Sonia Devi rested on a blanket on the packed dirt ground outside her thatched home in a village in the Begusarai district of Bihar. Her two-month-old daughter, Lovely, slept next to her, while her three other children played close by.
Sonia had been sterilized a few days earlier at the nearby government-run Primary Health Centre. That afternoon, as Sonia recuperated from her own operation, a few dozen other women were undergoing the same procedure.
Sterilization had been suggested to her by a local “asha,” one of the many public health counselors helping women, particularly those living in rural areas, navigate the system. The asha convinced Sonia that getting sterilized would allow her to better provide for the children she already had. Sonia said no other methods of birth control were offered to her, and she appeared unaware that other methods existed.
Female sterilization is the most common form of contraception in the world. While embraced by many women as their method of choice, it is also one of the only readily available methods in some places, including parts of India. Critics say that such widespread reliance on sterilization is the wrong approach, especially in areas where women have little access to other forms of birth control, or limited education about their options. The focus on sterilization also masks the constellation of issues that underlies decisions about family size—from high infant mortality rates to grinding poverty.
India’s family planning program has relied heavily on sterilization for decades—a single procedure that requires little follow-up care. Growing fear in India in the sixties and seventies that a rapidly burgeoning population would increase poverty and restrict economic growth led the country to focus more directly on population control as a strategy for development. That belief that overpopulation could endanger progress was widespread elsewhere in the world as well.
In the late 1970s, the push for sterilizations in India increased drastically, focusing particularly at that time on vasectomies for men. Charges of coercion have dogged the program due to the emphasis it has placed on sterilization quotas and strict targets. Although those targets were officially abandoned over a decade ago, they are still used in some states like Bihar, which has some of the highest fertility rates and lowest literacy rates in the country.
Bihar’s lagging development and high fertility have been a chief concern of Ajay Kumar, a government doctor and General Secretary of Bihar Health Services Association. About 15 years ago, worried that not enough attention was being given to the issue, Kumar says he organized a meeting called “War Cry Against Population Explosion.”
“We wanted to emphasize upon the state government,” he said, that “population is exploding, and one day, it will be uncontrollable.” He says he warned, “things will change in such a way that you cannot provide even the bread to the people. It will be very difficult and that may create anarchy.”
Although fertility rates have come down in India from 5.9 children per woman in the 1950s to 2.4 in 2012 according to UN and Indian Census data, population has still increased dramatically since the government first embraced population control. But even with that growth—from around 376,325 people in 1950 to 1.2 billion today—greater population density has failed to create the cataclysm once predicted. Most striking, India’s Human Development Index—a measure of a country’s progress in life expectancy, education, and standard of living – has increased by 58.7 percent between 1980 and 2013, according to the 2014 UN Human Development Report.
But as a citizen of Bihar, where women still have a relatively high fertility rate of about 3.5 per mother, Dr. Kumar says he remains worried: “Population stabilization has now become need of the hour for the whole world.”
Dr. M. P. Choudhary, who runs a Primary Health Centre in Bihar, is on the front line of that continuing battle against overpopulation, and estimates that he has performed over 10,000 to 15,000 sterilizations in the last 10 years. Sterilization targets are not the problem, he says, arguing that it’s instead the lack of a good healthcare infrastructure in some places that makes it difficult to safely meet those targets. India has been rocked by several sterilization camp scandals over the years, the most recent in November, when more than a dozen women died after being given adulterated medicines after their surgeries.
Dr. Choudhary, takes pride in the clinic he runs, which he says is focused on broader goals than simply meeting sterilization targets. He says infant mortality has decreased due to the clinic’s efforts to increase routine immunizations for babies from 11 percent to 69 percent in recent years; Choudhary hopes to bring that number to 90 percent. And the clinic has also greatly increased the number of deliveries it does onsite, aided in part by a government financial incentive introduced in 2007: 90 percent of women now give birth at the hospital instead of at home, making deliveries safer.
Such improvements in health are beneficial not just to mothers and their children; Dr. Choudhary says they’re crucial when trying to bring down fertility rates. If women are assured that their babies will likely survive to adulthood, they typically don’t feel the need to have as many children.
Southern India demonstrates the effect such broader efforts can have in the population wars. Development is higher and fertility lower there, underlining how improving health and other social conditions can reap major demographic benefits, by positioning women to decide to have smaller families on their own.
In Tamil Nadu, women have been having fewer children for years, and fertility there is below replacement level at 1.7 in 2012, according to the Census Commission of India. Experts point to the availability of more widespread health services, improved infant and maternal health, and higher levels of literacy, particularly among girls. Rising aspirations of parents for their children have translated into smaller family size, and even seemingly unrelated factors such as urbanization, good roads connecting rural areas to urban ones, and high rates of TV ownership (see here, for example) have been shown to play a role in fertility decline in the south and elsewhere.
Tamil Nadu’s family planning program has also aided the state’s fertility decline, increasing access to services—again, mainly sterilization—and initiating a media blitz to spread information about the benefits of small families in general. Family planning literature was dropped from helicopter in the countryside, and informational street plays and marches were held in towns. The family planning symbol—a red triangle—was made visible anywhere services were available, and local film stars and musicians got involved in spreading the word.
Family planning became just one facet of a broader state interest in improving people’s wellbeing. Social welfare programs have been in place for years, and have been more effective than similar programs in other states. Tamil Nadu was the first state in the country to implement the Noon Meal Scheme, which offered free lunches to schoolchildren—a boon not only for childhood nutrition, but also for school attendance.
Subha Sri, a gynecologist who works at RUWSEC, the Rural Women’s Social Education Centre in Chengalpattu, Tamil Nadu, says, “Tamil Nadu is a good model to uphold to look at the way development has actually contributed to lower fertility rates.”
“The fact of electricity, the fact of information access, the fact of mass media, the fact of education, the fact of livelihood opportunities because of education—all of those I think have contributed to lower fertility levels,” said Sri. Focus on those factors, she says, and questions of population control fade to the background. Fertility will come down on its own.
Viswanathan Murthy of Chennai, Tamil Nadu, agrees. As he welcomed his two children home from school one afternoon in December, he said that most people he knows don’t have more than two children anymore, regardless of their income.
“Family planning is a mind game,” says Murthy. When you take care of people's basic needs—feed them, educate them, make sure they have access to good hospitals—“the population problem will automatically get solved.”