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Family Planning In India: A Photo Portrait

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Crowds make their way through the Theagaraya Nagar Market in Chennai. With over 1.2 billion people, India is the second most populous country in the world. Rapid population growth has been a concern of the government for decades. Image by Sarah Weiser. India, 2014.

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Munni Devi, 25, rests with her newborn Sachin at the Darbhanga Medical College Hospital in the northern state of Bihar. Devi has two children. India's fertility rate has declined from an estimated 5.9 children per woman in the 1950s to 2.5 today. But fertility remains higher in northern India, and Bihar has one of the highest rates in the country. Image by Sarah Weiser. India, 2014.

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Manshi Kumari, 4, at her family's home in the city of Patna, Bihar. India has the world’s largest youth population—measured as those between ages 10 and 24. The country’s family planning program has long centered on sterilization, and health advocates say that in order to better address the needs of such a large young population, there needs to be greater investment in a wide range of birth control options. Image by Sarah Weiser. India, 2014.

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Phul Kumari Devi, center, cuts sugar cane with other women from Pahsara Village. Much of Bihar is rural, and fertility is often higher in rural regions. Dr. Shakeel ur Rahman, who runs an NGO in Patna, says that in impoverished areas, children are seen as a form of social security. And across India, sons are still preferred: “They want a male child, and unless there is a male child, the girl children will be produced again and again and again.” Image by Sarah Weiser. India, 2014.

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Ramjhari Devi, at her home in a village in the Darbhanga District of Bihar, has eight children. Image by Sarah Weiser. India, 2014.

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Students at the Gangraho village school in rural Bihar. Literacy rates are lower in Bihar than in any other state in India, according to 2011 Indian Census data. Experts draw a connection between level of schooling and high fertility. “Look at what education does to people’s lives,” says Subha Sri, a doctor in the southern state of Tamil Nadu. “When you’re literate,” she says, “you are automatically exposed to a lot more information.” She continues: “And I think that plays a role in actually deciding how many children you want, at what age you want them.” Image by Sarah Weiser. India, 2014.

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The city of Patna, Bihar, near the railroad station, one morning in December. Image by Sarah Weiser. India, 2014.

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Women in the maternity ward of the Darbhanga Medical College Hospital, in Bihar. In recent years the government has started offering monetary incentives to encourage women to give birth in hospitals. Widespread immunization programs have made children healthier. Dr. M. P. Choudhary, who works in Bihar, says that such efforts can influence family size. When maternal and infant health improves, and parents feel their children have a better likelihood of survival, they typically won’t have as many children. Image by Sarah Weiser. India, 2014.

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Lakshmi Thakur, 36, is an asha, an accredited social health activist, in the Begusarai District of Bihar. Ashas help women, particularly those in rural areas, navigate the public health system. As part of state incentive systems—which pay patients, doctors, and health care workers for every sterilization—ashas, some argue, may be influenced to push sterilization. In certain regions that’s still the only birth control option made available, despite the fact that the Indian government has promised to expand access to other methods of contraception. Image by Sarah Weiser. India, 2014.

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Surrounded by family members, women rest after having sterilization operations at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar in December. Sterilization is by far the most commonly used method of birth control in India. Particularly in rural regions, it is sometimes the only method women know, or that is made available to them. According to the most recent National Family Health Survey (2005-2006), 77 percent of sterilized women in India had never used any other method of birth control before sterilization. Image by Sarah Weiser. India, 2014.

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Women undergo sterilization operations at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar. A few dozen women were sterilized in one day. Although India officially abandoned sterilization targets years ago, unofficial targets remain in place, according to people working on the ground. One Primary Health Centre doctor says the targets in themselves are not necessarily the problem, arguing instead that it’s the lack of a good healthcare infrastructure in some places that makes it difficult to safely meet those targets. Image by Sarah Weiser. India, 2014.

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Nuta Devi, center, with her daughter, Manju, left, who rests after her sterilization surgery at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar. A sterilization clinic was held that day for women wishing to be sterilized. Many health care workers point out that sterilization is a one-time procedure that requires little follow-up care, and for rural women without regular access to health services, and less autonomy in their decision making, it can often be the best tool they have to control their own fertility. Image by Sarah Weiser. India, 2014.

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A few days after her sterilization operation, Sonia Devi, 35, recuperates at home with her newborn daughter, Lovely, her fourth child, in a village in the Begusarai District of Bihar. After she gave birth, Sonia says an asha told her about the option of using sterilization to limit her family size. Sonia didn't appear to be aware of other methods of birth control. Image by Sarah Weiser. India, 2014.

