P R I M E  C O N C E R N

sterilisation
Oops, sorry, we’ve killed you
16 women dying in a sterilisation camp in Chhattisgarh was no isolated incident, 15 women die on an average across the country every month during and after botched-up family planning operations
By Aditi Tandon
Shocking stories of disregard for human life continue to surface from Chhattisgarh’s Bilaspur, where 16 women recently lost their lives following a botched-up sterilisation camp at a local hospital.

Setting targets, missing aim
The Government of India may have abandoned the targeted approach to family planning in 1996 in deference to international conventions like the CEDAW which it signed, but it continued to promote incentives for sterilisations, boosting it as a preferred mode of birth control in India.

Huge unmet need for family planning
Population experts feel the focus of the Centre is grossly misplaced. Though India had in 1952 become the first country to launch a national programme emphasising family planning, it has not achieved much in terms of results. By 2050, it is projected to surpass China’s population and by 2026, it would be home to 1.4 billion people as against 1.21 billion today.

sterilisation
Oops, sorry, we’ve killed you
16 women dying in a sterilisation camp in Chhattisgarh was no isolated incident, 15 women die on an average across the country every month during and after botched-up family planning operations
By Aditi Tandon

Patients recovering at a Bilaspur hospital after complications following sterilisation operations at a special camp. Sixteen women who underwent sterilisation in the camp died. AFP

Shocking stories of disregard for human life continue to surface from Chhattisgarh’s Bilaspur, where 16 women recently lost their lives following a botched-up sterilisation camp at a local hospital.

Those who survived told investigators how they woke up during the procedure to feel unbearable pain and see fallopian tubes coming out of their abdomen. Their shared memory of laparoscopic tubectomy, a common family planning practice in India’s seven high focus states with the largest share of population, is of horror, pain and shocking neglect.

None of these women were told by the operating doctor if they were fit to undertake the procedure, though it is mandatory under Government of India manuals to inform acceptors of female sterilisation the status of their health before they agree to a procedure.

But in testimony after testimony from Bilaspur, survivors have spoken of their urine and blood samples being taken but no reports being shared.

All they remember is they were hastily herded towards unclean beds where they lay shoulder to shoulder as someone administered them injections (local anaesthesia). That the sedation was ineffective is clear from the fact that majority of these women woke up in pain screaming for relief while the doctor, now arrested, continued the procedure, finishing 83 tubectomies in five hours.

All participants were discharged within minutes of the operation despite the requirement of overnight post-operative care under the Government of India rules. They went off with sachets of medicines later found contaminated with rat poison.

Although the Bilaspur deaths remain by far the darkest chapter in the history of female sterilisations in India, deaths and complications in tubectomy camp settings are routine.

Every month, around 15 women on an average die on account of botched-up sterilisations, a permanent method of birth control which forms 37.3 per cent of India’s 48.4 per cent contraception figure.

Records of the Family Planning Division of Ministry of Health reveal that between 2008 and March of 2012, 675 cases of deaths of women post-sterilisation procedures were accounted for.

Families of these victims were legally compensated under the little-known National Family Planning Insurance Scheme the ICICI Lombard Bank runs in collaboration with the Centre. The scheme, effective since November 29, 2005, offers the following packages – Rs 2 lakh for death following sterilisation in the hospital or within a week of discharge; Rs 50,000 for death following sterilisation within eight to 30 days of discharge; Rs 30,000 for a failed procedure; and Rs 25,000 for any complication within 60 days of discharge from the hospital.

By the Health Ministry’s admission, payment worth over Rs 50.76 crore was made between 2010-11 and 2013-14 for 363 deaths and 14,901 surgery failures. During this period, 15,264 cases of sterilisation deaths, failures and severe complications were officially recorded and for each case, an average of Rs 33,255 per person was paid.

Needless to say, the maximum burden of complications was reported from the six very high focus states which practice female sterilisations with impunity to meet the national Total Fertility Rate (average number of children per woman) target of 2.1. These states are Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Jharkhand and Chhattisgarh.

