WUNRN
INDIA-TAMIL NADU STATE - 1 WOMAN
DIES FOR EVERY 1000 STERILISATION SURGERIES
Ekatha Ann John - October 20, 2013
India-Chennai: For a state that
prides itself in maternal health, this should be a shocker: One mother dies for
every 1000 sterilisation operations in Tamil Nadu. In five months, between
April and August this year, of the 1.39 lakh women who went under the knife for
sterilisation, 129 died following the procedure.
While officials in the health
department say they have to conduct further investigation to ascertain the
cause of death, experts in the field say it is the mad rush to achieve annual
targets, and poor infrastructure that claim lives. In the past three years, 190
women died post operation. This year, there has been a three-fold increase.
According to statistics from the
directorate of family welfare, 27 women died in 2011 and 34 in 2012 - the
highest in the country. Senior officials suspect sterilisation immediately
after a C-section could be the reason behind the spurt. "At least 70% of
the cases occurred following tubectomy done immediately after caesarian
operations. We are investigating the reason behind the increase. As of now,
we've asked district level officials to avoid undertaking the procedure
immediately after a C-section," said the official.
Though sterlisation is less
complicated for men, only 1% or just 750 of them came forward for sterilisation
in 2013. While for men, it is a simple 20-minute procedure, doctors have to
keep in mind several factors for women. The government records show no man had
died after sterilisation. "Sterilisation is often combined with caesarian,
abortion or normal delivery, so complications could arise because of other
factors," said Dr S Rathnakumar, maternal health advisor to the state
health society, Tamil Nadu.
Sources in the state health
department, however, attributed the deaths to poor adherence to pre and
post-operative care and complications due to anesthesia. Although the state has
introduced a safer and a more advanced method of sterilisation - through
laparoscopic incisions, 85% of the surgeries are usual tubectomy procedures,
due to lack of infrastructure. In this procedure, the fallopian tubes - through
which the egg travels to the uterus - are surgically blocked or cut. The
pin-hole procedures are reserved only for women after an abortion or during an
interval period after delivery.
The unusual increase in deaths
underlines two issues - callousness in recording data and poor facilities, say
public health experts. "If the number is to be believed, then the
government must have been under-reporting the actual number of deaths all
along. It just shows the laxity of the government in collecting facts,"
said Venkatesh Athreya, an economist who has worked extensively with the state
government on maternity welfare.
"If these women had died of
other complications like they say, then what are these complications. Why
aren't they reflected in the statistics? It just shows that certain procedural
protocols are not followed while investigating maternal deaths at the district
level. I am deeply shocked," said Athreya.
The number of failed
sterilisation operations in women also increased by 400 times in one year.
According to the statistics submitted by the state government to the Union
ministry, the number of failures following female sterilisation stood at 15,460
this year, 456 in 2012 and 408 in 2011. Officials had no explanation for this
unusual rise.
Simultaneously the number of
cases of complications following female sterilisation also saw a four-fold
rise, from 16 in 2011 to 63 this year. Officials said "most" of these
complications were not life threatening. Gynecologists say if post operative
care is not given properly, even seemingly simple complications could result in
death.
"Post-operative care is as
important as screening the woman before undertaking a tubectomy or laparoscopy.
A slight oversight could result in death," said Dr Geetha Haripriya,
chairperson and consultant in reproductive medicine, Prashant Hospitals.
Bleeding, infections, damage to the intestine and bladder and laceration of the
cervix and perforation of the uterus, blood vessels or the fallopian tube are
some of the risks attached to a botched surgery, she said.
"We should audit all these deaths. There should be a reason why Tamil Nadu is leading in the number of fatalities. It could be because of the lack of experienced surgeons at the district level. Whatever the reason, an investigation must be conducted," said the doctor.
