Shreeti Shakya*, CHSJ
Women were brought in groups to the camps during morning hours, were made
to wait for long hours before the arrival of the doctors. The arrival time of
the doctors was unknown in many camps and reason quoted for the same was scarcity
of human resource. Due to the late arrival of doctors and their determination
to complete their workload of ‘reaching the target’, the operations took place
outside of the prescribed hours which is from 9am to 5pm as mentioned in the guidelines
set by the MOHFW. In around 18 camps out of 35, the prescribed timing was not followed
and some operations went on till as late as 11.30 in the night, indicating the
importance given to fulfilling targets rather than
following the guidelines.
Counselling,
voluntary consent and undergoing tests before the procedure are a pre -requisite
as per the guidelines. Every woman has a right to receiving all the required
information about the procedure and also about the consequences in order to
make an informed decision. The observations from the camps highlight that there
were no rooms for counselling ensuring confidentiality as only in 11camps out
of 35, women were given information on other contraceptive methods,only in 9
women were explained about the ill effects and complications post sterilization
and in 8 camps were told about management and compensation in case of
complication, failure or death. In regard to taking informed consent, in 25
camps, no woman were read to or explained about the content of the consent
forms, and women were made to sign them without them knowing what was written
on in. Similarly, a set of mandatory tests like blood, urine, blood pressure,
weight and abdomen check-up are to be done before the surgery which will ensure
the eligibility for the procedure. Considering the status of anaemia among
women in MP, not conducting a blood test and also a pregnancy test before the
procedure puts the woman at great risk often leading to complications and
sometimes even death.
Makeshift OTs
The
guidelines state no sterilisation procedure can be conducted in a non-functional
OT, but this mandate was overlooked and 5 out of 35 camps had makeshift OTs in
the hall of the hospitals. Also the rooms had no privacy, it was flooded with
the women being operated on, women waiting for their turn along with relative
and doctors. Another practice observed was the use of cycle pumps in 11 camps to
inflate the abdomen, which is a gross violation of the standards of care which
have previously been reiterated in court judgments.
The sterilisation procedure ends with ensuring that women are not going
through complications, immediately after the procedure and months after it.
While long term follow up was not part of this exercise, the immediate care and
follow up by the nurses and doctors was
not be seen in the camps. On the contrary, due to inadequate beds, women
had to sleep on the floor, only 4 camps provided mattress and a blanket,
considering that it was winter months, no effort was made to feel women feel
warm and comfortable. Even at the time of discharge when adequate information
needs to be given about care and follow up, it was observed that in around 20
camps women were not checked for recovery and stability by the doctor or a nurse
until 4 hours nor were they given information on follow up and care before
discharge.
Even after a year of the landmark judgment by the Supreme Court, (Devika Biswas vs Union of India and Ors.) directing the state governments to put an end to the camp approach for sterilisation, operations still continue unabated in appalling conditions in these camps. Conducting sterilisations camps especially targeting women has been a common practice in the Family Planning Programme in India since decades. Even with standards for procedure of sterilication available since 1989, the focus has remained especially on female sterilisation and on fulfilling targets to control population.
The poor state of affairs in the
female sterilisation camps has been time and again brought to fore by different
Public Interest Litigations (PIL’s) filed by activists and civil society
members, for example a petition by activist Ramakant Rai as part of Health
Watch Forum UP Bihar was filed in the Supreme Court in 2003. The judgment for
this PIL in 2005 directed all states to adhere to the guidelines of the
ministry for such operations. Part of the order also directed to introduce a
system of having an approved panel of doctors entitled to carry on
sterilization procedures, set up Quality Assurance Committees, collect and
publish reports of the number of persons sterilised as well as the number of deaths
or complications arising out of the sterilisation and bring into effect an
insurance policy to compensate for death of the patient sterilised, in case of
post–operative complications.
Following this PIL, new guidelines
were formulated and older ones revised[1],
and on a positive note the Government also brought in the Family Planning
Insurance Scheme in November 2005. The various guidelines provide detailed guide to ensuring standards of quality regarding the place and
timings of where the camp must be conducted, number of operations allowed in a
day by one surgeon, women’s eligibility criteria, pre-operative counselling and
tests and post-operative check-ups and
overall care, taking informed consent of the women etc.
Even with multitude guidelines in
place, there is continued negligence on part of the states in implementing them
in the camps. A glaring example of the
utter neglect in camps came to light in Araria district of Bihar where 53 women
were sterilised within 2 hours by a single surgeon in unhygienic and dire
conditions. After witnessing the horrific negligence in this sterilisation camp,
Devika Biswasa social activist filed a PIL on the gross violations in 2012. Even
during the hearing of the case, news reports of violation came from the state
of Chhattisgarh, where 13 women had died in Bilaspur after undergoing
sterilisation operation in a camp, due to neglect in quality of the services
provided by the health system. The historic judgment which came on the petition
of Biswas in September 2016 was well received as it vociferously highlighted
the end to the camp approach within three years and outlined to strictly adhere
to guidelines for all procedures.
