The Economic Survey has pointed out that there will be a slowdown in the population growth in the coming decades in India. Apart from a drop in Total Fertility Rate (TFR) to 2.2, which is expected to fall further below the ideal replacement level fertility in a few years, the plummeting numbers also point to lack of awareness among couples about issues of infertility, say experts.
There is an inverse correlation between TFR and FLR (Female Literacy Rate) – TFR comes down when FLR goes up. Tamil Nadu achieved what demographers call as the optimum TFR of 2.1 (the rate at which one generation is replaced by the next), more than two decades ago, (it is now 1.7 and comparable to western European countries). In fact, all southern states have much lower fertility rates compared to their northern counterparts, whereas in states like Bihar and Uttar Pradesh, the rate is 3 and above.
Experts say that in the south, the changing lifestyle and the decision to postpone marriage and pregnancies for higher education and work will reduce the rates further in the coming years. Dr Shah Dupesh, consultant andrologist, Dr Shah’s Clinic in Chennai, observes that what happened in the western in the 1970s to 1980 is happening in India now.
And in India, the infertility issue is uniformly seen among different income groups. “Diseases related to menstrual hygiene, rampant among poor sections, block the fallopian tubes. The same sections also have a high rate of tuberculosis that hinders fertility in women. In the upper and upper middle income groups, women are now exploring relationships. Consumption of alcohol, smoking are common and so are sexual relationships with multiple partners. The latter can end up in pelvic inflammatory disease. Syphilis and gonorrhoea also affect women and can impact their child bearing capacity,” Dr Shah.
An increasing rate of sexual problems and health issues among men are also contributing to the fall in fertility rate, say experts. “Men are in the dark about sex education for a large part of their life. They have to be taught some basics through interventions when they are legally eligible to marry. In the urban set up, sexual relationship with multiple partners is high among men, which in turn makes them vulnerable to a host of sexually transmitted diseases,” he adds.
Alternatives to ‘timely’ pregnancy
Mushrooming fertility centres and the option for egg freezing for women have possibly made postponing pregnancies an easier option today. Dr Priya Selvaraj, infertologist, says, a good 20 years ago, when doctors were consulted by couples planning pregnancy, the ideal advice for the woman would have been to conceive before 30. “However, today we tell them to have at least one child before you hit 35,” she says.
With egg freezing and IVF as choices too, couples have to be educated about the low levels of success. “These options do not defy age and they have to understand that the rates are low less than 30 per cent,” she added.
A few decades ago, the age of menstruation was till 55 years and now it has come down to 48-50 years. “In this environment, one can’t say for sure that you will be fertile till 35 years or 40 years,” she observed.
Endometriosis a disease that is related to delayed pregnancy is also on the higher side, warn experts. The disease further hampers the chances of bearing a child.
The fertile problem
States like Rajasthan, Uttar Pradesh, Bihar, Madhya Pradesh, Chhattisgarh, Bihar, Gujarat and Jharkhand however are responsible for upping the TFR. The National Family Health Survey and the District Level Health Surveys show that most poor families, if assured of two living children do not want more. The unmet demand for contraception is also the highest in these states.
Higher fertility levels, early marriages, repeated pregnancies and mothers giving birth even in their late 40s are only exacerbating the problem. Contraception is not used by 66 or almost 2/3 per cent of those who need it the most.
Dr Shanthi Gunasingh, former director, Government Hospital for Women and Children, Egmore, says that an effective implementation of the ongoing programme Rashtriya Kishor Swasthya Karyakram (RKSK), which seeks to influence health-seeking behaviour of adolescents, can help address the high fertility rate. She says, “We have been seeing it reap excellent results across the state of Tamil Nadu. When girls reach the age of 18 they are in the marriageable age and in our society, many girls continue to get married at this age. However, we do not advocate having children before they are 20 or 21 years of age. Therefore, the programme we focus on in the state addresses the need for contraception and sexual health.” She adds that in the longer run, such programmes will show desirable results in states with high fertility rates.
“Tamil Nadu has had this awareness spread among even the lowest stratum of society much ahead of other states in the country,” she said.