____________________________________________________
From: WUNRN
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To: WUNRN ListServe
Sent: Tuesday, August 28, 2012 2:12 PM
Subject: India - Expanded Contraceptives - Targets - Sterilization
Issues
WUNRN
Human Rights Watch
INDIA - EXPANDED CONTRACEPTIVES -
TARGETS - STERILIZATION ISSUES
Reproductive Rights Must Be Integral
to Contraceptive Services
(New Delhi) – July 12, 2012 - India
should eliminate coercive female sterilization practices as it implements plans
for the expanded contraceptive services it announced at an international
conference in London, Human Rights Watch and two reproductive health rights
networks, the Coalition
Against Two Child Norm and Coercive Population Policies [4]and CommonHealth
Coalition for Maternal-Neonatal Health and Safe Abortions [5], said today.
The Indian government announced on July 11, 2012, at the London Summit for
Family Planning that it has brought about “a paradigm shift” in its approach
and will emphasize promotion and provision of contraceptives for birth spacing.
The Indian government announced that its new strategy focuses on “making
contraceptives available at the doorstep through 860,000 community health
workers,” providing services for inserting intrauterine devices (IUDs) on fixed
days in public health facilities, and improving post-natal services for IUDs,
especially in those public health facilities that have large numbers of women
coming to give birth.
But the ongoing focus of the Indian central and state governments on
achieving numerical targets for use of contraception, especially female
sterilization, has contributed to a coercive environment for several decades,
and should not be replicated going forward.
Unless India’s approach to contraception is revised, community health workers
may come under increased pressure to meet contraceptive targets, the rights
groups said. The government’s plans should ensure that all community health and
nutrition workers give women adequate information about HIV prevention,
sterilization, and other contraceptive choices.
Two years after the 1994 International Conference on Population and
Development, India announced that it would take a “target-free” approach to
family planning. Since then, the Indian government has stopped setting
centralized targets. But in practice, state-level authorities and district
health officials assign targets for health workers for every contraceptive method,
including female sterilization.
In much of the country, authorities aggressively pursue targets, especially for
female sterilization, by threatening health workers with salary cuts or
dismissals. As a result, some health workers pressure women to undergo
sterilization without providing sufficient information, either about possible
complications, its irreversibility, or safer sex practices after the procedure.
“Health workers who miss sterilization targets because they give proper
counseling and accurate information about contraception risk losing their jobs
in many parts of the country,” said Aruna Kashyap, women’s rights researcher at
Human Rights Watch. “The Indian government should work with civil society to
ensure that mechanisms to monitor progress in contraceptive use emphasize
quality and respect for reproductive rights.”
In June, Human Rights Watch interviewed more than four dozen Female Health
Workers and early childhood careand nutrition workers, called anganwadiworkers,
andAccredited Social Health Activists (ASHA) from two districts in Gujarat
state about their family planning work in rural areas, as well as various
health experts. Both Gujarat districts have large adivasi(indigenous
tribal) populations, which are among the most impoverished groups in the state.
More than 50 health workers told Human Rights Watch that district and
sub-district authorities assigned individual yearly targets for contraceptives,
with a heavy focus on female sterilization. Almost all said that their
supervisors or other higher-ups threatened them with adverse consequences if
they did not achieve their targets.
These included threats to withhold or reduce salary, negative performance
assessment, or suspension and dismissals. In one case, a health worker reported
that she was asked to falsify records to show she had met targets or else she
would be reported for poor performance. One women’s rights organization that
has more than a decade of experience working with community health workers in
various parts of Gujarat confirmed that state and district health authorities
have consistently set such targets and threatened health workers.
Experts from across India have repeatedly voiced concerns about contraceptive
targets leading to coercion and poor quality services. This was highlighted
during state-level consultations and a national conference hosted by the Family
Planning Association of India in New Delhi in June. At that conference, experts
reiterated their decades-long demand for contraceptive choice and better quality
services instead of a focus on numbers of people accessing contraceptives or
undergoing female sterilization.
“Information about contraceptive choice and quality of services should not be
sacrificed for numbers,” said Dr. SundariRavindran, steering committee member
of the CommonHealth Coalition. “Hounding a poor woman to get sterilized without
proper information and leaving her to deal with negative reproductive health
consequences cannot be seen as success.”
State authorities in some parts of India also use incentives – including cars,
gold coins, and drawings for prizes – to “promote” sterilization. Because male
sterilization is not well-accepted socially, this almost always means female
sterilization. The most recent District Level Household and
Facility Survey from 2008 [6]shows that
of the 54 percent of the population that reported using any method of
contraception, female sterilization accounted for 34 percent and male
sterilization accounted for 1 percent of contraceptive use.
