Examining the access to benefits and quality sterilization services among Muslim women in India

Abstract

Background

This research article examines the efficiency with which the Indian family planning programme provides care to Muslim women who opt to undergo tubectomies from public health facilities in terms of access to benefits/compensation as well as quality of services. The research subsequently intends to suggest suitable policies of affirmative action if required.

Methods

The research uses data from the women’s file from the latest round of the National Family Health Survey (NFHS-5, 2019–21). Adjusted odds ratios are used to examine the likelihood of Muslim women (i) receiving compensations offered for undergoing tubectomies in public health facilities by the government, (ii) receiving comprehensive information prior to their tubectomies and (iii) reporting a good quality of care during their procedures, in comparison with non-Muslim women.

Results

The findings from the research indicate that Muslim women in India have lower odds of receiving state sponsored compensations in comparison with non-Muslim women in India (AOR = 0.67; CI: 0.60—0.76). Consequently, a lesser proportion of Muslim women reported receiving compensations in comparison with non-Muslim women. The difference in the receipt of compensations was 18 percentage points between both cohorts. Critically, despite their challenges in obtaining compensations, the findings from this research also indicate how Muslim women in India have higher odds of receiving comprehensive family planning information prior to their operation in comparison with non-Muslim women (AOR = 1.15; CI: 1.02—1.29).

Discussion

Given the existing dearth of evidence in family planning literature on the issue, this research article calls for greater attention and investments in understanding the reproductive health vulnerabilities of Indian Muslims, especially in the context of increasing social hostilities towards the community in India. In this regard, to promote the equitable delivery of family planning services, the findings from this research highlight the urgent need for institutional reforms that facilitate an easier access to public benefits among Indian Muslims.

Background

Religion is intrinsic to social identity in India. Data from the Pew Research Centre’s nationally representative survey conducted among 29,999 Indians in 2020 estimated that 84% of people feel that their religion is very important to them [1]. While a majority (79.5%) of the Indian population identifies as Hindu, there also an estimated 200 million Indians (14.4%) who identify as Muslim [2]. As a secular democracy, equality and protection from discrimination are not only guaranteed but explicitly reinforced in the constitution of India. Sadly, religious minorities, particularly Indian Muslims, have consistently reported higher levels of deprivation on several development parameters, including reproductive health [3]. As recently published research studies by Indian demographers have shown, Muslim couples are less likely than Hindu couples (used as reference category in the three studies cited) to use modern contraception despite wanting to limit or delay pregnancies [4,5,6]. Unfortunately, even these studies constitute fragmented pieces of knowledge as they report on reproductive health vulnerabilities of Indian Muslims as a by-product of assessing other important family planning outcomes. Subsequently, reflections on the unique reproductive health vulnerabilities faced by Indian Muslims are lacking from these studies, simply because they are not designed to understand the same.

An important reason for a dearth of evidence on the reproductive health vulnerabilities among Indian Muslims may be the widespread belief that they are intrinsically linked to other development parameters such as education, wealth, and area of residence. For example, in 2006, the Sachar Committee—an inquiry commission authorized directly by the erstwhile Prime Minister’s office – was tasked to provide a detailed report on the causes of socio-economic inequity of religious and caste-based minorities in India [3]. In line with research studies from the time, the Sachar Committee emphasized how lower education and income levels were strong predictors for the poorer reproductive health outcomes among Indian Muslims [3]. However, like the Sachar committee report, in majority of scholarships that assess religious inequity in reproductive health outcomes, there is minimal consideration given to understanding supply side factors, i.e., the role of the state in extending high quality family planning services to Indian Muslims. This is also surprising given the increasing social vulnerabilities faced by Indian Muslims. As per the social hostilities index – a measure of conflict between religious communities within a country—India has the highest number of hate crimes committed on religious grounds in the world per annum [7].

