrants suggest a trend towards higher hormonal production and increased lifetime steroid exposure, and thus potentially higher risk of breast cancer among the young generations in this community. Signs of rapid growth and early maturation, developmental factors implicated in increased breast cancer risk, are already observable in this population. Socio-cultural adjustments among migrants have also influenced reproductive and dietary patterns; reduced support from the extended family, higher education and increased employment among women born and brought up in England are reflected in their older ages at marriage and first birth, and a decreased duration of breastfeeding. A departure from traditional low energy-dense and high fibre and protein diets, accompanied by a decrease in daily moderate physical activity have contributed to increased rates of obesity, both factors relevant for post-menopausal breast cancer risk. Albeit at a small scale, the patterns emerging from the present analysis are in agreement with the latest breast cancer epidemiological profiles reported for South Asians in the UK.
Email: a.nunez@ucl.ac.uk
Health differentials between Bangladeshi Migrants in London and Sedentees in Bangladesh: Implications for reproductive function.
Gillian R Bentley and Alejandra Nunez-de la Mora
University College London.
There are significant differences between populations around the world in levels of reproductive steroid hormones that may impact on fecundity and fertility. Most research that that has been undertaken to understand this variation has focused on differentials between the nutritional and/or energic status of the populations under study, but to date, comparatively little attention has been paid to the constraints imposed by pathogens and the consequent immunological challenges to reproductive function. The study reported here assessed the effects of developmental environments on reproductive hormone levels among migrant Bangladeshis to London as well as Bangladeshi sedentees in Sylhet, Bangladesh from where most migrants originate. Levels of salivary progesterone among women who spent their childhood in Bangladesh are significantly lower than white London women and second-generation Bangladeshi migrants who grew up in the UK. In addition, among women who migrated as children, levels of salivary progesterone correlate positively with age at migration. London migrants originate from well-nourished, middle class Sylheti families with low energy outputs. What then can explain their low progesterone profiles? Primary differences between Sylhet and London lie in hygiene levels, pathogen exposure, and access to good medical care. Life expectancy, even among the middle class in Bangladesh, is significantly lower than London residents, while levels of morbidity and consequent immune challenges are significantly higher. We provide further data on these factors for Bangladeshi sedentees and suggest that immune factors and health status during development should be measured more quantitatively in future studies if we are to understand better inter-populational variation in reproductive function.
Email: gillian.bentley@ucl.ac.uk
Choosing a permanent contraceptive method: A comparative analysis of the age and parity effects of sterilization in Brazil and India
Tiziana Leone1 & Sabu S. Padmadas2
1Institute of Education, University of London, UK, 2Division of Social Statistics, University of Southampton, UK
Brazil and India have shown declining fertility trends throughout the last three decades. Much of the fertility decline in these countries was fuelled by the increase in the use of female sterilization. Nearly two-fifth of the Brazilian and Indian women aged 15-49 years had sterilization particularly at younger ages (median: 30 years in Brazil, 25.7 in India). Although the governmental strategies to implementing family planning programs have been different in Brazil and India, both these settings emphasised particularly on the uptake of sterilization as a reliable method especially through the influence of local health providers. Sterilization use in these countries has become a culturally accepted and predominant method of contraception. Two questions arise in this context. How important is the effect of age and parity in explaining the higher levels of sterilization acceptance in Brazil and India? Do women make choices by their own or through the influence of partner/doctor? Using the 1996 Brazilian DHS and the 1998-99 Indian NFHS data, this paper will demonstrate that despite the timing and parity differences associated with sterilization, the reproductive spans of women in these countries are increasingly declining, largely as a result of sterilization acceptance. The age and parity effects were significant in both the settings; the latter was more accentuated in Brazil than in India. The paper is positioned in the context of understanding the reasons for higher acceptance of sterilization in these two countries that have had different intervention strategies towards family planning.
Email: t.leone@ioe.ac.uk
The uptake of modern contraception in a Gambian village: the spread of a cultural innovation over 25 years.
