National Family Health Survey Report (2019 – 2021) Dipping Fertility Rate of Meetei/Meitei women

Prof L Ranjit Singh
The National Family Planning Programme was launched in 1952 by the erstwhile Nehru administration during the first 5-year plan, the first by any country in the world at that time, with the main objective of lowering fertility rates and slowing down the population growth with the complementary benefits of advancing economic growth.
However, over the years the programme has undergone a shift in its priorities and in its present iteration is now focused on reproductive health with the principal aims of reducing maternal, infant and child morbidity and mortality; and improving adolescent health among a host of others.
Now, getting into the central theme of this article, according to the 5th National Health Survey (2019 – 2021) conducted by the Ministry of Health and Family Welfare, Government of India, the fertility rate of Hindu women in the reproductive age group of 15–49 years was 3.9 compared to 5.6 for Muslims, 5.8 for Christians and 4.1 for others.
With particular reference to Manipur, Child Birth Rate or Total Fertility Rate (TFR) stands at 2.2. Among the different communities in Manipur, the TFR for Meeteis/Meiteis has declined to 1.77 while the TFR for other indigenous communities of the State remains high. This is not surprising considering the fact that the fertility rate of Meetei/Meitei woman has been showing a dipping trend over the past few decades. As per the same report, the TFR for Hindus in Manipur is 1.77 while it is 2.34 for Muslims, 2.94 for Christians and 1.9 for other religions.
With a TFR of 3.3, Ukhrul has the highest TFR among all the districts of the State, closely followed by Senapati (3.1), Churachand-pur (3) and Tamenglong (2.9). This is in stark contrast to the modest TFR recorded in the valley districts : 1.7 for Imphal West, 2 for Imphal East and 2.0 for both Bishnupur and Thoubal. The TFR for Imphal West and Imphal East districts where the majority of the Meetei/Meitei community are concentrated, is much lower than all the other districts. The disparity between the two districts viz. Imphal West and Imphal East districts may be explained by the bigger Muslim population in Imphal East district compared to Imphal West district. More importantly, the required TFR for a population to stabilise stands at 2.1 children per couple and both these districts have a TFR below the replacement level. Therefore, not surprisingly, Meetei/Meitei who constituted 58.86% of the total population of Manipur in 1951, has dropped to only 44.21% in 2021.
Looking at the scenario in other Indian States, in Andhra Pradesh, the State Government has recently scraped the three decades old 2-Child policy which was mandatory for anyone seeking election to the Gram Panchayats as the policy was deemed counter productive. In the global context, China the erstwhile most populous country of the world, ended their one-child policy in 2016.
Presented herein is an analysis of changing trend in the demographic profile of the State
1) In our State, certain ethnic groups have a tendency for higher number of births per couple than others. This was clearly shown by National Family Health Survey (2019 – 2021) which depicted varying TFR in different communities and districts of Manipur. Eventually this can have a serious impact on the demographic profile of the State as we all witness today.
2) Demographers point to a number of factors driving this phenomenon : economic insecurity, shifting gender norms and a lessening stigma around the choice to remain even childfree.
3) Today, it may not be wrong to say that Caesarean delivery has become almost a household name as someone in every family has undergone this operation.  But “Caesarean Section on demand and request is a dangerous and unnecessary luxury” in the words of Dr Arul Kumaran, the President of Royal College of Obstetrics and Gynaecology. The current generation women who began as uniform wearing, van riding and tiffin eating children who hardly faced any hardship in their lifetime really find it difficult to bear labour pain. Hence, many of them prefer Caesarean delivery rather than having painful labour say for 10 to 12 hours and even longer sometimes. Hence, Caesarean delivery on Demand and Request has increased since beginning of 21st century worldwide and has gone up to 10 to 15 per cent of all deliveries globally and this is likely to increase further in future if the current trend continues. We, as health care provider can make labour pain-free, but that would require massive upgradation of physical infrastructure and equipment besides augmenting health care professionals. To achieve this, political will and commitment may also be an integral part.
4) The economic cost of Caesarean operation is also enormous when we  take into consideration the huge number of such operations being performed in the entire State.
5) The decline in fertility rate of Meetei/Meitei women is also partly due to lesser number of young women getting married. Women’s fertility is primarily dependent on age and that fertility peak occurs in the early 20s and decline in the third and fourth decade of life (falling sharply after age 35). Today many young couple intentionally defer marriage and even childbirth after marriage.
Late marriage has become a universal pheno- menon while completing education and looking for employment opportunity so as to enjoy financial stability at the time of marriage. Elderly women are more likely to suffer from infertility as the ability to precoma pregnant declines with advancing age. These elderly women need Caesarean delivery most of the cases say eg above 30 years because of advanced age and other age-related medical problems. These couples also almost always opt for lesser number of children.
6) Many couples who suffer from infertility are also untreated and under treated because of escalating cost of treatment. This may also add up to the lower TFR.
7) In contemporary society, many couples are also hesitant to have multiple children due to dwindling wealth and resources both in urban and rural areas alike. As per estimate, less than 10% of urban population have jobs with stable income. Even in rural areas people are facing gradual shrinking of farmland which is inherent with ever increasing population. It’s not only the increasing cost of raising multiple children but parents also find it difficult to enrol their children to good schools because of limited intake capacity. Because of all these facts, many couples wish to have lesser number of children as is evident in the State.
8) In maternity practice, there are instances when many pregnant women who otherwise would confine normally opt for Caesarean delivery much against scientific guidelines and physician’s clinical skill. Like any other major operations, Caesarean delivery has its own complications not only in the concurrent pregnancy but in future pregnancies as well. In addition to this, anaesthesia and related complications are equally distressing and dangerous.
9) We as maternity care providers prefer to perform Caesarean operation only 2 or 3 times on a single woman. Even though Caesarean operation is performed 4 to 5 times or even more in a single woman in Middle East countries, it is certain that with increased number of Caesarean operations being performed in a single woman, complications become doubled or trebled, putting life of the woman in danger in subsequent pregnancy and delivery.
10)  Since 1985, the international healthcare community has considered the ideal rate for Caesarean sections to be between 10-15%. Worldwide Caesarean section rates have been steadily increasing without significant additional benefit to the health of women and babies. As per available data, the prevalence of Caesarean sections in India increased from 17.2% in 2016 to 21.5% in 2021. In fact, Caesarean section rates are higher in Private hospitals than in Public funded hospitals and is a global trend.
11) The vast increase in availability of both public funded and private hospitals may also contribute directly or indirectly to higher rate of Caesarean births.
Not only physicians, patient and party are also equally contributory to the increased rate of Caesarean births in modern day maternity care services.
Demographic analysis is important to understand the characteristics of a population and how it may change in future. This is important for making crucial decisions in a democratic country like India. As we all know, what matters in democracy is number and power is always vested on the majority. It is worthwhile to remember that late Shri Atal Vihari Vajpayee even though remained as Prime Ministerial candidate for several years before he eventually became Prime Minister of Bharat only because of the game of arithmetic.
In fact, dwindling economy, shrinking farmland in rural areas, lack of resources and unemployment; all contribute directly or indirectly to the current disturbing demographic trend in the State. Social scientists, policy makers and everyone in the State have a collective role to play for change or slow down this demographic shift as we all are important stakeholders. Napolean Bonaparte once said “The world suffers a lot. Not because of the violence of bad people. But the silence of good people.”
The writer is President Manipur State Medical Council