Specifically in terms of reproductive health, for over a century, the comparatively higher fertility rates among Indian Muslims have also been politicised and misrepresented as an existential threat to Indian Hindus. For example, in 1909, the Bengalee, a Kolkata based newspaper, published a series of editorials which cited the multiple rounds of Census data to emphasise the issue of a supposedly ‘dwindling’ Hindu population. The editorials likened Indian Muslims to invaders and the fate of Indian Hindus to that of the Māoris of New Zealand or the Native Americans of the United States [8,9,10]. Similarly, nearly ninety years later, A.P Joshi’s ill-informed research titled ‘Religious Demography of India’ presented bogus evidence claiming that Indian Muslims would outnumber Indian Hindus by 2050 [11]. In recent years, such narratives have also adopted the rhetoric of ‘love-jihad’ [12, 13]. Central to the postulation of ‘love-jihad’ has been the construction of the Muslim male as a predatory hyper sexual entity, as well as pandering to the patriarchal trope of viewing women’s bodies as ‘colonizable territories’ that require saving [14]. Consequently, inter-faith marriages are falsified as deliberate attempts by Muslim men to somehow hypnotize non-Muslim women into adopting Islam and gradually ‘outnumber the Hindus.’ Additionally, with a near ten-fold increase in smartphone penetration rate in India over the last decade, scholars who track news items on social and visual media have also found an increased circulation of Islamophobic content on the higher fertility rates among Indian Muslims [15, 16]. Sikander and Sen’s individual research studies provide detailed descriptions on the variety of regressive digital iconology that are used to spread demographic anxieties against Indian Muslims in their own country [17, 18]. It is critical to note that, after accounting for the change in variables such as age, sex, fertility, religious conversion and international migration, research has shown that the religious demography of India will remain largely unchanged over the next 30 years [19].

With a majority of India’s human resources for health predominantly identifying as Hindu (only 4.4% of public health employees in India are Muslim), Indian Muslims may thus be likely to encounter service providers who may hold prejudices [3, 20]. Such prejudices have been previously evinced in Jeffery and Jeffery’s ethnographies from Uttar Pradesh (Northern India). Their research studies provide detailed descriptions of the experiences of disrespectful care routinely faced by Muslim women in public hospitals due their religious identity [21, 22]. This includes inappropriate practices of inter-personal communication such as providing counselling services in semi-private environments or mocking (instead of counselling) Muslim women for their childcare practices and repeated births [21]. Similarly, more recent qualitative evidence from Khanday’s study based in Mumbai and Donahue’s ethnography from Lucknow also detail the experiences of discourteous care faced by Muslim women in public hospitals such as being taunted for not removing burqa or being referred to by colloquially used, Islamophobic slangs [23, 24].

As the last two rounds of the National Family Health Survey (NFHS) reports published by the Ministry of Health and Family Welfare in India show, there was a 9.5 percentage point increase in the use of any form of modern contraception among currently married Muslim women (aged15–19) between the two survey rounds. In fact, more than 1/5th (21.8%) of currently married Muslim women (aged 15-49) reported having undergone tubectomies in the last round of the NFHS. With an increasing number of Indian Muslims reportedly favouring the use of modern contraception (including sterilization), this paper seeks to understand the efficiency with which the Indian family planning programme disburses family planning incentives and good quality services to Muslim women in comparison with non-Muslim women in India. By doing so, this paper seeks to identify suitable policies of affirmative action which may help improve reproductive health outcomes among Indian Muslims.

Methodology

In India, family planning benefits (incentives) are provided to men and women from economically vulnerable sections of society who opt to undergo sterilization as compensation for lost wages, transport, and meals. The amounts of compensation offered vary by state and range between Rs. 1000 (in states such as Telangana, equal to $ 11.98¹) to Rs. 3000 (in districts under the Mission Parivar Vikas, that have the highest fertility rates in the country, equal to $35.93²).

To capture the various data points, the research analyzed the women’s file from the latest round of the National Family Health Survey (last version downloaded 3rd June, 2023). The research used a sub-sample of women (n = 28037) who reported to have undergone tubectomies in public health facilities in the last five years, belonging to the middle, poor and poorest wealth quintiles. Details of sample size by select socio-economic cohorts are provided in Table 1.

