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JUNE 1987
Two Decades of Sterilization, Modernisation and Population Growth in a Rural Context*
Stanely A Freed and Ruth S. Freed
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Despite a popular reaction against the alleged coercive aspects of the sterilization programme during the Emergency from June 25, 1975 to March 21, 1977, the Government of India did succeed, much faster than might otherwise have happened, in establishing sterilization as a routine and acceptable option for couples wishing to terminate childbearing. In India, as in the United States, sterilization is now the principal birth control technique for couples who want to end childbearing rather than just to control the timing of pregnancies. This development has led to a certain journalistic optimism during the last two or three years at least in New York, concerning the possibility of controlling India's population growth. But caution has also been expressed and the reason could be found in a photograph accompanying one of the report: a sterilized mother, presumbly more or less typical, was shown sitting on a cot with four of her five living children, rather than the two, children that the government would prefer.
If a significant number of people who undergo sterilization do so only after having had five children, it seems clear that survivorship, that is, the average number of surviving children of mothers at the end of the childbearing span, will merit more attention than it has received until now. The fertility rate and the number of persons who "accept family planning", more often invoked than survivorship in discussions of population growth, are important, but to minimise the significance of the size of the completed families can lead to surprises when the decennia I census results are published. Thus the most noteworthy feature of the 1981 census of India is perhaps the slight increase in the rate of population growth during the 1970s in comparison to growth during the 1960s. despite an energetic governmental campaign to
introduce birth control, the growing use of contraception, most especially sterilization. a declining birth rate, and the modernisation of education, communications, and the economy. Although the growth rate only rose from 2.20 to 2.23 percent, it nonetheless did not decrease as had been expected. The apparent paradox of a stable or slightly increasing rate of population growth in the face of increasing modernisation, rising sterilization, and falling fertility has been something of a surprise. The usual explanation, that mortality has declined as fast or faster than fertility, while mathematically sound. offers little insight into a complex social phenomenon.
This essay concerns the relationships among sterilization, modernisation and survivorship in the north Indian village of Shanti Nagar (a pseudonym) based on the studies made in 1958-59, 1977-78, and1983. The 25 year period of research is especially noteworthy because it includes the end of the 1950s,when very few people were sterilized, and the 1970sjust after the Emergency when sterilization was well established. Studies carried out in a single village may fairly represent a limited region, but one must be very careful about extending the conclusions to the greater part of India or even to the north-western quadrant of the country where Shanti Nagar is located. However village studies have the important advantage of intensity and are a valuable complement to broad surveys.
Studies of change in the rate of population growth in India often concentrate on today on two principal determinants: modernisation and contraception. Modernisation is generally defined as a combination of some or all of the following processes: industrialization, urbanization, enhanced communications, spread of education, enhanced communications, spread of education,
* Condensed from the original in 'Economic & Politicalweekly', 20:49,2171-75, Dec. 1985
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improved health and nutrition, female employment outside the home, erosion of traditional customs, and an increase in specific attitudinal and psychological processes such as 'rational' as opposed to 'traditional' thinking. Sometimes severalattitudes or values are conceptually combined and designated as "modernity values" or a "modernitysyndrome".
Fertility is generally assumed, with qualifications to have an inverse linear relationship with most aspects' of modernisation. In India, effective contraception,the second important determinant of population growth, is chiefly sterilization. The widespread recourse to sterilization suggests that India's persistently high rate of population growth might be better understood if attention were to some extent shiftedfrom birth and death rates to survivorship because survivorship, sterilization, and the kind of fertility limitation means that is called 'parity specific' are all related. Parity-specific fertility limitation means that couples begin to limit their families only after having had the number of children that they want. Sterilization and survivorship are closely related because a couple's decision to undergo sterilization is based principally on the number of their survivingchildren especially sons. Parity-specific fertilitylimitation is influenced by the sex of children, for sons are preferred to daughters. There are many reasons for this preference, most of them widely recognised. Few couples are satisfied with just one son, for the rate of infant mortality is still high enough to make parents with only one son very anxious.
