Introduction Contraceptives are considered ‘the greatest life-saving, poverty ending, women-empowering innovation ever created’ (Gates 2019, 18). ‘Family planners’ – the global constellation of bilateral and multilateral entities, governments, philanthropies, research bodies, and NGOs working in the field of family...
Introduction
Contraceptives are considered ‘the greatest life-saving, poverty ending, women-empowering innovation ever created’ (Gates 2019, 18). ‘Family planners’ – the global constellation of bilateral and multilateral entities, governments, philanthropies, research bodies, and NGOs working in the field of family planning – rationalize investment and intervention into ‘excessive’ fertility along two lines: namely, reductions in unintended pregnancies, unplanned births, and maternal and infant mortality (UNFPA 2021); and the ‘cost-effectiveness’ of interventions (UNFPA 2014). While these are sound and valuable grounds for alleviating unmet needs for contraception per se, they do betray two dominant trends in global health: to frame health priorities primarily in terms of their relevance to economic growth (Kelly and McGoey 2018), and to pitch techno-medical interventions as ‘magic-bullet’ solutions for even the most intractable structural issues such as gender inequity, poor health infrastructure, and socio-economic discrimination (Adams et al. 2019).
Such initiatives also appropriate the rhetoric of community participation and gender empowerment to legitimize their continued operation (Cornwall 2006; Menon 2009). Following the 1994 International Conference on Population and Development in Cairo, family-planning programmes distanced themselves from population-control rhetoric and revamped the initiatives as responding to the sexual and reproductive health needs of women in developing countries where resources and political will were deemed lacking (Briggs et al. 2013). Significant scholarly work showcases that family planning in countries such as India effectively remains a top-down, incentivized, and even coercive programme targeted at curtailing the fertility of socio-economic minorities (Hartman and Rao 2015; Rao 2004; Shaw and Wilson, 2020). Despite robust scholarship and glaring power imbalances, it is challenging to critique any intervention that avoids the rhetoric of sexual and reproductive health and rights.
Part of this challenge pertains to how progress and impact are communicated. Quantitative measures such as total fertility rate and annual population growth rate are increasingly blended with qualitative, ‘human-interest stories’ (Storeng 2010). However, the participation of rural, poor, Dalit beneficiaries possessing little or no education is orchestrated using the agendas, funds, and expertise of large international organizations. The differential power relations and ensuing asymmetries in authority create doubts about whether women have an opportunity to express needs that may not align with what the change-makers have in mind (Ahearn 2001; Batliwala and Dhanraj 2004). The employment of human-interest stories is therefore somewhat deceptive and needs renewed resistance. Given the premium placed on women’s participation in family-planning projects, I ask: to what extent are the visions of family planners in consonance with the experiences of intended beneficiaries?
In 2016, the Bill and Melinda Gates Foundation funded the production of a six-minute film[1] on the impact of family planning in Uttar Pradesh (UP), India. It exemplifies the ‘population reduction with a human face’ approach that characterizes such initiatives. In this essay, I argue that family-planning exists in tension with the needs it claims to represent, necessitating an analytical shift from the ‘need’ for intervention to proclaimed purposes. Discussing my ongoing research on the use of participatory interventions in reproductive and child health programmes and the resulting impact on the nature and scope of women’s health in India, I confront three tenets of global family-planning projects: the unequivocal ‘need’ to have fewer babies, the safety and convenience of temporary methods, and the recourse to female sterilization. I ground this discussion in the sixty-eight in-depth interviews I conducted with women in the age group of 18 to 65 years old based in rural UP in 2020-21. This included interviews with Accredited Social Health Activists (ASHAs).[2] I also interviewed officials from the state public health department, the Gates Foundation, public health practitioners in UP and Delhi, and local private doctors, among others associated with the labyrinth of global health projects in the state.
Figure 1: Women conducting an SHG meeting (RGMVP 2020, 5:12). Used with permission.
In this essay, I argue that the power asymmetries, and the interpretation and representation of women’s reproductive needs exemplified in this film, signals a continuity of lopsided North-South relations in international development, which approaches fertility management in neocolonial and racialized terms but in the guise of women’s empowerment and health rights. A critical role of social medicine is to serve as a vanguard against depoliticized appropriation of subaltern narratives in communicating the efficacy and impact of family-planning projects. In this regard, one of the most powerful contributions of interdisciplinary research such as mine would be to have targeted populations qualify impact claims, instead of impact claims quantifying people’s needs.
