Thirty-year-old Ramsakhi Adivasi doesn’t want to be sterilised unless she becomes the mother of another boy. Ramsakhi, who lives with her husband in Teehar village of Sagar district in Madhya Pradesh, has four daughters and a boy. She still hopes that the next child will be a son!
Living in a kaccha house with her husband (who is a daily wage labourer at a brick kiln in the neighbouring district), Ramsakhi is in her third trimester. She hardly gets sufficient nutritious food to take care of herself and her brood of five children. But still, she has been convinced by her husband to produce children till the family doesn’t get another son. “Children are a gift from God, so nothing is there in our hand, or else I would have been a father of five sons,”Ramsakhi’s husband Dhansingh says in a quite careless manner.
Seven months ago, Ramsakhi conceived while she was away from the village with her husband at the brick kiln in Raisen district for a year. She didn’t bother to get herself checked in the nearby hospital or avail of the services rendered by the state government through the Village Health and Nutrition Day (VHND). The VHND is a monthly health camp held by the Union and state governments in rural areas, where more than a dozen health services are rendered to people, especially women and children, for free.
When a community health worker, accredited social health activist (ASHA), Rekha Dixit, learnt about Ramsakhi’s return to Teehar, she called her for a health checkup. Here, both the ASHA activist and an auxiliary nurse midwife (ANM), Lata Rohitas, stressed upon post-delivery sterilisation, to avoid having more children.
“We try to tell every women to get the sterilisation operation done after the second child, or at least, get an intrauterine contraceptive device (IUCD) inserted – so that the needed gap is maintained between pregnancies. But, only a handful of them listen to us,” said Dixit. She adds that, in the village, men dominate the family, and hence, women have to follow them. She also said that it is almost impossible talking to men about vasectomy (male sterilisation) or even about using temporary methods of contraception.
Like Ramsakhi, Bimla Prajapati of Dudhani village in Sheopur district hesitates to come outside of her semi-concrete house, whenever health workers and volunteers visit their doorsteps to offer health-related services. Moreover, she hardly talks to any ‘new face’ – be it health counsellors or government officials from the district or state. “They always ask about number of children I have. What’s wrong if I have nine kids? Do I ask for food from anyone?” she questions, as I tried to converse with her.
She was also asked by the ASHA worker and the ANM midwife to get herself sterilised just after she had her third daughter. However, both she and her husband refused the offer as they wanted a boy. Amongst her nine children, there are eight daughters and a 6-year-old son. The youngest one is a two-and-half year old daughter.
Two of Bimla’s daughters are married. The eldest one, Pinky (24) is a mother of two children. Surprisingly, her children are older than her youngest sister. “Bimla’s husband had to sell his few acres of land for getting both the daughters married. Still, the family is unable to look after the youngest girl due to which she is malnourished. Finally, after suffering from labour pain multiple times, she agreed for a laparoscopic tubectomy operation (LTT), which was conducted two years back,” an anganwadi worker, Sulochna Mehra, said.
Like Ramsakhi and Bimla, one is likely to come across numerous multiparous women – who give birth to children continuously, without the required spacing of two or three years. Not only does this affect the nation’s family planning process, it also brings misery in the lives of individual families.
Unfortunately, while experts say that multiparous mothers are more vulnerable to several health-related ailments like postpartum haemorrhage, vaginal rupture, severe anaemia, excessive bleeding etc, they also are of the view that the use of contraceptives is still a distant dream in rural areas.
“There are two things. First, if the mother is pregnant without a minimum gap of 18 months, her health will deteriorate, because that period is needed for total recovery, post-delivery. She is also likely to get anaemic (a high risk condition). Besides, it will be difficult for her to look after her children,” said Dr Meeta Agrawal, a Bhopal-based gynaecologist who’s been working in the field of mother and child health for 15 years. She said that since Madhya Pradesh has a largely patriarchal society, rural people believe that if a boy is not born, their family tree will not flourish.
“We all know that both men and women are needed to reproduce. But still, we come across cases where people want more and more boys, thinking that more sons are needed to show off their muscle power in society,” Dr Agrawal explains.
Data at the national and state levels reveals a grim picture in Madhya Pradesh, so far as family planning is concerned. As per the annual health bulletin of the National Health Mission (NHM), Madhya Pradesh has a set target of 5,50,000 sterilisations. In 2015-16, the state achieved 4,04,219 sterilisations – while in 2016-17, the figure dropped to 3,53,498. The annual achievement of intrauterine contraceptive device (IUCD) insertion was 51% for 2015-16 – while in 2016-17, there was a steep decline of 4% (down to 47%), compared to the previous year.
In many cases, the husband or the mother-in-law of the woman concerned prevents her from getting the IUCD inserted. On the other hand, there are cases where women were forcefully asked by their husbands to get the device removed a few days after the insertion.
“A few days ago, we had convinced a mother to have an IUCD inserted after she gave birth to her second child (a male). She got it inserted, but it had to be removed after two days because her husband started making a ruckus in the hospital. These things happen not only in rural areas but in urban areas as well, because the urban folk also believe several social stigmas and orthodox practices,” recalls Hemlata Garg, the women health counsellor at a government-run district Hospital in Sheopur. Last year, this district was in the news because of the many children deaths due to malnutrition.
To an extent, it is easy to convince the women to get the LTT operation done. But, getting their husbands ready for vasectomy is a daunting task, for many of them think that it will tarnish their image in society.
“Sometimes we come across men who say that if they are sterilised, they are likely to be pranked by friends who will question their manhood. This is a misconception which needs to be erased from people’s minds. Sterilisation has nothing to do with losing ‘sexual power’,”explains Dr Jyoti Chauhan, a senior gynaecologist with the women and child wing of Bundelkhand Medical College and Hospital (BMCH), Sagar.
Like in the country, there has been a sharp fall in the total fertility rate (TFR) in Madhya Pradesh. Here, the rate has declined from 3.1 children per woman in 2005-06 to 2.3 childrenper woman in 2015-16, according to the National Family Health Survey (NFHS-4). However, the percentage of male sterilisation has fallen down to 0.5% in 2015-16 from 1.3% in 2005-06.
Frequent pregnancies without spacing and having more children in the family leads to malnutrition among children below five years, especially in rural areas. Neither the mother nor the children are having timely meals.
“Rural women have no fixed timing for their diets. Even during their pregnancy, they hardly eat healthy food twice in a day. Moreover, they are burdened with too much domestic work which results in them skipping meals more often than not. In such a situation, producing more children will be always be an additional burden on the family – and on the mother in particular,” maintained Leena Singh, a social activist working in the field of community health for the past two decades. She added that giving birth to a boy is considered to be a matter of pride – and this multiplies the existing women health problems in a big way.
The data of the Sample Registration Survey (SRS) conducted by the Registrar General of India in 2013 revealed that the infant mortality rate (IMR) in Madhya Pradesh was 54 per 1000 live births, which was much higher than the national average of 40 per 1000 live births.
Bhopal-based social activist Sachin Jain says, “Even the early age of marriage is contributing to the problem in a big way – due to the fact that as the women conceive at a tender age, during their ‘fertile age’, their daughters are likely to already be married. In these cases, both the mother and the daughter may become pregnant at the same time, due to the lack of contraceptive measures.” He added that unless the males of the society do not come forward, it will be very difficult to solve the problem of increasing population, which in turn results in the ill health of women.