Unmet Need for Contraception in Malappuram District in Kerala A Case of Inequity
Submitted as part of SFC1 assignment by Shaik Nishan Ashraf (M2017PHHP017)
Kerala
The state of Kerala in India is well known for high achievements in human development. It has a human development index of 0.764 and gender-related development index of 0.745 (1). It has a literacy rates of 97.9 and 98.7 in women and men respectively, 72.2% women are with 10 or more years of schooling (2). It has a sex ratio of 1084 (3). Kerala is also a well-performing state when it comes to health, with the state being compared to developed nations for having similar health status indicators. However, like any society, inequities are present in Kerala, these inequities are often subtle arising from various causes. According to NFHS-4 data, Kerala has total unmet need for family planning of 13.7%, unmet need for spacing is 8.3% (2). Women between 20-24 years of age who married before 18 years is 7.6% (2).
The NFHS-4 operational definition for unmet need is as follows:
‘Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone the next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have unmet need for spacing if they are:
· At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years, or are unsure if or when they want to become pregnant.
· Pregnant with a mistimed pregnancy.
· Postpartum amenorrheic for up to two years following a mistimed birth and not using contraception.
Women are considered to have unmet need for limiting if they are:
· At risk of becoming pregnant, not using contraception, and want no (more) children. · Pregnant with an unwanted pregnancy.
· Postpartum amenorrheic for up to two years following an unwanted birth and not using contraception.
Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Unmet need for family planning is the sum of unmet need for spacing plus unmet need for limiting.’(2,5)
Malappuram
Malappuram district located in the northern part of Kerala has a population of 4.1 million of which 70.24% are Muslims, has a sex ratio of 1098 per 1000 males and shows (4). Literacy rates among women and men are 98.4% and 98.3% respectively (5). Availability and access to health facilities especially in antenatal care is high as shown by NFHS-4 data (5). 55.82%
population resides in the rural areas (4). Women who have completed 10 years of schooling stands at 65.5%(5). The district also has 23.3% of women between 20 and 24 years who married before 18 years of age (5). Total unmet need for family planning is 17.4% and unmet need for spacing is 11.3% (5). Malappuram has 16 Kerala Legislative Assembly constituencies and one Member of Parliament. All the representatives are men. Indian Union Muslim League is a major player in politics here. Regional head clerics of Islam are also based in this district.
The Inequity – Unmet Need For Contraception
Health inequity in Malappuram exists in the unmet need for family planning, both in terms of total and spacing. The indicators for the same in comparison with state figures are high and reflect a case of inequity.
Rural
Urban
Total
Malappuram
Kerala
Malappuram
Kerala
Malappuram
Kerala
Total Unmet Need
17.8
13.2
17.0
14.3
17.4
13.7
Unmet Need for Spacing
10.7
8.8
12
7.9
11.3
8.3
Source: NFHS-4, 2015-2016.
The above numbers, when set in a backdrop of higher than state average figures of child marriages (marriage happening at less than 18 years of age of a bride), lower number of women who complete 10 or more years of schooling, and the fact that there are no female representatives in the upper echelons of power, religion, and patriarchy helps in bringing forth the interplay of a plethora of factors that cause this inequity.
Young age at marriage is associated with low use of contraceptives and unmet need for spacing (6). Child marriages can be seen as a manifestation of patriarchy existing in the society (6). It also translates to a limited autonomy to make decisions pertaining to sexual and reproductive choices (6). Such women are also more likely to face domestic physical and sexual domestic violence (6)(7).
Gender-based structuring of Indian society, which is inherently patriarchal, has imposed checks on women’s autonomy in decision-making, movement and access to and control of resources, so much so that her free-will is denied (6). Gender equity, literacy, education and decision power are closely linked to reproductive health (6). Women’s standing in the community and household has a bearing on women’s access to contraceptives (6). Despite Kerala’s high HDI and GDI, traditional stereotypes and traditional views on gender roles still exist (7). Due to the overbearing influence of religion, patriarchy and lopsided gender role perception, the woman is forced to relegate herself to the role as a second-fiddle (7).
Less educated women are more at risk of having unmet need for family planning than more educated ones (6).
