Objects of state control

The tragedy of several women dying after undergoing sterilisation operations in the Bilaspur district of Chhattisgarh has once again thrown up uncomfortable questions around India’s population programme. Although the cases are being investigated and the exact cause of the deaths has not been ascertained, the incident brings to light the abysmal conditions in which women are compelled to accept government-provided contraception.
India is a signatory to an agreement at the International Conference on Population and Development (ICPD) in 1994 that called for a reproductive health and rights approach rather than a “population control” approach, with greater attention to male responsibility and the special needs of adolescents and youth. In keeping with the ICPD, India changed its family planning programme in 1996 to a target-free approach and emphasised the assessment of community needs for reproductive and child health services in 1997-98.

Despite these tall promises, however, in practice, India continued to punish citizens who had more than the approved number of children by denying them the right to contest elections to local bodies in some states, the right to obtain maternity benefits, scholarships and educational benefits that all children should have equal claim to. The government of India continued to promote and provide sterilisation as the preferred mode of contraception. This is a surgical procedure to be performed by qualified doctors, but doctors in the under-resourced public sector are in woefully short supply. Yet, contraceptive users are not using other methods that can be provided by nurses and even frontline workers, such as condoms, oral pills and so forth. The shortage of doctors leads to large numbers of women being operated upon within a short time in “camps” that are often organised in non-hospital settings in peripheral areas.

The sub-standard conditions under which female sterilisation was performed in camps was studied in 2002 by Healthwatch Uttar Pradesh, and a writ petition was filed in the Supreme Court (Ramakant Rai and Healthwatch UP vs Union of India). The court issued orders to the government in 2005, based on which quality standards were reviewed, quality assurance committees mandated in each district and insurance coverage set up for female sterilisation acceptors by 2006. Each woman who came for sterilisation was meant to sign a consent form read out to her if she was not literate, and informed about the insurance coverage in case of adverse effects. All sterilisation acceptors are entitled to a certificate in case they need to claim compensation.

However, the experience of poor women accepting sterilisation has not changed significantly, as evident from the Bilaspur sterilisation camps. Women continue to be the focus of all drives for small families, although terminal methods for women involve opening the abdomen, and vasectomies performed upon men would be much safer and lead to far less discomfort. The community health volunteers who provide health information have never been trained to speak on vasectomy and are unable to dispel common misconceptions around vasectomy leading to impotence or “weakness” in men. Their kit does not include a supply of condoms for younger couples wanting to delay the first pregnancy or space out their children.

These health workers can easily identify the women tired of not being in control of their reproduction and aspiring for better lives and small families. Since spacing methods are not promoted, women tend to have their pregnancies in quick succession. By the time they have had two or three children, the health department recognises their need for a contraceptive. The only method offered and therefore “preferred” is female sterilisation, euphemistically and erroneously referred to as “family planning”. It is hardly surprising that India has the dubious distinction of almost 98 per cent sterilisations performed upon women. Sterilisation targets continue to exist for female sterilisation, and sub-district health functionaries are often under pressure to meet their targets by March 31. The government of India may choose to deny this, but it is accountable for this discrepancy between policy and practice since population is a Central subject.

The records of the current disaster indicate that 83 women were herded into a camp, not in the sterile conditions of a hospital operation theatre but in an abandoned building once intended to be a private hospital. The sole qualified doctor who hurriedly performed these operations barely spent a few minutes on each woman and used only one laparoscopic instrument, which was obviously not sterilised between operations. These mass surgeries are recognised and publicly rewarded by the state government when any surgeon achieves 50,000 or 1,00,000 sterilisations.

The question is, how can the government at the state and Centre condone this gross violation of a woman’s right to safe contraception as promised 20 years ago at the ICPD? We do not hear about the responsibilities of men being addressed. It is astonishing that vasectomy is not promoted even though it is safer; neither does the state health department engage with men through male functionaries who can dispel the myths around the procedure. It is also a sad truth that the middle classes do not care about this anyway, since they do not use contraceptives offered by the government. The gender injustice of the population programme leaves them untouched.

Women from the poorer classes therefore continue to be objects of state control, a state that prefers to terminate their reproductive capacity as soon as it considers that they have produced enough future citizens, but does not look after their reproductive health before or after. There is an urgent need to build greater accountability for this violation and strengthen the public health sector, so that men and women can access year-round safe contraceptive services.

The writer is convener, National Alliance for Maternal Health and Human Rights.