1.1 POPULATION DYNAMICS: THE INDIAN PERSPECTIVE
Anita Soni, Seeru Garg, Ruchi Shah
DEFINITION
Population dynamics is a portion of ecology that deals with the variation in time and space of population in size and density for one or more species.
INTRODUCTION
In population dynamics, we study short- and long-term changes in the composition, size, and age of the population along with the biological and environmental processes influencing those changes. Fundamentally, it is the study of how population changes over time.
Population dynamics overlaps with other branches of research in mathematical epidemiology (the study of infectious disease affecting population). Over the past years, population dynamics has been complemented by the evolutionary game theory, which was first developed by John Maynard Smith.
With abundant resources and favorable growing conditions, a population has the potential to increase in number from generation to generation. The population's intrinsic growth rate (“r”) is considered exponential, if each generation increase is a constant percentage of the total population size. As population size approaches the carrying capacity:
- There may be increase in mortality rate and decline in the birth rate.
- The population may stabilize below the carrying capacity, known as a logistic or sigmoid (S-shape) growth curve.
- The population may overshoot the carrying capacity and then crash, resulting in repeated cycles of “boom” and “bust.”
- The population may oscillate around (or below) the carrying capacity.
POPULATION TRENDS IN INDIA
Population of India is currently growing at a rate of 1.44% per year. Hence, it has been projected that India would have a total of 2 billion, i.e., 16% of world's population. As per the 2011 Census, the population was noted as 1,210 million with a percent change of 17.7%. The National Population Policy (NPP)— 2000 states that India contributes 58% to population growth on account of demographic momentum and 20% of unwanted fertility due to unmet need of contraception. As a result, a “bulge” or baby boom is moving through the age structure of population (Fig. 1).
While global population has increased three times during this century from 2 to 6 billion, the population of India has increased nearly five times from 238 million to 1 billion in the same period. India's current annual increase in population of 15.5 million is large enough to neutralize efforts to conserve the resource endowment and environment.
COMPOSITION OF POPULATION
Population dynamics include birth rate (BR), death rate (DR), immigration (I), emigration (E), and age and sex composition. Birth and death rates are the most important determinants of population growth.
The annual growth rate for India was 1.19 in 2018. If the annual growth rate of a population is 1%, it doubles in 70 years. This law is called Malthusian model.
- <0.5%: Slow growing population
- 0.5–1%: Moderately growing population
- 1–1.5%: Rapidly growing population
- 1.5–2%: Very rapidly growing population
- >2%: Explosively growing population.
Fig. 1: Population trends in India.Source: Tradingeconomics.com: Ministry of Statistics and Programme Implementation.
After the formulation of the national family welfare program, India has reduced CBR from 28.3 (1995) to 21.4 (SRS bulletin, 2013). The maximum CBR has been reported in respect of Bihar (27.7) and the minimum in respect of Kerala (14.9) (SRS Bulletin, 2013). The CDR for the country has declined from 7.1 in 2011 to 7.0 in 2012 and 2013. The maximum CDR has been reported for Odisha (8.5) and minimum for Delhi (4.2). The IMR declined from 74 per 1,000 live births (SRS bulletin, 1995) to 40 (SRS bulletin, 2013). The maximum IMR has been observed in Madhya Pradesh (56) and the minimum in Kerala (12).
DETERMINANTS OF FERTILITY IN INDIA
Education plays a very important role in population control, especially women education that affects socioeconomic and demographic indicators, which are essential for population stabilization. The Task Force of the National Commission on Population (NCP) has identified these social, economic, and demographic indicators for population stabilization in India, which are directly or indirectly affected by women education.
- Total fertility rate
- Sex ratio
- Percentage of couples using family planning methods
- Child mortality up to the age of 2 years
- Maternal mortality rate
- Percentage of women receiving skilled attention during deliveries
- Percentage of children (12–24 months) getting complete immunization
- Nutritional status of children below 6 years
- Percentage of girls marrying below 18 years of age
- Percentage of births, deaths, and marriages registered
- Literacy rate—males and females
- Enrollment of children in schools up to the age of 14 years and the rate of dropouts
- Percentage of households with safe drinking water
- Percentage of villages connected by paved roads.
There are four fertility indicators, which help in demographic analysis:
- General fertility rate (GFR): Total number of live births in an area among the females in reproductive age group:WRA = Women of reproductive age (15–49 years)
- Total fertility rate (TFR): Total number of live births a female will bear during her reproductive years, assuming:The age-specific fertility rate (ASFR):Age-specific fertility rate (ASFR):
- Gross reproduction rate (GRR): Total number of daughters a female will bear during her reproductive years assuming the age-specific fertility pattern:
- Net reproduction rate (NRR): Total number of daughters a newborn girl child will bear during her entire life assuming the age-specific fertility and mortality pattern.
The fertility levels of women in urban India are much lower in comparison to rural areas of India. The main factors behind this change are ranging between children, age of marriage, education and better healthcare, widespread acceptance of family planning measures, and socioeconomic conditions. Age-specific fertility rate (ASFR) during 1981–2011 in India has fallen for women at all ages, indicating that fertility is increasingly being controlled through adoption of family planning measures.
At the younger age group of 15–19 years, fertility decline suggests a rise in the age at marriage of girls which increased from 17 years in 1971 to 21.2 years in 2012. Moreover, earlier fertility peaked at 20–24 and 25–29 years, but now it has peaked at only 20–24 years. This shows that the average span of childbearing has declined considerably, which is due to improvement in women education level and improvement in socioeconomic condition of women.
