KERALA, INDIA – Women and contraceptive decision-making in Kerala

Blog by TK Sundari Ravindran (above), The India Forum, 11 June 2021 (Excerpts)

Kerala’s below-replacement fertility figures obscure the poor awareness of contraceptive methods amongst women, pointing to the unfinished task of promoting independent and informed reproductive choices.

Kerala reached replacement-level fertility… in the late 1980s, at a time when most Indian states had high- or mid-level fertility levels. Over time, the accepted narrative explaining Kerala’s low fertility has been that women’s education led to increased awareness about the advantages of a smaller family. Women’s exposure to the family planning programme and their ability to make decisions led to the widespread use of contraception. Kerala’s declining infant and maternal mortality were acknowledged as enabling contextual factors.

A qualitative study (nested in a larger longitudinal study) that Sundari carried out in Thiruvananthapuram district during 2014-15 with 30 post-partum women and 10 healthcare providers came up with findings that suggested a very different reality regarding contraceptive choice. All of the women were literate. More than three-quarters of the respondents had post-secondary education and were from households above the poverty line. But their stories were not that of well-informed, healthy and empowered women who confidently exercised their reproductive choices.

First, most of the women had very limited knowledge and distrust of reversible methods of contraception and relied on less effective ‘natural methods’ to delay or space pregnancies. Second, women did not often have the freedom to make contraceptive decisions. Third, after achieving the desired family size, birth control was solely the woman’s responsibility. And fourth, pregnancy, childbirth and the post-partum period were fraught with health problems for many women and their newborn infants, which interfered with the use of post-partum contraception.

According to the National Family Health Survey of 2015-16 (NFHS-4), almost all women in Kerala knew about a modern method of contraception. While female sterilisation was the most widely known method (95.7%), more than 90% of the women knew about condoms, and more than 75% knew about oral contraceptive pills, intrauterine devices (IUD), and vasectomy. Yet…

A vast majority of women had only ‘heard’ of a pill that prevented pregnancy. Most did not know how oral contraceptive pills were to be used or how they worked… or confused them with emergency contraception.

Vasectomy was not widely known…

The general opinion was that the women had not found the use of condoms convenient or that their husbands did not like the method.

Copper T intra-uterine device was a much-disapproved method.

The general attitude amongst the respondents towards fertility control was to not use artificial methods till the desired family size was achieved.

The use of the withdrawal method for spacing gives some indication of women’s limited choices and freedom to control their fertility as per their desire.

The veneer of universal institutional deliveries, relatively low maternal mortality ratios, and very low infant mortality rates in Kerala mask the huge burden of pregnancy and delivery-related morbidity and neonatal morbidity resulting in poor quality of lives and interfering with women’s ability to prevent an unwanted pregnancy.

Dissemination of contraceptive information does not seem to be a high priority for Kerala’s family planning programme.

Limited knowledge on contraceptive methods might also be attributed to the absence of education on sexual and reproductive health issues in schools or even in universities.

The paper concludes:

  • We need studies to examine how Kerala’s unequal gender power relations play out in contraceptive decision-making.
  • The achievement of below-replacement fertility is not the end of the story for women’s reproductive health and rights, but only its beginning.

PHOTO: Inaugural session EPHP 2016, 2 May 2018