Religion has a role in shaping an individual’s gender role and very often than not, religion imposes some form of restriction, hence religious leaders have a role in mitigating or worsening
gender equality situation (7). Muslim girls are found to have more traditional outlooks than their non-Muslim counterparts (7). These traditional outlooks more often than not include acceptance of patriarchy. Muslim women were less likely to be sterilized and less likely to use family planning than non-Muslim women (6). Religion and patriarchy together and individually oppose the use of contraceptives (8).
Concept Map
Social Determinants
Economic Determinants
Political Determinants
No Representation
No Autonomy over resources
Unmet Need
Domestic Violence
Gender roles
Patriarchy
Cultural Determinants
Less Education
Religion
Child Marriage
Standing in community and household
The unmet need in contraception is caused by various determinants, all of which can be categorized into 4 major heads, namely social, cultural, economic and political. The social determinant this case is religion which acts through the agency of patriarchy. The cultural determinants are patriarchy which influences gender roles thereby undermining the standing of women in the society, giving her the perception of being the second fiddle to a male. The standing of a woman in a household or community is also influenced by political determinants, which in this case is the complete lack of representation in the state and central assemblies. This lack of voice in the political system undermines women’s capability to have a higher standing in the society. The third factor acting via lowered standing in the society is the lack of control and autonomy over material resources. Often in a patriarchal society women have no control over their material assets.
Patriarchy also acts through the institution of child marriage (bride under 18 years of age). The woman is neither sensitized, nor does she possess the voice to exercise her autonomy in marriage which include contraceptive and sexual choices. Child marriage victims are also found to be victims of domestic physical and sexual violence. Early marriage in a patriarchal society also deprives from the woman her opportunity to pursue education and career options. This leads to low levels of education which leads on to unmet need for contraception.
From the NFHS-4 data, it can be seen that there is inequity in both spacing and limiting, while the inequity in a woman who has never been pregnant or during the first unwanted pregnancy can be explained by means of child marriage and young age at marriage, the need for spacing in a post-partum woman and cases of limiting can only be explained by the other factors. The standing of a woman, the power she wields in her household and community have important role to play in the observed inequity.
Certain domains like patriarchy and religion, although classified under distinct headings, are cross-cutting and have pervasive influence over the other sub-domains in the occurrence of the inequity. The aspects of patriarchy can be seen to act on almost all the factors mentioned through its various agencies.
Limitations
While performing the literature review, aspects of domestic violence relating to or caused by contraceptive use was considered. Although data for birth control sabotage and physical abuse was found in the US and Ivory Coast contexts, relevant literature in the Indian context was hard to obtain.
References
1. Ministry of Women and Child Development Government of India, 2009, Gendering Human Development Indices: Recasting the Gender Development Index and Gender Empowerment Measure for India, http://www.undp.org/content/dam/india/docs/gendering_human_development_indices_summary_repor t.pdf accessed on 22 August 2017.
2. National Family Health Survey-4, 2015-2016, State Fact Sheet Kerala, http://rchiips.org/nfhs/pdf/NFHS4/KL_FactSheet.pdf accessed on 22 August 2017.
3. Kerala Population Census Data 2011, http://www.census2011.co.in/census/state/kerala.html accessed on 22 August 2017.
4. Malappuram District: Census 2011 Data, http://www.census2011.co.in/census/district/275- malappuram.html accessed on 22 August 2017.
5. National Family Health Survey-4, 2015-2016, District Fact Sheet, Malappuram, Kerala, http://rchiips.org/nfhs/FCTS/KL/KL_Factsheet_592_Malappuram.pdf accessed on 22 August 2017.
6. Sanneving, Trygg, Saxena, et al., 2013, Inequity in India: the case of maternal and reproductive health,
Glob Health Action 2013, 6:19145 – http://dx.doi.org/10.3402/gha.v60.19145
7. Kuruvilla. M, Nisha.P, 2015, Religion and Gender Role Perception: An Empirical Study Among Adolescent Girls in Kerala, International Journal of Education and Psychological Research, Volume 4,
Issue 2, Page 78-83.
8. Bhagat. RB, Praharaj Purujit, 2005, Hindu-Muslim Fertility Differentials, Economic and Political
Weekly, Volume 40, No 5, pp. 411-418.