Contraception Prevalence
Contraceptive prevalence rate is the percentage of women of age 15–49 years who are practicing any form of contraception or whose sexual partners are practicing any form of contraception. It is usually measured for women aged 15–49 years who are married or are in union. Contraceptive prevalence rate in India was reported at 53.5% in 2016, according to the World Bank collection of development indicators.
According to the data published in The Lancet, approximately 15.6 million abortions (range: 14.1–17.3 million) took place in India in 2015, giving an abortion rate of 47 (42.2–52.1) per 1,000 women of reproductive age of 15–49 years. They estimated 48.1 million pregnancies, a rate of 144.7 pregnancies per 1,000 women and a rate of 70.1 unintended pregnancies per 1,000 women. Abortions accounted for one-third of all pregnancies, while nearly half of pregnancies were unintended.
Target numbers of fertility and reproduction rates as a part of National Health Policy, 2017:
Target of NRR = 1
It gives replacement level and indicates population stabilization. To attain NRR of 1, we need TFR of 2.1 (due to unequal gender biased mortality) for which a couple protection rate desired is 60%.
SEX RATIO AND LIFE EXPECTANCY IN INDIA
Sex ratio is defined as the number of females per 1,000 males. It is one of the basic demographic characteristics of a population. The sex composition is affected by the differentials in mortality conditions of males and females, sex selective migration, and sex ratio at birth. “Female deficit syndrome” is considered adverse. A low sex ratio indicates strong male child preference and consequent gender inequalities, neglect of the girl child resulting in higher mortality at a younger age, female infanticide and feticide, higher maternal mortality, and male bias. Sex determination test, abortion services, and preconception sex services being easily available enhance this process.
Sex ratio of India has shown an increasing trend from 1991 to 2011. According to the 2011 Census, the overall sex ratio is 940 females per 1,000 males. There has been an increase in sex ratio recorded in 29 states and UTs whereas Bihar, Gujarat, and Jammu and Kashmir have shown a decline in sex ratio as compared to the 2011 Census. Kerala has the highest sex ratio of 1,084 followed by Pondicherry having 1,038. The sex ratio is lowest in Daman and Diu at 618. In 1950, the life expectancy in India (31 years) was less than half of the US (68 years). The life expectancy in India also differs by sex, which varies from state to state. In 1951, life expectancies for male and female were 38.7 and 37.1 years, respectively. However, by 2005, the life expectancy in India (64 years) was not far behind the US (77 years). The life expectancy of male and female in India reversed in recent years. In 2012, the life expectancy at birth for women was 67.7 years and for men it was 64.6 years. The overall current life expectancy for India in 2020 is 69.73 years, a 0.33% increase from 2019.
POPULATION POLICY IN INDIA
Population policies are formulated to address the unmet needs for contraception, healthcare infrastructure, and health personnel and to provide integrated service delivery for basic reproductive and child healthcare. The main objective is to achieve a stable population at a level consistent with the requirements of sustainable economic growth, social development, and environmental protection.
Five-Year Plans by the Government of India for Population Control
The central government formulated the “new national population policy” in February 2000.
The latest 12th 5-year plan (2012–2017) objectives are:
- To create 50 million new work opportunities in nonfarm sector
- To remove gender and social gap in school environment
- To enhance access to higher education
- To reduce malnutrition among children of 0–3 years
- To provide electricity to all rural areas
- To ensure 50% rural population to have accesses to safe drinking water
- To increase green cover by 1 million hectare every year
- To provide access to banking services to 90% of households.
The Population Regulation Bill, 2019, was a proposed bill introduced in the Rajya Sabha in July 2019 by Rakesh Sinha to control the population growth of India. According to the World Population Prospects 2019 report by the United Nations, the population of India is set to overtake that of China within 6a decade. The 2020 bill proposes to introduce a two-child policy per couple and aims to incentivize its adoption through various measures such as educational benefits, taxation cuts, home loans, free healthcare, and better employment opportunities. The 2019 bill proposed by Sinha talks about introducing penalties for couples not adhering to the two-child policy such as debarment from contesting in elections and ineligibility for government jobs.
The complex status of the India's population dynamics is at some point of demographic transition, in the process and moving to its final stage. India has already achieved the target of some demographic indicators, namely reduction of crude death rate to (7.0) and crude birth rate to (21.4) per thousand and TFR is 2.4. The cohort comprises mainly the working age group as compared with the dependent population. Hence, there can be accelerated skilled development and economic growth of India.
FURTHER READING
- Begon M, Harper JL, Townsend CR. Ecology. Individuals, populations and communities. Oxford: Blackwell Scientific Publications; 1986.
- Bloom DE, Canning D, Fink G. (2008). Urbanization and the wealth of nations. Science. 2008;319(5864):772–5.
- Bloom DE. (2011). Population dynamics in India and implications for economic growth. [online] Available from: https://cdn1.sph.harvard.edu/wp-content/uploads/sites/1288/2013/10/PGDA_WP_65.pdf. [Last accessed November, 2021].
- Census India. (2011). Decadal growth: 2011 Census of India. [online] Available from: www.censusindia.gov.in. [Last accessed November, 2021]
- Government of India, Planning Commission. An approach to 12th five-year plan. New Delhi, India. 2011.
- Manjul P, Rupam T. Population dynamics in India. Int J Sci Eng Res. 2016;6(1):
- Ministry of Health and Family Welfare. (2015). Health and Family Welfare Statistics of India, 2015. [online] Available from: http://mospi.nic.in/statistical-year-book-india/2015/199. [Last accessed November, 2021]
- Ministry of Statistics and Programme Implementation (MOSPI). Population trends in India. [online] Available from: http://mospi.nic.in. [Last accessed November, 2021].
