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.
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.
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.