Women’s Autonomy and Demography: Women pay the price for population control

Prevelance of female sterilisation over male sterilisation

India is one of the first countries in the world to have formulated family planning programmes. Family planning programmes like mass sterilisation in India were introduced in response to the booming population . However it is female sterilisation (tubectomy) which has always been prevalent over male sterilisation (vasectomy) or other contraceptive methods.

Recently, in one of the worst medical disasters in India’s history, many women lost their lives in a mass sterilisation camp organised in Chhattisgarh. Family members of the victims have reported how women were pressurised to undergo sterilisation. Mahesh, brother-in-law of one casualty, told the Indian Express newspaper, “They [health workers] said nothing would happen, it was a minor operation. They herded them like cattle.”

However, this is not one of the rare cases where mass sterilisation camp has killed women. Between 2003 and 2012, as estimated by various reports, thousands of women died in sterilisation camps organised in various states including Uttar Pradesh, Tamil Nadu, Maharashtra, Karnataka and Andhra Pradesh.

Violating all medical guidelines, sterilisation camps like the one in Chhattisgarh and others are often found to have used contaminated medicines, rusted surgical equipments and unhygienic environment. Guidelines which set the maximum limit of surgeries to 30 a day, have often been ignored by doctors in sterilisation camps, were the operations outnumber the limit. The cause of such tragedies can be related to sheer medical negligence, apathy of doctors towards patients, poor state of health services in India and above all violation of women’s rights over their bodies.

The District Level Household and Facility Survey (DLHS)  in 2007–08 revealed that over 35 per cent of married women in  the the reproductive age group ( 15–49 years) had undergone tubectomy, as against 1 per cent of men who have undergone vasectomy. This is despite the fact that Tubectomy as an irreversible method of birth control is a more complex procedure than vasectomy.

In this light, it is important to comprehend the relationship between family planning in India and female sterilisation.

No choice for women: Social pressure, national targets

The DLHS data in 2012-13 have also indicated State Governments preference on female sterilisation over other contraceptive methods in India’s family planning programmes. For example, in Andhra Pradesh, during 2007-2008 and 2002-2013, 60 and 63 per cent women in the fertile age range had been operated respectively. However, during the same period, the number of men who underwent sterilisation, came down from 4 to 2 per cent. A similar trend was observed across many states in India.

This trend can be traced to the deep rooted social belief that the primary role of women is that of  reproduction and child rearing. Instead of looking at family planning as a responsibility of both men and women, family planning programmes in India have been directed at women by and large.  Added to this there is a tremendous social stigma attached to male sterilisation. Along with the fear of impotency, physical weakness, “it becomes a question of manhood”, says Rukmini, a District Reproductive and Child Health (RCH) Officer from Karnataka. “Unfortunately social stigma nearly always ensures the fairer sex is the subjugated lot…………….where women are more likely to go under the knife rather than men.”

(The Hindu)

In a patriarchal society, women usually have little autonomy within and outside the household; they also have limited control and no voice over their own reproductive and contraceptive choices. Hence they are always made easy targets of family planning programmes. For most women, sterilisation is not a choice, it is a diktat. Thus women are forced to undergo sterilisation, sometimes without their knowledge or opportunity to provide consent. According to the DHLS 2007-08, 40 per cent of women who got operated across India were illiterate. When women are poor and uneducated, they are more vulnerable, and are easily persuaded to accept the painful and irreversible contraceptive method through financial or other incentives. They are forced to undergo sterilisation either by authorities responsible for family planning programmes or by family members who are in need of monetary benefits. Women are convinced to undergo surgeries by luring them with cash incentives. “The husband of a Baiga tribe woman who died after undergoing tubectomy at a government-organised sterilisation camp in Bilaspur district alleged that health workers put pressure on them and also held out a promise of money for consenting to the operation.” (India Today) This is nothing but grave violation of women’s rights.

In 2012-13, the District Level Household and Facility Survey highlighted poor quality family planning services which were offered to women. Women were not informed about the side-effects of sterilisation or about other methods of contraception. Even where women were counseled, the staff strategically refrained from giving adequate and correct information. For example, in Maharashtra, only 17 per cent of the women were told about the side-effects, while in Punjab and Haryana only 14 per cent and 11 per cent women respectively were given any information related to other methods of contraception. Hence majority of these women could not have provided "informed consent" due to lack of awareness and knowledge.

“The government of India denies that there are targets but they’re clearly set and when it goes down to the district or village level that’s a real problem. Extreme pressure is the crux of the problem,” says Sona Sharma, joint director for advocacy at the New Delhi-based Population Foundation of India. Senior officials sometimes threaten health workers of reducing remuneration or suspending them from work. “Health workers who miss sterilisation targets because they give proper counseling and accurate information about contraception risk losing their jobs in many parts of the country,” said Aruna Kashyap, women’s rights researcher at Human Rights Watch.

To achieve the desired target, in some districts, more than the prescribed numbers of tubectomies are performed single handedly by a medical practitioner in unhygienic and inappropriate conditions. As a perk, compensation is given to service providers as well as acceptors of sterilisation. Unofficially material benefits are also given to health workers and agencies organising sterilisation camps.  In 2011, service providers in Rajasthan were reported to have been offered motorcycles, television sets, even Tata Nano cars.

Reproduction and contraception is for women: the social perception

In a study carried out in central India about the men’s perception of contraception, it was found out “Men viewed "family planning" as synonymous with female sterilization, whereas they saw "contraception" as referring to spacing methods, knowledge of which was limited. Thirty-four percent of men reported that their wives had been sterilized; 79% of men who did not rely on any permanent method said they wanted their wives to be sterilized. In focus group discussions, most men reported themselves as their family's sole decision maker about reproductive health.” (Male Perceptions on Female Sterilization: A Community-Based Study in Rural Central India by Arundhati Char, Minna Saavala and Teija Kulmala).

Female sterilisation being dominant, use of other spacing methods like Intrauterine Device (IUDs), condoms  are limited,  despite the fact that there is a high unmet need in spacing. According to DLHS III, all the spacing methods together account for just 25.5 per cent of the current contraceptive use, compared to female & male sterilisations which account to 75.5 per cent. Social and cultural acceptability of female contraceptives over male contraceptives have also set a high competitive bar on pharmaceutical industry and research that is prepared to invest more on the former than the latter. According to RH Reality Check (a daily publication providing news, commentary and analysis on sexual and reproductive health and justice issues) “research on male contraception is 50 years behind research on female contraception.”

Need to re-look at nation level population programmes from women’s perspective

It is a common perception shared by society that reproduction, and therefore contraception, is the responsibility of a woman. Despite all talks of empowering women and their reproductive autonomy, the right to choose whether to have children or not and the freedom to choose the methods of fertility management, based on access to proper information, has been largely denied to them. This gets translated in the family planning programmes and practices as well. It is sad that it is only by the death of several women in a botched up attempt at sterilisation that the whole issue has been bought to the fore.

It is time for the nation to understand that fundamental to the success of any family planning programme is the enhancement of women’s freedom and it should involve both men and women in its population stabilisation goal. More men should be involved in family planning programmes “not as targets for vasectomy but as partners within a gender-equality paradigm,” says Dr Abhijeet Das, Director of CHSJ and an assistant professor at the Department of Global Health, University of Washington.

The need of the hour is to look at India’s population programmes from the perspective of the women who are forced to suffer its consequences. In addition, there is an urgent need to improve public health services in India, make doctors and health agencies more accountable and eliminate coercive family planning porgrammes, to ensure that women in Chhattisgarh or any other place do not become victims of faulty sterilisation drive!

Abhishikta Roy