Table 1 Distribution of sample based on select socio-economic characteristics (n = 28,037)

In terms of the rationales used for the sampling strategy, only the responses from women who reported to have undergone tubectomies in the last five years were included to avoid recall bias. Additionally, only women surveyed from the middle, lower and lowest wealth quintiles were included in the research design for two reasons. Firstly, it helped remove economic vulnerability as probable cause for the differences in the compensations received, as has often been hypothesized by existing literature (mentioned earlier). Secondly, given this is a pan-India analysis, several states only extend family benefits to women who belong to below poverty line households. Further, the research also did not consider the responses of women who reported receiving either less than Rs. 100 or more than Rs. 3000 as incentives. This is because, apart from the family planning indemnity scheme (compensations for complications or death from sterilization), in no state is an incentive of over Rs. 3000 provided to a woman for undergoing tubectomies. Hence, these were assumed to be data entry errors. Finally, given a critical objective of the research is to understand the relationship between the government and Indian Muslims, respondents (non-Muslim and Muslim) reporting to receive benefits from the private sector were not included in the sample.

Three dependent variables were used for the analysis. The first, “Received compensations for sterilization,” analyzed whether, economically vulnerable woman, undergoing tubectomy in a public facility received compensation for sterilization (coded in binary within the data set, 0 for “No”, 1 for “Yes”). The second, “Method Information Index for Sterilization (MII for Sterilization)” was adapted from the method information index (MII). The MII is easily calculable from the DHS surveys and is increasingly advocated as an ‘actionable metric’ to measure ‘quality of care’ in family planning services across several countries [25]. The method information index indicates whether contraceptive users receive adequate information about all available contraceptive methods, side effects of the methods, and how to deal with the side effects if experienced—at method initiation. The variable used for this analysis also integrated into the MII responses to the question “Before your sterilization operation, were you told by a healthcare provider that you would not be able to have any (more) children because of the operation?” asked in the NFHS 5. To create the variable, all the four items were coded as 0 for ‘no’ and 1 for ‘yes’. Thus, the compiled index values of women varied from the 0 to 4. A further recode of this variable was done to arrive at MII for sterilization, wherein women reporting an index value of 0 to 3 were coded as “No information received or partial information (No)” and only those reporting an index value of 4 were coded as “Full information (Yes)”. Finally, the third “Reported quality” assessed the disparities (if any) in the quality of services experienced by women during their respective procedures. The variable for “Reported quality” was constructed using responses to the question “rate care received during and immediately after the sterilization.” Four responses were provided in the NFHS-5 “very good,” “all right,” “not so good” and “bad”. These were converted into a binary of “Not Good” (combing responses of “all right,” “not so good” and “bad,” coded as 0) and “Good” (consisting of responses “very good”, coded as 1). The variable was included to ensure a more holistic approach towards understanding the ‘quality of care’ provided.

For the independent variables, religion (reference category “non-Muslim”), education (reference category "no education"), caste (reference category “general/none of the,” category), age of the respondent (reference category "25-29"), place of residence (reference category “urban”), heard of family planning on the internet (reference category “no”), heard of family planning on mass media, i.e. any messages heard on tv, newspaper and/or radio (reference category “unexposed”), parity at sterilization and age at sterilization were selected.. The independent variables were selected on the basis of previous research studies, mentioned earlier [4, 5]. The age reference category, 25–29 age cohort was selected given the increasing prevalence of early sterilization in India [26].

Chi-square test was applied to understand the differences in receiving compensations for sterilization as per the select socio-economic cohorts of women sampled in the study. Further, multi-variable logistic analysis were conducted to understand the individual association between the predictors and outcome variables. The list of variables included for regression analysis was finalized after checking multicollinearity among the predictor variables through the Variable Inflation Factors (VIF) test. Based on the same, the variables of age and parity at sterilization were dropped from the models given the VIF for both variables was greater than 5. In all the analyses, weights were used to restore the sample’s representativeness. The analyses were done with STATA (version 17) with a significance level of 5 per cent.