Aside from family planning programs, sterilization is pursued through other
programs that are entirely funded by state governments. For example, five
states have introduced “girl child promotion” programs, which provide monetary
benefits to parents of girls, with a final cash benefit if she reaches the age
of 18 unmarried. But to receive benefits, a couple must produce a sterilization
certificate.
Experts have repeatedly called for the Indian central government to refashion
its family planning program to take into account social factors related to
childbearing, including early marriage, the preference for sons, infant and
child mortality, and the country’s lack of social security for the elderly.
The Indian central government’s failure to implement social security programs
has been a major deterrent to contraceptive use since many families say they
rely on their children, especially sons, to care for them in old age. India
created a National Policy for Older Persons in 1999 and passed the Maintenance
and Welfare of Parents and Senior Citizens Act, 2007. But little has been done
to implement the policy and law.Indian experts participating in the Delhi
conference pointed out that pursuing an agenda of sterilization without
addressing old age security only increases the risk of illegal sex-selective
abortions.
“Son preference and choices about birth are intrinsically linked to fears about
old age insecurity,” said Dr. Subha Sri, steering committee member of
CommonHealth coalition. “By failing to address old age security for the poor,
India is both turning its back on families pressured to meet targets and
increasing the likelihood of sex-selective abortions.”
India’s family planning program focuses predominantly on women, with little
interaction and engagement with men. At the same time, it is men who often
decide when to have sex and how many children to produce. For India to be
successful in its renewed efforts at family planning, it should engage
effectively with men too, the rights groups said.
With early marriage prevalent in many areas and with India having the highest
number of adolescents in the world [7],
information about reproductive and sexual health should become an important
part of both school curricula and health services for adolescents. India’s 2003
Youth Policy specifically recognized that “information in respect of the
reproductive health system should form part of the educational curriculum.” But
nearly a decade after the Youth Policy was introduced India has yet to
introduce compulsory sex education for adolescents.
“In sex education, there are no shortcuts to engaging with both adolescents and
men,” said Dr. Abhijit Das, steering committee member of the National Coalition
Against Two Child Norm. “India should treat age-appropriate compulsory sex
education – both inside and outside schools as integral to its new chapter on
family planning and find a way of engaging men effectively.”
As India moves into its new phase of contraceptive services, the Indian
government should:
For details of the findings of Human Rights Watch’s research in
Gujarat state, statements of health workers, and information about India’s
family planning program, please see below.
Pressure for Female Sterilization and IUDs; Threats and
Incentives
In June, Human Rights Watch interviewed health workers about family planning
practices in two districts in Gujarat. More than 50 health workers said that
each of them was assigned individual targets for family planning services,
including female sterilization and insertion of IUDs, that they were expected
to meet every year. Almost all said that their supervisors or other higher-ups
inappropriately pressured them with threats to achieve such targets.
Threats to Meet Sterilization Targets
Five Female Health Workers interviewed by Human Rights Watch said that each of
them, together with their male counterpart (called a Multipurpose Health
Worker), had to ensure that at least 30 women were sterilized annually. They
delegated meeting this target partly to ASHAs, the community health workerswho
helped “motivate” women to undergo sterilization. At the village level, anganwadi
workers also said they had sterilization targets to achieve and were expected
to speak to women they knew.
One angawadi worker, Truptibein (name changed), recalled a planning
meeting for anganwadiworkers with their supervisor in April:
Each of us has to bring five women for operation [sterilization] in one year, the CDPO [Child Development Project Officer] told us in the meeting. This announcement they make every year… It has been like this almost since the time I was appointed [in the late 1980s]. If we don’t do this, they say they will deduct our salary or that our salary will be stopped.
Truptibein said that when these targets are not met:
They shout at those who have not fulfilled their targets during meetings. It’s humiliating. They say, “If others can achieve the target, why can’t you? You must know some women? You must have relatives or some contacts after working in the villages? Use them and get women operated [sterilized].”
