Munni Devi, 25, rests with her newborn, Sachin, her second child, at the Darbhanga Medical College Hospital in Bihar in December 2014.

A state in northern India, Bihar has lagged in development. Literacy rates are among the lowest in India, while infant and maternal mortality rates are higher, and health infrastructure is less developed.

India has the world’s largest youth population – measured as those between ages 10 and 24.

Manshi Kumari, 4, at her family’s home in the city of Patna, Bihar.
Phul Kumari Devi, center, cuts sugar cane with other women from Pahsara Village, Bihar.

The state remains primarily rural. Fertility can be higher in rural and more impoverished areas; traditionally more children meant more hands to help out with farming.

Health advocates say that in order to better address the needs of such a large young population, there needs to be greater investment in a wide range of birth control options.

Ramjhari Devi, at her home in a rural village in the Darbhanga District of Bihar. She has eight children.
Students at the Gangraho village school in rural Bihar.

Literacy rates are lower in Bihar than in any other state in India, according to 2011 Indian Census data. Experts draw a connection between level of schooling and high fertility. “Look at what education does to people’s lives,” says Subha Sri, a doctor in the southern state of Tamil Nadu. “When you’re literate,” she says, “you are automatically exposed to a lot more information.” She continues: “And I think that plays a role in actually deciding how many children you want, at what age you want them.”

In certain regions sterilization is still the only birth control option made available, despite the fact that the Indian government has promised to expand access to other methods of contraception.

Women in the maternity ward of the Darbhanga Medical College Hospital, in Bihar.
Lakshmi Thakur, 36, is an asha in the Begusarai District of Bihar.

Ashas, accredited social health activists, help women, particularly those in rural areas, navigate the public health system. As a part of state incentive systems—which pay patients, doctors, and health care workers for every sterilization—ashas, some argue, may be influenced to push sterilization.

According to the most 2005-2006 National Family Health Survey, 77 percent of sterilized women in India had never used any other method of birth control before sterilization.

Surrounded by family members, women rest shortly after having sterilization operations at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar.
Women undergo sterilization operations at the Cheria Bariarpur Primary Health Centre. A few dozen women were sterilized that day at the centre.

Although India officially abandoned sterilization targets years ago, unofficial targets remain in place, according to people working on the ground. One Primary Health Centre doctor says the targets in themselves are not necessarily the problem, arguing instead that it’s the lack of a good healthcare infrastructure in some places that makes it difficult to safely meet those targets.

Many health care workers point out that sterilization is a one-time procedure that requires little follow-up care, and for rural women without regular access to health services and less autonomy in their decision making, it can often be the best tool they have to control their own fertility.

Nuta Devi, center, with her daughter, Manju, left, who rests after her sterilization surgery.
Sonia Devi, 35, at her home in the Begusarai District of Bihar with her young baby, Lovely, beside her.

Sonia Devi had undergone a sterilization operation a few days earlier. After she gave birth to Lovely, her fourth child, she says an asha told her about the option of using sterilization to limit her family size. Sonia didn’t appear to be aware of other methods of birth control.

“If you want to move the needle on population control, this is the epicenter,” Don Douglas, Director of Patna’s Janani Surya Clinic says about the region. In recent years Bihar has started offering monetary incentives to encourage women to give birth in hospitals instead of at home.

Gurrai Kumari, 18, holds her newborn niece, as the baby’s mother, Nisha, 21, rests after delivery at the Darbhanga Medical College Hospital in Bihar.
Rashmi Devi, 31, pregnant with her third child, is examined by Dr. Gunjan Trivedi at the I. B. Smriti Arogya Sadan Hospital in the city of Darbhanga, Bihar.

Improving prenatal care and widespread immunization programs can make children healthier, says Dr. Gunjan Trivedi.

The Janani Surya Clinic is working to expand access to counseling services and education about a wide range of contraceptives.

Neha Sinha, a health counselor at the Janani Surya Clinic in Patna, Bihar, advises a family on birth control options.
Seema Devi, 33, helps her daughter, Semeran Kumari, 6, remove her school uniform after class at their home in Patna.

A patient of Patna’s Janani Surya Clinic, Seema Devi chose to limit her family to three children. After using a Copper-T IUD for years, she opted for the more permanent option of sterilization. She said it would be difficult for her and her husband to support another child, and to provide their three children with the kind of education they want for them.

Literacy rates are much higher in the state of Tamil Nadu and across southern India in general, and fertility rates are lower. Tamil Nadu has had a robust history of social welfare programs, such as the midday meal program, which provides free lunches to schoolchildren. Now a nationwide program, it was first introduced in Tamil Nadu and has been particularly effective there in improving both attendance and childhood nutrition.

Sanmugam Loganathan looks up at his teacher, S. Kanmani, as she reviews his notebook at the Panchayat Union Middle School in Tamil Nadu.
B. Rajeshwari, 23, cares for her first child, a 5-day-old daughter not yet named, at the Medavakkam Primary Health Centre in Tamil Nadu. A family friend, Radish, far left, looks on.

In Tamil Nadu, maternal and family health care have been part of the state government’s longstanding investment in public health.

The Centre delivers 150 to 200 babies a month, and Dr. Ravichandran, the director, estimates that over 90 percent of women from the surrounding area now give birth at the hospital rather than at home.

A newborn, seconds after delivery, is carried to the neonatal area in the Medavakkam Primary Health Centre.
Newborns at the Medavakkam Primary Health Centre in Tamil Nadu.

A recent state program targeting maternal health has increased the amount of money provided to mothers below the poverty line. Payments are made in three installments: following completion of an array of tests and a sonogram during her pregnancy, following birth in a government facility, and, several months later, following the baby’s first immunizations.

Dr. Subha Sri, of Tamil Nadu, says that when looking at broader questions about population and fertility rates, one needs to think beyond the availability of family planning services. “People have to make a choice to actually use those services, and people will make that choice if…they see how it’s actually going to change their lives.” But sometimes the more powerful predictor of family size is tradition. Dr. Shakeel ur Rahman, of Patna, says that in impoverished and often rural areas, children—and boys specifically—are seen as a form of social security: families “want a male child, and unless there is a male child, the girl children will be produced again and again and again.”

A mother, with her infant beside her, at the Medavakkam Primary Health Centre in Tamil Nadu in December.

One Woman’s Story

Photos, Video and Text: SARAH WEISER / RETRO REPORT