Family planning: Have we completed a full circle ?

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Family planning and birth control share a bond with one another. On one hand, phrase “to plan a family” is participatory, thought provoking, and sounds like a management exercise. On the other phrase “controlling birth” seemingly empowers humans to do, what only nature could or mostly could not achieve. These two phrases are like two sides of the same contraception coin, coloured by religious taboos, women’s liberation, and even national ambitions for a better future. Over the years, these thoughts were modulated by our perceptions about population growth and its changing demographics.

An era of high fertility and baby boomers

Despite ups and downs due to famines, plague, and human conflict fertility was generally high, across the world till the beginning of the second world war. Celibacy seemed to be the most effective birth control measure, that obviously never had a mass appeal. Cervical caps, diaphragms and creams were rather struggling to find their place. Across North America and Western Europe, the period between 1945 and 1965 was marked by baby boomers, a rebound rise in fertility rates and population growth.

This population boom, re-ignited an old debate. Way back in 1798, Thomas Robert Malthus had proposed a theory, also known as a malthusian trap. Population growth is geometric, but food-grain production is arithmetic, he said. If we grow unchecked, we will outstrip our food supply. Fast forward to 1965, an International congress on Family planning in Geneva, was first in the series to promote birth-control. Aided by likes of Rockefeller and Ford foundations, this discourse went global. Incidentally birth control pills had just been launched, and intra-uterine devices had also made their debut.

Unlike the west, developing countries like India, had a high fertility rate. An Indian woman in 1951 was expected to give birth to about 6 children in her lifetime. She was married at an early age, had low education levels and no access to either information about birth spacing or control. This situation prompted India to be the first country in the world to initiate a National Family Planning program in 1952. However in first fifteen years of its inception, the program was rather slow, to either pick up its pace, or become part of the nationwide narrative.

Birth of the red triangle

By mid-1960s, the global conversation about family planning was fuelled by demographic, health and human rights concerns. Limitation in resources was a key demographic concern, while aim to reduce maternal mortality, and to improve infant mortality were key health concerns. In 1967, UN added a third dimension to this concern, and declared that ability to decide on birth or its spacing is a fundamental human right.

In 1966, an Indian official named Dr Dharmendra Kumar Tyagi was heading National Family Planning Program. We required a simple, non-verbal symbol to identify any location where family planning services were available. He created a red-triangle and used it over all family-planning communication materials. Red signifies health delivery. Triangle was easy symbol to draw. In coming years, this symbol became global.

Dharmendra Tyagi had a rather short life. He died aged 41 in 1969. Two decades later, when Phil Harvey (an American philanthropist) funded a new contraception-based organisation, he named it after Mr Tyagi as DKT international. The red triangle symbol lived on for years, and was a huge success. Postage stamps played their part in bringing in family planning inside the households.

The intensive implementation 1970-1980

While higher education levels amongst the baby boomers, rise in feminist movements in the west, and a gradual decline in the fertility rates had their impact on limiting family size. Since birth control was often equated with abortion, huge religious divide was an impediment for a strong family planning movement in Europe and United States.

On the other hand, India was much more progressive. With a political and military victory against Pakistan in 1971, India legalised safe medical termination of pregnancy (MTP) in 1972.

From 1975 to 1977 we had “emergency years” in India. During these times, aggressive family planning measures, and reported forced vasectomies earned disrepute for the program.

The immediate post emergency years 1977-1980

After loosing National elections in 1977, Indira Gandhi was out of power for next three years. A state of emergency in the preceding years and an aggressive implementation of tubectomies and vasectomies, were part of the narrative of this loss. An intensive review of the program was done and coercive pre-1976 approach was withdrawn.

The program was renamed from “Family planning” to “Family welfare”. The approach was of education and voluntarism. By 1978, we had revised minimum age for marriage to 18 for girls and 21 for boys. Two-child norm was promoted through various mass media approaches, including philately. Various birth control measures including pills, intra-uterine devices, tubectomies and vasectomies however continued to be made available through the program.