- Park K. Park's Textbook of Preventive and Social Medicine, 23rd edition. India: Bhanot Publishers; 2015.
- Pritchett L. Desired fertility and impact of population policies. Popul Dev Rev. 1994;20(1):1–55.
LONG QUESTION
1. What is population policy? Describe the population policy in the Indian context and the main events or factors that have shaped it since independence.
SHORT QUESTIONS
1. What are the determinants of fertility in India?
2. What are the main fertility indicators?
3. What is contraceptive prevalence and what factors affect it?
MULTIPLE CHOICE QUESTIONS
1. If annual growth rate of a population is 1.5%, how many years will it take to double?
- 105 years
- 70 years
- 100 years
- 110 years
2. New parameter added in 2020 population regulation bill is:
- Unmet needs for contraception
- Healthcare infrastructure
- Health personnel
- Two-child policy
3. The twelfth 5-year plan includes the following objectives, except:
- To remove gender and social gap in school environment
- To enhance access to higher education
- To reduce malnutrition among children aged 0–3 years
- To ensure all rural areas to have access to safe drinking water
4. The current life expectancy for India is:
- 67.9
- 64.6
- 69.7
- 67.7
5. Crude birth rate is defined as:
6. Sex ratio of India is:
- 618
- 940
- 943
- 1,048
7. All are fertility indicators, except:
- General fertility rate
- Total fertility rate
- Gross fertility rate
- Gross reproductive rate
8. Determinants of fertility in India are all, except:
- Total fertility rate
- Sex ratio
- Infant mortality rate
- Maternal mortality rate
1. a | 2. d | 3. d | 4. c | 5. a | 6. b |
7. c | 8. c |
Mandakini Megh, Bhumika Kotecha Mundhe
INTRODUCTION
This chapter considers the past, present, and future perspectives of the population stabilization and the government policies projected with regard to the same. India was the first country in the world to have launched a national program for family planning in 1952 under India's first Prime Minister Mr Jawaharlal Nehru. Over the decades, the program has undergone transformation in terms of policy and actual program implementation and currently being repositioned to not only achieve population stabilization goals but also promote reproductive health and reduce maternal, infant, and child mortality and morbidity. However, the severity of the current situation can be understood by the mere fact that India has 17% of the world's population on 2.4% of the global land. If the current trend continues, India will overtake China by 2045 and will become the most populous country of the world.1
A very rapid increase in the population for a long time may be termed population explosion (i.e., if the birth rate is much more than the death rate for a long time, it may lead to a population explosion).1 The Prime Minister of India, Shri Narendra Modi, in his speech on Independence Day said that Jansankhya Visphot (Population Explosion) may affect the future of our children (Fig. 1).
Fig. 1: Demographic transition model.Source: http://www.coolgeography.co.uk/GCSE/AQA/Population/Demographic%20Transition/Demographic_Transition_Model.jpg
There are evidences of the following effects due to population explosion:1
- Living standards of people drop
- Rise in crime and violence
- High level of unemployment
- Thousands go hungry due to poverty and one-third of the population are below the poverty line
- Famine: Lack of food and cooking fuel
- Poor health
- Poor sanitation services
- Environmental degradation in terms of air, water, and soil pollution
- Deforestation and ecology modification and distribution of agriculture holdings
Bare facts1
- Every sixth person on the globe is an Indian and by the turn of this century, every fifth living person will be an Indian
- 49% of the increase in India's population is from four states: Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh.
The history of growth of India's population can be divided into four distinct phases: (1) the stagnant growth stage (1901–1921), (2) the steady growth stage (1921–1951), (3) the rapid growth stage (1951–1981), and (4) the high growth stage with definite signs of slowing down (1981–2011). Over the period of time, India has moved from a high stationary stage to a late expanding stage of demographic transition (Fig. 2).2
ASSOCIATED CHALLENGES WITH THE POPULATION STABILIZATION
- Level of education: Lack of education in women results in their early marriages. Not only does early marriage increase the likelihood of more children, but it also puts the woman's health at risk.
- Socioeconomic factors: The desire for larger families, particularly preference for a male child, also leads to higher birth rates.
- Inadequate use of contraceptive: Women in rural areas of northern states, such as UP and Bihar, are still giving birth to four or more children. This is because the contraceptive prevalence rate is <10%.The development of the present policy of population control by the government of India falls into following distinguishable periods:
- The period of “indifference” (before 1947): The colonial government of Britain was largely indifferent to population growth. Though the British Government was indifferent to population control policy in India, the enlightened section of Indian public along with some politicians urged the government to develop a population control policy.PK Wattal was the pioneer who wrote a book on Population Problem in India in 1916. Among Indian politicians and political parties, it was supported by Jawaharlal Nehru, Mahatma Gandhi, Shubhash Chandra Bose, and Bhore Committee.
- The period of “neutrality” (1947–1952): Postindependence, the early apathy of the Government to develop population policy was attributed to its preoccupation in drafting the constitution and finding India's way in international relations. Finally, 3 years after independence, the National Family Planning Program was launched in 1952.
- The period of “experimentation” (1952–1961): The first 5-year plan (1951–1956) was laid with the objective of “reducing birth rate to the extent necessary to stabilize the population at a level consistent with the requirement of the national economy.” One of the national sample survey reports revealed that the population of India had grown substantially, which was confirmed in 1961 census.