Figure 2: Sia Dulari (RGMVP 2020, 5:40). Used with permission.
Variegating family-planning needs
The film was shot in Gaura village, in Mohanlal Ganj block[3] on the outskirts of Lucknow, the same block where I conducted fieldwork in 2020-21. It is largely rural with about 48% of the population belonging to scheduled castes and scheduled tribes. Over 65% of the population is unemployed, and the remaining rely on farming, agricultural labour, and intermittent wage work. Of those in stable employment for over six months, women constitute 18% (Ministry of Home Affairs 2021). The film incorporates these women within a predetermined script, narrativizing fundamental principles of the family-planning enterprise, namely the reference to the trouble of ‘excessive’ births, contraception as a solution, and the explicit mandate to have fewer babies. I argue, in contrast, that contraceptive needs are heterogenous in practice. There is a diversity of opinions on this matter, often not conforming to the unequivocal representation of how contraception improves women’s health, empowers them, and reduces poverty.
Public health films are not a new phenomenon. In 1968, Population Council partnered with Disney to create a 10-minute film called Family Planning. The purpose of this endeavour was to reach people of reproductive age across the developing world with the universal mandate to limit family sizes (Sreenivas, 2021). In Africa, they were a medium to address populations with messages on optimal health behaviours, perpetuating racialized assumptions of native populations being deficient in knowledge, hygiene, and morality (Vaughan, 2007). Relatedly, Fraser McNeill (2011) examined the use of folk songs by HIV/AIDS peer education programmes in South Africa. Similarly, Uttar Pradesh has a rich culture of folk songs. (Sahai-Achuthan, 1987).
The Gates Foundation funded film serves a more complex and novel function. As per interviewees, the purpose was to showcase the impact of the Foundation’s family planning investments in Uttar Pradesh. The film’s audio is in Awadhi and Hindi. And viewers not familiar with these languages are served by the English subtitles. The film also remains relevant for local women as a family planning campaign tool, and a more informal pleasure of seeing oneself in a video. Therefore, the film is mobile – it travels among beneficiaries, to the English-speaking world, to the global health community, inviting each gaze to witness the impact of Gates Foundation.
In the opening scene, the women sing ‘Karo bachhe kam paida naari’ (women should have less [sic] kids)[4] (Rajiv Gandhi Mahila Vikas Pariyojana (RGMVP) 2020). Decisions to have more babies are linked with the experience of losing babies. Illness and death of infants and children under five are a serious problem in UP. Over 66.4% of children under the age of five are anaemic, 39.7% are stunted, and 32.1% are underweight (IIPS 2021). UP also has the highest under-five mortality rate: about 60 deaths for every 1000 births, with over half these deaths occurring within a month of birth (Dandona et al. 2020). The predominant risk factors for these deaths are maternal and child malnutrition, unsafe drinking water, lack of sanitation, and air pollution (Dandona et al. 2020). The high burden of infant deaths in UP calls for a closer examination of the resounding mandate to ‘have fewer kids’.
In rural UP, when poor families experience infant death, doctors and nurses are not likely to offer explanations. Aarti’s[5] second baby was born via caesarean section and died two days later. The doctor said it was sepsis. The family remained unconvinced but conceded to the loss as ‘fated’. Bindoo’s[6] baby died due to congenital abnormalities. Talking about the loss, she and the women in our discussion group agreed that ‘it was better for [the baby] to die’. The indifference says less about hard-hearted apathy and more about strategic detachment in the face of structural inequalities and deprivations (Scheper-Hughes 1993). Similarly, interviewees processing loss as a misfortune does not necessarily mean that they are delusional about their suffering. It springs from an attentive realization that losing one’s baby remains as commonplace as the absence of doctors and adequate services, and the sheer inability to hold the system accountable.
