Spurred
by cash incentives, state workers in the state of Rajasthan offer
prizes to women to undergo tubal ligation in mass sterilization drives.
Critics call it a coercive process that restricts women's right to know
their contraceptive choices.
Credit: Swapna Majumdar - Women await their turn for sterilization at a primary health
A
few days after Rukma Devi underwent sterilization in the Rajsamand
district of Rajasthan, she suffered intense pain in her abdomen. Fever
and body aches followed.
Devi
had registered at one of the state's "sterilization camps," part of the
nation's campaign to reduce the number of births. The effort is
characterized by drives conducted in village primary health care clinics
that aim to meet government targets of sterilizing as many women,
through tube tying, as possible within a certain time span.
A
few months later, when the abdominal pain still hadn't gone away, the
mother of four went to a local doctor and got some shocking news.
She was pregnant.
Rajasthan, in the north of India,
has earned the dubious distinction as the state with the most failed
sterilizations in 2012. Out of 2,609 failures reported so far this year,
772 were registered in Rajasthan, according to the national
government's statistics. The average number of children a woman bears in
Rajasthan is 3.3, far higher than the national average of 2.6
These
statistics provided the backdrop for legal and health activists to
discuss ways to curb the sterilization push over a two-day meeting in New Delhi in late November.
Kerry
McBroom is director of the reproductive rights unit of the Human Rights
Law Network, a New Delhi-based group of lawyers that has already
spurred the Supreme Court to rebuke the national and state governments
for unhygienic sterilizations of poor, low-caste women in many parts of
the country, including Rajasthan. She said women's rights at
sterilization camps are being violated by doctors and health facilities
across the county who flout national and international ethical and
procedural guidelines.
"The
quality and nature of information that health workers provide women and
their families to convince them to be sterilized is questionable,
raising doubts about informed consent," McBroom said.
She
cited the Indian government's 2006 quality-assurance protocol for
sterilization services as well as 2011 guidelines by the International
Federation for Obstetricians and Gynecologists on female contraceptive
sterilization.
Mandatory Information
Both
standards say that before a woman undergoes sterilization she must be
informed about other, reversible forms of family planning. She must also
be counseled about possible complications and, if deciding on the
sterilization option, be provided with hygienic conditions and adequate
medical equipment.
Of the 225 million women aged 15 to 49 sterilized worldwide, 40 percent live in India.
Roughly 80 percent of all women in India
use sterilization as their contraceptive method primarily because the
government promotes sterilization as a means of family planning and
population control.
But this sterilization overdrive leads to an inordinate degree of failure.
In
the past three years Rajasthan has paid more than $10 million to
compensate women for failed sterilizations, according to information
obtained under the national Right to Information Act by Yedunath
Dashanan, an activist based in Jaipur, the state capital.
The
government's reply to that application, released in September 2012,
showed 4,200 failed sterilization cases in Rajasthan between 2009 and
2011. The response also showed 16 deaths due to sterilization
complications. Tubal ligation is generally safe, but in parts of India
such procedures are carried out in violation of prescribed safety
standards, often with fatal consequences for marginalized women.
Still,
the state government continues to promote female sterilization to
stabilize its population and lower fertility rates. In keeping with its
goal of achieving 698,604 sterilizations in 2012-13, the state medical
and health department asked its health workers in July this year to
sterilize 100,000 people within the fortnight coinciding with World
Population Day (July 11).
To
meet these targets, state health officials offer cars on a lottery
basis and free cooking gas connections to promote sterilization. Each
health worker who facilitates the operation also receives cash
incentives, which are openly mentioned in family planning programs.
Coerced Sterilizations
Incentives
such as these lead to coerced sterilization, mainly of women, said Dr.
Abhijit Das, director of the Centre for Health and Social Justice, a New
Delhi-based nongovernmental organization working on gender equity and
health.
"India
focuses on female sterilization as its main tool of family planning,"
said Das. "There is a lack of choice as providers focus only on
sterilization. Women accept it as the best option as no information is
provided about other family planning methods."
Das
added that the lack of information violates the National Population
Policy 2000, which stresses informed choice and target-free approaches
in administering family planning services. State medical practitioners,
he said, reveal a worrying degree of ignorance about national and
international ethical guidelines on sterilizations.
About
1.7 million women in Rajasthan do not have access to contraceptives,
Das said. "There is also a lack of understanding of potential adverse
outcomes for sterilizations. The poor technical quality of the services
provided is leading to increased deaths, increased failures and
morbidities."
In
a 2010 study of 749 women who underwent these sterilizations in the
Bundi district of Rajasthan, authors found 2.5 percent became pregnant,
far above the international standard for pregnancy following failed
sterilizations of 0.5 percent.
The
study was conducted by Manjri, a nongovernmental organization based in
Nainwa, Bundi district, in collaboration with the Centre for Health and
Social Justice. It found that 88 percent of participants were not told
about failures or complications and 27 percent received no advice about
post-sterilization care.
Violations included conducting only three of the 11 mandatory physical examinations before the surgery.
Almost
all the women were discharged within four hours of the operation, which
involves cutting or blocking the fallopian tubes, although 7.6 percent
of them were still unconscious. This too apparently violates the
nation's health standards that say a patient can be discharged four
hours after the tubal ligation surgery only if her vital signs are
stable, she is fully awake, has passed urine and can walk.
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