- The beginning of policy of population control (1961–2000):
- Second and third 5-year plans (1956–1961 and 1961–1966): The population growth from 1951 to 1961 was rapid accounting to 21.5%. To overcome such a national issue, the government adopted the extension approach to family planning in the third plan. This plan also included a separate Department of Family Welfare in the Ministry of Health and Family Planning in 1966.
- Fourth 5-year plan (1969–1974): An important measure was the integration of family planning services with health, maternity, and child healthcare and nutrition. The main aim here was to reduce the birth rate to 25 per 1,000 persons by 1980–81. The steps taken were in the following areas: social acceptability for a small family, increasing information and knowledge about family planning methods in both urban and rural areas, and making available the various devices and equipment to the couples. A more selective approach was adopted wherein couples in the reproductive age group of 25–35 years were persuaded to undergo sterilization as a matter of national emergency. Also, monetary incentive was given to couples undergoing sterilization.Since the birth rate was varied in different states, targets of sterilization were fixed in various states. The number of sterilizations rose from 9.4 lakh in 1973–1974 to 82.6 lakh in 1976–1977. Under the banner of national emergency, many states resorted to unfair and coercive methods to sterilize people of all ages. This led to mass resentment and unrest among the people. As a result, the family planning program became very unpopular.
In 1977, post national emergency, the government announced the new population policy renaming the family planning program to the family welfare program. This program did have a leeway to the common man. The main features of this policy were:
- Fixing the marriage age for girls at 18 years and for boys at 21 years. This has been implemented by the Child Marriage Restraint (Amendment) Act, 1978
- Making sterilization voluntary
- Including population education as part of normal course of study
- Monetary incentive to those who go in for sterilization and tubectomy
- Private companies to be exempted in corporate taxes if they popularize birth-control measures among employees
- Use of media for spreading family planning in rural areas, etc.; this policy put an end to compulsory sterilization and laid emphasis on voluntary sterilization.However, this slowed down the family planning program. As a result, the number of sterilizations fell from 82.6 lakh in 1976–1977 to 9 lakh in 1977–1978.
- Sixth, seventh, and eighth 5-year plans (1980–1985, 1985–1990, and 1990–1995): The efforts were done to control population by determining long-term demographic aims such as net reproduction rate, crude birth rate (CBR), crude death rate, and couple protection rate.The government replaced the earlier Population Control Approach by the Reproductive and Child Health Approach in October 1997 with the intention to decentralize area-specific macroplanning. It led to several new schemes for improving quality and coverage of welfare services for women, children, and adolescents such as child survival, safe motherhood program, and universal immunization program (UIP), and reproductive tract infections (RTI).
- Ninth 5-year plan (1997–2002): During the ninth plan, the earlier approach of using NRR (Net Reproduction Rate) of 1.0 was changed to a total fertility rate (TFR) of 2.1. This level of TFR been projected to be achieved by 2026 in the plan. One of the important strategies of this plan was to undertake area-specific microplanning, i.e., at the primary health care (PHC) level.In 2001, the National Policy for Empowerment of Women was adopted with the ultimate objective of ensuring women their rightful place in society by empowering them as agents of socioeconomic change and development.
National Population Policy, 2000
The population of India on May 11, 2000, had risen to 100 crores from 23 crores over a period of 100 years. This meant that all efforts of population stabilization taken so far seemed to be elusive.
The National Population Policy (NPP) was announced in 2000. It had three types of objectives:
- The immediate objective:
- To address the unmet needs for contraception, healthcare infrastructure, and health personnel
- To provide integrated service delivery for basic reproductive and child healthcare
- The medium-term objective: Bring TFR to the replacement level by 2010.
- The long-term objective: To achieve a stable population by 2045.
The NPP 2000 relies more on persuasive and positive measures rather than on coercive methods. It lays emphasis on both the qualitative and the quantitative aspects of population.
A major cause for worry for policy makers is that the sex ratio of children has declined for all age groups as compared to 2001. The decline is more pronounced in the younger age groups, especially below 20 years. There has been a constant decline in child sex ratio (CSR) over the last four to five censuses and there is a particularly steep decline in the report of 2011, which registered a fall from 927 girls per 1,000 boys in the age group of 0–6 years to 918 per 1,000 boys. This led to the aggressive implementation of the Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act, rules and regulations by the government to improve the skewed ratios. While the sex ratio has seen a decrease, the silver lining is that there is an improvement in survival ratio and there is an upward shift for all age groups during Census 2001–2011.
The National Family Planning Program of the Ministry of Health and Family Welfare is guided by the tenets of the NPP 2000 and oversees its implementation. Under this program, the service delivery data are regularly reviewed through annual review meetings, supportive supervision visits, common review missions, etc.
As a result of the government's efforts, the successes achieved as on February, 2020 are enumerated below:3,4
- The TFR has declined from 2.9 in 2005 to 2.2 in 2017 (SRS)
- 25 out of 37 states/UTs have already achieved replacement level fertility of 2.1 or less
- The decadal growth rate has declined from 21.54% in 1999–2000 to 17.64% during 2001–2011
- The CBR has declined from 23.8 to 20.2 from 2005 to 2017 (SRS)
- The teenage birth rate has halved from 16% (NFHS III) to 8% (NFHS IV).
