The series of botched tubectomies that left 11 women dead and 50 hospitalised in Chhattisgarh on Monday was a tragedy waiting to strike India’s family planning programme, claimed outraged health workers and activists claim it.
On November 8, a team of one doctor and one assistant reportedly performed more than 80 sterilisation surgeries on women in a span of barely five or six hours at a free family planning camp at a private hospital in Bilaspur, Chhattisgarh. Within 24 hours of the surgeries, many of the women began complaining of abdominal pain and vomiting. By Tuesday, 11 women had died, 30 were in critical condition and at least another 20 had to be hospitalised.
The obvious errors by the doctor seeking to operate on a large mass of women in a short span of time with poor equipment and facilities is only the tip of the iceberg when it comes to the problems with implementing India’s National Family Planning Programme, say activists.
The root of the problem, they believe, is that for decades, family planning campaigns have heavily emphasised achieving numerical targets for contraception, and prioritised female sterilisation over other contraceptive methods in an almost coercive manner.
Women at a sterilisation camp in Chhattisgarh. Photo: Sulakshana Nandi.
“What happened in Bilaspur could have happened anywhere in the country, because it reflects a systemic failure,” said Sulakshana Nandi, a member of the Jan Swasthya Abhiyan in Chhattisgarh.
India’s family planning programmes were infamously intimidatory in the 1970s. After the Emergency, it focused on setting targets on the number of women and men being brought in for sterilisation and other contraception methods. It was only in 1996 that India finally announced that it would adopt a target-free approach to family planning.
However, according to a 2012 report by the non-profit organisation Human Rights Watch, the situation on the ground is completely different. State- and district-level health officials routinely set targets of the number of people that health workers (including nurses, midwives and accredited social health activists) must bring in for sterilisation every month.
This has led to a situation where everyone involved in the sterilisation process has financial incentives to participate, from the patients themselves to the health workers motivating them to attend the camps as well as the doctors performing the surgery. In some states like Gujarat, according to the HRW report, child workers at anganwadis and health workers claim to have been threatened with salary cuts and job losses if they did not meet their targets. Consequently, these health workers often end up giving faulty information to women about other contraceptive options, so that they inevitably agree to sterilisation.
“When you don’t give people any other option, is it not forced contraception?” said Jashodhara Dasgupta, a public health activist and a member of the Health Watch Forum in Uttar Pradesh.
In Chhattisgarh, where Monday’s tragedy took place, activists give a bleak picture of the way in which sterilisation camps take place. In a written statement condemning the death of the Bilaspur women, the All India Democratic Women’s Association states:
While acknowledging the practice of target-based sterilisations, some doctors believe the situation is compounded by the lack of professionals qualified to perform tubectomies and vasectomies in India.
Around a decade ago, most Indian states moved from conventional sterilisation procedures to laproscopic sterilisation, a faster kind of surgery that requires a higher degree of skill and entails greater risk for the patient.
“There are very few people who can perform this surgery, and the public health system finds it very difficult to retain these specialists,” said Dr T Sundararaman, former director of the National Health Systems Resource Centre in Chhattisgarh. “This is why targets are set for the specialists, and they rush to get more and more patients operated in a short period of time.”
Coupled with unhygienic and low-quality surgical equipment and facilities for doctors, such rushed deadlines make for a lethal combination.
Gender imbalance
The bigger issue, however, say many activists, is the glaring gender imbalance in the family planning programme’s policies, which systemically place the responsibility of contraception on women.
“Even today, all the focus is on permanent methods of contraception – tubectomy and vasectomy – and between them, there is greater focus on tubectomies because it is easier to mobilise women,” said Nandi. “These operations are offered to women in the most inhuman conditions, and there is no emphasis on temporary contraceptives like intra-uterine devices, oral pills or condoms.”
The figures are telling – reports reveal that in 2008, 54% of the Indian population used contraception, of which female sterilisation accounted for 34% and male sterilisation accounted for just 1% of contraceptive use.
“The government works on the assumption that men will not step forward to opt for contraception, even if it is the simple condom,” said Sundararaman. “To increase male participation in contraception, we would have to invest a lot more in campaigning and also rethink sexual culture.”
Meanwhile, women continue to suffer the consequences of their burden at mass sterilisation camps such as the one gone wrong in Bilaspur.
“Such drives are a violation of a woman’s reproductive rights, her right to health and also a violation of gender justice,” said Dasgupta. “The entire government machinery needs to be pinned down and made accountable for this.”
