How India's birth control battle falters in rural district

Pratima Kumari, a government health worker in the eastern Indian state of Bihar, sets off on her mini scooter every morning, crisscrossing vast corn fields and pineapple orchards to visit villages and meet young, married couples.

She offers contraceptives and birth control pills for free in the Kishanganj district and talks to the couples about birth control and the benefits of having just two children.

But it's mostly been a losing battle in Kishanganj, which has the highest fertility rate of any district in India, soon to be the world's most populous nation.

"The minute I tell couples to use contraceptives or suggest permanent birth control, they ignore it or just change the topic," Kumari told Reuters.

Kishanganj, and Bihar, are exceptions in India, which has over decades controlled its population growth.

The national fertility rate, or the number of children a woman has on average, fell to 2.0 in 2019-21, just below the replacement rate of 2.1, official data shows.

But Bihar, one of India's least developed states, had the highest fertility rate of 2.98. State health officials estimate Kishanganj's fertility rate at 4.8 or 4.9.

Successive state governments have been aware of the population growth problem, particularly in Kishanganj, and have mounted programmes to curb it.

Besides the free distribution of contraceptives and birth control pills, the state pays 3,000 Indian rupees ($36.50) to women who get sterilised and 4,000 rupees to men. Health workers who get people sterilised are paid 500 rupees per surgery.

Yet the results have been poor.

Fear of sterilisation

"I talk to women while they are experiencing labour pain and nudge them to undergo sterilisation immediately after delivery," said Parvati Rajak, a medical officer in one of Kishanganj’s seven government health centres.

"But the final choice is always made by the family," she said, minutes after helping a woman deliver her fifth child.

Jahan Sheikh, a mother of four and pregnant for the fifth time, said she was not in favour of sterilisation.

Sheikh said her mother-in-law told her it was good to have at least five children as they would help in the farm and at home. "I don’t know but getting a sterilisation operation makes me nervous. What if there are problems after the surgery? Who will take care of my kids," she asked.

A 2021 Bihar planning and development department report said the state had a sterilisation target of 871,307 people in 2020 but managed just 401,693 or 46 per cent.

Men refused to undergo sterilisation as they thought the procedure would harm their masculinity, health workers say.

In Kishanganj, only 0.2 per cent of the male population was sterilised while it was 22.8 per cent for the female population, the state government report said.

Just minutes after giving birth to her fifth child at a government clinic in Kishanganj, Zamerun, the wife of a mason, said she would try to secure permission from her husband to undergo sterilisation before leaving for home.

"The problem is people shy away from using them and we need to continuously remind them about it."