Will India Accept Birth Control?
The son of medical missionaries, who accompanied his parents on their rounds of the Indian villages, DR. CARL E. TAYLOR has been thinking deeply about India and medicine during his graduate work at the Harvard School of Public Health. He went out to India as a medical missionary in 1947 and will return there next winter to teach Public Health at the Christian Medical College, Ludhiana. The following article, which won first prize in the Essay Contest sponsored by the Planned Parenthood League of Massachusetts, evaluates the cultural factors that determine the reaction of Indians to birth control.
by CARL E. TAYLOR, M.D.
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A BASIC misunderstanding leads most Westerners to criticize Asiatics for being so numerous. Few of us realize that India’s population has been increasing less rapidly than that of most other large countries except France.
In Western countries, as standards of living rose, there was first a sharp drop in death rate, followed by a much slower decline in birth rate. During this interval of imbalance between the two rates, population increased from two to seven fold. These extra people provided the manpower for the industrial revolution. The large unexploited areas available in Europe and her colonies served as shock absorbers in taking up both the population pressure and the output of the new industries.
By contrast, India has been in a progressively deteriorating situation. Before the coming of the European, civilization had already flowered and the population had grown to the limits imposed by the social and economic resources of the time. The checks of famine, war, and disease restrained further growth. From 1875 to 1900 repeated famines caused an average of 10 million deaths per decade. India’s great plague epidemic started in 1890 and during the next ten years there were between 19 and 28 million deaths. The influenza epidemic of 1918-1919 is said to have caused at least 12 or 13 million deaths. To these should be added the recurrent epidemics of cholera and smallpox and the estimated one million deaths each year from malaria.
With the establishment of the Pax Britannica some of the checks were eliminated and the population grew. Although the rate of increase was slower than in the West, the starting population was much larger, making the average increase in a normal decade in India equal to the total population of many European countries. As a result the population density continues to be greater than that of any other large country in the world.
The high birth rate is in itself an important cause of death. Starting at puberty, most Indian women have babies as fast as is biologically possible. Indian women average six or seven children in addition to uncounted miscarriages and abortions. Only three or four babies survive to adulthood; it has been estimated that one fifth to one fourth die before they are one year of age, and 45 per cent before they are five.
The maternal mortality is so high that, although the over-all death rate of women is 10 per cent lower than that of men, during the childbearing period it is 25 per cent higher than the male rate. One out of every ten girl wives is doomed to die in childbirth.
The frequent births do not take their toll in mortality alone. The suffering and disability caused by a more or less continuous state of pregnancy, under chronic conditions of neglect and poor diet, is so great that it cannot be quantitated. With monotonous regularity the following story was hoard from mothers coming to our hospital in north India with obstetrical emergencies. The first baby had been born normally and so had the second a year later. The mother continued to nurse both babies and when she became pregnant again she began to feel tired. Complications started to appear and subsequent deliveries were increasingly hazardous. Perhaps she would enter the hospital with an anemia so severe that hemoglobin readings of 10 to 15 per cent were obtained. Or perhaps, because she nursed each child until he was two, her system had been so depleted of calcium that severe osteomalcia or softening of the bones had developed. I have seen a number of women whose pelves and legs were completely telescoped, and whose skeletal systems were contorted into caricatures of the human form. Yet these women would present themselves at the hospital with full-term pregnancies that required Caesarean section. Other severe complications of pregnancy such as eclamptic convulsions were common.
Added to these hazards are the dangers to the children. With so many children around a home there is less possibility of providing food and the other essentials of life for each child. Large numbers die of common infections, and those that survive are burdened with chronic diseases which make efficient and happy living difficult. No other single health measure would so significantly improve maternal and child health in India, as adequate family planning.
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SEVERAL socioeconomic measures aid in providing for the surplus population. Improved methods of food production, opening up new areas for cultivation within the country, emigration to other countries, and stimulation of urbanization and industrialization have been largely responsible for India’s maintaining the present precarious balance between population and production. It is becoming increasingly difficult, however, to provide in these ways for the more than 4 million people being added to the population each year.
Postponement of marriage would lower fertility. In 1930 the Sarda Act set the minimum age for marriage of girls at 14, but there was much political opposition because of British sponsorship and in the villages it was often defied as a patriotic gesture. Even if enforced, this law would not lower the birth rate because few girls go to live with their husbands before they reach puberty. The important fact is that only 13 per cent of the girls in the very fertile 15 to 20 age group remain unmarried.
Both Malthus and Gandhi fell that the problem could be solved by moral injunctions to practice self-control. Gandhi recommended in 1925 that parents should be forced to separate if they did not practice abstinence alter having had three children.
Sterilization is a reliable method of restricting births, but its application is necessarily limited. There are few hospitals in India; there is a certain hazard and discomfort involved, especially for women; and there is a finality about the procedure which eliminates the concept of family planning or child spacing. In spite of this, our experience in the United Provinces was that a fairly large number of women and an occasional man agreed to surgical sterilization.
Because of the strong hold of the past on Indian customs and mores one might think that if would be particularly hard to change reproductive habits.
The village people tend to change their way of life as social groups, and then only when they become aware of an effective answer to a need which is felt generally among them.
In the acceptance of social change women are often more conservative than men. In this instance women are the principal sufferers. That they are already aware of their need soon becomes evident to anyone who has worked in a zenana clinic. The articulation of this need will, however, remain latent until they know about the possibilities of child spacing. My own experience and my conversations with other physicians convince me that large numbers of women will eagerly accept any advice or help offered them. On being asked why they did not try spacing their children, women would answer that it was their fate to be pregnant as much as possible. When it was explained that it was not necessary they immediately showed interest and asked for details.
