Sterilisation judgment: Beginning of a longer battle to reorient family planning programme

http://www.firstpost.com/india/sterilisation-judgment-beginning-of-a-longer-battle-to-reorient-family-planning-programme-3015478.html

-- By Maya Palit

In April 2012, Salamuni and her husband, a rickshaw puller based in Bundelkhand, visited a hospital in Chitrakoot. She was pregnant and ill, and they assumed she would get better medical treatment there. The doctor on call, Ranjana Sharma, was aggressive in her attempts to convince Salamuni to have a sterilisation operation. Despite Salamuni insisting that she was too weak, Sharma made her sign a document, gave her an injection, and initiated an abortion as well as sterilisation before the anaesthesia kicked in. According to Salamuni’s account, the doctor spent three hours pumping air into her to locate the nerve, and when she screamed from the pain, the sari she was wearing was stuffed in her mouth before she lost consciousness. She had to spend eight days recovering at a hospital in Allahabad after the ordeal because the bleeding wouldn’t stop, she told activists from Sahayog, a women’s reproductive health advocacy group.

Salamuni’s case was an extreme version of the scores of botched sterilisation jobs that are frighteningly common in India. Earlier this year, the central government reported 113 deaths caused by tubectomy surgeries in the last year, but several women’s health activists have rejected this as a conservative estimate, and the National Alliance on Maternal Health and Human Rights (NAMHHR) suggested during a press conference last Friday that approximately 1,000 of the 4 to 5 million women who undergo sterilisation die every year. This has been attributed to the appalling conditions under which the abdominal operation is conducted – often in dharamshalas, under torchlight at night, sometimes with very poor hygiene and unsanitary tools like bicycle pumps and rusty scalpels.

The particularly horrific case of the 18 women who died in 2014 after contracting septicemia and other complications in a sterilisation camp in Bilaspur, Chhattisgarh is now widely known. RK Gupta, the doctor who operated on 83 of those women over five hours was briefly put in police custody but then released because of insufficient evidence. The news that in the same year he had been rewarded for his ‘record’ career of 50,000 surgeries only epitomises the target-obsessed mentality of the Family Planning programme.

It was the gory details of a similar incident that took place four years ago — when 53 Dalit and Scheduled Caste women were operated on at night in a government school in Araria, Bihar — that convinced the Supreme Court last week to direct the Centre to end sterilisation camps across the country, acting on a petition filed in 2012 by health rights activist Devika Biswas. Activists working on maternal health and human rights have since organised meetings to discuss the implications of the judgment. While they welcomed the decision, they were not optimistic about the 3-year transition period which the Court provided the Centre, and said that until an actual blueprint is written out to end these mass camps, it is difficult to say what impact the judgement will have.

Kavita Krishnan, Secretary of the All India Progressive Women’s Association and member of the CPM pointed out at the conference that the family planning debate is still very much centred on tackling population control rather than focusing on women’s reproductive rights: "The question [should not be] about which is the next best technological fix in contraception but about what actions will empower women to gain control over their bodies, and encourage men to take responsibility for contraception," she said. Unfortunately, the focus on population control has governed family planning since the late 80s, ever since the Pomeroy method of tubal ligation through laparoscopy made abdominal operations easier to conduct. And as Deepa Dhanraj’s 1991 film Something Like A War shows, doctors had begun conducting them in unsanitary situations early on: “I spend 45 seconds per operation. I have conducted 3,13,939 operations, this year, more than two thousand in schools and government halls…” says one gynaecologist in the film.

Abhijit Das, co-founder of Healthwatch Forum and a trained doctor working at the Centre for Health and Social Justice in Delhi, added that paranoia about the population explosion has been so deeply ingrained in the public mindset that the government feels justified in its search for quick-fix solutions. The alternative, he says, is aiming for population growth to be spread over years: “India has a very young population. What you want is for reproduction to take place over time, rather than people having many babies and getting sterilised at 24. Sterilisation should also happen later because it has been associated with high regret and hysterectomy rates.”

One of the most crucial questions that was raised at the NAMHHR conference concerned the (lack of) temporary contraceptive and alternatives in the family planning programme. The post-partum intra-uterine contraceptive device (PPIUCD) is another measure that has been gaining popularity. Rajdev Chaturvedi, from the Gramin Punarnirman Sansthan in Azamgarh, Uttar Pradesh, spoke about increasing cases of the device being inserted without women’s consent or knowledge after they give birth. He was also skeptical about the impact of the judgment, claiming that the real change would involve the improvement of access to counselling for women regarding contraception, as at the moment they are targeted while they are vulnerable and in pain during deliveries.

Jashodhara Dasgupta, a coordinator of Sahayog who also works with Healthwatch Forum, UP, emphasised the importance of expanding the objectives of family planning to include a variety of contraceptives so that women can make “informed choices”. These include measures for those who find the PPIUCD invasive or adolescents at the start of their sexual lives, for whom sterilisation is entirely unnecessary. “The government has put off a long-term vision that encompasses the diversity of people’s needs for so long,” she said.

But the reason that non-consensual sterilisation is so rampant in the first place is because doctors are given annual (unofficial) targets or ELAs (Expected Levels of Achievement) to fulfil. Although the recent Supreme Court judgement directs the government against encouraging “incentivised consent” or setting even informal targets for health workers, this may well conflict with India’s commitment to providing contraceptive services to 48 million additional users as part of its family planning goals for 2020. And as of last year, more than 80 percent of the annual family planning budget was spent on promoting sterilisation. Even though the most recent National Family Health Survey statistics suggest that female sterilisation has decreased overall in many states in the last decade, in states like Andhra Pradesh, as many as 68.3 percent of women across rural and urban areas have undergone sterilisation — it doesn’t look like a problem that can be completely eradicated right away.

It remains to be seen, then, whether this judgement will be the beginning of a much longer battle to reorient the family planning programme.

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