Prioritizing Reproductive Rights: The Continuing Struggle for Quality of Care in Family Planning Services

Prioritizing Reproductive Rights: The Continuing Struggle for Quality of Care in Family Planning Services

Rudrakshina Banerjee and Shreeti Shakya, Centre for Health and Social Justice

Control over one’s fertility is an important marker of women’s empowerment and a long standing demand of the feminist movement. Feminists have viewed the ability to control one’s fertility as an integral part of the right to self-determination. At the same time, there have also been concerns about the thrusting of contraceptives on women in the interest of controlling ‘population explosion’. India’s family planning program, one of the oldest and largest in the world, has the potential to give women access to much needed contraceptive services, but it is riddled with concerns around coercion and quality of care. There is an over emphasis on limiting methods as opposed to spacing methods, although the latter is what is required. As per the latest National Family Health Survey data, substantial focus continues to be given to permanent contraceptive methods, especially female sterilizations. Yet, despite female sterilization being the mainstay of family planning in the country, quality of care remains questionable. Guidelines on Standards of Female and Male Sterilisation were first issued by the Government of India way back in 1998 in order to improve the quality of family welfare services and ensure the well-being of the person undergoing sterilisation during every aspect of the procedure. However, incidents of non-compliance and violations led to filing of a writ petition in the Supreme Court of India (DevikaBiswas v Union of India). In September 2016, the court issued a strong order upholding reproductive rights and asked for a moratorium to be put on the camp-based approach and to stringently follow quality guidelines. One year after this order, we undertook an analysis of news reports related to violations arising in the conduct of female sterilizations, to understand the situation on the ground. Our analysis reveals thatdespite the Supreme Court’s directive, myriad problems continue.

Between October to December 2017 Centre for Health and Social Justice tracked news reports on the issue of female sterilisationsfromsix states. 62 news reports were collected from the states of Bihar(11), Jharkhand(3) Uttar Pradesh(9), Madhya Pradesh(30), Chattisgarh(4) and Rajasthan(5). The reports bring out different kinds of violations during sterilisation camps, someresulting in complications and even deaths. In the states of Uttar Pradesh, Bihar and Rajasthan the districts from where the incidents have been reported are all high focus districts under the Mission ParivarVikas.

 An analysis of the reports reveals a range of violations of guidelines. According to the reports, women were made to wait for hours before the surgery, as doctors were not available, and for some women surgeries were conducted in late evening.Even though the guidelines mandatesthe camps to be organised between 9am to 5pm. At acamp in Chhattisgarh,it was reported that the medical college kept 18 women waiting for 2 days without food, pre check-ups were done only on the second day, after which 4 women were found not fit and were sent home and the rest were operated on the third day. In a camp in Madhya Pradeshthe doctor reportedly left during the day and came back at 5.30pm to continue the procedures whereas in another campthe procedures started only at 6pm and operations went on till late night. In another camp, whenwomen and family members objected to the poor quality, the doctor reportedly fled leaving many women unconscious on the floor.

The guidelines mandatefor a detailed screening procedure which involves pre-operative testsand counselling to ruleout thosewho are unfit for the operation. This mandate was not followed as according to the reports,in many cases women reported pregnancy few months after the procedure. In onecamp in MP, a woman wasreportedly given anaesthesia before assessingher eligibility and waslater asked to go home without being operated upon. In an alarming case from Bihar, it was reported that a 16 year old unmarried girl was sterilised without her consent.

The maximum number of operations that can be conducted per camp in one day is 30 but the reports outline, that several camps violated this standard. Violations werereported in 19 sterilisation camps across the states (except Chhattisgarh) risking women’s lives and disregarding their right to access good care.Reportedly in Bihar the number of procedures in a daywent to 52, in UP it was 40, in MP it was 100, in Jharkhand 50 and in Rajasthan the highest with 145 women. Women also reported rude and abusive behaviour of staff. In one camp in MP a woman was slapped and pushed in the operation theatre by the staff, and in another women were treated like animals as stickers were put on women's forehead to differentiate between operated one’s and non-operated one’s thus disrespecting  women’s dignity.

As per the reports, violations continued even after surgery as most of the women were not given beds to rest on and bed sheets/blankets were not provided, stretchers were not availableto carry women after the operationand most of them lay in open verandaeither on the floor or on dirty rugs. The guidelines clearly mention provision of a separate room to rest for recuperation. This scenario was observed across all the states. Ironically one such hospital of Chhattisgarh has been awarded as one of the best hospitals in the state. In a camp in Bihar, families werereportedly asked to pay for stretcher services, medicines and syringes. These violations shows the lack of vigilance on part of  health service providers as patients are not being given entitled services and are asked to pay bribes.

Four cases of death were reportedfrom Bihar and MP as a result of poor quality of services. In a casereported from Bihar a sterilisation operation reportedly resulted in a death where the bladder of the patient was cut instead of the tube, and referral was also delayed. In the 3 cases from MP, the reason for death was not mentioned however reports do talk about delay in post mortem by health officials.   

This dismal state of affairs reflects the apathy of the state and its lack of commitment to uphold women’s rights. This is especially a matter of concern, as it raises questions about India’s commitment on the international platform Family Planning 2020 (FP2020), to provide access to voluntary contraception to 48 million additional women by the year 2020. At the Family Planning Summit in 2017, India also made a large monetary commitment to these goals, which indicates its enthusiasm; however the paradigm of reproductive rights needs to be upheld. These incidents reflect that women’s dignity is being disregarded by subjecting them to unsafe procedures resulting in complications and death. Inspite of several Supreme Court orders and Comprehensive guidelines there appears to be a resistance to adhere to these. These violations call for an urgent need and significance to be given to reproductive health care and rights of women which is critical to safeguard their human rights.