Current Issues
Population stabilization is a stage when the size of the population remains unchanged. Census data released by the Office of the Registrar General shows that at the national level, the TFR has declined from 2.5 to 2.2 during 2001–2011.3,4 So, India has begun moving toward population stabilization showing a drop of 0.3 points in the TFR. (The TFR is the number of children born or likely to be born to a woman in her lifetime.)3,4
Data with the Health Ministry shows that so far, only 24 out of 35 states have achieved the TFR of 2.1 (2019) that are yet to reach the targeted TFR and 10 big states still have a higher TFR. Bihar leads at (3.4), UP (3.1), MP (2.9), Rajasthan (2.8), Jharkhand (3), Chhattisgarh (2.6), Assam and Gujarat (2.5), and Haryana and Odisha (2.3).
The proportion of married women to total number of women is at 49.9% in Census 2011 as against 47.7% in Census 2001. The corresponding figure in case of males has increased to 46% from 43.6% during the same period. For women, the average marriage age has increased from 18.3 to 19.3 years and for men from 22.6 to 23.3 years during Census 2001–2011. There are 30 million currently married women in the age group of 15–49 years.5 The desired fertility rate is 1.8 which indicates that women in India prefer to have no more than two children.6
According to the NPP 2000, India should have reached a replacement-level fertility rate of 2.1 by 2010 to attain population stabilization at 145 crores by 2045. However, India expects to reach population stabilization of 2.1 TFR at 165 crores by 2040.6
Current Trends in Population Stabilization
NITI Aayog7
NITI Aayog is responsible for charting India's road map toward attaining the commitments under the Sustainable Development Goals, particularly in critical social sectors such as health and education. A 3-year action agenda and a 7-year strategy have already been prepared by the NITI Aayog and placed in the public domain.
The federal policy think tank of NITI Aayog consults subject specialists and officials to find ways of strengthening the country's population policy and family planning programs. The consultation is expected to result in recommendations that will address the regional disparities in the outcome of population stabilization programs. The NITI Aayog move comes in the wake of Prime Minister Narendra Modi flagging, in his Independence Day speech 2019, the need for controlling the explosive growth in population.
The key recommendations are likely to include helping women make informed choices about delaying pregnancy and ensuring there was a sufficient gap between childbirths, stepping up access to contraceptive choices, addressing sociocultural barriers toward contraception, increasing public spending on family planning, investing in behavior-change communication strategies, and treating population stabilization and family planning as a national priority. The NITI Aayog said that India is at a stage where birth rates are falling but population continues to grow due to the fact that >30% of the population is young and in the reproductive age group.
GOVERNMENT INITIATIVES
The government is taking several steps to sensitize people and generate awareness of the need for population control. Some of the important initiatives are as follows:5
- 360° media campaign: The first phase of the campaign was launched in 2016 and the present second phase comprising TV commercials, posters and hoardings, year-long radio show, and a dedicated website on family planning was launched in 2017
- World Population Day and fortnight as well as Vasectomy Fortnight are observed every year to boost awareness.
- Promotional activities such as Saas Bahu Sammelans, Nayi Pehel Kits, mobile publicity vans, and advocacy meetings are undertaken to increase awareness in high-fertility Mission Parivar Vikas districts.
The government is implementing various schemes for improving access to quality family planning services, details of which are given below.
Steps being taken by the government for population control:
- Mission Parivar Vikas: This was launched to increase access to contraceptive and family planning services in 146 high-fertility districts with TFR of 3 and above in seven high focus states. These districts are from the states of Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand, and Assam that itself constitute 44% of the country's population.
- New contraceptive choices: New contraceptives, namely injectable contraceptive and centchroman, have been added to the existing basket of choices.
- A new method of intrauterine contraceptive device (IUCD) insertion immediately after delivery, i.e., postpartum IUCD (PPIUCD), has been introduced.
- Redesigned contraceptive packaging: The packaging for condoms, oral contraceptive pills (OCPs), and emergency contraception pills (ECPs) has now been improved and redesigned so as to increase the demand for these commodities.
- Compensation scheme for sterilization acceptors: Under this scheme, the Ministry of Health and Family Welfare (MoHFW) provides compensation for loss of wages to the beneficiary and also to the service provider (and team) for conducting sterilizations.
- Scheme for home delivery of contraceptives by ASHAs at the doorstep of beneficiaries.
- Scheme for ASHAs to ensure spacing in births.
- Scheme for provision of pregnancy testing kits in the drug kits of ASHAs for use in communities.
- Family planning logistic management and information system (FP-LMIS): This is dedicated software to ensure smooth forecasting, procurement, and distribution of family planning commodities across all the levels of health facilities.
- National family planning indemnity scheme (NFPIS) under which clients are insured in the eventualities of death, complication, and failure following sterilization.
- Ensuring quality of care in family planning services by establishing quality assurance committees in all states and districts.
- Appointment of dedicated RMNCH+A (Reproductive, Maternal, Newborn, Child and Adolescent Health) counselors at high-case load facilities.
- Improved demand generation activities through a 360° media campaign.
As a result of these efforts, the country is knocking on the door of replacement level fertility and is on track to achieve TFR 2.1 by 2025.
The Population Control Bill, 2019 (or Population Regulation Bill, 2019), is a proposed bill introduced in the Rajya Sabha in July 2019. The purpose of the bill is to control the population growth of India.
The 2020 bill proposes to introduce a two-child policy per couple and aims to incentivize its adoption through various measures such as educational benefits, taxation cuts, home loans, free healthcare, and better employment opportunities. Penalties for couples are not adhering to the two-child policy such as debarment from contesting in elections and ineligibility for government jobs.