Moreover, family-planning initiatives work with an unquestioned assumption that poor women in developing countries are ‘only concerned with controlling their conception’ (Unnithan-Kumar 2006, 16), whereas bearing children is an expected, and often even desirable, milestone for attaining an adult female identity (Riessman 2002; Unnithan-Kumar 2006). Women who face problems conceiving are considered ‘inadequate’, which generates stigma and stress even among young couples. Assisted reproductive technologies are widely available in cities across India but remain a prerogative of the urban elite (Bhardwaj 2002). In Lucknow, IVF treatments can cost between ?70,000 and ?1,40,000 (roughly £700 to £1,400). This is out of reach for the women I interviewed; for example, one interviewee seeking treatment had a daily family income of ?250–300 (less than £3). Incurring this prohibitive expense would plunge her family into significant debt.
Even those who can afford treatment might hesitate, considering that family-planning programmes are associated primarily with spacing or limiting fertility. Alternatively they may pursue a more heterodox approach, consulting doctors along with indigenous healers (Unnithan-Kumar 2006). The stresses around infertility and the frequency of infant death in UP, a state with a high fertility rate, reveal the tension characterizing social stigma about infertility, population politics, and economic constraints that distort and shrink care seeking (Inhorn and van Balen 2002). If addressing women’s needs is indeed the foundation of family-planning initiatives, it seems counter-intuitive to ask women to have fewer babies, when in fact women should lose fewer babies.
The rhetoric of ‘choice’
Access to a variety of safe and affordable contraceptive methods can enhance women’s control over reproduction. However, the narrative of individual women being ‘empowered’ by family-planning neglects the fact that reproductive decisions are shaped by familial and social obligations (Unnithan-Kumar 2006). The availability, quality, and suitability of methods also shape decisions. Here, experiences concerning the precarious safety and reliability of contraceptives become relevant. Global and national family planners endorse post-partum intra-uterine devices (IUDs), condoms, and birth control pills in terms of their safety, affordability, and value in relieving gendered and economic suffering (BMGF 2016), downplaying serious and long-term side effects (Hartmann and Rao 2015). We see this endorsement in the film, when a woman says, ‘In mein se koi bhi cheez hum istamaal kar sakte hain’ (we can use any of these [methods]), while the translated subtitles read: ‘Any of these methods work safely’ (emphasis added) (RGMVP 2020, 2:26). While safety is important, at no point in the film do the women discuss it. The translation serves to reassure English-speaking viewers, not those being educated in the risks of their ‘pathological fertility’.
Among my interviewees, instances of safe and uncomplicated IUD insertions were the exception not the rule. One interlocutor was pushed to use an IUD after her first delivery, but she conceived soon after. Following her second delivery, the nurse pressed for another IUD insertion. She recalled, ‘they fitted it such a hurry…it climbed up to my chest’.[7] She complained of swelling, pain, and white discharge. While her husband was also being pressed to get a vasectomy, she said it was ‘not good for the man to get it done’.[8] One of the ASHAs in the village mentioned during one of our interactions that injecting Antara (medroxyprogesterone acetate) does not suit everyone, as it commonly causes excessive bleeding, menstrual issues, and white discharge. She admits that she avoids telling women about Antara, ‘because later when women face issues, they will curse me’.
Young women are often confused about the ‘normality’ of vaginal bleeding following an abortion or miscarriage. The lack of knowledge can delay timely care seeking, and numerous anecdotes in the community about failed IUDs and side effects create scepticism around the efficacy of birth-control methods. Therefore, it is no surprise that despite the availability of various methods, female sterilization remains the predominant contraceptive method (18%) in rural UP (Indian Institute of Population Sciences [IIPS] 2021). The prevalence of sterilization is due to both a programmatic ‘push’ for the procedure, as well as a function of women’s preference for the same after they have had two or more surviving children. Women typically turn to sterilization after an adequate display of fertility, through early, repeated, and precarious pregnancies. The Indian government also prefers sterilization considering that it is a one-time procedure, bypassing the need to invest in comprehensive quality health care or to confront patriarchal and caste-based norms (SAMA et al. 2014).
Figure 3: The woman in the pink sari illustrates a ‘non-user’ (RGMVP 2020, 3:34). Used with permission.
