World Population Day 2021: Need to work on women’s access to health services, says Divya Santhanam, Population Foundation of India

Every year on 11th July, world population day is celebrated. The objective of the world population day is to draw attention to issues arising out of population growth and/or decline (in some cases). India has the second highest population in the world, only behind China and it is set to become number one in the coming decades. The uncontrolled growth in population has given rise to many problems in India including uneven distribution of healthcare services among both the genders. Women in India face the burden of family planning, educational disparity, social stigmas and much more. In an exclusive conversation with Financial Express Online Divya Santhanam, Senior State Programme Manager, Population Foundation of India talked about the issue and this year’s theme on raising awareness around women’s and girl’s needs for sexual and reproductive health. Excerpts:

The burden of Family Planning and contraceptive use largely falls on women in rural India. How does this impact the overall health and wellbeing of women?

Women’s health has been severely impacted by deeply ingrained social norms that limit their ability to take decision-making into their own hands. This is especially true of women’s reproductive health and fertility, and family planning remains a woman’s prerogative. Stigma and taboo act as barriers to women’s agency in accessing sexual and reproductive health services or negotiating contraception with partners.

Women from rural areas are particularly susceptible to these challenges due to barriers to access to health services. Frontline workers are most often the first and only point of contact to the health system for these women.

The impact of the COVID-19 pandemic on women’s reproductive health needs is likely to be significant. In India, nearly two million women reportedly faced restricted access to abortion services and 26 million couples faced limited access to contraceptives as a result of the disruption in health services during the lockdown. Besides aggravating pre-existing challenges, COVID-19 may push back years of progress and impact maternal and child health, poverty reduction and gender equality.

Rural India faces enormous education disparity and digital divide as compared to its urban counterparts. What methods could be adopted which can actually help in educating and creating awareness on Sexual and Reproductive Health?

One of the key ways to educate and empower men and women about the need for safeguarding their sexual and reproductive health is by sharing effective and evidence-based messaging at the community level. Social and behavior change communications (SBCC) have proven effective in breaking taboos and engaging communities in taking action to improve health outcomes. Engaging and sensitizing community leaders, frontline health workers and other healthcare providers, as well the users themselves about issues such as male participation in the uptake of contraception, creating a demand for family planning services and improving women’s participation. In rural India, the need of the hour is to enable information delivery via open dialogues with trusted sources as well as mass media platforms such as radio and television.

Facilitating comprehensive sexuality education (CSE) in schools can help enable open conversation around sexual and reproductive health and ensure young people are aware of safe sex practices. CSE encourages respectful peer behavior between girls and boys as well by exploring power dynamics, consent and other key issues. Dispelling myths and fears around sexuality can help uphold sexual and reproductive health rights and empower young people to exercise agency over their bodies.

As compared to other countries where Sex Education has been added to the academic curriculum, India is way behind with regards to this even in urban cities. How necessary is it to impart Comprehensive Sexual Education to the youth?

Comprehensive sexuality education (CSE) is key to removing barriers around reproductive and sexual health outcomes. By addressing concerns such as consent or bodily autonomy, it decreases the propensity for gender-based violence and adverse mental health issues. The physical, psychological and emotional changes that young people experience during adolescence can be trying. Without the right guidance, adolescents may find it difficult to navigate issues such consent, relationships, physical changes, avoiding unintended pregnancies and accessing safe abortion services. Comprehensive sexuality education is also critical in reducing intimate partner violence, handling peer pressure and reporting abuse. The absence of accessible, non-judgemental and private adolescent-friendly information, counselling and services can affect young girls and boys struggling to comprehend the complexities of adolescence.

Despite these benefits, comprehensive sexuality education in India has been viewed as being at odds with India’s values. Inhibitions coupled with stigma around sexual and reproductive health, especially for the unmarried, have resulted in the continuation of poor reproductive health practices. Today, the importance of equipping young people with the knowledge and information they need to determine and enjoy their health and wellbeing is stronger than ever.

Comprehensive sexuality education provides references to resources and services and helps young people develop life skills including critical thinking, communication and negotiation, self-development, and decision-making. It fosters positive attitudes and values, including respect for self and others, self-esteem, and most importantly positive attitude toward their sexual and reproductive health.

In India today, CSE is not taught in schools but government programs such as Rashtriya Kishore Swasthya Karyakram (RKSK – National Adolescent Health Programme) and the recently launched Ayushman Bharat School Health Programme have elements of SRH education. The need is to prioritize the implementation of these programmes, especially given the impact of the COVID-19 on school closures.

India has the largest adolescent population in the world at 253 million, with many unaware about their Sexual and Reproductive rights. What could be the repercussions of this in the long run?