Family Planning, 2020: Family planning division is working on the national and state-wise action plans so as to achieve Family Planning 2020 goals. The key commitments of Family Planning 2020 are as follows:
- Increasing financial commitment on family planning whereby India commits an allocation of 2 billion USD from 2012 to 2020
- Ensuring access to family planning services to 48 million (4.8 crore) additional women by 2020 (40% of the total Family Planning, 2020 goal)
- Sustaining the coverage of 100 million (10 crore) women currently using contraceptives
- Reducing the unmet need by an improved access to voluntary family planning services, supplies, and information.
Janasankhya Sthirata Kosh
The Jansankhya Sthirata Kosh (JSK) (National Population Stabilization Fund) has been registered in 2004–2005 as an autonomous society established under the Societies Registration Act of 1860 with Rs 100 crore grant from the government. This had an aim to promote and undertake activities aimed at achieving population stabilization at a level consistent with the needs of sustainable economic growth, social development, and environment protection by 2045.
It implemented the following schemes:
- Prerna Scheme (for delaying marriage, childbirth, and spacing)
- Santushti Scheme (Public Private Partnership for sterilization services)
- National Helpline (for information on family planning).
However, the JSK has been discontinued on 08/02/2019 vide the cabinet decision on 07/02/2018 and various schemes for population control are being supported under the National Health Mission.8
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- Ministry of Health and Family Welfare. (2019). Population control. [online] https://pib.gov.in/PressReleseDetailm.aspx?PRID=1593004. [Last accessed November, 2021].
- Press Information Bureau. [online] Available from: http://pib.gov.in/PressReleseDetailm.aspx?prid=133018 [Last accessed November, 2021].
- India Today. [online] Available from: http://www.indiatoday.in/business/story/niti-aayog-to-draft-roadmap-for- [Last accessed November, 2021].
- Journals of India. (2019). Jansankhya Sthirata Kosh. [online] Available from: https://journalsofindia.com/jansankhya-sthirata-kosh/. [Last accessed November, 2021].
LONG QUESTION
1. What precautions should the doctor take so that the MTP is safe medicolegally?
SHORT QUESTIONS
1. Who can perform MTP?
2. What are the pre-requisites for MTP approved center?
4. Discuss: consent in MTP.
5. Judicial activism in abortion law in India: Dr Nikhil Datar Vs Union of India. Discuss
MULTIPLE CHOICE QUESTIONS
1 Inj Anti-D ______ mg should be administered in ABO incompatibility after first trimester MTP.
- 300 µg
- 150 µg
- 50 µg
- 200 µg
2 The permissible legal limit for MTP (under MTP Act 1971) in case of abnormal fetus is:
- 19 weeks
- 24 weeks
- 20 weeks
- 22 weeks
3 The amendment in 2002 in MTP Act dealt with:
- Increasing the permissible limit to 24 weeks
- Validating use of mifepristone and misoprostol
- Both a and b
- None of the above
4 The forms to be filled up in a case of MTP are:
- Form A + Form B
- Form I
- Form I + Form C
- All of the above
5 Medical MTP can be done uptil:
- 35 days
- 49 days
- 63 days
- 52 days
6 Second trimester MTP requires:
- Opinion of 2 RMPs
- Form 2
- Government hospital only
- Medical management
1. c | 2. c | 3. d | 4. c | 5. b | 6. a |
1.3 LEGAL ASPECTS IN MEDICAL TERMINATION OF PREGNANCY AND CONTRACEPTION
Nikhil Datar, Meghana Shedge
INTRODUCTION
Contraception and abortion are two important health rights of a woman. Social structure of male dominance, religious beliefs, and lack of health education change the outlook toward these issues. Thus, they do not remain to be pure medical issues.
In India, abortions are governed by a specific Act of the parliament, namely “Medical Termination of Pregnancy Act (MTP Act).” Contraception is not specifically covered by any law yet general principles of medical ethics, namely autonomy, justice, beneficence, and nonmaleficence, must be kept in mind by the healthcare provider.
LEGAL ASPECTS OF MEDICAL TERMINATION OF PREGNANCY
Abortion is a criminal offence according to the Indian Penal Code. This code was drafted in 1860 by the British, which is still the law of the land.
Sections 312 to 316 deal with the offences against unborn. Both a woman seeking abortion and the person helping her can be punished for this offence. Many women lost their lives while undergoing illegal abortions. In order to prevent this maternal mortality, India passed the MTP Act in 1971. It decriminalized the abortions in a limited manner. It carved out an exception to the general law, namely the Indian Penal code. Thus, abortions strictly done under the norms laid down by the MTP Act are not illegal anymore. However, if one transgresses the limits laid down by the MTP Act, a doctor can face criminal charges and may get prescribed punishment, which could be fine and/or imprisonment.1
The MTP Act was further amended in 2002 to introduce medical abortion by giving medications. Judicial activism by the author who filed the case, Dr Nikhil Datar Vs. Union of India, and series of cases filed in various High Courts and Supreme Court has paved way to another amendment. While this chapter is being written, the amendment to the MTP Act has been passed in both the houses of the parliament and has received the assent from the President of India. Yet the rules and regulations have not been amended and the amended law has not yet been applied. This amendment has upwardly revised the gestational age for termination to 24 weeks and above.2
Thus, for this article, MTP Act (1971 and 1992) and rules and regulations (1975 and 1992) have been taken into consideration.
A gynecologist must know the exact provisions of the MTP Act so as to stay clear of the potential medicolegal implications. The Act has eight sections and rules and regulations.
Section 2: Who can do MTP?