Women survivors of Chhattisgarh sterilisations recently said they went for surgeries because they had no other option and wanted to control their families. All of them admitted to having been motivated by Accredited Social Health Activists whom the Centre pays incentives to encourage couples to opt for birth control methods.

A Community Health Centre doctor in the state when asked if targets were prescribed acknowledged the trend, saying, “I personally have a target of around 800 sterilisations a year. One can never achieve more than 60 per cent. Non-achievers are publicly humiliated by government functionaries while achievers are publicly rewarded.”

Dr RK Gupta, under whose watch 16 out of 83 acceptors of tubectomies died in Bilaspur, was last year rewarded by Chhattisgarh Chief Minister Raman Singh for completing 50,000 tubectomies.

Major Violations

Feb 2012

Sterilisation camp at Kaparfora govt middle school, Araria, Bihar: 53 women operated in two hours; pregnant Dalit miscarries; many suffer physical harm

2010

Bundi camp, Rajasthan: 88 pc women not told of permanence of procedure; only 3 of 11 mandated pre-operative tests done; mother of three dies

Aug 2013

Odisha: Researchers document cases where women in labour are forced to agree to tubal ligation after they deliver the second child at a health facility

Nov 2013

Shanti Mahanand dies of excessive bleeding after sterilisation at Bargarh, Odisha. Vein cut in haste to operate

2011-12

In UP, 79 women aged 15 to 19 sterilised against GOI manuals which allow procedures only on women above 25 years.

Setting targets, missing aim

The Government of India may have abandoned the targeted approach to family planning in 1996 in deference to international conventions like the CEDAW which it signed, but it continued to promote incentives for sterilisations, boosting it as a preferred mode of birth control in India.

Since 1981, the government has been implementing a centrally-sponsored scheme to compensate acceptors of sterilisation for loss of wages for the day on which he or she attends the medical facility for undergoing the procedure.

Wages under the scheme have been frequently revised, and the last revision took place on September 7, 2007 when the compensation for male sterilisation (vasectomy) in a government facility was raised from Rs 1,000 to Rs 1,500 per person and for female sterilisation (tubectomy) from Rs 800 to 1,000.

Similar procedures in private settings attract more incentives – Rs 1,500 each for vasectomy and tubectomy.

The reason for increasing numbers of sterilisations in private camp settings is also hidden in the Centre’s own data on incentives for sterilisations.

When conducted in public facilities, the majority incentive goes to the acceptor of sterilisation but when conducted in a private facility, it goes to the facility and the motivator.

So, of the Rs 1,000 compensation for female sterilisation in a government hospital, the acceptor gets Rs 600 as against Rs 150 for the motivator; Rs 100 for drugs and dressing; Rs 75 for the surgeon; Rs 15 each for the nurse and operation theatre technician; Rs 10 for refreshments and Rs 10 for camp management.

In the private facility, however, the acceptor of sterilisation gets no money. Of the promised Rs 1,500 per surgery, Rs 1,350 goes to the facility and the remaining to the motivator.

“This incentive-based approach to sterilisations must end. The government has the responsibility of providing couples with a basket of contraceptive choices where the preference should be for spacing methods instead of permanent methods of birth control such as sterilisations. Let us not forget, 96 per cent sterilisations in India still involve women,” says Poonam Muttreja of the Population Foundation of India.

All women’s groups agree with the need to do away with incentives for sterilisations which they say are as good as target setting. Health Minister JP Nadda, however insists, “The Centre does not set any targets for sterilisations. Family planning is a voluntary, consent-based movement.”

Camps to meet numbers

The Centre has for the purpose of monitoring population growth categorised states into three, depending on their Total Fertility Rates (TFRs) or the average number of children per woman.

There are six very high focus states with TFR of more than or equal to 3; high focus states with TFR more than 2.1 and less than 3 and non high focus states with less than or equal to 2.1 TFR.

Evidence shows sterilisation camps for females are mostly organised in very high focus and high focus states which are constantly under pressure to deliver the TFR targets. Incidentally, it was also in these very states that the most significant dip in population growth rates was recorded as per 2011 Census.

