Srinagar: There were happy smiles outside ward number 11 in Jammu and Kashmir’s (J&K’s) largest maternity hospital, as a young doctor told Bilkesa Jan’s attendants that the 29-year-old had delivered a healthy baby. 

“This is our third child,” said Jan, who lives in Kulgam district, 70 km south of Srinagar, home to the union territory’s largest maternity facility, the government-run Lalla Ded Hospital. Her husband Mushtaq Ahmad, 31, a soft-spoken daily labourer said, "I am happy that I have been blessed with a third baby."

“These days having three children is very uncommon, most people would rather have only one or two children, but I've always thought that a large family makes a happy family,” said Bilkesa Jan. 

Her elder sister Yasmina Jan held the newborn in her lap and reminisced about days when people had larger families.

“When I was a child in the 1990s, most individuals had at least three or four children,” said Yasmina Jan. “Those were the days, were they not?” 

Back in 1990, the average woman in what was then the state of J&K gave birth to more than three babies. In 2021, the year for which data were last available, that number had declined to 1.4, the same as Japan, which is regarded as being in the throes of a demographic crisis.

The number of births per woman is called total fertility rate (TFR) or simply fertility rate, widely regarded as an indicator of social welfare & economic stability, and its decline is often considered an indicator of economic success.

“Decline in TFR is often considered as a sign of success,” said Bashir Ahmad Bhat, associate professor and a demographer at the Population Research Centre at the university of Kashmir and a life member of  American Population Association.

But in J&K, declining fertility has become a cause for concern because it has been achieved without significant economic success in a region wracked by insurgency and political instability.

In May 2022, Article 14 reported how chemistry graduates and taxi drivers working at construction sites were a manifestation of its unemployment rate—at 25% in March 2022 almost three times the national average at the time. 

More than a million were not even looking for jobs, thousands of which were lost by the revocation of the region’s special constitutional status, a security crackdown and Covid-19. Instead, wracked by violence, stress and unemployment, soaring heroin addiction was ravaging J&K youth, we reported in August 2022.

Declining Fertility = Prosperity: The Global Case

Falling fertility is associated with decreased infant mortality rates, an increase in per capita GDP (gross domestic product), better access to family planning options, delayed marriages, improved health infrastructure and the empowerment of women through education.

Research has shown (here and here) that TFR tends to decline, as countries develop and flourish, a trend that has held good for almost all industrialised nations. 

The best example is South Korea, where per capita income increased from $158 in 1960 to about $34,000 in 2022 over six decades, while TFR decreased from 5.85 to 0.9.

“Without a question, TFR tends to decrease when a nation embarks on its developmental journey,” said Bhat. “India has also experienced notable economic expansion from 1990, and as a result, TFR has declined.”

In 1990, India liberalised its economy and embarked on a new phase of industrialisation, growing its GDP from $320 billion to $3.18 trillion in 2022.  The TFR decreased from 3.39 in 1990 to 2.0 in 2020, according to the latest available data from the National Family Health Study (NFHS).  

India's TFR decline has been accompanied by higher levels of education for women, later marriages, better family planning options and rising per capita income. Some of these advances have been evident in J&K as well, in particular the health infrastructure.

"This is an outstanding accomplishment and an indication of the state's progress and expanding health infrastructure,” said Tabasum Jabeen, director general of the J&K government’s family welfare department. “There is no denying the fact that TFR tends to decline in developed nations, therefore it is encouraging that J&K is seeing the same trend.” 

Jabeen attributed fertility declines to free access to a range of contraceptive options, educational home visits by healthcare workers and healthcare professionals and promoting awareness about contraceptive choices.

But, as we said, while J&K’s fertility decline mirrors the developed world, it has not been accompanied by similar prosperity.

While J&K’s economy has expanded and per capita income has risen, according to the union territory’s economy survey for 2022-23, the latest available union government data released in July 2023 reveal that J&K ranks fifth from the bottom by state gross domestic products of 31 states and union territories, worse off than West Bengal, Chhattisgarh, Madhya Pradesh and Rajasthan. 

A conservative Muslim-majority state with a conservative Hindu majority, J&K is also an outlier in global evidence that religiosity tends to reverse fertility declines.

Concern Over India’s Third-Lowest Fertility

Although overall fertility in India decreased from 3.14 to 1.99 over three decades, the TFR of 27 states fell below 2.1 children per woman or below what is called the replacement level, a stage at which the population replaces itself and there is no new population growth.

Among India’s larger states and union territories, J&K in 2021 reported the fastest fertility decline, falling from 4.5 in 1980 to 3.14 in 1990 to 1.44 in 2020. 

Only two states, both far smaller, have a lower fertility rate: Goa with 1.1 (but reporting a marginal rise from 1 in 1990 to 1.1 in 2020) and Sikkim with 1.3.

“Although the decline in fertility rates is generally considered good, J&K has shown a huge decline,” said Bhat.

Falling birth rates have some adverse consequences, as the cases of Japan and China indicate. Demographers predict that by 2070, there will be 90 million people in Japan, down from 129 million in the 1990s, with the working-age population dropping to 49 million by 2050 from a peak of 80 million at the close of the 1990s. 

Similarly, China's population growth is slowing, and experts predict it will peak at less than 1.5 billion sometime in the 2030s, with a possible 27% decrease in China's working-age population over the next 40 years.

What Lies Ahead

“In the long run, fertility fall will create chaos, even if the immediate effects might not be felt right away,” said Bhat, the university of Kashmir demographer.

The population of J&K was nearly 15 million according to the 2011 Census, the latest available data, and is expected to remain the same in 2036, if the TFR climbs to 1.5. Birth rates will drop, and the population will age.