According to Section 2 of MTP Act and MTP Rules 2002, the registered medical practitioner (RMP) must be registered with state medical council and have qualification in accordance with section 2 of the Indian Medical Council Act (1956). The RMP adequate training/experience is as follows:
- Training house surgery post of 6 months in obstetrics and gynecology (OB-GYN)
- RMP should have assisted 25 cases and done five cases independently in any institute which is approved as training center (for this experience, the RMP is eligible to do MTP only up to 12 weeks)
- Postgraduate degree/diploma in OB-GYN.
Section 3: In which conditions can the MTP be done?
MTP can be done:
- If there is a risk to the life of a woman
- If there is a grave injury to the physical or mental health of the motherThe law further defines the “grave injury to mental health.” It states that the below situations will be considered as grave injury:
- Anguish caused by pregnancy alleged out of rape
- Anguish causes by pregnancy caused due to failure of contraception by a married woman or her husband.
While determining the risk of injury to health, “actual and reasonably foreseeable environment” should be taken into account. - If there is a substantial risk that if the child were born, he/she shall suffer such serious mental or physical abnormalities as to be seriously handicapped.
Till what weeks of gestation can the MTP be done?
If the MTP is done to immediately to save the life of the woman, there is no upper limit on gestational age (Section 5).
For all other indications, the MTP can be done only up to 20 weeks of gestation.
Consent-taking for MTP
A written consent of the woman is mandatory. It should be taken in FORM C. The consent of the guardian is taken, if she is <18 years or lunatic. (This word is replaced by mentally ill in the amendment of 2002.)
An RMP must form his opinion in good faith while conducting the procedure.
For MTP to be done up to 12 weeks, one RMP can opine. For MTP beyond 12–20 weeks, opinion of two RMPs is required.
When MTP is done beyond 20 weeks as an “immediate necessity to save the mother's life”, one RMP is enough to opine.
Section 4: Where can one do MTP?
MTP can be done only at a government hospital or hospitals approved by the government.
For medical MTP, approval of place is not required but the RMP must satisfy the criteria of qualification and experience. An RMP can provide the medical MTP only if the patients have an access to the approved center. Thus, the place must display the letter from the owner of approved place stating that the patients will be provided with the emergency services at the approved place 24 by 7.
How should nongovernmental clinics/hospitals get approval for MTP?
Approval of place is mandatory for surgical MTP.
The owner should apply in Form A to the Chief Medical Officer (CMO). The CMO inspects the place within 2 months of application and then recommends to committee, which gives an approval in form B within 2 months of inspection.
The owner has to display the certificate at a prominent place within the premises.
Section 6: The central government can make rules, which have to be passed in the parliament.
These rules are about the qualification of RMPs and the procedural aspect of approval of the place.
Section 7: States can make regulations related to MTP.
Contravention of any regulation attracts penalty of 1,000 rupees.
The regulations deal with the following:
- There is a prescribed form in which the RMP has to register the details of cases:
- Form I: The RMP/RMPs should certify his/her opinion regarding the MTP in Form I within 3 hours of such termination.
- Custody of forms: The RMP has to make a sealed envelope of forms I and C and handover to the owner/head of the hospital/CMO of the state.
- The RMP should write the serial number from the admission register and name of the RMP/RMPs. The word “Secret” should be written.
- The owner should keep in safe custody. He/she shall make a monthly report in Form II.
- In case MTP is done under Section 5 at a place not approved for MTP, the serial number and place shall be kept blank.
- Admission register: Form III.
It is important that the register has all the 14 columns as described.
The admission register needs to be kept for 5 years from the end of the calendar year it relates to.
A fresh serial number for a new calendar year is given. The serial number will be in this format—5/2020.
It is confidential and not open for inspection except for any person under the authority of law; on application by an employed woman, the RMP can grant a certificate for the same.
The name is not to be entered in any case-sheet, operation theater register, follow-up card, or any other document or any other register. Only the serial number must be entered.
Section 8: It provides protection to the RMP from any suit related to MTP.
When MTP is done diligently and in good faith, the RMP enjoys the protection of law. Thus, if the RMP follows all the rules and regulations correctly, it can be said that the MTP is done in good faith and conscientiously. Thus, it is vital that 14standards laid down by the ministry are followed by the RMP while doing the MTP cases.1
EXAMINATION AND INVESTIGATIONS
Elaborate history should be elicited with proper examination; ultrasonography as a routine is not mandatory.
Basic blood investigation such as Hb, blood group, and urine testing to be done.
In cases of Rh incompatibility, injection Anti-D—50 µg in the first trimester and 300 µg in the second trimester should be administered.
- Another important aspect is to provide counseling before and after the MTP.
- Medical management: MTP can be done up to 7 weeks of gestation with mifepristone and misoprostol regimen: On day 1, mifepristone 200 mg oral tablet followed by 400 µg misoprostol oral/vaginal/sublingual on day 3. The Drug Controller of India has allowed use of combipack of mifepristone and misoprostol until 63 days of gestation. It is expected that the amendment to the rules will take into consideration this discrepancy and resolve the same.Also, symptomatic treatment for abdominal pain/nausea/vomiting/loose motions should be provided.
- Treatment of failure: If POCs are seen in cervix, digital evacuation or vacuum aspiration (VA) can be done.If USG suggests incomplete evacuation, additional 600 µg of misoprostol can be given.If no sac seen, “wait and watch” approach can be followed.