In the film, Sia Dulari is the protagonist who champions family-planning in her village. She visits a woman in a pink sari who, sitting next to her husband and five children, is meant to typify a ‘non-user’ of contraception. Note that, in Hindi, the woman is talking about her concerns regarding an ‘operation’ (tubal ligation) and not refusing contraception per se. She fears complications that often follow sterilization – concerns such as bleeding or infection or even the need to rest and recover. She cannot afford ‘complications’ because she needs to tend to domestic and farm work. Apprehensions around potential complications are well-founded. A 23-year-old interviewee underwent a postpartum tubectomy, following which her periods became irregular, and the bleeding did not stop for weeks. Doctors, however, denied her a hysterectomy considering her age. For three years, she relied on painkillers and injections to manage the discomfort and household chores. Her uterus was removed in 2020.
Rural, poor, Dalit, and Muslim women are blamed for intergenerational poverty because of their ‘failure to curtail fertility’ (Nandagiri 2021; Unnithan-Kumar 2006; Wilson 2008; 2015). This is also seen in the film (RGMVP 2020, 3:50), which shifts responsibility away from the cluster of forces that link poverty, health, and reproduction to make these women appear at fault. Persisting neglect of socio-political forces results in contraception exacerbating health risks rather than ameliorating them. One interviewee was married at 17, and when she delivered her first baby, a son, via caesarean section, her haemoglobin level was 6 g/dl.[9] She was asked to improve her diet, but her health did not stabilize. Five years later, pregnant again, her haemoglobin dropped to 4 g/dl when she went into labour. She is now insisting on sterilization to avoid future ‘risk’ because, she says, ‘there is no blood in my body’. Low haemoglobin is not just a function of repeated pregnancies and deliveries, but also of familial responsibilities, inadequate nutrition, low income, poor-quality services, and a distorted family planning agenda. These ‘political aetiologies’ show that ‘the ways in which people make sense of illness are inevitably political moves that either ignore or speak to power’ (Hamdy 2008, 563). The women I spoke with, for example, connected iron deficiency with deficiencies in health infrastructure, which create and distribute risky pregnancies and make childbearing a ‘burden’.
While this interviewee and others in the community did not always have an ‘ideal’ number of children in mind, the decision to curtail fertility points is clearly linked with several socio-economic considerations, pressures, and obligations. This demands a recalibration of one’s aspirations and priorities. Therefore, there is a need to extend the construction of fertility-related decision making beyond a superficial reference to reproductive ‘choice’.
The spectacle of participation
In the film, a woman in a yellow sari points out that ‘kamai hoye, to chahe jitney ladka paida karo’ (if you have the income, you can produce as many babies as you like). Women’s drive to limit their fertility is not determined by the fact that they do not want any more babies, but that they do not have the means to support their desire. However, the translated subtitle states: ‘And everything is so expensive these days’ (RGMVP 2020, 4:38). This translation changes the meaning, editing out her concerns about the dearth of income because it does not fit with the film’s narrative. The social change being envisaged here is one that intends to make women curb their aspirations (and reproductive potential) rather than improve the likelihood that those aspirations will be met.
Given the heterogeneity of experiences, why did the women in the film lend their voices to the unidimensional characterization of their contraceptive needs? With huge investments in family planning, hyper-exposure to urban or foreign officials, and a decrepit public health system, people have become accustomed to ‘posturing’ in the presence of outsiders. Writing about HIV in Sierra Leone, Benton (2015, 109) states that such posturing is a ‘strategic attempt to articulate struggles that women face in a way that resonated with common representations of them’. Speaking on camera, participants typically feel intimidated and are more likely to soften and modify their stance (Kapoor 2004). Perhaps they also hope to remain in the field of vision of those wielding power over resources (Benton 2015; Scott 1985). This orchestrated participation produces a self-disciplined womanhood through which the family planners legitimize sustained intervention into ‘third world’ fertility.
Critiquing these tenets of family-planning projects is not intended to expose international financial and technical assistance as being inherently insidious, nor does it cast the women who participate in such interventions (‘beneficiaries’ in the language of such projects) as passive victims. People can and do benefit from expanded access to healthcare regardless of project goals and intent. However, increased vigilance is needed towards questions of who is deciding the urgency and gravity of health needs within developing countries, and on what basis. Social medicine is valuable because it can critically examine the linkages between global health issues and the ‘problems of funding (capital), globalization (scale), and quality and focus (method)’ (Adams, et al. 2014, 180). A small group of elite practitioners gets to frame what counts as health priorities, in line with donor expectations, aligned with economic growth and productivity, and minimizing engagement with the political and socio-economic arrangements under which illness is produced and distributed (Farmer 2004; Vaughan 1991; Young 1982).