Conditions in
Camps of Madhya Pradesh after the Biswas PIL Judgement
Following the judgment on the Biswas
PIL, Maternal Health Rights Campaign (MHRC), a rights
based network of more than 50 organisations based in the state of Madhya Pradesh
(MP) took the responsibility to observe 35 camps across 11 districts to
understand the compliance of guidelines in the camps. As part of this observation
exercise, evidence was generated using
an observation checklist, by capturing photographs of the ongoing activity and
situation, and through conversations with beneficiaries about their experience
with the services and facilities they received and behaviour of the healthcare
providers. The observations were made during the winter months of December 2016
and January 2017, which fall under the peak season for sterilization. The
observation and analysis has been done keeping in alignment with the prescribed
standards in the guidelines issues by ministry of health and family welfare (MOHFW).
The observations
and statistics from the exercise undertaken by MHRC reveal that even after the
directives, the camp approach continues to violate the rights of the women and
camps continue to be conducted in poor conditions.
Timing and
Information Regarding the Procedures:
Number of
Procedures
As per the
guidelines, for maintaining quality services, each surgeon should restrict to
conducting a maximum of 30 procedures a day spread across 8 hours (9am- 5pm)
with the availability of 2 laproscopes. The findings however highlight contrary
observations as only 9camps followed this criteria. Even in these 9 camps, the
number of procedures were conducted between 25 minutes to 2 hour 30 mins, which
is otherwise recommended to be spread during the 8 hours allotted time, therefore
raising questions on the quality maintained during the procedure. Doing excess
procedures is strictly prohibited by the Supreme Court yet they were carried
on, in some of the camps around 60-80 women underwent the procedure in a single
day. It was also reported that in one of the camps, officials entered only enough
names so as to not go beyond the cap, and other names were entered on other
dates or not entered at all indicating a malpractice. This purposeful act can complicate
the lives of the woman for future reference in case of complications or failure
and also provides a false database.
Pre-Operative Procedures
Counselling,
voluntary consent and undergoing tests before the procedure are a pre -requisite
as per the guidelines. Every woman has a right to receiving all the required
information about the procedure and also about the consequences in order to
make an informed decision. The observations from the camps highlight that there
were no rooms for counselling ensuring confidentiality as only in 11camps out
of 35, women were given information on other contraceptive methods,only in 9
women were explained about the ill effects and complications post sterilization
and in 8 camps were told about management and compensation in case of
complication, failure or death. In regard to taking informed consent, in 25
camps, no woman were read to or explained about the content of the consent
forms, and women were made to sign them without them knowing what was written
on in. Similarly, a set of mandatory tests like blood, urine, blood pressure,
weight and abdomen check-up are to be done before the surgery which will ensure
the eligibility for the procedure. Considering the status of anaemia among
women in MP, not conducting a blood test and also a pregnancy test before the
procedure puts the woman at great risk often leading to complications and
sometimes even death. |
A makeshift OT table which was not movable and placed at a wrong
angle
|
The
guidelines state no sterilisation procedure can be conducted in a non-functional
OT, but this mandate was overlooked and 5 out of 35 camps had makeshift OTs in
the hall of the hospitals. Also the rooms had no privacy, it was flooded with
the women being operated on, women waiting for their turn along with relative
and doctors. Another practice observed was the use of cycle pumps in 11 camps to
inflate the abdomen, which is a gross violation of the standards of care which
have previously been reiterated in court judgments.
Post-Operative
Procedure
|
|
Conclusion
The
overall scenario of the camps through observations made by MHRC, suggests a
dismal picture. Not even a single camp qualified following the standards and
procedures. These are just 35 camps which have shown the gruesome reality,
however the findings from these observations are enough to understand the
commitment of the state to improve women’s reproductive health. As the
judgement completes one year, the Government still does not have a plan to end
the current approach. Though the government has introduced the Mission Parivar
Vikas to ensure that services reach out to every couple, quality of care in
each of the services remain a matter of concern. It is thus important to
discuss the pathways of the current programme and a commitment from the state
to learn from the past experiences and come up with strategies which will
ensure informed decision making by women, remove social barriers to bring men
to the forefront to take equal or even greater responsibility in using
contraception, focus on the highest attainable quality of care in delivering
all contraceptive method with special attention to spacing methods, steadfast action to bring
an end to all camps and most importantly on this run ensuring
women’s empowerment to decide for their own reproductive health, care and
fertility. Without such deliberation and an increasing demand to limit
fertility, women’s health and life will continue to be at risk.
*ShreetiShakya
works as a research officer at the Centre for Health and Social Justice (CHSJ).
To know more about CHSJ Pls see www.chsj.org
[1]All family planning related guidelines can be found on ministry’s website
- http://nhm.gov.in/nhm/nrhm/guidelines/nrhm-guidelines/family-planning-guidelines.html
No comments:
Post a Comment