Alokabein(name changed), a municipal corporation community-based health worker (officially called a link worker) who works in a slum in Gujarat told Human Rights Watch:
I have to bring one woman every month for the operation. The MO [medical officer] or my supervisor says, “Go bring them from wherever you want, it’s not our business. Find them. But you must bring one woman for operation every month. If you cannot even bring one woman in a month for operation it means you are not doing your work properly.” They say they will complain about us. [Or] remove us from our jobs if we don’t complete this target. We are told, “Until a woman agrees for the operation keep hounding her.”
To meet targets, health workers said they repeatedly visited women to
convince them to get sterilized. Truptibein said, “I have to keep going to
women’s houses. Sometimes in one week I go 10 times to one woman’s house.”
Alokabein said:
These government officers and doctors don’t know what it is like to work and live in the same basti [area]. If we don’t get the mother-in-law and husband to agree for sterilization, tomorrow they will create problems for the daughter-in-law and they will all show up in our houses since we live in the community.
Gujarat state is not alone in the practice of threatening to punish health
workers who fail to meet sterilization and other family planning targets. The
Indian government’s Advisory
Committee for Community Action [8],a
health advisory body, reported in 2011 that the Madhya Pradesh state government
had suspended health workers for not meeting family planning targets.
Even though Gujarat has established targets for many forms of contraceptives,
health workers said pressure from supervisors was strongest when it came to
female sterilization. Two health workers said they felt constrained to present
women only with the choice of female sterilization and emphasize that option
over other methods of contraception. Alokabein said she risked the ire of her
supervisor by discussing other contraceptive options:
To fulfill targets they operate [sterilize] really young women—20, 22, 24, 25 years. These women are really young and then their bodies gain weight after a few years and they find it very hard to work... They [supervisors] tell us not to tell women these things. But women can see for themselves that this happens so they are reluctant. So I tell young women to use Copper T [IUD] if they don’t want to go for operation. If my supervisor finds out I’ve been saying this in the slum she will shout at me. Maybe I’ll lose my job, but maybe she won’t be that angry because I can tell her I’ve fulfilled my Copper-T target. But because she doesn’t go to the slum and I make the reports, she doesn’t know all this and I get saved. I feel really bad telling women they should only do operation. This kind of pressure for operation is not correct.
Examples of Threats to Meet IUD Targets
Health workers in Gujarat told Human Rights Watch that they also faced threats
and pressure if they did not meet targets for women agreeing to use Copper-T,
an IUD.They said that they had an annual target for Copper-Ts, and in some
cases were pressured to falsify records to show that the targets were met.
Alokabein said she was asked to bring at least three women every month for
insertion of the Copper-T:
One month I was not able to fulfill my Copper-T target so my supervisor said, “Don’t you know three women’s names from your slum? Just write three women’s names and give it.” I felt really bad and fought with her. I said “How can I write three women’s names even if they haven’t come for this?” She got really angry with me and told me to just write three names if I did not want to get into trouble for not meeting my target. So I wrote some three women’s names saying they had come for Copper-T.
These problems are not unique to Gujarat. Indian health rights activists
have for decades pointed to the flaws in this target-driven
incentives-disincentives approach and shown how this approach violates women’s
reproductive rights.
Incentives to Meet Sterilization Targets
In addition to threats against health workers, some states have offered
“incentives” for sterilization, drawing widespread
criticism from Indian civil society [9]. In 2011, the Madhya Pradesh government announced that anyone opting
for sterilization would get a Tata Nano car, and at least one district
announced gun
licenses [10]for men who agreed to be
sterilized.Similarly,several
districts in Rajasthan state [11]in 2011
announced lucky draws for couples who opted for sterilization, giving away expensive
prizes including cars, bikes, and refrigerators.
Pressure for female sterilization comes up in other government programs beyond
family planning. For example, the condition of sterilization is attached to
“girl child promotion” programs in five states in India. Associate Professor
T.V. Sekher of the Tata Institute of Social Sciences, the author of a United
Nations Population Fund-sponsored study
[12]about Indian programs to promote
acceptance of girl children and correct son preference, said that Andhra
Pradesh, Karnataka, Madhya Pradesh, Punjab, and Himachal Pradesh state
governments had programs in which couples had to produce sterilization
certificates to be eligible for benefits (including monetary payments). This
led to female sterilization because that was considered more socially
acceptable than male sterilization, he said.
