The Baby Slump: The Fear of Plummeting Birth Rates Looms Over India

IT WAS ALMOST a decade ago when Dr Bandana Pradhan Subba was pursuing a fellowship in reproductive medicine in Guwahati’s Institute of Human Reproduction, a well-known in-vitro fertilisation (IVF) centre in the city, that she began to notice the vast numbers of patients from her home state Sikkim doing the rounds of IVF clinics in the city. “It was very moving to see them so far away from home,” Dr Subba says. “Many had quit their jobs so they could stay for extended periods to continue with their IVF treatment. A lot of them were under pressure and their marriages were under stress because they were childless.”

These individuals had travelled all the way to Guwahati because Sikkim had no IVF centres, and even the infertility treatment provid­ed in the nearby city of Siliguri in West Bengal, where most patients from Sikkim usually head to for medical care, was at a nascent stage. This experience would push Dr Subba to set up an infertility clinic in Sikkim’s capital Gangtok, Nobelstride Fertility and Diagnostic Centre, and expand it to offer IVF treatment in 2023.

This clinic, which continues to remain the only IVF centre in the state, is today at the forefront of one of the Sikkim government’s key measures to halt the rapidly declining birth rate in the state. Sikkim is producing far too few babies, fewer than anywhere else in the country. It has a frightfully low total fertility rate (TFR) of just 1.1 (the average number of children that a woman in the state can expect to bear in her lifetime), well below 2.1, the “replace­ment level” at which births balance deaths. The state government’s officials however point out that its own surveys show that the state’s TFR is even lower and hovering somewhere around 0.8.

The state has responded by goading couples to having more babies by tying salary hikes in government jobs to the birth of more children, offering year-long maternity leaves, and giving incentives in the form of cash transfers and subsidising IVF treatment.

Sikkim’s low fertility may be dire, comparable to some of the lowest fertility societies in the world, but it is hardly an outlier in the country. It may seem a curious thing to fret about, given that at an estimated 1.47 billion, nearly a fifth of the world’s population, lives in India, but birth rates are rapidly falling across the country, and in some states, have dipped well below the replacement level of 2.1. This is most pronounced in the southern states, but even in states like Bihar and Uttar Pradesh, which at 2.8 and 2.6, respectively, have the highest TFR in the country (according to the Sample Registration Survey for 2023 that was released last year), their birth rates are in decline compared to their past. The overall TFR in the country itself has fallen to 1.9, according to the Sample Registration Survey for 2023. However you slice the numbers, either by religions, states or whether the population is urban or rural, while the rates may vary, there is a decline occurring across all of them.

Alok Vajpeyi, a demographer who serves as the lead, Knowl­edge Management and Core Grants at the Population Foundation of India, points out that the effects of this decline may not be visible given the sheer number of youths in India’s population right now. But the effects of low TFR will start becoming visible in another 15 to 20 years.

The anxiety over what this decline will bring has been high­est in the southern states. And it has now led to Andhra Pradesh’s Chief Minister Chandrababu Naidu—whose state’s TFR has fallen to 1.5—to introduce a slew of measures to encourage couples to have more children. This policy, which shifts the state’s focus from “population control” to “population management” and which is expected to be implemented soon, provides, among other things, a cash incentive of ₹25,000 on the birth of a second or third child, free education in government institutions till such a child turns 18 years, ₹1,000 monthly for the first five years if it is the couple’s third child to buy nutritional supplements, and also subsidises the cost of IVF procedures.

The reasons why southern states like Andhra Pradesh are witnessing such a rapid decline in birth rates, according to demographers, are the same. Rapid ur­banisation, female empowerment and the growth in education levels means that people are putting off getting married or having children to focus on their careers, and when they do, they are usually content at having just one child.

There are good reasons to be worried about declining birth rates. The conver­sation around the low TFR in southern states might have been foreshadowed by fears over whether this will lead to a decline in political power, when a delimitation process could lead to the populous northern states gaining more seats in Lok Sabha. This fear seems to have been allayed now with the com­ing increase in seats in the Lower House now being tied to the Women’s Res­ervation Bill. But there are other equally pressing concerns. Dr Srinivas Goli, associate professor of demography at the In­ternational Institute for Population Sciences, points out that such low TFR will have a big impact on the country’s demo­graphic dividend, the so-called economic growth opportunity that comes from having a working-age population that is larger than those who depend upon them. And this impact will be felt hardest, he says, by those states with the lowest TFR. “Our esti­mates show that the demographic dividend hits its peak some­time around 2035. Thereafter, it starts declining. The dividend will still be there, but in a declining model up to 2060, when it becomes negative. But even before that, by around 2047, it [the dividend] starts becomes ineffective. The ageing burden will become much larger than the demographic opportunity from a working-age population,” says Goli. According to him, at the current rate of declining birth rates, there is a big chance that India will get older before it gets rich.

In Sikkim, whose tiny population is composed of many dif­ferent ethnicities, the concerns are even more dire and existential. Rohini Pradhan, special secretary-cum-programme director of Sikkim INSPIRES (Integrated Service Provision and Innovation for Reviving Economies) which falls under the state’s planning and development department, describes the low birth rate in the state as a demographic crisis. “It poses a very significant, long-term risk for the state,” she says.

THE REASONS CITED For the state’s low birth rate is the same as elsewhere in the country, from rapid urbanisa­tion to gains in education and employment. Women’s participation in the workforce here is also believed to be higher than elsewhere in the country, and a scarcity of economic opportunities in the state means that many youths move outside for jobs, leading to marriages later in life.

