Slowing population growth: Why families get smaller in size with better access to healthcare
It’s a paradoxical fact. Families become smaller as better nutrition, vaccination and healthcare ensure couples lose fewer children to malnutrition and infections, such as diarrhoea, pneumonia, sepsis and tuberculosis
India’s most comprehensive report card on health released earlier this year shows India’s total fertility rate (TFR) has dropped from an average of 2.7 children per women in 2006 to 2.2 a decade later. Around two in three states that are home to half the country’s population are well below the “replacement” TFR – the desired family size when the population stops growing – of 2.1 children per woman, shows countrywide data from the National Family Health Survey-4.
The country’s average family size is being pushed up by seven of India’s most populous states, where TFR remains above 2.1. Bihar, Uttar Pradesh and Jharkhand are the laggards, with family sizes higher than 2.5. But even there, the decline in population growth has been impressive. Uttar Pradesh has shown the highest decline in TFR (1.1%), followed by Nagaland (1%), Arunachal and Sikkim (0.9%), shows NFHS-4 data.
The boom may be over, but the growth will continue. India is home to the world’s largest youth population, with 40% of its population under the age of 20 years (Census 2011). This will push its 1.3 billion population to overtake China’s by 2024 to make India the world’s most populous nation.
“For India as a whole, 75% of population growth in the coming decade will be due to momentum from India’s large youth population that is in or about to enter childbearing age,” said Diego Palacios, country representative, UNFPA India.
“Population growth is slowed by delaying marriage, delaying first birth, increasing space between children and providing quality family-planning services, which must be done in conjugation with schemes that empower women and enable them to delay marriage and childbirth,” said Palacios.
Families in India will continue to shrink as more people get access to contraceptives and better nutrition, vaccination and healthcare to prevent newborn and child deaths from malnutrition and common childhood infections like sepsis, diarrhoea and pneumonia.
Casebook family
It’s happening, but in fits and bursts. Rama Ahirwai’s life is a study in how most states achieved population stabilization.
Rama, 29, lives in a two-room house with her husband Kamlesh, mother-in-law Ramkail, sisiter-in-law Anjali and sons Umang and an unnamed newborn boy in village Baroh in the Ganj Basoda block of Madhya Pradesh’s Vidisha district. Like all other men in the village, Kamlesh cuts stone in a massive quarry behind their home, and makes enough to get food for his family and alcohol for himself. He has little time, money or inclination to worry about the health of his family of five.
Though Rama is among the three in four (75.4%) women in India who doesn’t earn and is dependent on her husband for money, she has more say in household decisions than women did a decade ago. Primary schooling has taught her little more than the alphabet and writing her name, but she’s smart enough to know she cannot depend on her husband for support in childbirth and rearing her children. “He’s out all day and has no time for the children. He says it’s not his job, so I do it better than he would,” she said.
So Rama does the best she can for her family. She’s ensured both her children were delivered free at a government health centre in neighbouring Pathari health centre by availing of all the maternity health benefits given under the Janani Shishu Suraksha Karyakram. The scheme provides free and cashless delivery at a health centre, free medicines and diagnostics, free food during hospital stay and free transport to hospital and back.
Her mother-in-law Ramkali is dismissive of the fuss, but doesn’t grudge Rama getting the attention. “Everyone delivers in a hospital these days, when I had my five children, no one did,” said Ramakali. “They say children in hospitals survive and both her boys have. In our day, we had more children because we would lose half to fate.”
Only three of Ramkali’s five children – two girls and Kamlesh, 30 – are alive today. Pooja got married at 18 seven years ago but the youngest Anjali, 22, doesn’t plan to marry anytime soon. “I walk 5 km one way with a friend to study at Agnihotri College in Pathari, where I’m doing Arts (Bachelor’s, second year). It’s tough but I really want to become a teacher. I don’t want marriage or children right now,” said Anjali.
Services on call
Half of India’s children are born in a public health facility, with close to 80% children born in a public or private hospital or health centre. This makes the quality of care and advice on contraceptives, childhood vaccination and nutrition at the hospital or health centre critical for the mother and newborn’s health. This doesn’t always happen.
Rama didn’t get information on contraception or spacing. Her children were born 18 months apart when the ideal gap between two births is three years. She is breastfeeding her baby, but has got no nutrition advice at the hospital or the Asha worker. Chalk markings on her wall show an ANM has visited her home to review the health of both her newborn and toddler under the state government’s ongoing month-long Dastak Abhyan to check malnutrition. But it’s just a mark on the wall, no one has reviewed the children’s weight, height and health. “Didi wrote on the wall and went away, but did not come inside to look at children. No one has come to see if they’re okay,” said Anjali.
The challenge, as always, is tracking and reviewing the providers to ensure the available services reach the families they are meant for. “Motivated ASHAs (community health workers) can change the health of their community so both she and the community gain. We had an Asha who earned Rs 21,000 a month as incentives for ensuring everyone used all the services available to them,” said Dr BB Sharma, block medical officer in neighbouring Ichhawar in the Sehore district of Madhya Pradesh. If everyone works as well, India’s population growth will stop growing sooner than later.