Health Ministry insiders acknowledge that India’s goal of reaching TFR of 2.1 by 2015 depends mainly on the performance of very high focus and high focus states which, in turn, resort to mass female sterilisations in camps to push targets.

SAMA, a women’s group working on reproductive rights, has now called for a blanket ban on camp sterilisations. Imrana Qadeer, a women’s right activist, says, “According to the Registrar General of India, the very high focus states will take 25 years to reach the TFR of 2.1 if the family planning programme is implemented in its mandated voluntary form. You can see why these states are pushing for the camp approach.”

The Health Ministry’s own compilations reveal that the very high focus states wait for central family planning funds to land in the fag end of the year so these can be used to sterilise women in camps and meet the yearly sterilisation targets which almost all states set.

Brinda Karat of CPM says camp sterilisation of women in private settings is the worst form of human rights violation. “What you need is a 24 by 7 public health service where women wishing for permanent birth control can access sterilisation when they want. Why should there be camps?” she asks.

877 tubectomies a day!

• Chhattisgarh, a very high focus state, has a TFR of 2.8 and sterilises on an average 344 women every day. Bihar, with the highest TFR of 3.7 in India, sterilises on an average 1,492 women a day; Madhya Pradesh with a TFR of 3.2 resorts to 1,512 female sterilisations daily on an average. Rajasthan with a TFR of 3.1 sterilises on an average 840 women a day and UP with 3.5 TFR conducts an average of 877 tubectomies a day.
• The latest data available with the Centre for 2011-2012 reveals a whopping 49,06,430 sterilisations being conducted in a single year across India. Of these, 47.3 lakh (over 95 pc) involved tubectomies as against 1.75 lakh vasectomies on men.

Huge unmet need for family planning

Spacing between two childbirths in India is less than three years in 61 pc of all births. File photo

Population experts feel the focus of the Centre is grossly misplaced. Though India had in 1952 become the first country to launch a national programme emphasising family planning, it has not achieved much in terms of results. By 2050, it is projected to surpass China’s population and by 2026, it would be home to 1.4 billion people as against 1.21 billion today.

Contrast these challenges with access to contraception and one traces a huge gap. Contraceptive use among married women aged 15 to 49 years is just 56.3 per cent. Though the wanted fertility rate across India, as revealed by the National Family Health Survey-3, is 1.9, the actual national Total Fertility Rate is 2.1.

Clearly, there is a huge unmet need for family planning. “Yes the need is 22 per cent as per the District Level Health Survey of 2008,” admit Health Ministry officials. They add that spacing between two childbirths in India is less than the recommended three years in 61 per cent of all births. That explains female sterilisations as the easy option to attain population stabilisation goals.

“It is not just easy, it is financially rewarding with little or no accountability for operating doctors, who treat women as cattle. In none of these sterilisation camps are doctors ever equipped with gloves, disinfectants, equipment or clean linen to ensure safe procedures,” says Devika Biswas, the Araria-based activist currently pursuing in the Supreme Court a petition that documents the horrors of India’s female sterilisation camps and calls for strict directions to states which treat women as tools to meet TFR targets.

In January 2012, a single surgeon performed sterilisations on 54 women in a government school in Kaparfora of Bihar’s Araria district. Spending less than two minutes per surgery, he left the women writhing in pain with most of them finding themselves in a pool of blood. The case led to a petition in the Supreme Court, which is seeking directions to states to follow Government of India’s sterilisation guidelines. The final arguments are due on December 2.

The guidelines had come into force following another SC judgment in 2005 which called for protection of women’s dignity during sterilisations.

“We have documented a series of violations of guidelines which say that not more than 30 surgeries can be held in a day; no camp will be held in schools; 18 people must form the team at each sterilisation camp and every state must maintain a record of women’s consent forms complete with their age, number of children and health condition,” says Biswas.

States are also supposed to ensure that each sterilised woman is given a certificate of the procedure as proof of surgery. “In 80 per cent cases, women are not given a certificate of sterilisation. So, deaths or complications are never recorded,” says activist Ramakant Rai, whose petition in the Apex Court had forced the Health Ministry to lay down Male and Female Sterilisation Guidelines and Manuals.