From 3.1 children per woman in 1991 to 1.4 in 2021, Kashmir is confronted with an above-average fall in the fertility rate. Fazil Buchh talks to various health experts to understand the factors behind the trend that can impact future growth
The latest National Family Health Survey (NFHS) for 2019-21 has revealed that in Jammu and Kashmir, there has been a sharp fall in the total fertility rate (TFR). From having two children during their lifetime, the women in Jammu and Kashmir now have an average of 1.4 children in their childbearing life. This is far below the national average when the last survey was conducted in 2015-16.
Jammu and Kashmir’s TFR was 3.6 in 1991. It fell to 2.3 in 2007 and later to 2. Now it is at 1.4.
Infertility in Jammu and Kashmir has been a major subject of concern for at least the last decade. Different experts have attributed it to diverse reasons, most linking it to the socio-psychological impact of the situation. There are various syndromes at work and a lot of it is attributed to the emerging lifestyles in which livelihood issues take a primary seat and marriage is pushed to the back burner.
Medical doctors attribute failure in conceiving a lady after a year-long marriage as a major indication of infertility. Experts have their own dichotomy of infertility. If a woman has never bored a child, it is called primary infertility. However, when a first-time mother is unable to conceive again, it is called secondary infertility.
“There has not been any latest survey regarding infertility incidence rate in Kashmir,” a senior doctor said. “Over the years, the population size has increased and there is a need to conduct an extensive survey at the grassroots level to conclusively establish the trend if any. However, it seems that infertility is prevalent as we frequently hear from the doctors that they witness an increased number of cases.”
The last survey was published in 1997 in a leading American journal, in which it was established that 15 per cent of couples in Kashmir are confronted with infertility. Of them, two-thirds were treated but in one-third of the cases, it was permanent infertility.
“We came to know that the crises owed to issues in one-third of males and one-third of females,” Dr Shariq Masoodi, a senior endocrinologist at SKIMS, who was part of the study, said. “In the balance one-third, the infertility was due to indeterminate causes.”
The researchers found that sperm abnormality was the primary reason behind infertility. In these cases, males lack sperm or have a very low quantity, he said.
“In the case of females, Polycystic Ovarian Syndrome (PCOS) and Premature Ovarian Failure (POF) are the major causes. The gynaecologists from outside have also informed us that POF is more frequent in Kashmir as compared to other states,” Masoodi said. “We do not know the exact reason behind the increase of POF cases. Normally, if this condition arises after the age of 35, it is termed as normal but if the same happens before 35, then it is premature”.
PCOS and POF
The recent NFHS indicates that around 60 per cent of Kashmiri married women report PCOS or more reproductive health problems, which is significantly higher in comparison to the national average of 40 per cent. The percentage of POF (premature ovarian failure) among infertile women below 40 years of age is also abnormally high – 20 to 50 per cent when compared to the nationwide rate of one to five per cent.
Experts attribute the phenomenon of increasing infertility to late marriages, which is popular in Jammu and Kashmir. More than 50,000 women, who have crossed the marriageable age, are still awaiting marriage in Kashmir, most of them in Srinagar.
The last census of 2011 found that 55 per cent of the population in Jammu and Kashmir had never married despite falling in the marriageable age – 54.7 per cent men and 45.12 per cent women. The national average then was 49 per cent. Only 25 per cent of women in Kashmir marry in their 20s.
In the Kashmiri context, a paper by Navshad Ahmad Wani and two of his colleagues revealed in 2017, that the actual average age of marriage for Kashmiri men is 31.53 years and 27.8 years for females. This is much higher than the national average. In the last 30 years, the marital age for Kashmiri women has risen from 18-21 to 27-35 years.
Researchers assert that early marriages lead to a healthy new generation and delayed marriages create serious issues for the couples, society and the new generation. “Earlier, it was being said that the genes remain unchanged but the fact is that they change with age and retain the shifts and transfer it to the new generation,” one genetics expert, who wishes not to be named, said. “In early marriages, the generally shared by the couples are healthy, unlike the older people. Though the couples marrying late also have children, they will be smarter and healthier if they are born earlier.”
