In India, women carry the burden of contraception

Nishi and Rajat Kumar are two software engineers working for a top multinational company in India’s financial capital Mumbai.

They decided to not have more children after the birth of their daughter five years ago, so the highly-qualified, ‘liberal-minded’ couple, whose names have been changed to protect their identities, decided to opt for sterilization. But it was the woman who went under the knife.

“Obviously, it’s me. After all, an unwanted pregnancy would affect me only — physically, emotionally and professionally,” said Nishi. Rajat refused to undergo an “unmanly” vasectomy, as he believed it would lead to low libido and impotence.

Like the Kumars, most Indian couples believe that the responsibility of permanent contraception lies on women alone. Of the 1.47 million sterilization procedures conducted in India between 2017-18 (till October), only 6.8% were performed on men.

The pattern remained the same across rural and urban areas. Even states with high literacy rates, like Kerala, Karnataka and Maharashtra recorded a low percentage of male sterilizations.

“Male sterilization is viewed as culturally unacceptable in India, even though tubectomies (for women) tend to be more complicated than vasectomies (for men),” said Dr. Tushar Jagtap, a sexual medicine expert from Mumbai. “Vasectomies have no side effects but misconceptions are common,” he said.

Female sterilization is also the most common method of contraception worldwide, with 19% women, aged between 15-49, relying on it. A 2013 United Nations study found that the share of tubectomies was 29% in China, 22% in the United States and 8% in the United Kingdom.

The study also revealed that men in developed countries were more willing to share the burden of contraception than their counterparts in emerging economies. The male sterilization figure was found to be 1.1% in India, 4.5% in China, 16% in the US and 21% in the UK.

Scars of Emergency

India was the first country to embark on an ambitious population control program in 1952, when the annual population growth was around 2.2%.

The drive caused a major controversy in 1975, when the then prime minister Indira Gandhi declared a state of emergency, which in India refers to a period of governance in which the president perceives grave threats to the nation or from a financial crisis.

The prime minister’s son, Sanjay Gandhi, began an aggressive campaign to sterilize poor men during the Emergency. “Hundreds of men were forced to undergo sterilization. Several even died due to botched up operations. This created a fear among the masses,” President, Federation of Obstetrics and Gynaecologists Society of India, Dr. Nandita Palshetkar said.

In the last few decades, the government’s family planning program has remained excessively skewed towards female sterilization due to this “infamous” male sterilization drive, Dr. Palshetkar said.

Not just permanent contraception

Women shoulder the responsibility of using temporary contraceptives as well. According to a government survey, only 5.6% of married women in India rely on their partners using condoms, while 41.6% take on the responsibility of family planning (36% tubectomy, 4.1% oral pills and 1.5% intrauterine devices). The remaining 52.8% don’t have access to any birth control.

“Although condoms are 98% effective, and generally do not cause side effects, their usage in India is very low because of a patriarchal mindset,” Dr Jagtap said.

On the other hand, contraceptive pills for women have several side effects like nausea, headache, depression and breast tenderness. “Pills function by altering the hormonal balance of the body. Their prolonged use, more than 6-7 years, is unadvisable. Those who smoke or drink should also avoid then. Intrauterine devices can also cause irregular menstruation. In case of untreated infections of upper and lower uterine tract, the device gets also infected,” Head of Medical Education and consultant gynaecologist at Mumbai’s Sir HN Hospital, Dr. Rekha Daver said.

Experts say this is because the concept of informed consent in contraception is missing in most Indian public health facilities. “Contraceptives should be provided from a rights perspective and men and women both should be provided full information regarding side effects. Involving men in family planning and reproductive health programs can contribute to more equitable relations between partners,” State Program Coordinator of United Nations Population Fund (Maharashtra), Anuja Gulati said.

Women also find it difficult to start the conversation on contraception with their partners. “Taking a pill is far more convenient than urging a reluctant husband to use a condom. In fact, I started taking pills a week ahead of my wedding on my mother’s advise,” a Delhi-based female journalist said, on the condition of anonymity.

Sandeep, a marketing executive, said he uses condoms to safeguard his partner from the side-effects of pills. “However, if something happens in the spur of the moment, I ask her to use emergency contraceptive pills,” he said.

Women are left with little options in those ‘spurs of moments,’ or when their partners insist on not using condoms as they ‘hamper the pleasure,’ said Niharika (name changed), a management student.

This disregard for women’s health is pervasive and worldwide, and even educated women are often unable to negotiate with their partners.

Limited methods for men

Contraceptive pills for women have been available for almost 70 years. However, other than the condom, which was invented in 1855, a temporary male contraceptive has yet to be introduced.

A male contraceptive pill and a gel were developed recently, but they are not available in markets yet. A birth control shot for men was also tested a few years ago, but the UN-sponsored study was called off in 2011 because of “side-effects” such as pain where the injection was administered, increased libido and mood swings. Activists point out that advocacy and use of female contraceptives has persisted, despite their side-effects.

With India set to become the world’s most populous country by 2030, the government is working on a strategy to shift the focus of family planning from female to male sterilizations. “The proposed National Policy for Women 2017 intends to encourage men to bear the burden of contraception,” an official said.

The draft policy has been awaiting approval of India’s lawmakers for a year, however.