In a world where poor women in low-resource settings receive the greatest attention to their reproductive health needs through short-term, donor-funded projects, it complicates the relationship of exchange because the poor can never repay the beneficence of donors. Instead, they are obligated to return the attention through a set of participatory postures. In this regard, national policy makers and global health leaders must acknowledge their complicity in sustaining and even exacerbating gender inequality and poor health outcomes for women.
The trend of short-term, ‘fly-in fly-out’ projects, and their overemphasis on techno-medical innovations to address even the most deep-rooted structural problems, can be confronted by mobilizing ‘slow’, sustained, and open-ended research and remaining ‘resolutely local’ in framing any need for intervention (Adams 2016). For instance, I based my ongoing research in a location where I had worked as a public health researcher previously and drew upon my familiarity with the epidemiological and socio-cultural landscape of the field site. And while I was a class and caste outsider, the lack of a camera and notebook perhaps made my queries seem less threatening. Although participants knew I was using an audio recorder, we discussed general health matters devoid of names and identifiable details. Further, since family planning is defined primarily as a reprieve from excessive fertility or unmet contraceptive needs, suffering that emerges from losing multiple babies or failed contraceptive procedures is considered normal, that is, it lacks ‘exceptionality’ for family planners gazing from above (see Benton 2015, xi). Therefore, the family-planning mandate for poor woman to space and limit pregnancies is a post-hoc fallacy of birth control as a solution for poverty. It does not account for the causes and conditions that make pregnancy unviable, childbirth risky, and infant survival uncertain.
Conclusion
The incorporation of women from socio-economically marginalized communities as ‘empowered’ users and propagators of the family-planning agenda illustrates the lopsided power relations generated and perpetuated by contemporary global health. Family-planning projects capture and circulate certain kinds of experiences, while minimizing or erasing the plurality of health needs. Grounding research in local knowledge and diverse experiences is not merely an exercise in revealing different knowledge: it also exposes dangerous asymmetries in knowledge making (Neely 2019). Perhaps more significantly, it also creates an authoritative boundary around what counts as ‘Women’s health’. While this ‘ontological turn’ can destabilize monolithic narratives, one must remain cognizant of homogenizing interpretations (Holbraad et al., 2014). Participants must be given room to escape arguments and categories within which they are captured (Mol, 2014). Social medicine serves to populate global health with these necessary ontological differentiations that are granular, contradictory, and unyielding to quantification.
[1] The film can be accessed at: https://www.facebook.com/saathihaathbadhanalko/videos/855638944968420/ or https://drive.google.com/file/d/1Fjk719ME3RnI2nLvoIJqKIpfIL8UBcsF/view. In Uttar Pradesh, Rajiv Gandhi Mahila Vikas Pariyojana (RGMVP) is a programme focusing on microcredit activities and women’s empowerment through formation of Self-Help Groups (SHG). With support from the Gates Foundation through a larger project, SHG members were trained to impart knowledge and skills on reproductive and child health in the community.
[2] ASHAs are female community health workers engaged by the Ministry of Health and Family Welfare as ‘honourary’ workers. Under India’s National Rural Health Mission (NRHM), ASHAs serve as a local interface between the community and the public health system. They receive performance-based remuneration.
[3] In rural India, a block is a community development administrative unit at the sub-district level.
[4] As translated in the film’s subtitles.
[5] Pseudonym
[6] Pseudonym
[7] This hints at an intrauterine perforation, which is typically uncommon with IUD insertions. While there is no way of confirming if this was the case here, her experience reveals that often the procedure is performed by unskilled personnel in a hasty manner, with little regard to the woman’s safety and comfort.
[8] There are near pervasive reservations about vasectomies, not just in the community but also among policy makers (SAMA et al. 2014). Misconceptions about side effects are a common reason (Shattuck et al. 2016). It can also be linked to the infamous forced vasectomies conducted during India’s National Emergency (1975-77).
[9] During pregnancy, Hb levels <7.0 g/dl is graded as severe anaemia. This is associated with an increased risk of maternal and infant mortality, pre-term births, and low birthweight (Ramachandran and Kalaivani, 2018; Stephen et al., 2018).
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