A report on population projections released by the ministry of health and family welfare in 2020 said that the annual number of live births per 1,000 population,  called the crude birth rate, in J&K was 15.1% between 2011 and 2015, expected to drop to 12.3% by the end of 2036. The median age of the population, which was 23.3 in 2011, is predicted to rise to 36.3 in 2036. 

Bhat said fertility declines in many European countries led to a fall in the proportion of younger people, causing labour shortages that forced them to import labour through immigration, “even though the TFR there was more than what is currently in J&K”, said Bhat.

Western European countries, such as Germany, France, Netherlands, the UK and Switzerland, with TFR higher than 1.4 eased immigration policies to avoid labour shortages, according to this 2005 European Union paper, leading to a net immigration of around 16.7 million between 1960 to 2000.

J&K has struggled with labour shortages for years, leading to an in-migration of more than 1.1 million, according to the 2011 Census, making up about 17% of the population. In 2022, the Valley received about 400,000 migrant workers, most associated with the construction sector. 

“As a society we should be really concerned about this (fertility) decline,” said Bhat. “The critical issue lies in the nature of population decline—once it commences, it tends to persist and is challenging to reverse or takes a considerable amount of time to recover.”

Many issues have been blamed for J&K’s falling fertility, from late marriage to obesity to caesarean- or c-section deliveries to conflict to the overboiling in aluminium vessels of nun chai, the salty tea of the Kashmir Valley.  

C-Sections & Working Women 

Experts we spoke to said high rates of C-section deliveries were a significant reason for J&K’s plunging TFR. While many studies have reported a drop in fertility after a C-section, it is uncertain whether the relationship is causal.

The union territory has almost twice as many C-section procedures as the national average, with urban areas reporting higher rates than rural ones, according to NFHS-5, conducted in 2019-2020.

More than 47% of deliveries in J&K are C-sections, compared to the national average of 22%. Medical recommendations for C-section deliveries are recommended only in emergencies, which accounted for only 15% of C-sections in the region.

An anxious family outside the operating room of a private hospital in Anantnag, 60 km south of Srinagar, as a woman undergoes a caesarean- section delivery, the proportion of which is nearly twice the national average/ AATIF AMMAD

“The increase in C-section deliveries is partly due to inadequate health infrastructure, which increases the likelihood of complications during labour,” said a Srinagar gynaecologist, speaking on condition of anonymity. 

“To ensure smoother deliveries and minimise the risk of complications, surgeons often opt for C-sections due to the limited availability of reliable healthcare facilities,” she said. “Many women also choose C-section since it is less painful and smoother, and people feel that c-section deliveries will keep both mother and child safe.”

J&K’s young men and women are marrying later than they ever did. The average age of marriage was 31.53 for men and 27.8 years for women in three major cities, Sopore, Baramulla and Srinagar, according to a 2018 survey of 35 women  by Naushad Wani, an assistant professor in psychology at the Women’s Degree College Srinagar. 

Data from NFHS-5, released in 2021, showed that the overall mean age of marriage for women in J&K is 23.6 years, for men 28.6 years; the women were the latest to marry in India. The national average age for marriage for men is 24.9 and for women 19.2. 

Over the past 25 years, the average age of marriage for Kashmiri women has increased from 18-21 to 27-35, according to Naushad’s survey. 

"The peak fertility of women is between 18 and 25 years, but nowadays most women marry either in their late 20s or early 30s,” said Mausama Rizvi, a Srinagar gynaecologist. “By that time there is already a significant decline in their fertility.”

Some said more women were working and prioritised their careers over starting families more than ever before, leading to delayed marriages, often after these peak fertility years. 

“Late marriage and conflict are the two main reasons that have heavily contributed to the decline in TFR,” said Naushad.

Her study revealed that the percentage of women aged 18-29 marrying after the legal age of 18 (the legal age when the study was conducted) was 5.5%, compared to the national average of 24%.

Conflict & Ovarian Disease

Conflict over 70 years in J&K, said experts, had created an environment of insecurity and played a significant role in lowering Kashmir’s fertility rate, by affecting a number of social and economic variables known to affect fertility.

“Conflict disrupts access to healthcare, education, and essential services, and studies show that fertility rates tend to decline in conflict zones,” said Naushad. “It also alters the trajectory of the sex ratio and makes it challenging for locals to access healthcare, education, and other essential services.”

Studies conducted in other conflict zones, such as Rwanda, the Congo, and Afghanistan, support the idea that conflict affects fertility rates. Studies indicated that the reproductive health of women is particularly vulnerable in conflict situations due to limited access to healthcare and challenging living conditions.

Mental stress from conflict has taken a toll on the physical health of young women, especially their maternal health, with nearly 800,000 people suffering from post-traumatic stress disorder (PTSD), experts have said.

Two major diseases, polycystic ovarian syndrome (PCOS) and premature ovarian failure (POF) have been identified as another factor responsible for infertility among women. Nearly a third of married women in J&K reported PCOS or other reproductive health problems, according to NFHS-5.

"We are alarmed by the increasing incidence of diseases like PCOS and POF,” said Rizvi. “Back in the 90s, during our college days, cases of PCOS and POF were rare occurrences. It's only in the past two decades that we have witnessed the surge in such cases." They were, she said, responsible for falling fertility, although why this was happening was not clear.

 (Mohammad Aatif Ammad Kanth is a Delhi-based journalist who writes on financial, economic, and environmental issues. Zuhaib Rashid Bangroo is a teaching fellow at Ashoka University.)  

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