Because the birth rate in the state is so low, some like Dr Subba have even begun to wonder if there may be a link between infertility and the state’s high altitude. “I think this needs to be studied because I have seen it among my patients. Those who come from the plains, their sperm quality is much better than what we see in those from the state, even among people who lead a clean lifestyle, with good diet and exercise,” she says.

The state government is now embarking on a new study where it is partnering with the Indian Council of Medical Research—Na­tional Institute for Research in Reproductive and Child Health (ICMR-NIRRCH) to look specifically at why the birth rates are de­clining so rapidly and to assess the state health system’s prepared­ness to address infertility-related reproductive health needs. “The data collection for the pilot project has just begun and we hope to complete it in 12 months. The findings will help inform the state’s future policies on this issue,” Pradhan says.

Andhra Pradesh’s new policy that incentivises couples to have more kids may have generated headlines, but Sikkim has been do­ing this for quite some time. Since 2022, it has rolled out a series of in­centives that effectively pays couples to have more children. These range from tying salary increments with having more children, extending maternity leave to one year and introducing paternity leave (in government jobs) to cash incentives and subsidising the cost of IVF procedures by offering up to ₹3 lakh (for two IVF cycles). Another novel initiative, one that attempts to foster a connection between the environment and young families, is the state’s ‘Mero Rukh Mero Santati (My Tree, My Legacy)’, where families are given 108 tree saplings to plant when a child is born. “If they have their own land, they can plant these sap­lings there. If not, the government gives some space in a forest area. And when the child is born, something like a passbook is provided to the families, where on one page you record the developmental milestones of the child, things like vacci­nations given. And on the other page, you record the development of the tree,” says Rohini Pradhan.

Because the state’s various benefits and incentives like maternity leave en­titlement and salary increments are tied to the maintaining of this passbook, it becomes incumbent upon new parents to pursue this initiative. There may be an element of coercion built into this initiative, but about three years since its introduction, it is said to have been embraced wholeheartedly. “You see parents going and celebrating mile­stones like the child’s birthdays in the plantation area. Even forest guards, who weren’t always viewed positively because they were seen as an enforce­ment agency, are now viewed much differently,” Pradhan says.

Even the state’s financial assistance for IVF procedures is be­lieved to have had several takers. The state officials did not reveal how many couples opted for this until now, but according to one official, over 200 couples had already availed of it until October last year, with over 50 of them resulting in births.

APART FROM THESE measures, the Sikkim government is said to be considering more initiatives, from an assist­ed reproductive centre that will be built in Gangtok’s Sir Thutob Namgyal Memorial Hospital to talks of a monthly cash transfer to women for a year after the birth a second or third child, and even having state-funded childcare attendants to reduce the burden women face when having to choose between professional responsibilities and parenting.

Some policies like those that provide longer maternity leaves, introduce flexibility at the workplace, and goad fathers to share in the workload of parenting, according to experts, do hit the right spot when it comes to attempts at stabilising declining birth rates. But other schemes like cash incentives and subsidising IVF rarely have a meaningful impact. “South Korea spends billions annu­ally on subsidies, house benefits, and childcare incentives. But its fertility rate still hit a low of 0.72 in 2023. So I think what works better are comprehensive family-friendly policies, universal childcare, gender-equal parental leave, flexible working hours, safe public transport, and tackling gender-based violence. Unless these deeper constraints are addressed, fertility will not rebound sustainably. There may be temporary increase, but it will con­tinue to decline,” Vajpeyi says.

India’s southern states usually cite the advancements in their education levels, employment opportunities and success in implementing family planning pro­grammes for their low birth rate. But could it actually be that what they are going through is not necessarily caused by these advancements but part of a larger worldwide trend towards fewer births, something even the more popu­lated northern Indian states are going through, albeit at a slower rate?

The economists Dean Spears and Mi­chael Geruso point out in their book After the Spike: Population, Progress, and the Case for People, published last year, that birth rates are declining in much of the world and population control measures have never had any significant impact on fertil­ity patterns in the long run. They argue against a grand theory of fertility decline and show how India’s declining birth rate challenges many of these theories. Some of the theories often cited in the West, such as fewer marriages taking place, women choosing to have children later in their life and increase in women’s participation in the workforce makes little sense in India, where women’s participation in the workforce remains low, most have children in their early 20s, and marriages and religiosity still remains high.

“We’ve heard people blame the decline of marriage. But the reason why birth rates in India are below replacement can’t be that people there aren’t getting married anymore, because people there are getting married. Marriage remains almost universal, happens early, and usually leads quickly to a birth. Divorce is unusual in India, low fertility is happening without a conflict between parenting and women’s careers,” Spears and Geruso write in the book.

Many demographers believe that the decline in birth rates cannot be reversed, but that by reducing the costs women bear on having children and improving living standards, governments can attempt to stabilise the decline. And over the long run, states can cushion the impact of an ageing population on the economy by boosting healthcare so that older citizens can have longer and more productive lives. These thoughts are the last thing in the Binu Basnett’s mind, who after a year-long maternity leave is now preparing to return to work in Gangtok. The 35 year old who had a son last year through IVF, something that was subsidised by the state, has had a long and difficult journey towards pregnancy. She had been trying to have a child for years, before she learnt that her infertility was caused by endometriotic cysts. The cysts had so damaged her fallopian tubes that it needed to be removed caus­ing permanent infertility.

Basnett went through an IVF procedure after the surgery, and although she was sceptical about her chances, she con­ceived and gave birth to a boy last year. “My son has completely changed our lives. There used to be so much sadness before, but now every day is like a gift,” she says.