Gyanibai Meena still remembers how scared she was when her stomach kept swelling seven years ago. The doctors at a primary health centre near her house in Parnala village in Rajasthan’s Pratapgarh district told her that she could have a gaanth or tumour in her stomach. But when she went to a referral hospital, the doctors told her that there was no tumour. She was five months pregnant.

This came as a shock because the 34-year-old had undergone a sterilisation procedure in 2008 – a couple of years after she had her fourth child.

The procedure, called tubectomy or tubal ligation, is a surgery that blocks the fallopian tubes, which prevents eggs from travelling from the ovaries to the uterus, thereby preventing pregnancy. It is the most common sterilisation procedure in India, where female sterilisation accounts for 98% of all sterilisations.

Complications and deaths from female sterilisation surgeries have been frequently reported in India, partly because such procedures are often conducted on a mass scale in poorly-equipped medical camps. Not much attention, however, has been given to cases like Meena’s, where the surgery itself failed to prevent pregnancy.

Internationally, the sterilisation failure rate in women is about 0.5%. Some reports suggest that the rate is higher in India. A 2010 report released by the non profit organisation Centre for Health and Social Justice, based on conversations with 749 women in Bundi district of Rajasthan, suggeste that the failure rate in the district was 2.5%, five times that of the international standard.

Dr Abhijit Das, director of Centre for Health and Social Justice, said that women are often not screened to check if they are pregnant before they undergo the sterilisation surgery. “Sometimes, the surgeons in a hurry also mistake ligaments instead of the fallopian tube and band them instead,” he said. “If women undergo tubectomies at a very young age, the chances of recanalisation (restoring the flow in the tube) is higher.

Government compensation is hard to get

In 2005, the Supreme Court ordered the Union government to lay down norms for compensating women like Meena who suffer complications or failure after the sterilisation surgery, as well as the families of those who die on account of it. The government fixed the Rs 30,000 compensation for failure, up to Rs 25,000 for complications and between Rs 50,000 and Rs 2 lakh in case of death.

However, this compensation is not easy to get.

For one, there is confusion over the time period during which the compensation can be claimed.

According to the Family Planning Indemnity Scheme, a union government scheme established in 2005, the woman can claim compensation with district authorities within 90 days of the “occurrence of the event of death/failure/complication”.

When it comes to cases of failed surgeries, some government officials interpret the time period as starting from the date of the sterilisation surgery, but others interpret it as starting from the beginning of the pregnancy.

Dr SK Sikdar, deputy commissioner for family planning with the Ministry of Health and Family Welfare, said that the 90 day limit starts from the time a woman discovers she is pregnant. He said that they have clarified this to the state governments from time to time.

Poonam Muttreja, executive director of the nonprofit organisation Population Foundation of India, said the ambiguity shows that the scheme had been drafted poorly. “Civil society was not consulted while the scheme was drafted,” she further pointed out.

In Rajasthan, the health department has denied compensation to women on the grounds that they filed claims after the stipulated time, said Sudhindra Kumavat, a lawyer who has represented women reporting failures of sterilisation at the Rajasthan High Court.

Dr SM Mittal, director of Rajasthan’s family planning programme, said that as per guidelines, women who have undergone sterilisation surgeries must go back to a government health facility a month later for a checkup. If they are not pregnant, the surgery is considered successful, and a certificate of sterilisation is issued. “If they are pregnant, we offer them abortion services,” he said.

Mittal admitted there is nothing in the programme to address the needs of women who may get pregnant beyond the first month after the surgery.

Sulakshana Nandi, a researcher who is a member of the health advocacy organisation Jan Swasthya Abhiyan, said women often do not return to the health facility after their surgery. “The stitches are usually removed by the ANM [Auxiliary Nurse and Midwife] in the village itself,” she said.

Lack of awareness

But the larger problem is that many women who underwent sterilisation did not know that they were eligible for compensation in the case the surgery fails.

Many women, like Gyanibai Meena, are not counselled about the various possible complications or possible failure of the procedure, said Chhaya Pachuali, senior programme co-ordinator of Prayas, a non-government organisation working on health ad gender in Rajasthan. Often, the women are not told about their eligibility for compensation either.

The National Family Health Survey 2015-’16 showed that only 46.5% of users of any kind of contraception – permanent or temporary – were told about their side effects and possible failures. In Rajasthan, this figure is even lower at 43.5%, and in Pratapgarh district, it drops to as low as 26.7%.

Sikdar, however, defended family planning departments, claiming that compensation for side effects and failure is mentioned in the consent form that a woman is made to sign before the sterilisation surgery. But, in a country where levels of literacy are low, would it not be better to verbally inform patients?

“We cannot say to the face of the client or family that if the women dies, she can get compensation,” he said.

Legal fight

Given the low levels of awareness, when Prayas decided to take help women who experienced sterilisation failures move courts for compensation, the organisation had a tough time finding complainants.

“A lady from Prayas came to our bus stop and asked around,” said Mukesh Dholi, a resident of Hiraji ka Kheda village in Chittaurgarh district. “Some villagers told her that there is a case of sterilisation failure and sent her to our home.”

Dholi’s wife, Pushpa, underwent a surgery in 2008, but was pregnant again four years later. She had a son in 2013.

Pushpa Dholi’s case became one of seven in which the Rajasthan High Court, on October 3 this year, ordered the family health department to pay compensation. Over the last three years, Prayas has helped 38 women in the state successfully fight for compensation in the court for sterilisation failure.

Meerabai Meena, her husband Mohanlal with their three year old daughter Laxmi. Credit: Menaka Rao

Long-lasting trauma

But the paltry sum of Rs 30,000 as compensation cannot reverse the long-term effects of an unwanted pregnancy.Forty-seven year old Meerabai Meena had four children before she underwent a sterilisation procedure in 2003. Ten years later, the resident of Rosadipada village in Baswara district was shocked to discover she was three months pregnant. “We went to about some three doctors to get an abortion but they refused,” she said. Abortion is allowed upto 20 weeks, a little over four months.
Meerabai Meena now has a three-year old child, Laxmi. “I have to take her to work and often carry her while working.” This is hard, given that she works as a daily wage labourer in the fields.
Gyanibai Meena too is struggling with the aftermath of her failed surgery. In 2010, she had her her fifth child. The multiple childbirths, and the failed surgery, have led to serious health problems and she experiences a constant stomach ache and, sometimes, difficulty breathing, she said.
And then there are the lifelong social and economic effects.
Gyanibai Meena’s daughter, Aarti, is now seven years old and goes to school. Mocking the compensation of Rs 30,000, Meena’s husband Rajmal asked: “Will the government pay for her further studies and her wedding?”