On Wednesday, the Supreme Court directed the union government to “make efforts to ensure that sterilization camps are discontinued” within three years, asking the government to persuade state governments for this purpose.
The court also ordered implementation of established legal, medical and technical standards for sterilisation. Further, it told the government to ensure proper monitoring of the programme, investigate sterilisation failure, complications or death, and increase the compensation amount in these cases.
In response to complaints that government health workers with targets for sterilisation were forcing women to undergo the procedure against their will, the court said that it would “leave it to the good sense” of state governments to ensure that targets were not fixed.
These directives were part of the judgement in the case of Devika Biswas Vs Union of India on widespread negligence and human rights abuses in sterilisation camps.
The petition, filed in 2012 by a health activist with the Bihar Voluntary Health Association through the Human Rights Law Network, is the second public interest litigation to be filed on the subject.
More than a decade earlier, a petition had been filed by Ramakant Rai from Healthwatch Forum, a network of health advocacy organisations. That petition had asked the Supreme Court to direct the government to implement its standards for female sterilisation, punish those who violated the standards, and compensate women who had been harmed. The petition emerged from investigations and studies done by Healthwatch on the conditions of sterilisation camps and were confirmed by the testimonies of women at public hearings. Researchers encountered horrific scenes in the course of their work:
“...The woman was lying on the table with her head turned upside down at an angulation of almost 45 degrees on the makeshift operating table. She is asked by the assistant ‘side se kas ke pakar ke rakho’ (‘hold tightly to the sides’) and rebuked when she slips down because of the steep angle ‘upar utho…upar khisko’ (‘climb up…shift upwards’). Her petticoat was turned on her face and two persons firmly held one leg each. The surgeon is ready to give a nick and put in the trocar. The local anaesthetic and sedative had been applied over 30 minutes ago when she was outside and she cries out as the nick is made.”
“The OT was roughly 16 feet square with no windows and damp walls. In this room there were three operation tables, three doctors, four nurses, four ANMs, one chowkidar-cum-instrument clerk and two ward boys working in it at the same time. Two persons were continuously going in and out of the OT bringing in and taking out clients. There were gauze pieces soaked with blood and antiseptic as well as used gloves lying all around the OT. There was a continuous squishing noise as the slippers of the surgeons and assistants and OT boys stepped on these.”
In its 2005 interim order, the Supreme Court instructed the government to establish requirements for the sterilisation procedure and for the conduct of these camps, and to ensure that they were followed. Standards were spelled out for the qualifications of doctors and health workers in the team, and for infrastructure and equipment.
The procedures for obtaining informed consent, conducting safe surgery and ensuring proper post-surgical monitoring were described. The court also ordered the government to punish doctors who violated the guidelines, and to compensate women or their families for failure of surgery, or for injury or death. Yet 10 years later, hundreds of women die in sterilisation operations every year.
Unrecorded sterilisation deaths
In August 2016, the government told the court that 113 women died after tubectomies in 2015-2016. According to figures presented in Parliament, between 2003 and 2012, 1,434 tubectomy deaths were reported across the country, about 150 a year or about three per week.
But the official figures are underestimates, according to Abhijit Das of the Centre for Health and Social Justice in Delhi, which is part of the National Coalition against the Two Child Norm and Coercive Population Policies. In a 2004 paper in the Economic and Political Weekly, Das and his co-authors estimated that 19 of every 1,00,000 women who undergo tubectomies in India die – more than five times the rate reported by the government. There is no reason to believe that this death rate has changed.
Between 40 lakh and 50 lakh tubectomies are conducted annually, which means between 760 and 950 women die annually from this elective procedure, or more than two women a day. Half of the women undergoing this surgery suffer long-term complications like pain, bleeding and infection.
These numbers don’t figure in the official records because many deaths on the operating table will never get recorded, says Jashodhara Dasgupta of Sahayog, a Lucknow-based non-profit organisation and part of the Healthwatch network. “In government hospitals, when a woman dies during childbirth, the staff simply vanishes, and the same could happen when women die following tubectomy.”
The vast majority of sterilisations in India are conducted on women, though male sterilisation or vasectomy is short, simple and safe. The tubectomy, or cutting of the fallopian tubes, is more risky. About 60% of tubectomies in India are done through open surgery. Laparoscopic tubectomy is conducted with instruments inserted through small incisions in the abdomen and has a higher risk of puncturing an organ or a blood vessel, and infection.
In both types of surgery, women with anaemia, heart or lung disease, general weakness and other health conditions are at greater risk of complications and death. The procedure should be done only by trained doctors and it requires high standards of competence, infection control and screening. According to the government’s manual of standards and quality assurance in sterilisation services, laid down after the 2005 Supreme Court order, three surgical teams together may conduct a maximum of 30 sterilisations in one day. The manual also states that women should be given information, in a language they understand, on the risk and consequences of sterilisation as well as other contraceptive options before their consent is obtained for surgery.