One might think that, for sterilized couples, family size depends on sterilization, for sterilization puts an end to childbearing. In fact, the relationship isthe reverse; sterilization depends on the number ofcouple's living children, especially sons, because couples practice gender-influenced parity-specific fertility limitation. They do not have a sterilization operation until they have all the children that they think are necessary. The fertility rate has rather a peripheral role in such a perspective on family size and the rate of population growth. Husbands and wives do notbase their sterilization decision on the number of live births, the basis of the fertility rate, but rather on the number and sex of the surviving children.
Population Growth
Shanti Nagar, located in the north of the Union Territory of Delhi, is in general demographically and economically similar to many of the villages in the adjacent parts of Haryana and Uttar Pradesh. From the 1950s to the 1970s, Shanti Nagar experienced an economic, educational, and communications revolution. The village acquired electricity, brick houses replaced mud huts, and streets were paved.
Farm machinery have largely displaced bullock power and hand labour. Frequent bus service has increased theease of commuting to urban areas where many of the men have urban jobs. Radios are now common, and there are some television sets, and newspapers are delivered daily. The educational level has risen dramatically for both men and women. Modern health facilities are more easily accessible. A nurse-midwife regularly visits the village to discuss, amongother matters, family planning and sterilization. Many villagers have been sterilized. The village has become much more modern, more prosperous, and better informed about governmental programmes including the Family Planning Programme. Modernisation has had relatively little effect on the family,which generally maintains its traditional form and functions. There were 110 families in the 1950s and176 in the 1970s with an average of more than seven members in both decades.
During the intercensal period of 19.5 years, the population increased by 525 persons (65.7%), tantamount to an average annual rate of population growth of 2.59 percent, rather higher than the all India figure of about 2.21 percent for two decades from 1961 to 1981. When we include in the calculation individuals currently living away from Shanti Nagar who are members of the vil1age families (for example, sons living away from home for the purposes of employment) while excluding married daughters visiting their parents because they are no longer permanent residents of the vi1lage, the average annual rate of population increase was 2.77 percent. The crude birth rate during the intercensal period was estimated at 38.5. It should be borne in mind that both the rate of population growth and the estimated crude birthrates are averages over a period of years and could be expected to have changed, perhaps significantly, during the period. The proportion of males in the population increased from 51 % in the 1950s to 52.5 % in the 1970s. The population increase has been much less for young children than for old persons. For example, the percent increase from the 1950s to the 1970s for children two years of age and lesshas been only 23 percent as compared to 66 percent for the whole vil1age. Although Indian censuses may tend to under-numerate children four years of age and younger, we think that the principal reasonthat the increase in the number of young children is relatively modest is due to intense birth control programme that the Government of India pursued during the Emergency. We began to take our 1977 censusonly about 6.5 months after the end of this 21 month period. Therefore, the relatively small number of infant’s upto about 2.5 to 3 years of age partly reflects the effectiveness of the sterilization programme during the Emergency.
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Sterilization
We knew of only one sterilized person in Shanti Nagar before 1968, but from then on at least one person was sterilized every year. When we took our census in 1977-78, there were 68 sterilized persons, both men and women, equivalent to 26 % of the women of childbearing age (15-45 years). By late 1983, there were 93 individuals. Sterilization has run an uneven course. From 1968-74, 3, 4 individuals on the average were sterilized annually. Then came the 21 months of the Emergency, and the average number of persons who underwent sterilization increased to about 20 per year. After the Emergency, the figure returned to almost to the pre-Emergency norm; from 1977 to late 1983, 4.7 persons were sterilized per year. The big jump in sterilizations during the Emergency was due to the strong campaign mounted by the government, which was especially effective with men holding government jobs. Most of the men sterilized during the Emergency were in governmental service.
Before 1977, men had 53 percent of the sterilization operations. After the Emergency, this figure dropped to 15 %. This noteworthy change in the proportion of men to women who undergo sterilization is probably related principally to the introduction of the surgical technique of laparoscopy, which has become popular and has made female sterilization easier, but there are probably other reasons as well. An important post-Emergency development is the lower age at which people are sterilized. Before the end of the Emergency, the mean age of a woman either at her own sterilization or that of her husband was 33.2 years; after the Emergency, it was 29.1 years. Correlated with the decline in the average age at sterilization is a reduction in the average number of children per sterilized couple. Couples sterilized before or during Emergency had families of five living children; people sterilized after the Emergency had an average of 4.25 children. The average sterilized couple had about three sons and daughters, a sexual disparity that appears to be increasing. Until the end of Emergency, sterilized couples had an average of 1.4 sons to each daughter, but afterwards, they averaged twice as many sons as daughters. It isimportant to note that sterilization by itself cannot influence the sex of children. However if either by random chance or the mistreatment of female children, a couple has more sons than daughters, sterilization makes the makes the situation more permanent, provided that there are no untimely deaths of sons.