The two persons in the family most likely to object were the husband and the mother-in-law. If one or more sons were living and healthy even they could often be persuaded to permit the trial of simple contraceptive measures. With the husband financial arguments were most powerful. The production of children can scarcely be considered economically profitable. Although boys are an asset, girls are a financial liability because they have to be provided with a dowry. The motherin-law usually runs the home and was interested in the fact that a healthy daughter-in-law with intervals between pregnancies could do more housework than an invalid.
The social factor which is perhaps most important in maintaining the high birth rate is the universality of marriage. Because so many women from 15 to 40 die, there is a shortage of marriageable girls. Hindu widowers are expected to remarry but widows are not. As a result girls are often married at or near puberty, but many men have to wait until they are 20 or 30 years old to be supplied with a wife. Although this difference in age has no apparent biological effect on the couples fertility, it does have a profound sociological effect. A mature man has some difficulty in accepting a girl half his age as his equal and partner. The subjection of women lends to be maintained in spite of all efforts to improve their status.
The spread of birth-control information is also limited by the fear, especially on the part of the men, that availability of contraceptives will cause a deterioration of morals. In the social group that is most aware of this danger the life of the women is hedged about with so many other safeguards that contraceptives would probably not increase promiscuity.
A final cultural block to birth control is a psychological one. There is a strong feeling of futility on the part of Indians, particularly low-caste villagers. They have the fatalistic attitude that their condition could not possibly get much worse and they say that a few more children will not greatly affect their status.
The religious deterrents
There is no definite prohibition of birth control in the Hindu scriptures or traditional doctrine. On the contrary, the Kama Sutra (Aphorisms of Love), a semi-scriptural book written by Vatsyayana about the third century B.C., is said to contain descriptions of crude birth-control methods.
Some of the post-Vedic Hindu scriptures, such as the Laws of Manu, have been interpreted, however, as supporting the desirability of girls being married before puberty. One Hindu priest explained this to a friend of mine as being due to the belief that each ovum represents an individual life. According to this interpretation of the doctrine of the sacredness of life, the permitting of any ovum to escape fertilization and maturation into a person is equivalent to killing that individual, and the bleeding of menstruation represents his lifeblood. Therefore it is the father’s duty to arrange for his daughter’s marriage before puberty and the husband’s duty to see to it that his wife menstruates as seldom as possible. Although this belief is probably not widely accepted, it illustrates the sort of religious interpretation that might be circulated if anticontraceptive prejudices were aroused.
In the Hindu religion a powerful deterrent to family limitation is the need for a son to participate in the funeral rites. If some other relative has to be relied on there is danger that the soul may not make a successful transmigration. Some of these ceremonial functions are the lighting of the funeral pyre, seeing that the skull cracks to permit the soul to escape, and scattering the ashes in the Ganges or some other sacred river. Obviously a good Hindu will want to have at least two sons to be sure that one will survive him. The joint family system has a significant but diminishing influence in keeping up the birth rate. The pooling of the resources of related families spreads the financial responsibility for the children’s support.
The psychological factor of fatalism is of great importance among Moslems. The Koran teaches that each life is completely foreordained from the time of conception, and this shifts the responsibility for what happens to the children from the parents to God. There is no teaching in the Koran against contraception, but there is certain merit attached to having children since this increases the number of the followers of the Prophet.
Moslem traditions attach considerable importance to sex. The women are confined to their zenanas even more strictly than their Hindu sisters, and their whole life is centered in their husbands. Not many Moslems are now able to afford polygamy. because of the shortage of females, most girls are married; thus polygamy could scarcely be an important factor in keeping up the birth rate.
It has been suggested that the Moslems’ birth rate is the highest in India because their meateating habits increase libido. There is no evidence for this although there may be some relationship between infertility and nutritional deficiencies. There is similarly no scientific proof for De Castro’s theory that chronic hunger increases fertility.
Before any mass birth-control program in the Orient can be effective, better contraceptive techniques will have to be developed. Methods nowavailable are too expensive and complicated for the average villager. The best chances for success probably lie with measures used by women. Research must be directed towards finding cheap, simple, nontoxic, yet effective techniques which can be used by women with minimum home conveniences.
There is great danger that a birth-control program might appear to be of Western origin, thus arousing antiforeign prejudices. Vocal religious objection must be carefully guarded against. If religious edicts and interpretations banning contraceptive’s were once made public it would be infinitely harder to get them revised than to handle the early stages of the program in such a way as not to arouse the opposition of the priests and pundits. It would be particularly desirable to develop a simple contraceptive technique or modification of an existing technique by research in India. If the method were given a typically Indian name the prejudice against foreign interference would probably be avoided. To limit the chance of improper use, contraceptives should at first be distributed from health centers, hospitals, and other medical institutions.
At an opportune time legislation should be encouraged to raise the minimum age for marriage of girls to 18 or 20 years. With independence there is a greater likelihood of responsible participation in law enforcement on the local level than there was with the Sarda Act of 1930. Sociologic measures which tend to decrease the birth rate by raising the standards of living and education should be applied as rapidly as resources become available.
The problem of overpopulation can be attacked immediately and directly with a properly administered birth-control program. Indian cultural patterns present no insuperable barriers to such a program. In fact, I have found that many village people already realize that as the number of their children increases, the physical and economic health of the family decreases. Popular acceptance will probably follow rapidly the development of effective and appropriate birth-control methods. With this approach, India’s demographic future may be faced with optimism.