The government is required to pay Rs 30,000 to a woman when the surgery fails, up to Rs 25,000 reimbursing medical expenses for complications, and between Rs 50,000 and Rs 2 lakh to the family of a woman who dies during or after surgery. But even in the case of officially reported failures, injuries or deaths, many families do not receive compensation because they were not given the certificate of sterilisation necessary for them to apply for compensation – or they don’t have the time and resources to pursue their application.
Health advocates emphasise that such deaths are inevitable because of the government’s obsession with population control, its overwhelming focus on female sterilisation as a contraceptive method, and its complete disregard for poor women’s health and rights.
Appalling operating conditions
In 2008, Healthwatch and Centre for Health and Social Justice interviewed women and doctors in 17 camps in five states, and also documented the infrastructure in these camps. Most of the women were less than 30 years old, non-literate, and had never used contraceptives. Seventeen percent had not been given information on any contraceptive other than sterilisation, barely one in 10 of the women had read the consent form, and 4% had not signed or affixed their thumbprint on any form.
Two of the camps did not have a generator, five had no oxygen cylinder or running water, seven had no examination table, and three had no blood pressure monitoring apparatus. It was common practice for women to be made to lie on bare mattresses after the procedure as there were no beds or bedsheets. In many camps, the surgical instruments were not consistently sterilised; one didn’t even have a boiler for this purpose. Women had to wait two to five hours after registration to be operated upon, and by the time they got to the operating table, the anaesthetic could have worn off.
These findings were only confirmed by other investigations and studies. In Bundi, Rajasthan, 749 women who had undergone sterilisation were interviewed. None of them had been screened with all the necessary tests. Only 12% had been counselled about other contraception, 88% were not told of complications, and only one woman said she was read out the consent form before her thumbprint was taken. None of the women were monitored for four hours after surgery as required, and 8% of the women were discharged when they were unconscious. Fifty-eight percent of the women reported one or more side-effects after the procedures.
In Malda, West Bengal, television reporters recorded more than 100 women being dumped in a field after the surgery, as there were no beds on which they could rest and recover. At a camp near Bhubhaneshwar, Odisha, where 56 women were sterilised in one day, the doctor used a bicycle pump to introduce air into the women’s abdomens instead of an insufflator to introduce carbon dioxide at a controlled pressure and temperature. He insisted that it was routine practice when the right equipment was available, and he had done 60,000 tubectomies, many of them with bicycle pumps.
“In Madhya Pradesh, we found that camps were being held in schools and dharamshalas, contrary to government guidelines," said Das. “Major surgery is done as if they’re cutting toenails. The question is not so much why are women dying in sterilisation camps – it is why more women are not dying.”
The 2012 public interest litigation by Devika Biswas and others was triggered by a visit to a camp in Kaparfora, Bihar. The camp had been held in a government school, contrary to government standards. Fifty-three women were operated on, under torchlight, within a period of two hours. There was one doctor in the camp and he did not change gloves or disinfect the equipment between surgeries. Once the operation was over, the women were left to recover on mats without any monitoring. One woman was operated upon even though she was pregnant, and suffered a miscarriage as a result.
The public interest litigation stated that investigations had found similar circumstances prevailing in camps in Maharashtra, Rajasthan, Madhya Pradesh and Kerala. In 2014, the state of Chhattisgarh was added to this list.
The Chhattisgarh tragedy
The largest number of reported deaths in a camp took place in November 2014, when at least 18 women died at four camps in Bilaspur, Chhattisgarh, where 137 women underwent tubectomies. Thirteen women died following the operation, and five women died after being given pre-operative medication.
Investigations found that a single surgeon operated upon 83 women in two hours at the first camp – or less than two minutes per surgery –in an abandoned hospital which had not even been fumigated beforehand. The women had been prepared for surgery by ward boys who carried them into the operation theatre and positioned them on the table. Junior staff made the incisions on the women’s abdomens. The surgeon used a single laparoscope on all 83 women, dipping it in disinfectant between procedures, and the women recuperated on the floor of the corridor outside the operation theatre. The families of the women who died did not even receive their medical records, post-mortem reports or death certificates.
Though the surgeon was arrested following public outcry, he was eventually released because the state medical association protested, and no action seems to have been taken against him. Earlier in 2014, he had been felicitated by the government for conducting a record 100,000 tubectomies. Incidentally, the government indemnifies doctors for Rs 2 lakh per claim for death due to tubectomy, up to four such claims a year.
The deaths were a reminder of the state’s preoccupation with population control and targets, states a report into the Chhattisgarh deaths, by SAMA Resource Group for Women and Health, Jan Swasthya Abhiyan, and the National Alliance for Maternal Health and Human Rights. The report called for an overhaul of the family planning programme which focuses on population control of poor and marginalised women, doing away with incentives and targets, and doing away with the emphasis on female sterilisation.
With the aggressive target-driven approach pursued for decades, the report said, “the tragedy in Chhattisgarh was waiting to happen.”