Ruth Mace1, Nadine Allal1, Rebecca Sear2 and Andrew Prentice1 1University College London, 2London School of Economics
The life history of women in 4 neighbouring villages in rural Gambia has been collected over 50 years by the MRC. In 1975 a medical centre opened in one of the villages which supplied modern contraceptives, free of charge, to women who wished to use them. We collected data from over 700 married women on when they first started using modern contraceptives, if ever. Contraceptive use is now fairly prevalent but an ideal of a large family size remains and more than 50% of reproductive age women have not used contraceptives even after so many years of availability. However there are striking differences between village and age cohorts. One village withdrew from the research project and thus did not have access to the health centre. Their use of contraceptive is so low they provide a striking example of the importance of easy access to contraceptive services.
For the other three villages, we used event history analysis to examine determinants of time to first use of modern contraception for all women aged between 15 and 49, any time between 1975 and the time of the survey (2001). Years of exposure to the new technology, cohort, age, parity, wealth and village all had significant effects. Cohort was the biggest effect. Women currently in their 20s were 4 times more likely to start using contraceptives than were women who were of a similar age 20 years ago: uptake rate appears to be doubling every ten years and is far from saturation point. There are highly significant differences between villages which persist over the 25 years, with the two villages with close social links progressing at a similar rate of uptake, and another village, where most people were from a different clan, progressed at a much faster rate. Parity did have a significant effect, with women with few children being less likely to use contraceptives. That the effects of village and cohort appear to be much stronger determinants of time to first use than the effects of family size, wealth or education suggesting that cultural transmission is very important in determining first use of modern contraceptives.
Email: r.mace@ucl.ac.uk
Nazarius Mbona Tumwesigye, Roger Ingham and David Holmes
University of Southampton
Introduction: Previous research confirms that condom use within a relationship declines with time, age and number of partners. Primary data on condom use in first, most recent and second most recent relationships of young people in Uganda was analysed to find out whether the same pattern exists and factors that determine the changes in of use within and between relationships.
Methods: The participants in the study were unmarried young people aged 15-24 years from Kabale and Mukono districts. Consistency of use was defined by use of condom at start and most recent event of relationship while inconsistence meant the person used a condom only at one of the two events. With three outcomes of consistent, inconsistent and non-use a multinomial logistic regression model was fitted to identify independent factors associated with the level of consistency.
Results: The results showed a decline in condom use from first to latest relationship. Factors associated with consistent condom use were residence in Mukono district, higher education level, being in school, not taking alcohol and higher age at first sex.
Conclusion and implication: The results show a need for implementers and policy makers to revisit their sensitisation strategies for young people in Kabale, uneducated/with low education, not in school and those that start sex early.
Division of Social Statistics, University of Southampton
E-mail nmbonat@soton.ac.uk
Mohammad Amirul Islam, Sabu S. Padmadas and Peter W.F. Smith
Division of Social Statistics, University of Southampton
Inconsistency in reporting contraception between spouses is less understood, especially in developing settings. This particular research problem challenges the accuracy of measuring contraceptive prevalence rate, which is traditionally calculated based on women's responses. This article investigates the extent of consistency in reporting contraception using the recent Bangladesh demographic and health survey. Inconsistency in contraceptive use reporting between spouses was about 25%. The discrepancies in reporting use were found common among condom, pill and traditional method (periodic abstinence) users. The discrepancies observed were more accentuated for husbands who reported method use while wives did not. Two-level random intercept logistic regression analysis suggests that consistency in reporting of contraception is significantly high among respondents who are from Sylhet, Dhaka, Rajshahi and Chittagong divisions, from rural areas, have less number of children, and discuss family planning with partner. Significant community variation is also evident from the analysis. This article further investigates the inconsistency in condom reporting and reveals that couple education and age difference between spouses are significant determinants of inconsistent reporting of condom use. The levels of inconsistent condom use reporting were found common among wives' responses. However, it is difficult to establish from the data whether wives are over/under reporting condom use.
Email: islam@soton.ac.uk