Poor Quality Information and Lack of Informed Consent
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, Human Rights Watch found. Sheetalbein (name
changed), an ASHA, said, “I tell these women you can get yourself operated.
They put rings inside and tie the birth tubes and you can go back to the doctor
and take the rings out if you want to have children again.”
This inaccurate information contradicts the 2006 Standards
for Female and Male Sterilization [13],
which clearly states that sterilization is difficult and expensive to reverse.
The International Federation for Obstetricians and Gynecologists in its 2011 Guidelines
[14] for Female Contraceptive
Sterilization states that:
Information for consent includes, for instance, that sterilization should be considered irreversible, that alternatives exist such as reversible forms of family planning, that life circumstances may change, causing a person later to regret consenting to sterilization, and that procedures have a very low but significant failure rate.
At least two health workers reported to Human Rights Watch that women came
back to them and reported that they wanted to have the sterilization procedure
reversed. Several other health workers reported that female sterilization
procedures had failed. None of them had discussed these possibilities with
women before taking them for sterilization.
Similarly, contrary to Indian central government standards
[13]for pre-sterilization counseling about
how the procedure does not prevent transmission of HIV and other sexually
transmitted diseases, several Female Health Workers said that they were not
aware of any HIV-related information they needed to provide to women before or
after sterilization. When specifically asked whether they or the other outreach
workers explained the risk of HIV to couples and counseled them to engage in
safer sex even after sterilization, they said they were not aware of this.
Health workers told Human Rights Watch that both they and their male
counterparts actively seek out women for sterilization because they “found it
easier to convince women than men” to be sterilized.
Targeting Families with Sons, Larger Families
The preference for sons remains one of the most complex challenges for family
planning in India. Families from Gujarat told Human Rights Watch that they
preferred sons because of their capacity to do agricultural work and because
they could support parents in old age, and felt girls get married and go away
to their in-laws’ homes. Women who have borne sons are sought out by health
workers as prime candidates for sterilization, sometimes without their informed
consent.
Health workers from two districts of Gujarat told Human Rights Watch they
targeted women who had already given birth to sons. One ASHA who was herself
under pressure from her supervisor to be sterilized said she did not want to
undergo the procedure because she had only one son, who was very young. She
said that she approached women who had already had sons, and that most families
prefer to have at least two sons before they agree to sterilization. Another
ASHA said, “I tell women you have had two boys so you can get the operation done.”
The Center for Health and Social Justice and Manjari [15],
a nongovernmental organization, has also found that health workers target
families with sons for female sterilization in Rajasthan.
In addition, health workers said Gujarat state’s unwritten two-child norm
influenced whom they targeted for sterilization. A few health workers said that
doctors from public and private hospitals told them to press women who had
already had two live births to be sterilized. ASHAs from two villages said they
conducted a survey to find families that had more than two children, and went
to those homes to encourage women to be sterilized.
Indian health rights activists have repeatedly underscored the importance of
tackling son preference and old age security effectively, while implementing
family planning programs. Most recently, Indian experts from across the country
reiterated the need to abandon the small-family norm and address social
security for the elderly at the national conference on family planning in June.
Activists at the conference cited sex-selective abortions as a danger of
aggressively pursuing female sterilization and a small-family norm in the
context of son preference.
Sterilization and IUD “Camps”
Many states in India perform sterilization en masse through “camps,”
which involve using surgical facilities for one or more days for dozens of
procedures. Recently, Tamil Nadu state also started conducting IUD camps.
In 2008, the Indian central government developed guidelines
[16]for “fixed day static services” to move
away from the earlier method of conducting sterilization through periodic
camps. However, these have actually resulted in what health workers now refer
to as “weekly camps.” According to the 2008 guidelines, a district or block
health facility should conduct 30 sterilization procedures every week. The 2008
guidelines supplement the Indian government’s 2006 Quality Assurance
Manual for SterilizationServices [17]and
the 2006 Standards
for Female and Male Sterilization Services [13].
