Rekha Devi (21) from Digha in Patna made a trip to the local clinic on her own to get an IUD (Intra-Uterine Device) inserted, as she was keen to space the birth of her children. "I had a baby a few months ago and didn't want to make a mess of my life by getting pregnant too soon. So I had to take this initiative on my own because it is I who would suffer," says Rekha, who has studied till class 10.  

Rekha and Poonam are just some of the rural women in the states of Bihar and Jharkhand who have taken it upon themselves to control the size of their families - their poor educational and economic status notwithstanding. 

Many women in these states, even those who have never been to school, are gradually coming to understand the disadvantages of having more than two children. They are now availing of the family planning initiatives run by the government and NGOs such asJanani. This NGO runs the Titli Centers that Rekha and Poonam had approached.

Each Titli Centre, located in various parts of both states, has a man and a woman (usually a married couple) called Rural Health Practitioner (RHP) and Woman Health Practitioner (WHP), respectively. A total of 40,893 centers in the two states give non-clinical products and over-the-counter (OTC) rapid test services like a pregnancy dipsticks to rural clients, besides providing counseling on reproductive health issues. Some of the women of the Titli Centers have been trained as Women Outreach Workers (WOWs) and go out into their communities and create awareness about the birth control options. 

Janani has a three-pronged network: of medical clinics; village-level Titli Centers; and shops in urban and rural markets that provide impoverished people with affordable and safe options for family planning and reproductive health care.

As more women are becoming aware of the birth control options available to them, they have begun to take decisions about their family size. From 1999 to 2006, the Janani centers performed 116,599 abortions, 82,197 sterilizations and 1,500 vasectomies. Around 43,931 women opted for IUDs and 51,660 for injectables in the same period. The NGO also recorded a sale of 1.85 million oral pills in 2006.

Sixty per cent of the people who visit the centers in the interiors of Bihar have monthly household incomes of less than Rs 3,000 (US$1=Rs 40). Dr M.K. Singh, who is in charge of a center in Mahua, says that on an average they conduct two abortions per day. Besides, ligation, IUDs and injectables are also popular among the women. From January 2006 to May 2007, 1,219 women got themselves ligated at this centre. In the same period, 750 opted for abortion, 24 for IUD and 11 for Depo. 

However, only 11 Non-Scalpel Vasectomies (NSV) were conducted at the clinic in the same period. "There is a common misconception among people that NSV affects men's health and their working capacity. Even the women won't let their menfolk go in for it," says Singh.

According to Dr Prabha Prakash of Patna Surya Clinic, run by Janani, there is also a feeling among women that NSV would affect their husband's sexual prowess. However, she adds that rural women are more receptive to family planning methods compared to their urban counterparts. "If they are made aware of the options, they readily opt for something that suits them. Village women are on the look out for more permanent solutions like ligation rather than pills because if there is an irregularity in taking the pills, it does not serve any purpose. Besides, they have to travel a considerable distance to the clinic so they want something that can last for a long time," she says.

As IUDs can give protection for up to 10 years, they are becoming common among women. As the age of marriage is low in villages, even women in their early 20s need a permanent solution to keep pregnancy at bay. So, it is not uncommon to find young village women opting for ligation as they have already had two to four children. 

Information and contraceptives made available by Janani have led to a rise in the Couple Years of Protection (CYP) to 0.65 million in 2006. This was found in a survey conducted by the NGO. One CYP is generated when one couple prevents a pregnancy for one year by using any contraceptive method. 1.75 CYP averts 1 birth. Thus, the total number of births averted in 2006 by the NGO was 693,801. The different methods that contributed to this CYP were ligations (39 per cent), Postpils (0.2 per cent), Pills (19 per cent), NSV (0.4 per cent), IUDs(3 per cent), abortion (5 per cent), condoms (34 per cent) and Depo (0.2 per cent).

Interestingly, Bihar is the only major Indian state to have shown an increase in decadal growth rate between 1991 and 2001. According to National Family Health Survey II (1998-1999), the Total Fertility Rate of the state is four as against the national average of 2.7. The Planning Commission estimates that the number of sterilizations per 10,000 un-sterilized couples in Bihar is 110 as against 934 in Tamil Nadu, 1,297 in Karnataka, and 1,230 in Andhra Pradesh.