The usual explanation for the greater number of males than females in north India is the preference of males and
the suspected mistreatment of female children. It is also possible that female children are under-numerated in censuses. One explanation does not preclude the other and both may be involved. The motive for most respondents for not being sterilized was too few sons. On the other hand the expense of raising children was overwhelmingly the main motive for undergoing sterilization. Couples alsofrequently cited the governmental sterilizationcampaign, principally its coercive aspects as reason for the operation, and some people said that thesterilization was needed in their cases because of specific female health problems.
That parent seems to be especially concerned with the expenses of childbearing calls attention to the value of child labour in the rural areas where children work on the family farm from an early age. Although the value of their labour remains considerable, the modernization of agriculture has generally reduced the amount of child labour needed. Moreover there has been an increase in employment opportunities that require educational qualifications. Under these conditions, the maximum economic return from a child involves an investment that most parents cannot afford for a large family which combined with the declining value of child labour puts pressure on parents to terminate childbearing after fewer children than would have been the case a decade or two earlier.
However, the cost of childbearing and the value of child labour of children are not the only factors that parents need to take into account when considering sterilization. There is also the question of the economic security that children provide and this one consideration may outweigh all the low-fertility motives in the thinking of many parents.
Respondents regarded all contraceptive measures (condom, Copper T, loop or foam) except sterilization as unreliable and/or dangerous. The majority of sterilization took place within 10 months of the couple's last childbirth that is, just before the end of what one respondent called the "safe period", which is approximately II-month post-partum amenorrhoeic period that accompanies breastfeeding when there is no supplementary feeding of the infant.
Living children, Sterilization and Modernisation
The relationship of the number of living children, sterilization and aspects of modernisation are investigated by multiple regression analysis, a commonly used
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statistical technique to establish a linear relationship between a dependent variable and several independent variables. The dependent variables are the number of living children and sterilization. The independent variables form two groups: the modernisation variables, namely urbanisation (defined as an individual's having lived and/or worked in a city some time during his/her life) and education as they affect women, family heads and husbands; and the biological and traditional variables namely a woman's age, caste rank, family land-ownership, and whensterilization is the dependent variable, number of living children. The most prominent conclusion tobe drawn from the analysis is that women's age and sterilization are the only two variables strongly related to the number of surviving children. That a woman's age and the number of her living children are positively related is basically a truism; therefore, the strong probabilities of a significant relationship in both the 1950s and the 1970s are no surprise. Sterilization and the number of surviving children are also positively related; when all other variables are held constant, a sterilized couple has 1.28 more children than an un sterilized couple. That a contraceptive measure is positively related to the number of living childrenwould appear to be a paradox were it not for the fact that people decide to be sterilized after having had a certain number of children, especially sons. Therefore, a sterilized woman has more children than her unsterilized counterpart when variables such as age are controlled.
None of the modernisation variables has a significant relationship with the number of living children. The probabilities in the case of both women's urbanisation and the urbanisation of family heads are low enough to attract attention, but the effects of the two variables are not consistent; the relationship is positive for women's urbanisation and negative for the urbanisation of family heads. The inconsistent effect of the urbanisation illustrates a noteworthyfeature, aside from the insignificant probabilities ofthe modernisation variables: they do not always show consistent effects where one would expect to find them.
When sterilization is taken as the dependent variable, we find a strong positive association between it and the number of a mother's living children. There is also a significant positive relationship between sterilization and the urbanisation of husbands, a connection that is probably valid because men classified as urbanised almost always held city employment, frequently in government, and were therefore especially vulnerable to the sterilization campaign. However, the relationship of urbanisation and sterilization does not extend to family heads, another example of the apparently inconsistent effects of the modernisation variables.
There is also the possibility thatthe education of family heads may be positively associated with sterilization although the connection is weak. The apparent lack of any significant relationship of either the woman's education or that of her husband with sterilization would weaken the general inference of a general association of education and sterilization.