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Neha Sinha, a health counselor at the Janani Surya Clinic in Patna, Bihar, advises a family on birth control options. The bulk of India’s unmet family planning needs are in the northern states, Bihar and Uttar Pradesh in particular, says Director Don Douglas. "We see women coming in all the time, age 23, 24, with three and four children already, and saying 'enough - I've had enough babies.'” Douglas says that lack of education, especially for girls, helps to explain Bihar's high fertility. Girls are being taken out of school early and married at a young age; over half of all women in Bihar are married before age 18. "If you want to move the needle on population control, this is the epicenter," he said. Image by Sarah Weiser. India, 2014.

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Seema Devi, 33, helps her daughter, Semeran Kumari, 6, remove her school uniform after class, at their home in Patna, Bihar. Though she came from a large family, she decided her third child would be her last, and after using a Copper-T IUD for years, she chose to get sterilized. She said it would be difficult for her and her husband to support another child, and to provide their three children with the kind of education they want for them. Image by Sarah Weiser. India, 2014.

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Sanmugam Loganathan looks at his teacher, S. Kanmani, as she reviews his notebook at the Panchayat Union Middle School in the Kancheepuram District of Tamil Nadu, a state in southern India. Literacy rates are much higher in Tamil Nadu and across southern India in general. The state government has used various schemes to improve literacy, including offering free textbooks, uniforms, bus passes and bicycles. The Midday Meal Scheme, a nationwide program that provides free lunches to schoolchildren, was first introduced in Tamil Nadu, and has been particularly effective in improving attendance and childhood nutrition. Image by Sarah Weiser. India, 2014.

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A man peddles through a neighborhood in Chennai, Tamil Nadu. The state has much lower fertility rates than elsewhere in India. There has been an effective family planning program for years here, but experts say that big improvements in the health and education system have been just as important. Maternal and infant health have greatly improved, literacy rates are higher, and infrastructure developments like roads and electricity are more widespread. Image by Sarah Weiser. India, 2014.

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In recent years in Bihar, maternal care has improved too. Here, Rashmi Devi, 31, pregnant with her third child, is examined by Dr. Gunjan Trivedi at the I. B. Smriti Arogya Sadan Hospital in the city of Darbhanga, Bihar. Image by Sarah Weiser. India, 2014.

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Gurrai Kumari, 18, holds her newborn niece, as the baby’s mother, Nisha, 21, rests after delivery at the Darbhanga Medical College Hospital in Bihar. Image by Sarah Weiser. India, 2014.

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A newborn, seconds after delivery, is carried to the neonatal area in the Medavakkam Primary Health Centre in Tamil Nadu. The Centre delivers 150 to 200 babies a month, and Dr. Ravichandran, the director, estimates that over 90 percent of women from the surrounding area now give birth at the hospital rather than at home. In Tamil Nadu, maternal and family health care have been part of the government’s longstanding investment in public health. Image by Sarah Weiser. India, 2014.

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Newborns at the Medavakkam Primary Health Centre in Tamil Nadu. The state has had a robust history of social welfare programs. A recent one targeting maternal health has increased the amount of money provided to women below the poverty line, says Dr. Ravichandran. Payments are made in three installments: following completion of an array of tests and a sonogram during her pregnancy, following birth in a government facility, and, several months later, following the baby’s first immunizations. Image by Sarah Weiser. India, 2014.

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B. Rajeshwari, 23, cares for her first child, a 5-day-old daughter not yet named, at the Medavakkam Primary Health Centre in Tamil Nadu. A family friend, Radish, far left, looks on. Image by Sarah Weiser. India, 2014.

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A mother, with her infant beside her, at the Medavakkam Primary Health Centre in Tamil Nadu. Dr. Subha Sri, working in the region, says that when looking at broader questions about population and fertility rates, one needs to think beyond the availability of family planning services. “People have to make a choice to actually use those services, and people will make that choice if they see how it’s actually going to change their lives.” Image by Sarah Weiser. India, 2014.

These photos and related videos also appear in Retro Report: "A Journey through India: The Legacy of Population Fears."

Fertility rates remain high in Bihar, a northern state in India that has also lagged in development. Literacy rates are low, and infant and maternal health is worse than in other regions of the country. The family planning program remains centered on sterilization, and access to different birth control options can be limited in rural areas—access even to sterilization can be limited to sterilization camps, where often dozens of women will undergo the procedure in one day. Doctors point to an underfunded health system that lacks the resources to provide consistent and quality care to women.

In the south, meanwhile, where literacy rates are higher, and maternal and infant health better, fertility is also lower. In Tamil Nadu, a history of social welfare programs has helped address issues like school attendance, nutrition, and maternal health. Infrastructure developments have connected rural areas to urban centers through roads. Electricity projects have brought power—and with that, televisions—to even the most outlying areas. All those factors, experts say, can have an impact on fertility rates.