SURGICAL METHOD FOR MEDICAL TERMINATION OF PREGNANCY
- Vacuum aspiration or dilatation and evacuation:
- Vacuum aspiration is preferred over the traditional dilatation and curettage. The evidence shows that there is 3–4 times higher chances of excessive bleeding, infection, and perforation as compared to D&C.
- The need for dilatation is lesser in VA and the recovery is faster.
- Vacuum aspiration should be done in case up to 12 weeks size for MTP/miscarriage/incomplete abortion and retained products of conceptions (RPOCs).
Priming of the cervix: Tablet misoprostol 400 µg 3–4 hours prior oral or vaginally and injection prostaglandin F2α (PGF2α) can be administered 45 minutes before.
- Methods of second-trimester MTP: Surgical, medical, and miscellaneous: Surgical method is not commonly used, but when required priming can be done by tablet misoprostol 400 µg; per vaginum 3–4 hours prior or per oral route 2–3 hours prior is preferred. Few prefer to use osmotic dilators before evacuation of uterus.A hysterotomy can be attempted in case of failure of medical method or if an associated gynecological procedure needs to be carried out.The medical method uses tablet mifepristone + misoprostol, but it is not yet approved in India.By the WHO regimen, misoprostol 400 µg can be given every 3 hourly for five doses.
- Second-trimester MTP: Mifepristone + misoprostol for second trimester is not currently recommended in India.Permitted methods are:
- Ethacridine lactate
- Dilatation and evacuation (maximum 16 weeks) and hysterotomy
- Adjuvant therapy which includes tablet misoprostol for priming and PGF2α/20 units of oxytocin for hastening the termination.
- Postabortion advice: 75% women ovulate and 6% conceive within 2–6 weeks of abortion.All contraceptives can be offered after first-trimester MTP including laparoscopic tubal ligation (TL).A laparoscopic TL cannot be done after second-trimester MTP, but abdominal TL can be done.
MTP beyond 20 Weeks: Judicial Activism
- In 2008, Dr Nikhil Datar filed his first case against the Union of India where he helped a woman with 24 weeks period of gestation with severely abnormal fetus for termination and ever since then he has helped more than 150 women to file cases for termination of pregnancy beyond 20 weeks.
- These cases paved way for the proposed amendment to the existing Act. The amendment has been formally passed in both the houses of parliament and received the assent of the President of India. It is expected that the government will notify the application of the amended Act any time in near future.
LEGAL ASPECTS IN CONTRACEPTION
As stated earlier, although there is no specific law governing the subject of contraception, the general framework of ethics and law needs to be followed. The general principles of reproductive rights include:
- The rights of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility, which are not against the law.
- The right of access to appropriate healthcare services that will enable women to safely go through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.
Reproductive health problems can be prevented and solved by offering an array of contraceptive methods, techniques, and services. The couples should be empowered to select, change, and discontinue a method as per their needs. Proper screening, provision of contraceptive services in adherence with guidelines, management of side effects, and follow-up 15procedures for specific contraceptive methods are the key elements in reproductive health.
Current trends in family planning in India show a high level of knowledge among eligible couples, yet the acceptance remains low, especially for spacing methods. Female sterilization remains the most widely used family planning method in spite of efforts to popularize male sterilization.
Counseling is the cornerstone:
- A single method of family planning cannot be recommended to everyone. Family planning counseling can help a woman and/or her partner to choose which method best suits him or her.
- Counseling facilitates decision-making, promoting continuation of contraceptive, counseling about side effects, prevention of unwanted pregnancy, and also sex education.
CONCLUSION
A gynecologist plays a vital role in ensuring the reproductive health of the society. This subject is not purely medical in nature. It has ramifications into rights, ethics, and law. While treating the patients, the doctor should also stay safe and within the limits of law.
REFERENCES
- Ministry of Health and Family Welfare. The Medical Termination of Pregnancy Act, 1971. [online] Available from: https://main.mohfw.gov.in/acts-rules-and-standards-health-sector/acts/mtp-act-1971. [Last accessed November, 2021].
- Ministry of Health and Family Welfare. The Medical Termination of Pregnancy Amendment Act, 2002. [online] Available from: https://main.mohfw.gov.in/acts-rules-and-standards-health-sector/acts/mtp-act-amendment-2002. [Last accessed November, 2021].
LONG QUESTION
1. What precautions should the doctor take so that the MTP is safe medicolegally?
SHORT QUESTIONS
1. Who can perform MTP?
2. What are the prerequisites for an MTP-approved center?
3. What are the indications to perform MTP?
4. Discuss consent in MTP.
5. Discuss judicial activism in abortion law in India: Dr Nikhil Datar Vs Union of India.
MULTIPLE CHOICE QUESTIONS
1. Injection Anti-D ______ mg should be administered in ABO incompatibility after first trimester MTP.
- 300 µg
- 150 µg
- 50 µg
- 200 µg
2. The permissible legal limit for MTP (under MTP Act 1971) in case of an abnormal fetus is:
- 19 weeks
- 24 weeks
- 20 weeks
- 22 weeks
3. The amendment in 2002 in MTP Act dealt with:
- Increasing the permissible limit to 24 weeks
- Validating use of mifepristone and misoprostol
- Both a and b
- None of the above
4. The forms to be filled up in a case of MTP are:
- Form A + Form B
- Form I
- Form I + Form C
- All of the above
5. Medical MTP can be done until:
- 35 days
- 49 days
- 63 days
- 52 days
6. Second-trimester MTP requires:
- Opinion of two RMPs
- Form 2
- Government hospital only
- Medical management
1. c | 2. c | 3. d | 4. c | 5. b | 6. a |