These guidelines require that sterilizations be performed only with informed
consent and counseling about possible complications, and require hygienic
conditions and adequate equipment. Yet experts told Human Rights Watch that not
all camps meet these requirements, sometimes resulting in complications from
sterilization surgeries and even deaths.
Following orders of the Supreme Court in public interest litigation brought in
2003, the central government created an insurance plan to compensate families
for deaths arising from female sterilization-related complications. But the
focus on the numbers of women sterilized at these camps has overshadowed
concerns about quality. Experts have repeatedly expressed concern that this
insurance program is not being implemented properly and that quality continues
to be a problem.
For example, in February 2012, a health rights activist from Bihar filed a public
interest litigation [18] with the
Indian Supreme Court alleging lack of informed consent and poor quality
services when 53 women were sterilized in Bihar state within two hours.
Health workers in Gujarat told Human Rights Watch that between 40 and 150 women
are sterilized in weekly camps in their district. Dr. Abhijit Das from the
Centre for Health and Social Justice, a leading Delhi-based health rights
organization, told Human Rights Watch that he found at least one gynecologist
in Madhya Pradesh state conducting 250 to 300 sterilizations on some days.
In one state, a study found that the state’s approach to female sterilization
forced doctors in the public hospital to commit so much staff time to
sterilization camps that other basic reproductive health care suffered. A civil
society team that investigated
[19]maternal deaths in Barwani district of
Madhya Pradesh state found that the senior gynecologist from the district
hospital was absent four days in a week, performing sterilizations in camps.
Recent evidence suggests that the “camp” approach is being expanded for
insertion of IUDs as well. A gynecologist from Tamil Nadu told Human Rights
Watch that Tamil Nadu has started conducting camps in primary health centers
for insertion of Copper-T IUDs. She told Human Rights Watch that camps in her district
insert IUDs in 30 to 35 women a day. She expressed concern about the quality
and availability of sterile equipment at primary health centers to handle this
many procedures and also expressed concerns about informed consent.
Policies and Numerical Targets
India adopted a “Target-Free Approach” to Family Planning in 1996 and
introduced the National
Population Policy [20]in 2000, which
“affirms the commitment of government toward voluntary and informed choice and
consent of citizens while availing of reproductive health care services, and
continuation of the target free approach in administering family planning
services.” The “target free approach” does not, in fact, eliminate targets,
which were originally driven by the notion of populationstabilization. Even
though on paper it leaves setting targets to states using a community-needs
approach, little has changed on the ground.
Despite the policy’s stated commitment to reproductive health, informed
consent, and choice of contraceptives, local experts have consistently
criticized it for continuing “population control” and “population
stabilization” as the approach for family planning. Experts from across the
country at the June conference in New Delhi recommended that the Indian central
government review the National Population Policy to shift its focus from
demographics to individual rights.
Female sterilization continues to be the predominant method of family planning
in India. The preference for female sterilization as a method of family
planning is reflected in funding patterns, said the Centre for Health and
Social Justice, based on its analysis of budgetary allocations for annual
health plans for 2011-2012. Even states that have achieved replacement
fertility continue to pursue female sterilization as a key contraceptive
method. For example, recent health survey data shows that even states like Tamil Nadu [21]– which has already achieved replacement
fertility – pursue female sterilization as the predominant method, though it
has recently shifted attention to IUDs using the camp approach.
Every state sets targets in its annual health plan for female sterilization,
male sterilization, insertion of IUDs, and distribution of contraceptive pills.
A central government body, the National Project Coordination Committee, reviews
these targets and allocates funds for family planning in every state.
Sterilization targets are increased manifold at times. For example, Dr. Abhijit
Das from the Centre for Health and Social Justice, found that in Bihar state
fewer than 150,000 sterilization operations were “achieved” in 2005-2006 and
the target for 2011-2012 was set at 650,000 – nearly a four-fold increase.
Similarly, he told Human Rights Watch that Madhya Pradesh set a target of
700,000 for sterilization, doubling what was achieved in earlier years.