Family planning in India: When failing to plan, is planning to fail

Deaths of women caused by unsanitary and unsafe sterilisation procedures have been a shameful chapter in India’s family planning (FP) history.  They are also a recurring phenomena, but fail to garner enough collective outrage for the wrongdoers to be held accountable. In this regard, the Supreme Court’s (SC) order on September 14, 2016, came as a landmark step towards a reform in the FP program, and for building a system more cognisant of women’s sexual and reproductive health and rights.

This ruling comes in response to a PIL filed by Devika Biswas, a health rights activist hailing from Bihar, who has worked in the development sector and has been associated with the Integrated Child Development scheme in Bihar.

Problems with the Family Planning program in India

The SC pointed out a host of issues with the current implementation of the FP program, which demand immediate attention and correction. It said that the basis of Biswas’ PIL were the events of January 7, 2012, when 53 women underwent a sterilisation procedure in the Kaparfora Govt. Middle School in the Araria district of Bihar, between 8:00-10:00 pm. Only one doctor operated on all the women, reportedly without changing his gloves. The procedure took place in a school instead of an accredited hospital— using school desks as beds, without running water and under torchlight. Moreover, the patients were neither given any counselling, nor did they undergo any pre-operative tests.

Similar incidents of negligent, unsanitary surgeries, as mentioned in the SC ruling, were reported in Bilaspur (Chhattisgarh) in November 2014 and Balaghat (Madhya Pradesh) in February 2012. According to research done by the Centre of Health and Social Justice (Delhi) in 2010 in Bundi (Rajasthan), sterilisation procedures took place there on 749 women, mostly underprivileged, between 2009-2010. Out of these, 88% did not receive information about complications and side-effects. The failure rate here was 2.5%, which is 5 times the international standard of 0.5%. In July 2011, a local journalist of Wayanad and a Chief of the Kattunayakam tribe met with many women in Kerala, who complained they were coerced into going through the procedure, thus raising concerns about the tribe’s population.

Targeting socially vulnerable groups, as in the case of the Kattunayakam tribe, is another disturbing trend in the implementation of the FP program. The SC report, in this context, defines vulnerable groups as the economically weaker sections of the society that do not have access to the “range of reproductive health information, goods, facilities and services”, in order to “make informed, free and responsible decisions about reproductive behaviour”.

This apparent targeting is testament to the purely number-based agenda driving the health-workers, with incentives being given for achieving the ‘target’ number of sterilisations— as it is much easier to coerce or lure economically weaker sections. Even though it was announced in 1996, that the target-based approach will be done away with, the practised reality remained vastly different. Reduced to an undignified statistic in a government ledger, women have been known to undergo sterilisation even in candle-light, with the appropriate equipment often being dispensed with.

The SC made the significant observation that the FP program, with its agenda for population control, is “effectively a relentless campaign for female sterilisation”. According to statistics from the Ministry of Health and Family Welfare, 97.4% of the sterilisations being performed on women in 2012-13; in 2014-25 the figure went up to 98.1%. Between 2010-13, 363 people have been reported dead as a result of the procedure.

These procedures are done not only in violation of consent, but are also often carried out using coercive methods and misinformation. Women’s access to information is low, and difficult. Not only because many of them  are not at liberty to venture outdoors, but also because literacy rates among rural women are alarmingly low. Therefore, any physical posters or notices are redundant. The intervention of community radio in some parts of the country, and the mediation of ASHA workers is still the only window to information for several women.

Women’s access to technology and information, especially in rural areas, is not only difficult, but riddled with surveillance by other family members. According to data recently reported by Groupe Spécial Mobile Association (GSMA), men are 25% more likely to own SIM cards than women, and are 62% more likely to be internet users as compared to women. This is an important indicator of the skewed access ratio of women to information technology. Creating awareness around healthy contraception, and post-op care, therefore becomes a huge challenge, with the results often being mortality and morbidity. It is important to note here that most women who are prevailed upon to undergo these procedures belong to vulnerable groups.

The problem of post-op care is worsened by the absence of follow-up procedures between the patient and medical practitioner, just like there are no provisions for screening women before sterilisation. As a result, women suffering from anaemia and other conditions are also operated upon without due diligence.

One of the fundamental indicators of India’s failure to design and implement the FP program with a holistic view to overall development, is that India’s healthcare spending accounts for a measly 1.3% of the Gross Domestic Product (GDP), according to data from the Population Foundation of India (PFI). This is not only lower than all BRICS countries, but is also one of the lowest in the world. The problem is compounded by the fact that the issue of family planning is viewed almost uni-dimensionally through the lens of population control.

Sterilisations are a fairly simple procedure, and according to research, also one of the safest. Yet, in India, far too many women have suffered as a result of this. It is important to bring about a paradigm shift in the manner in which FP is being visualised and executed in India, instead of furthering the blind spot for women’s health.

The SC’s Intervention

The SC order was welcomed by researchers and activists as a landmark intervention in a program that was marred by decades of executional dereliction and lethargy of vision. Significantly, the SC ruling mentioned that the attitude of the Central government, in treating sterilisations as a “public health issue” thereby making the State governments accountable, “appears to be a case of passing the buck”. The Centre was overlooking Entry 20A in the Concurrent List, which is “Population Control and Family Planning”, of which sterilisations are an obvious and direct part. The SC has therefore exhorted the Central and State governments to respect the structure of cooperative federalism.

It stated that, for the time being, no doctor without gynaecological training and at least 5 years of experience should be allowed to carry out sterilisations.

A provision was also laid down for compensating the families of those who died as a result of the procedure, amounting to Rs. 1 lakh.

The Centre has been directed to lay down uniform guidelines for the conduct of the operation within a period of 4 weeks, and to ensure that FP targets are not ‘fixed’. Sterilisation camps are to be stopped in the next 3 years.

Family planning should be improved through making awareness-related content available in all regional languages, and by easing access to the empanelled doctors.

The Road Ahead for Policy-Makers and Public

The biggest challenge and fundamental need is to view health as a social justice issue, and FP from a women's rights perspective rather than a simplistic welfarist approach.

Women's rights need to be at the centre of FP program, making space for legal justice in case of mortalities and morbidities as a result of  sterilisation.

Equal emphasis has to be laid on spacing methods of contraception, such as oral pills (like Centchroman, popularly known as Saheli and Novex), injectable contraceptives, intrauterine devices and even female condoms.

Civil society has also, time and again, clamoured for an increase in healthcare spending to at least 3% of the GDP, instead of the current 1.3%.

The Centre must prevail on the State governments to follow the guidelines already formulated by the Department of Health and Family for Safe Sterilisations. The Indian Medical Association and the Federation of Obstetricians and Gynaecologists Society of India must also be made to weigh in with recommendations and guidelines.

For the purpose of reaching out to the teeming millions in India, collaboration is key. Partnerships with community radio operating in regional languages, as also with grassroots organisations working in rural areas, is the way forward for the dissemination of information.

The Supreme Court had stated in its order that “it is time that women and men are treated with respect and dignity, and not as mere statistics in the sterilisation program”. Not only do we need to proceed with a more humanised attitude, but we must also question the use of sensationalised, narrow frameworks of language and iconography, and make it body-positive, pleasure-affirming, egalitarian and cognisant of the woman as an autonomous entity. The stigma around abortion as a crime must be dismantled by highlighting the need for safe, consensual, sanitary abortions as a part of planned parenthood. Moreover, the time has come to not only talk about ‘planned’ families, but also ‘equal’ families.