WUNRN
INDIA - CASH INCENTIVES FOR
STERILIZATION OF WOMEN - CONCERNS FOR
MANDATORY INFORMATION ON PROCEDURE
& ALTERNATIVES + HEALTH SAFETY
Spurred by cash incentives, state workers in the state of Rajasthan offer prizes to women to undergo tubal ligation in mass sterilization drives. Critics call it a coercive process that restricts women's right to know their contraceptive choices.
A
few days after Rukma Devi underwent sterilization in the Rajsamand district of
Rajasthan, she suffered intense pain in her abdomen. Fever and body aches
followed.
Devi had
registered at one of the state's "sterilization camps," part of the
nation's campaign to reduce the number of births. The effort is characterized
by drives conducted in village primary health care clinics that aim to meet
government targets of sterilizing as many women, through tube tying, as
possible within a certain time span.
A few
months later, when the abdominal pain still hadn't gone away, the mother of
four went to a local doctor and got some shocking news.
She was
pregnant.
Rajasthan,
in the north of
These
statistics provided the backdrop for legal and health activists to discuss ways
to curb the sterilization push over a two-day meeting in
Kerry
McBroom is director of the reproductive rights unit of the Human Rights Law
Network, a New Delhi-based group of lawyers that has already spurred the
Supreme Court to rebuke the national and state governments for unhygienic
sterilizations of poor, low-caste women in many parts of the country, including
Rajasthan. She said women's rights at sterilization camps are being violated by
doctors and health facilities across the county who flout national and
international ethical and procedural guidelines.
"The
quality and nature of information that health workers provide women and their
families to convince them to be sterilized is questionable, raising doubts
about informed consent," McBroom said.
She cited the Indian government's 2006 quality-assurance protocol for
sterilization services as well as 2011 guidelines by the International
Federation for Obstetricians and Gynecologists on female contraceptive
sterilization.
Mandatory Information
Both
standards say that before a woman undergoes sterilization she must be informed
about other, reversible forms of family planning. She must also be counseled
about possible complications and, if deciding on the sterilization option, be
provided with hygienic conditions and adequate medical equipment.
Of the 225
million women aged 15 to 49 sterilized worldwide, 40 percent live in
Roughly 80
percent of all women in
But this
sterilization overdrive leads to an inordinate degree of failure.
In the
past three years Rajasthan has paid more than $10 million to compensate women
for failed sterilizations, according to information obtained under the national
Right to Information Act by Yedunath Dashanan, an activist based in Jaipur, the
state capital.
The
government's reply to that application, released in September 2012, showed
4,200 failed sterilization cases in Rajasthan between 2009 and 2011. The
response also showed 16 deaths due to sterilization complications. Tubal
ligation is generally safe, but in parts of
Still, the
state government continues to promote female sterilization to stabilize its
population and lower fertility rates. In keeping with its goal of achieving
698,604 sterilizations in 2012-13, the state medical and health department
asked its health workers in July this year to sterilize 100,000 people within
the fortnight coinciding with World Population Day (July 11).
To meet these targets, state health officials offer cars on a lottery basis
and free cooking gas connections to promote sterilization. Each health worker
who facilitates the operation also receives cash incentives, which are openly
mentioned in family planning programs.
Coerced Sterilizations
Incentives
such as these lead to coerced sterilization, mainly of women, said Dr. Abhijit
Das, director of the Centre for Health and Social Justice, a New Delhi-based
nongovernmental organization working on gender equity and health.
"
Das added
that the lack of information violates the National Population Policy 2000,
which stresses informed choice and target-free approaches in administering
family planning services. State medical practitioners, he said, reveal a
worrying degree of ignorance about national and international ethical
guidelines on sterilizations.
About 1.7
million women in Rajasthan do not have access to contraceptives, Das said.
"There is also a lack of understanding of potential adverse outcomes for
sterilizations. The poor technical quality of the services provided is leading
to increased deaths, increased failures and morbidities."
In a 2010
study of 749 women who underwent these sterilizations in the Bundi district of
Rajasthan, authors found 2.5 percent became pregnant, far above the
international standard for pregnancy following failed sterilizations of 0.5
percent.
The study
was conducted by Manjri, a nongovernmental organization based in Nainwa, Bundi
district, in collaboration with the Centre for Health and Social Justice. It
found that 88 percent of participants were not told about failures or
complications and 27 percent received no advice about post-sterilization care.
Violations
included conducting only three of the 11 mandatory physical examinations before
the surgery.
Almost all
the women were discharged within four hours of the operation, which involves
cutting or blocking the fallopian tubes, although 7.6 percent of them were
still unconscious. This too apparently violates the nation's health standards
that say a patient can be discharged four hours after the tubal ligation
surgery only if her vital signs are stable, she is fully awake, has passed
urine and can walk.