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On November 8, a team of one doctor and one assistant reportedly performed more than 80 sterilisation surgeries on women in a span of barely five or six hours at a free family planning camp at a private hospital in Bilaspur, Chhattisgarh. Within 24 hours of the surgeries, many of the women began complaining of abdominal pain and vomiting. By Tuesday, 11 women had died, 30 were in critical condition and at least another 20 had to be hospitalised.
The obvious errors by the doctor seeking to operate on a large mass of women in a short span of time with poor equipment and facilities is only the tip of the iceberg when it comes to the problems with implementing India’s National Family Planning Programme, say activists.
The root of the problem, they believe, is that for decades, family planning campaigns have heavily emphasised achieving numerical targets for contraception, and prioritised female sterilisation over other contraceptive methods in an almost coercive manner.
Women at a sterilisation camp in Chhattisgarh. Photo: Sulakshana Nandi.
“What happened in Bilaspur could have happened anywhere in the country, because it reflects a systemic failure,” said Sulakshana Nandi, a member of the Jan Swasthya Abhiyan in Chhattisgarh.
India’s family planning programmes were infamously intimidatory in the 1970s. After the Emergency, it focused on setting targets on the number of women and men being brought in for sterilisation and other contraception methods. It was only in 1996 that India finally announced that it would adopt a target-free approach to family planning.
However, according to a 2012 report by the non-profit organisation Human Rights Watch, the situation on the ground is completely different. State- and district-level health officials routinely set targets of the number of people that health workers (including nurses, midwives and accredited social health activists) must bring in for sterilisation every month.
This has led to a situation where everyone involved in the sterilisation process has financial incentives to participate, from the patients themselves to the health workers motivating them to attend the camps as well as the doctors performing the surgery. In some states like Gujarat, according to the HRW report, child workers at anganwadis and health workers claim to have been threatened with salary cuts and job losses if they did not meet their targets. Consequently, these health workers often end up giving faulty information to women about other contraceptive options, so that they inevitably agree to sterilisation.
“When you don’t give people any other option, is it not forced contraception?” said Jashodhara Dasgupta, a public health activist and a member of the Health Watch Forum in Uttar Pradesh.
In Chhattisgarh, where Monday’s tragedy took place, activists give a bleak picture of the way in which sterilisation camps take place. In a written statement condemning the death of the Bilaspur women, the All India Democratic Women’s Association states:
“Such ‘camps’ keep getting organised daily in various parts of the state. The government gives unwritten targets to all its health functionaries. Sterilisations are often dependent on doctors coming from other blocks, district or the private sector....Many a times the ‘camp’ has to get cancelled because the doctor does not come or he/she comes only if certain number of cases has arrived. All this leads to extreme harassment of the women patients.”
A lack of specialists
While acknowledging the practice of target-based sterilisations, some doctors believe the situation is compounded by the lack of professionals qualified to perform tubectomies and vasectomies in India.
Around a decade ago, most Indian states moved from conventional sterilisation procedures to laproscopic sterilisation, a faster kind of surgery that requires a higher degree of skill and entails greater risk for the patient.
“There are very few people who can perform this surgery, and the public health system finds it very difficult to retain these specialists,” said Dr T Sundararaman, former director of the National Health Systems Resource Centre in Chhattisgarh. “This is why targets are set for the specialists, and they rush to get more and more patients operated in a short period of time.”
Coupled with unhygienic and low-quality surgical equipment and facilities for doctors, such rushed deadlines make for a lethal combination.
Gender imbalance
The bigger issue, however, say many activists, is the glaring gender imbalance in the family planning programme’s policies, which systemically place the responsibility of contraception on women.
“Even today, all the focus is on permanent methods of contraception – tubectomy and vasectomy – and between them, there is greater focus on tubectomies because it is easier to mobilise women,” said Nandi. “These operations are offered to women in the most inhuman conditions, and there is no emphasis on temporary contraceptives like intra-uterine devices, oral pills or condoms.”
The figures are telling – reports reveal that in 2008, 54% of the Indian population used contraception, of which female sterilisation accounted for 34% and male sterilisation accounted for just 1% of contraceptive use.
“The government works on the assumption that men will not step forward to opt for contraception, even if it is the simple condom,” said Sundararaman. “To increase male participation in contraception, we would have to invest a lot more in campaigning and also rethink sexual culture.”
Meanwhile, women continue to suffer the consequences of their burden at mass sterilisation camps such as the one gone wrong in Bilaspur.
“Such drives are a violation of a woman’s reproductive rights, her right to health and also a violation of gender justice,” said Dasgupta. “The entire government machinery needs to be pinned down and made accountable for this.”