There are other major factors responsible for infertility-related problems. These are hormonal imbalances, unhealthy lifestyles and stress.
“We are witnessing late marriages due to various socio-economic reasons,” Dr Masoodi said. “Women with POF condition exhaust their ovulation reserve by the time they marry due to which they are not able to conceive. If this condition is diagnosed timely, it is advisable for such patients to get married earlier so that they can conceive.”
The crisis is that there is an epidemic of metabolic syndrome in Kashmir which causes multiple diseases like diabetes, fatty liver, cholesterol increase, thyroid problems and PCOS. Women are more susceptible to hormonal imbalance and they have increased levels of male hormones. It affects the patient’s childbearing capacity, causes irregular periods and raises the patient’s risk of other health problems, including diabetes and high blood pressure. Though the medical condition is treatable, it is timely detection and medical help that matters.
Unhealthy food habits are being seen as the major cause behind the increased reproductive health problems in Kashmir. Earlier, Kashmir used to have natural and organic food and a lot of physical work. Now it is a huge market for pesticide-showered foods and processed foods which are energy-dense or carbohydrate dense but lack nutritional value. The use of chemicals in foods is eventually getting into the human body at the molecular level thus harming the metabolic system.
The fall in physical activity – partly because of the surging services sector and technology, most of the consumed foods become pro-inflammatory.
“We do not burn the calories as physical activity is minimal. The energy gets stored as fats and these get deposited in the liver and other vital organs which eventually creates inflammation problems like blood inflammation, liver inflammation and ovary inflammation,” Dr Masoodi said. “Change in lifestyle is the basic cause for the growth of metabolic syndrome.” Exercise apart, he suggested consumption of organic foods, whole-grain flour or brown rice and avoidance of using technology for every physical work – switching off TV, fridges, and lights. It requires new consumer behaviour.
Endocrine Disruption Chemicals (EDC) are the molecules that disrupt the normal feedback mechanism of the endocrine system. Some are proven while some are presumed. Some are general while some are specific to the area. Pesticides, preservatives, fertilizers, weedicides, nutrient-enriching sprays – almost every chemical, falls under EDCs. The exact impact of EDCs is not known but experts believe that the gene expression of the Kashmiri populace has changed and the environment has an important role in it.
Kashmir’s new economic model – which evolved in a close and apparently unwritten and unintended partnership between the policymakers and the corporate world, is playing a crucial role in erasing the traditional economy. While everybody requires no less than one litre of milk a day, it is hardly one of the 25 families in Kashmir periphery that owns a cow. Until recently, no family in a rural setting would be around that had not a cow, a small herd of sheep and a lot of backyard poultry.
Though the families are battling to retain the traditional vegetable gardens, they have given up having cows and sheep, even poultry rearing at home is rare.
“In Shopian, our orchards offer so much fodder grasses that you can manage half a million cows,” Wasim Ahmad, an apple grower said. “We are facing the crisis that nobody is willing to harvest these grasses. We used mechanical systems to cut it and then throw it away.”
Though Ahmad owns two cows and sells almost 15-20 kgs of milk on daily basis, he said the people now “feel” the stink of the cow dung. “People do not rare sheep saying the dog population has increased to a threatening proportion and it is also impacting the poultry as we,” he asserted. “People have grown white collar, now we get auto-loads of fresh vegetables in villages on a daily basis and some people have abandoned their vegetable gardens too.” This urbanisation in resource-abundant Kashmir is hitting the health of all.
Senior gynaecologist Dr Nighat Firdous said that one of the possible causes of low TFR over the past two years could be the Covid19 pandemic. Doctors also advised people to avoid pregnancy because of the threat that newborns may contract the disease.
“People impacted by Covid19 do not want to conceive immediately,” Nighat said. “When we were asked about the preparation regarding the third wave, I suggested we must advise people not to conceive children for some time. It would be an additional burden to the already health crisis we were facing.”
Dr Nighat said that the age of marriage has risen and it is causing infertility. “Our elite class or those who can afford timely marriage delay it because they are chasing their goals, and ambitions which they prefer over marriage,” Nighat said. “The low-income class delay marriage because girls do not get timely proposals or due to various resource issues.”
