The tragic deaths of more than a dozen women in India recently, after being sterilized in assembly-line style by a doctor and his assistants eager to cash in on as many procedures as possible on a given day — at least 83 in a few hours in this case — are the symptom of a disastrous family planning system that deprives most poor women of any other choice. They know they are risking their lives.
“Unmet need for contraception is not a demand failure,” Poonam Muttreja, executive director of the independent Population Foundation of India, said in an interview in 2011. “The demand exists, the supply does not.”
In November, Muttreja said in a statement: “Family planning saves lives. When it ends up taking the lives of young mothers, or inflicts them with lifelong morbidity, it is a tragedy of monumental proportions as we have seen in Chhattisgarh. PFI urges the government to make available a wide range of quality temporary contraceptive methods, give clear and adequate medically accurate information, including the benefits and risks, so that individuals can choose the method they want to adopt.”
Fewer than half the women of childbearing age in India use any “modern” contraceptive, United Nations data show, and for most of them that means sterilization.
The breakthrough International Conference on Population and Development, held in Cairo in 1994, made the case for choice very clear: reproductive health, most nations of the world agreed, included “the right of men and women to be informed and to have access to safe, effective, affordable methods of family planning of their choice.”
The medical abuse of women in often filthy “sterilization camps” set up on designated days in India is not strictly a result of population control policies, as many have surmised. Those policies were largely abandoned after forced sterilization of men took place in the 1970s.
The situation arises instead from indifference to the health and rights of women and the failure to offer alternatives. A major problem is the setting of targets, often in corrupt local or state health care systems, which allow doctors to offer incentives, such as a small amount of cash or a gift, to a poor woman who may want to limit the number of children she has, while contributing something to the family’s meager resources. The doctor is rewarded according to the number of women he sterilizes.
Human Rights Watch, which has tracked sterilization in India, said earlier this year that in addition, “women and girls with intellectual disabilities continue to be sterilized without their consent.”
India is not alone in relying on sterilization as a major birth-control tool, though it stands out for denying poor women, many at a very young age, a choice of other and reversible methods. Globally, according to the UN Population Division, 18.9 percent of women, married or in an established partnership and using any “modern” birth control are sterilized, compared with 2.4 percent of men.
India, with 1.2 billion people, leads the world numerically in female sterilization, with almost 36 percent of women seeking contraception undergoing the procedure, while only 3.6 percent use birth control pills, and statistically virtually none use injectables or implants that are popular — and available — in many other developing countries.
Sterilization for women in Africa is statistically low: in single percentage digits except for South Africa, Namibia and Cape Verde, according to recent data from the UN Population Division. Figures are higher generally in Latin America and the Caribbean, with the Dominican Republic reporting 47.4 percent of women using sterilization as a family planning method, a higher percentage than in India, but far lower numerically.
In Asia, China and Thailand are the leaders in percentage terms — 28.7 for China and 23.7 for Thailand. In many of these places, however, tubal ligation procedures are performed in a hospital or clinic, reducing complications. To add to the sad story of Chhattisgarh, women were sent home with phony antibiotics and painkillers, a widespread problem in India, where pharmaceutical products are often found to be fraudulent.
In a report in September this year, the Guttmacher Institute, a leader in family planning research, looked at 109 low- and middle-income countries, including India, where contraceptive practices were skewed inordinately to one method.
The report made this important distinction: “Skewed method mix is not a definitive indicator of lack of choice or of provider bias. Rather, it is a potential red flag, worthy of further investigation at the country level. If the preference reflects cultural or societal norms (in the presence of reasonable access to a range of contraceptives), then there is no reason for concern. By contrast, if the predominance of a single method results from lack of access to multiple methods or provider bias, then choice is compromised.”
The deaths in the Indian state of Chhattisgarh have provoked outrage in the Indian media. The Hindustan Times, in an article titled “Death by Sterilization in India: Chhattisgarh Is Just One Horror,” pointed out that the procedures that left at least 13 women dead and almost 140 ill, some of them critically, directly violated a 2005 Indian Supreme Court ruling that a medical team should conduct only 30 tubal ligations a day, with each doctor limited to 10.
“In 2012, India committed to providing 48 million additional women and girls with access to contraceptives by 2020,” the newspaper reported. “However in India about one in five women of reproductive age do not have access to [a] modern method of contraception.”
As a result, millions of women are herded into sterilization camps and clinics. The newspaper added that this number may in fact grow as India tries to meet its targets in providing family planning and takes the easy way out by expanding sterilization.