Twenty-one per cent of the total population is made up of adolescents (Census 2011). However, amongst this population knowledge and correct information on SRH is low.

Unfortunately, according to the fourth National Family Health Survey (NFHS-4, 2015-16), 27 per cent of all women between 20 and 24 years of age were married before they turned 18. Eight per cent of women aged 15-19 years were already pregnant at the time of the survey. While only ten per cent of currently married women aged 15-19 years, and 16 per cent of sexually active unmarried women in the same age group used any modern contraceptive method Delivering quality services that are tailored to young people may improve service use, adherence to contraceptive methods, and increase the likelihood of obtaining ongoing care. On the contrary, the lack of adequate information and services around family planning and sexual and reproductive health would increase young women’s chances of getting pregnant before becoming physically and emotionally ready. It would deprive them of the opportunity to make informed choices and have control over their sexual and reproductive health and lives, free from coercion, violence, discrimination and abuse.

There’s a stigma when it comes to discussing Sexual and Reproductive Health in Public. Why does this exist given how core an issue this topic is?

The discussion around sexual and reproductive health in India, especially for unmarried adolescents and youth, has always been constrained by social norms and taboos around sex and sexuality. Inhibition and fear layered by misconception and stigma around sexual health and sexual health rights have further created controversies making Comprehensive Sexuality Education (CSE) a journey of ups and downs in the country.

Stigma, in the form of deep-rooted patriarchal norms or even healthcare worker bias, has the ability to not only adversely impact women’s sexual and reproductive health (SRH) but also has direct bearing on bodily autonomy and integrity for women and girls. Social norms that stigmatize women’s have disadvantaged women and inhibited their ability to make their health and fertility decisions for centuries. Although family planning (FP) and sexual and reproductive health (SRH) are predominantly considered to ‘women’s business’, the timing and number of children women have is often not a decision they make for themselves. Social norms, taboos and prejudices act as barriers and prevent women from accessing SRH services as well as negotiating contraception with their partners.

India is home to 253 million adolescents, the largest population globally. As per Census 2011, more than 62 per cent of the country is aged between 15 and 59 years, and the median age of our population is less than 30 years. Our ‘demographic dividend’ represents the potential for economic growth based on the age structure of our population. However, the stigma associated with adolescent SRH, combined with the continuing practice of child marriage puts this population at grave risk.

For years women have been refused their right to body autonomy or taking reproductive decisions for their body due to a patriarchal society. Is there a change seen now and how so?

Sexual and reproductive health and rights (SRHR) directly impact bodily autonomy and integrity for women and girls, which in turn defines many other areas of life. Over the years, India has shown improvements in women’s access to family planning and sexual and reproductive health services. The unmet need for family planning declined from 20% in 1992-93 (NFHS-1) to 13% in NFHS4 (2015-16). According to data from the first phase of NFHS-5 (2019-20) which surveyed 22 states and union territories, there has been an increase in the uptake of spacing methods.

These developments can be attributed to the efforts made by government and civil society organizations to ensure greater reach and provision of family planning and SRH services. Another important factor that influences women’s health and fertility decisions is the education level of both partners. The number of women with over 10 years of schooling has also witnessed an improvement over the years. Despite the progress made, challenges remain and the COVID-19 pandemic threatens to reverse much of the progress made through the decades, if urgent measures are not taken.

The theme for World Population Day 2021 is “Raise awareness around Women’s and Girl’s needs for Sexual and Reproductive Health”. Why is it important especially now amidst the pandemic to speak up on this?

The COVID-19 pandemic is among the greatest challenges to global public health. The pandemic has impacted already vulnerable population groups differentially, particularly women and girls. The gendered impact of COVID-19 has exacerbated pre-existing inequalities and underscored vulnerabilities in social, political and economic systems.

Increased vulnerability of women and children during health and social emergencies, due to exploitation, sexual violence, disruptions in protective social networks and decreased access to services is widely documented. It is crucial therefore that we divert resources to essential health services including family planning, gender-based violence, maternal and child health to ensure that sexual and reproductive health is not further impacted.

Due to the pandemic, more women are likely to drop out of school or the workforce, impacting their access to independent livelihoods and financial sustainability. Across the globe, women already earned less, held less secure jobs and were more likely to be employed in the informal sector. With worldwide lockdowns, restrictions and quarantines, women’s economic and livelihood activities were significant reduced, thereby increasing poverty and food security for both women and children.

Women’s access to health services are already restricted due to social norms, lack of bodily autonomy and gender stereotypes, the diversion of resources to COVID-19 has further exacerbated this. Thereby making them more susceptive to health risks. Even as COVID-19 vaccinations are rolled out across the country we see that once again, far fewer women than men have received their vaccination due to a lack of access, digital divide and myths and misconceptions.