Decade of consolidation 1980-1990s

Indira Gandhi was back in power in 1980. The Family welfare program was also dusted and was brought back to the centre-stage. Gradually contraceptive intake amongst women was increasing. The contraceptive usage in Indian women had increased from 14% in 1976 to about 45% by 1996.

By 1981, the fertility rates were down to be between 3 and 4, in different parts of India. This meant that women were having two less children in their lifetimes, as compared to women in 1951.

In 1980, the health-based, time-bound target-oriented family planning measures in the family welfare program were revived. There was a reduced emphasis on sterilization, and greater emphasis on spacing methods. This was implemented without any aggressive campaigns or mass camps for sterilization as were adopted in earlier years.

Towards the end of 1980s, something dramatic had started happening in the Southern states. In Kerala, where in 1966 there were 37 births per 1000 population, by 1988 the number was down to 20.

While crude birth rate had fallen, number of infants dying per 1000 births, had also fallen in Kerala. In 1988, it was down to 27 much below the national average of 60 in the same year. Same trends were seen in Tamil Nadu, Karnataka and Andhra Pradesh.

The phase of Women’s empowerment in 1990s

In the 1990s, India’s policy focus was economic. As economy was re-structured, we opened up our markets to products as well as investments. We decentralised our Health programs, to the states, primary and community health centres.

Further threat of HIV-AIDS overshadowed the family welfare program as well. In 1994, the family welfare program was again renamed. Now this was “Reproductive and Child Health” or RCH. Red triangle – an integral symbol of the yesteryears, was now out of favour in the new rejig. Moreover targets for family planning were also abandoned, and the program measures became entirely voluntary.

Family Planning however, spreads its wings to many countries

India was not the only country to have a family planning program. Between 1976 and 1998, the number of countries that had policies to
reduce population growth increased to 75, and a total of 179 countries in the world (representing 99% of population) facilitate access to contraceptives.

In 1979, China followed India to launch even more brutal family planning program. This was China’s one-child-policy as one of the ways country was to reach its economic goals. China followed this policy till 2016. Fertility rate in China declined tremendously. However, lack of younger generation, and shrinking workforce became a bigger concern. Today, China’s one-child policy is counted as more of a folly.

Where are we in terms of population now !!

In 2024, India may have surpassed population of China. India is now the most populous country in the world. Today it is not a shame, but a moment of pride as younger demographics means more workforce, and hence more economic growth.

In last two decades, India has achieved a Total Fertility rate of 2.0 This means that w are already at a replacement level, and as soon as the number drops below this level, the population starts to decline. In fact most states in India already have a Total Fertility rate of less than 2, and population decline has started. Except Bihar, Uttar Pradesh, Jharkhand and a few states in the North East – All others had a below 2 TFR as per the 5th National Family Health Survey (2021). Further, TFR in urban areas remains lower than rural parts of corresponding states. States in Southern India are worried, that their population may further decline in coming years.

Epilogue

Postage material documents political symbolism. A recent philately review of population control efforts identified many such symbols. After 1990s, we have started depicting one, rather than two children. Aggressively marketed red-triangle of 1967, faded away from post-1991 philately. It became much small in Family Planning Association of India first day cover in 1999.

Unlike 1970s, today we are not shy about our rising numbers. Rise in food-grain production has proved malthusian hypothesis wrong. More numbers mean a larger market, and a more robust economy. Tables seem to have turned. Who would have imagined that falling fertility rates will also become a worry for India. By 2050, India will also have the same situation of an ageing population, and fewer young people around. As we, like all other countries of the world embark on this demographic challenge, there are already calls from Indian political leaders that now is the time to have more children.

We have indeed completed a full circle, but low fertility, that is now more of an economic and an empowerment issue, will be hard to reverse by a mere rhetoric !!