In terms of limitations, given the research used a sub-sample of the data based on the parameters of wealth and use of public sector to determine the eligibility for receiving compensations, there may have been a segment of the population belonging to either rich and richer cohorts or who could have received compensations for sterilization from accredited private facilities that were missed out for the analysis.

Results

94.51% of the sample constituted of non-Muslim women. Further, nearly 89.62% of the respondents reported belonging to either scheduled castes, scheduled tribes, or other backward classes. 90.90% of the respondents belonged to rural areas. 37.31% of the sample reported having received no education. 92.57% of the women in the sample were between the ages of 20 to 40 and nearly all women in the sample were also 2 + parity (98.39%). 34.04% of the women in the sample also reported having been sterilized before the age of 25. Finally, 16.40% of the sample reported having heard of family planning messages on the internet whereas nearly 52.97% of the women reported having heard family planning messages over mass-media.

The findings from the analysis showed that a greater proportion of non-Muslim women reported receiving compensation for tubectomies in comparison with Muslim women. The difference in the receipt of compensations was 18% between both cohorts (Table 2). Further, the results from multivariable analysis also indicated that Muslim women had lower odds (AOR = 0.67; CI: 0.60–0.76) of receiving compensations for sterilization in comparison with non-Muslim women (Table 3). This was despite the higher odds (AOR = 1.15; CI: 1.02–1.29) among Muslim women to receive comprehensive information prior to their tubectomies in comparison with non-Muslim women (Table 4).

Table 2 Association between receiving compensation for sterilization and select sociodemographic characteristics of the study sample (n = 28,037)

Table 3 Results from multivariable logistic regression model examining women’s likelihood of receiving compensation for sterilization by selected characteristics, 2019–2021

Table 4 Results from multivariable logistic regression model examining women’s likelihood of comprehensive information prior to their sterilization by selected characteristics, 2019–2021

In comparison to Muslim women, caste-based minorities fared better in terms of being able to access compensations for their sterilizations. A greater proportion of women from caste-based minorities, i.e. those belonging of Scheduled Caste (SC), Scheduled Tribe (ST), and Other Backward Class (OBC) cohorts reported receiving compensations for sterilization in comparison with those reporting to not belong to any caste (Table 2). Subsequently, the results from the multi-variable analysis also showed that women from SC, ST and OBC communities had higher odds of both; receiving compensation for sterilization (AOR = 1.27; CI: 1.16–1.40 for SC, AOR = 1.18; CI: 1.07–1.31 for ST, AOR = 1.36; CI: 1.24–1.48 for OBC) as well as receiving comprehensive information (AOR = 1.30; CI: 1.19 – 1.43 for SC, AOR = 1.76; CI: 1.59–1.95 for ST, AOR = 1.34; CI: 1.23 – 1.47 for OBC) prior to their tubectomies (Tables 3 and 4). That said, women from the SC and OBC communities also had lower odds (AOR = 0.82; CI: 0.75 – 0.90 for SC, AOR = 0.76; CI: 0.70–0.82 for OBC) of reporting the care they received during their sterilization/ tubectomies as ‘good quality’ (Table 5).

Table 5 Results from multivariable logistic regression model examining women’s likelihood of reporting good quality sterilization services by selected characteristics, 2019–2021

Further, a greater proportion of women between the ages of 20–30 and of 2 + parity received compensations for sterilization. A lesser proportion of women who chose to undergo tubectomies after their first child (61.59%) reported receiving compensations for sterilization in comparison with women with 2 + parity (71.95%, Table 2). Additionally, a lesser proportion of women who opted for sterilization post 30 reported getting compensation in comparison with women who opted for sterilization before they were 30 (Table 2).

