Spotlight on family planning as India surpasses China as world’s most populous country

While China’s formerly steep rate of population increase is starting to plateau, India’s curve still forging upwards

India is set to become the world’s most populous country on April 14, a title China has held for decades. Faced with a large – and growing ­– population of more than 1.4 billion, India’s family planning service is under pressure to maintain a decreasing fertility rate.

A UN forecast predicts that on April 14 the Indian population will reach 1,425,775,850 – a number that dethrones China from its long-held position as the world’s most populous country.  

The exact population of India today is unknown ­(a 2021 update on the decade-old census was indefinitely delayed by the pandemic) but all signs point to exponential growth. While China’s formerly steep rate of population increase is starting to plateau, India’s curve is still forging upwards. 

It is estimated that India has added 210 million – almost the number of people in Brazil – to its population since the last census 12 years ago. As of 2020, it has gained roughly 1 million inhabitants each month.

The population of India – and China – is now equivalent to the entire continent of Africa, and dwarfs that of Europe and the Americas. 

But over the same decades that population growth in India has soared, fertility rates have been falling. In 1964 Indian women had six children on average, today they have closer to two, in part, due to the state family planning service, which India claims it was the first country to provide when it launched in 1952.

“The primary goal was to slow population growth as a means of supporting the economic development of the country, which was only a few years old at that point,” says Anita Raj, Professor of Global Public Health, Director of the Center on Gender Equity and Health, University of California at San Diego.

The scheme has had some successes: India’s 2022 family heath survey found that almost 100% of married women and men aged 15-49 are aware of at least one method of contraception. The public health sector is the provider for 68% of people who use modern contraceptives (products or medical procedures used to prevent pregnancy such as condoms, the pill and IUDs, as opposed to traditional methods such as the withdrawal or rhythm methods or abstinence).

Yet, faced with a soaring population there is work to do. “Total fertility rates have declined for years,” says Raj. “However, if the goal was truly reproductive choice and women’s reproductive autonomy, then more should be done.”

Sterilisation

The most used form of pregnancy prevention in India is female sterilisation, which accounts for 38% of all contraception used. “The emphasis of the national family planning programme historically was on family size, and consequently, sterilisation was the focus,” says Raj.

Yet, male sterilisation rates account for just 0.3% of all contraception methods. This is partly due to a patriarchal society – the family heath survey found more than a third of men regard contraception as “women’s business”.

But there is also resistance to male vasectomy due to lingering “stigma and taboos", says Debanjana Choudhuri, a gender rights specialist based in India.

In the 1970s, economic and social stagnation led the Indian government to launch a mass drive to sterilise men as a population control method. Heavy-handed enforcement saw men pressured into having vasectomies on pain of having their salaries docked or losing their jobs. Poor men risked being picked up by police from railway and bus stations before being sent for sterilisation.

The result in modern India is that “no scalpel vasectomies have a very poor uptake", Choudhuri says. “Men aren’t doing enough.”

State efforts still shy away from diversifying contraceptive methods. Sterilisation for men and women is incentivised with payment, and some states have introduced a two-child policy with penalties such as bans on holding government jobs for those who do not comply. The private health sector is the main provider of contraceptive of pills, injectables and condoms.

Recent public health provision of UDIs could be a “game changer in achieving method mix”, says Choudhuri, “but it will take 5-10 years to become popular. There is an immediate need for a healthier method mix, sensitisation, and awareness of long-acting reversible contraception and other short-term methods.”

Contraceptive control 

Aside from placing the burden on women, reliance on female sterilisation limits women’s options. “Sterilisation does not support birth spacing, which is important for maternal and infant health and survival. It also is not a solution to ensure women’s control of timing of pregnancies, only limiting of them,” says Raj.

“If sterilisation is the women’s choice and supports women’s health, then that is fine; but too often these decisions are built on family and community expectations.”

Socio-economic conditions also define many women’s choices around family planning. The 2022 family health survey found poorer, less educated women living in rural areas are likely to have more children at younger ages and have less exposure to family planning messages than their wealthier, educated and urban counterparts.

Geography also plays a role, with women in the poorest parts of east India less likely to use any contraceptive methods at all, and especially less likely to use modern contraceptive methods.

“Evidence from all over the world shows when women are given the choice to control their fertility and the opportunities around it [such as education and economic opportunity] you're always going to see family sizes coming down,” says Alistair Currie, campaign manager from Population Matters, a UK-based charity that addresses population size.

Lowering the fertility rate

Forecasts predict that India’s population will continue to increase for decades to come. The UN’s “medium variant” projection puts the peak of growth at 1.7 billion people in 2064. “Low variant” projections would see the growth curve start to flatten in 2047.

As they are, efforts from the Indian government are slowing population growth at an increasingly rapid rate, but data indicates family planning has a greater role to play. There remains a significant gap between the wanted fertility rate (number of children women want to have) of 1.6, and the actual fertility rate of 2.

“We would hope to see a situation in which all pregnancies are wanted and that people have the capacity to make a choice [to get pregnant],” Currie says. “If that were the case, then we would see a lower fertility rate in India.”

In addition, a population growth spurt looms: nearly half of the Indian population is below the age of 25, likely to have children of their own in coming years.

At the moment, many of this demographic lacking vital information about contraceptives, Choudhuri says. “There’s a prejudice that comes with the family planning programme – because it’s called family planning many people feel that it is not aimed at them. The adolescent population needs to be brought into the contraception conversation. Right now, they are excluded, and that’s alarming.”