Sterilisation deaths are the natural consequence of India’s obsession with population control

In November this year will be the second anniversary of the death of 18 women in a sterilisation camps in Bilaspur district, Chhattisgarh. A total of 137 women had undergone tubectomies in conditions that would be unacceptable in a veterinary hospital.

The women’s deaths were met with outrage, forcing a judicial inquiry and promises of action. Unfortunately, nothing seems to have changed. Three months after the 18 women died, a camp in Azamgarh, Uttar Pradesh, conducted sterilisations under torchlight.

The Supreme Court’s judgement on Wednesday ordering the government to shut down sterilisation camps is welcome. But to really make a difference, the government would have to drastically change its approach to “family planning”.

Hundreds of women die in these camps every year, because of the government’s obsession with population control, the coercive methods used to achieve it, and the almost exclusive emphasis on female sterilisation.

There is a global spotlight on India, a belief that it is producing too many children, says Jashodhara Dasgupta of Sahayog, a Lucknow-based non-profit organisation and part of the Healthwatch network of advocacy organisations. This view guides government policy and its focus on female sterilisation, even in the face of evidence that the sterilisation camp approach is killing women. “Barely a month after women died in Chhattisgarh camps in 2014, the mission director of the National Health Mission described sterilisation deaths as mere ‘mishaps’.”

Bypassing contraception

Despite its lip service to women’s health, the government does not prioritise temporary contraception, and the family planning programme is essentially a female sterilisation programme. In 2007-2008, the government’s District Level and Household Facility Survey found that about 34% of currently married women aged 15 to 49 had undergone sterilisation. About 12% said they used temporary methods like condoms, oral contraceptives or intrauterine devices. More than 95% of sterilisations in 2010-2011 were tubectomies. The median age at which a woman gets a tubectomy is 25 – some women are sterilised at an even younger age.

So women get pregnant within a few months of marriage. After repeated pregnancies, sterilisation is presented as their only contraceptive option. “They go to camps ‘voluntarily’ but they don’t really have any choice,” said Dasgupta. They often spend money on medicines and tests, and for transport to the camps, besides skipping the day’s wages. The women who died in the Chhattisgarh sterilisation camps were daily wage labourers, from Dalit, adivasi and other backward castes.

Women who are already malnourished are further weakened after many pregnancies. The normal haemoglobulin level for women is 12-15 grams per decilitre, and 7-10 grams per decilitre is classified as "moderate anaemia". More than 56% of women are anaemic, according to the National Family Health Survey in 2005-2006. Yet government guidelines permit operations on women with levels as low as 7 grams per decilitre.

Repeated violations

Almost all sterilisations are conducted in camps, according to Devika Biswas, though the records may show otherwise. Biswas is a health activist with the Bihar Voluntary Health Association who filed the petition in the Supreme Court on human rights abuses in sterilisation camps, on the basis of which the court has just issued directives to the government.

The judgement accepted the petition’s contention detailing specific violations in sterilisation camps in Uttar Pradesh, Rajasthan, Madhya Pradesh, Chhattisgarh, Maharashtra and Kerala. Women from vulnerable groups are sterilised without their consent. Consent forms are not available in the local language. Health workers are under pressure to meet targets for sterilisation operations. Due to a shortage of doctors certified to conduct surgery in these camps, they are hired on contract. Information on sterilisation failures and deaths is not made public, let alone the investigation results, and any compensation.

At a press conference following the Supreme Court judgement, health activists from Madhya Pradesh and Uttar Pradesh confirmed that nothing had changed since a 2005 Supreme Court order demanding standards in sterilisation camps. Camps are held in dharamshalas, violating government guidelines, cycle pumps are used instead of insufflators, quality assurance committees are non-functional.

Money for incentives, not for facilities

Coercion extends beyond sterilisations. More recently, the government has realised that its Janani Suraksha Yojana, meant to encourage women to deliver safely in a healthcare institution, is an opportunity to conduct tubectomies and intrauterine device insertions. Women in the hospital for delivery are approached when they are in pain and disoriented, even barely conscious, and the potential for coercion is high. As the government expands its family planning focus to include intrauterine devices, health activists are coming across women who had the devices inserted without their consent or knowledge.

“Vulnerable women go for surgery in an environment where there is no professional ethics, no consent, no maintenance of standards, and where there is a pressure for numbers,” said Dasgupta. “The deaths are predictable.”

Very little money is spent on the infrastructure and facilities in sterilisation camps, though they constitute the bulk of the entire family planning programme. A multi-organisation team’s report into sterilisation deaths in Chhattisgarh noted that of the Rs 397 crore family planning expenditure in 2013-'14, 85% or Rs 339 crore was spent on tubectomies. Less than 5% of the money spent on tubectomies was spent on the camps themselves. The remainder was spent on incentives, to health workers who persuaded the women to come to a camp, women who accepted to be sterilised, doctors, and other staff.

Celebrating Population Stabilisation Fortnight

The better option to mass tubectomies would be to improve infrastructure and ensure qualified staff at the health centre and community hospital level. But it is apparently easier and more efficient to bring staff and facilities together in camps, where women can be taken through the process as if they are on an assembly line. Sterilisation camps are also necessary to meet the government’s targets, euphemistically described as “estimated levels of achievement”.

Most camps are conducted between September and October, and money for the camps is released accordingly. However, an aggressive month-long campaign is carried out between June 27 and July 24, when the government machinery works itself up into a frenzy, first for a Mobilisation Fortnight and then for a Population Stabilisation Fortnight.

Celebration of World Population Day and Fortnight were made mandatory from 2012-2013, and a report of the National Health Mission mentions that 1.5 lakh sterilisations and 4 lakh intrauterine device insertions were done in this period in 2015. States are rated on the number of sterilisations conducted and intrauterine devices inserted, and hospitals with the maximum number of sterilisations are awarded prizes. According to the Department of Health and Family Welfare’s 2013-2014 annual report, celebrations in Delhi were flagged off with students marching to build momentum for the cause of population stabilisation. Geographical information systems were used to map 450 districts, identify the population of each village and target those who had not been reached by the family welfare programme.

Preoccupation with population control

The Human Rights Law Network, which represented Devika Biswas in her petition, and the National Alliance for Maternal Health and Human Rights welcomed the Supreme Court judgement but with caution. “Population control is still the primary concern that drives the family planning program which is still focussed almost entirely on women – this is something that just an SC judgment won’t change.”

In fact, the Supreme Court’s judgement asserts the importance of population control and of sterilisation as a means to achieve it. When disagreeing with the Union government’s argument that the responsibility to ensure standards in sterilisation camps rested with the states, the court quoted the Sarkaria Commission on the Union government’s responsibility to this programme:

It is well known that a significant part of the fruits of development is neutralised by the high growth in population. With more mouths to feed, less savings are available for development. Large addition to the population has its impact on every aspect of the nation's life. Many of the ills of the society can be traced back to large numbers who are unable to find a rewarding employment. It is necessary to recognise this inter-dependence between family planning and other sectors. We are, therefore, of the view that Population Control and Family Planning is a matter of national importance and of common concern of the Union and the States.’

As long as population control is seen to be of national importance, the court’s order to ensure standards in sterilisation operations will have limited impact at best, and poor women lives will remain vulnerable to coercion, illness and death in the family planning programme.