The findings from the multivariable regression also showed that women from rural areas had higher odds (AOR = 1.32; CI:1.23- 1.43) of receiving compensation for sterilization, but lower odds (AOR = 0.91; CI: 0.85–0.98) of receiving full information and good quality services (Tables 3, 4 and 5). In terms of exposure to family planning content, women exposed to FP messages on the internet (AOR = 1.40; CI:1.30–1.50) and women exposed to FP messages on mass media (AOR = 1.45; CI: 1.37- 1.53) channels had higher odds of receiving comprehensive information on sterilization prior to their tubectomies (Table 4). Interestingly, women having received higher or secondary education, had lower odds (AOR = 0.66; CI: 0.56 – 0.78 for higher education, AOR = 0.74; CI: 0.69 – 0.79 for secondary education) of receiving compensation for sterilization, in comparison with women reporting to have received no education, (Table 3). Further, despite having higher odds of receiving full information on sterilization prior to the operation (AOR = 1.48; CI: 1.27–1.72), women who had received higher education had lower odds (AOR = 0.76; CI: 0.66 – 0.87) of reporting the care received during the sterilization procedures as “good quality” (Tables 4 and 5).

Discussion

As the findings from the research suggest, Muslim women who opt to undergo tubectomies from the public sector in India face more constraints in accessing the monetary benefits that they are entitled to in comparison with non-Muslim women. This is despite the findings indicating that the relative access to comprehensive information on tubectomies prior to the operation may be better among Muslim women. Such a scenario may allude to how the interplays between citizenship and access to public health benefits affect the reproductive rights of Indian Muslims, perhaps even more than the outreach and access to family planning services [27]. Hence, the equitable distribution of compensations for sterilization ought to be a critical policy consideration for the Indian family planning programme given that more than 3/4th of the programme budget is allocated for the same [28].

Further, the analysis conducted does not show any significant association between quality-of-care experiences and religious identity, which may be because of the under-reporting of negative experiences due to the sensitive nature of the topic and a presumed Hawthorne effect. Thus, more qualitative research, similar to Khanday’s investigation from Mumbai, may be required to better understand the constraints faced by Indian Muslim women in obtaining compensations for sterilization [23, 24].

Finally, from the perspective of equity, the findings show that the challenges for improving family planning outcomes are heterogenous in India and are dependent on the nature of social-vulnerability. Where on the one hand Muslim women, as a religious minority, had lower odds than non- Muslims to receive compensations for sterilization, caste-based minorities (SC/ST/OBC) had higher odds of receiving compensations in comparison with who reported to not belong to any caste. That said, caste-based minorities, namely those who are SCs and OBCs, also reported lower odds of reporting the quality of care they experiences as being “good.” In this regard, the findings from the research find resonance with Chattopadhyay’s framework of viewing inequitable access to healthcare from the perspective of ‘graded citizenship,’ wherein, the ‘citizenship itself is graded, and not all marginal groups experience either the same form or the same intensity of mistreatment’ [29].

Conclusion

India is at a unique juncture in its family planning experience. Replacement fertility has been achieved and the family planning programme can perhaps finally be liberated from its long-standing dictate of ensuring “population stabilization,” and instead focus more on reproductive rights-based issues [30]. Academic writings that have attempted to envision the future of the Indian family planning programme in such a paradigm have previously indicated the need to promote equitable outcomes as a key consideration [28]. Yet, apart from a select few pieces of evidence, the current predicament of Indian Muslims with regard to their inequitable access to good quality reproductive health services is seldom explored. In addition to the select research studies which argue for corrective action against discrimination and even instances of disrespect and abuse faced by Indian Muslims in public health facilities, this research also suggest the need for more structural reforms which integrate a more caring, sensitive, and equitable approach in the provision of public benefits. Additionally, as research conducted on housing and unemployment welfare in India show, without proper community-based networks, Indian Muslims become less likely to receive key public benefits [31]. Building on these logics, as a corrective measure, this research suggests that information channels that have been effective in providing information on sterilization to women within Muslim communities (such as ASHAs³and other local public health staff), could also be sensitized so as to also effectively provide information on how to claim compensations for sterilization.