Social reformer Raghunath Dhondo Karve was well ahead of his time when he pioneered family planning in Mumbai in the 1920s. Independent India’s first government caught up in 1952 when it started the world’s first family planning programme. There have been missteps since, such as Sanjay Gandhi’s forced sterilization drive. On the whole, these programmes have done well in tackling India’s fertility challenge. The recently released report on the fourth round of the National Family Health Survey (NFHS-4), carried out in 2015-16, shows where it has succeeded—and where shortcomings remain.

The total fertility rate has declined to 2.2, marginally above the replacement rate of 2.1. This is substantial progress from 2005-2006 when NFHS-3 pegged the rate at 2.7. There are a number of takeaways from slicing the numbers in different ways. The first is the geographic variance. The fertility rate in 23 states and Union territories—including all the southern states—is below the replacement rate. It is substantially higher in a number of states in central, east and north-east India. Bihar, for instance, has the highest rate at 3.41, followed by Meghalaya at 3.04 and Uttar Pradesh and Nagaland at 2.74. Plainly, the nature and scope of the fertility-related public health challenge facing state governments varies widely. So must the response. The most effective way of enabling this is a greater role for local bodies in both urban and rural areas—an item on the incomplete devolution agenda.

Second, breaking up the fertility rate by the background characteristics of female respondents produces the central takeaway. Education is a clear differentiator. Women with 12 years or more of schooling have a fertility rate of 1.7, while women with no schooling have an average rate of 3.1. Birth order backs this up. Thirty-one per cent of births to women with no schooling were of birth order four or higher. The corresponding rate for women with 12 years or more of schooling was 2%.

Education levels are strongly correlated with another important aspect of the fertility rate. Higher levels of schooling mean lower levels of teenage pregnancy. In the 15-19 cohort, as many as one-fifth of the women with no schooling have begun childbearing, while only one in 25 women in the same cohort who have had 12 years or more of schooling have done so. Teenage childbearing, in turn, results in greater health risks. The median birth interval in the 15-19 group is 22.6 months. Birth intervals smaller than 24 months “are associated with increased health risks for both mothers and newborns".

The implication is clear. Lack of education robs women of reproductive control, feeding into India’s maternal and child health problem. Combined with younger pregnancies and higher childbearing rates, it also constrains women’s economic choices. This, in turn, reinforces a lack of reproductive control—44% of women who are unemployed use modern contraceptives while 60% of women who are employed for cash do so—perpetuating a vicious cycle.

The skewed pattern of contraceptive usage is the third takeaway. Knowledge of contraceptive methods is now almost universal in India; the government has done well here. Despite this, men have not taken up the responsibility of managing fertility. The most popular contraceptive method by far, at 36%, is female sterilization. Male sterilization—a less invasive and easier method with a much lower chance of medical complications—accounts for a mere 0.3%. Male condom usage is low as well, at 5.6%. The public healthcare system, which accounts for almost 70% of modern contraceptive usage, doesn’t do enough to address this problem caused by societal attitudes. Only 54% of women were informed of other available contraceptive methods while 47% of women were informed of the possible side effects of their chosen method.

The initial decades of India’s family planning efforts were shaped by foreign funds and agencies that were driven by Malthusian economics. That particular logic has long since been debunked. Now, the Centre and state governments must catch up. The National Population Policy (NPP) of 2000 explicitly rejected the numbers game—the targeted approach that had dominated fertility management until then. But the hangover remains with the National Health Policy 2017 again setting a fertility rate target. And it took the Supreme Court, in its 2016 verdict in Devika Biswas vs Union of India & Others, to call for an end to sterilization camps. These corral poorly informed women, largely in rural areas, in order to hit bureaucratic targets, often violating reproductive rights in the process.

Almost a century ago, Karve took the then radical view that women could best confront the fertility challenge via emancipation and gender equality. That continues to hold true today. Successive governments have done well over the decades; NFHS-4 shows improvement in almost all metrics from the 2005-06 NFHS-3. Now, they must focus on enabling educational and economic opportunities for women.

Has India made sufficient progress in addressing the fertility health challenge? Tell us at views@livemint.com

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