Adding a new aspect to the crisis, Dr Nighat said, childbearing is getting another delay even after marriage as the new couples prefer their “settlement” before thinking of a child. “People should not defer pregnancy. In medical language, when a lady crosses the age of 32, she is known as elderly as far as conceiving a child is concerned,” Dr Nighat said. “Women now marry at 30 so they must rush to be mothers.”
While tackling hundreds of women of diverse age groups, Dr Nighat has found that there is a sort of hysteria prevalent among girls about PCOD. “We observe a lot of panics but they need to know that it is a metabolic disease and not a malignancy,” the doctor said. “The metabolic syndrome in our society is prevalent because of our lifestyle. Changes in lifestyle will help them.”
A Hidden Crisis
There is yet another issue that has not been taken seriously by society or the medical fraternity – Tuberculosis. It is being presumed as one of the medical causes of infertility. Dr Zahoor, who is a scientist at CSIR-IIIM said that doctors usually treat patients with various medicines and they try to check them for TB only after their treatment fails. “The crisis with TB is that it manages to hide in the host cell and avoids getting detected in the first go,” Dr Zahoor said.
Confirming the trend, Dr Nighat said that earlier they used to get more cases from urban areas but now the trend is shifting as a good number of cases report to hospitals from rural settings as well. She sees it as the outcome of a change in lifestyle.
“When we investigated the rural cases, we found that due to tuberculosis, tubes of women get damaged,” Dr Nighat said. “Pelvic Inflammatory Disease is also on the rise and it also causes infertility. There is also a significant number of people who do not disclose their reproductive diseases because of the taboo attached to them. They do not like to get admitted to the maternity hospital because of the fear that it will affect their marriage. Many such girls can be cured if they get timely treatment.”
Though Jammu and Kashmir has a huge network of diagnostic infrastructure, Covid19 did impact at least the TB screening. Doctors said this infrastructure must be reused on the pre-Covid19 pattern so that the TB cases are timely detected.
“TB is an important contributing factor to infertility in Kashmir. We locate these patients after getting into their family history and in certain cases, these detections take place by chance, like during laparoscopy,” Dr Nighat said.
“There is an area in Kashmir where infertility is a resident crisis,” Dr Nighat said. “Though people marry normally but due to TB and pelvic infection, infertility is prevalent there.”
Mother of too many ailments, stress induces the crisis in almost every disease. It is linked to the ecosystem and doctors say it has been a perpetual crisis. What is adding to the mess is the information overload that is now available on the tip of a finger. Stress triggers hormonal imbalance. Doctors suggest that a serious counselling campaign must start at the college level for young girls.
Off late, the high costs of living have made family planning a popular option. Couples take oral contraceptives without the proper consultation of doctors. “Not every person requires a contraceptive,” Dr Nighat said. “If a patient suffers from obesity or liver enzyme disorder, oral contraceptives will be detrimental to her health.”
The newer crisis that the gynaecologists’ have located is endometriosis, a phenomenon in which a particular tissue lining starts growing outside the uterus collecting unnecessary blood in the pelvic region and triggering ovarian defects and retrograde menstruation. Doctors say Kashmir has a pretty high incidence of this disease and it contributes to infertility. Even though there is an emphasis on improving menstrual hygiene, a huge population of women lack access to better options for societal or monetary reasons. Their use of unhygienic and unsafe alternatives has its own implications on their health in which fertility could be one area.
“Unhygienic menstrual products left women vulnerable to various kinds of problems, including menstrual boils, infertility and cervical cancer,” Dr Nighat said. “The lack of knowledge around safe menstrual practices as well as misinformation about the use of sanitary pads has compounded the problem”.
Before the low TFR trends trigger a crisis, the policymakers and the civil society must form a high-power committee of experts that must have an interdisciplinary approach to understanding the issue. After understanding the problem better, they can suggest remedial measures, which can be implemented in a phased manner. Though the federal health policy is central and centrist, not every single initiative can fit all the states across India. There are certain areas like Jammu and Kashmir that have diversity in their problems which are apparently dissimilar to other geographic places.