Women’s health
Population Control
How women pay
the price for
population control
Despite the serious toll it takes on women’s health,
female sterilisation remains the most prevalent form of
contraception in India. ruhi kandhari reports
W
hile memories of the 21 months of
Emergency in 1975-77, imposed
by the then prime minister Indira Gandhi, survives even today
in the minds of Indian men as the fear of
forced sterilisation, the country’s population control policies have shifted over the
years since then to target the politically
less powerful and vulnerable poor women. Almost the entire burden of what is
euphemistically called “family planning”
is today borne by women. And it has taken a toll on the health of large sections of
women in the country.
In fact, the mainstay of our population
control strategy comprises two methods
targeted at women — tubectomy (female
sterilisation surgery) and insertion of an
intrauterine device (iud) also known as
Copper-T. Neither method is known to
be suitable for all women. Yet, in the rush
to meet targets, these methods are widely promoted and their adverse effects on
women ignored. The public health infrastructure is not geared to manage contraception, the staff is not trained in counselling women or seek their informed
consent, and pain is considered an acceptable side-effect.
According to the latest National Family Health Survey, conducted in 2005-06,
a third of the women in the reproductive age group have undergone surgery
for sterilisation and thousands have been
inserted with iuds, with or without their
consent, at some point in their lives. After months of suffering pain, many women have to visit private clinics to get the
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tehelka 11 october 2014
iuds removed as the government hospitals largely refuse to do so.
While the World Contraception Day
was observed on 26 September, the time
is apt to take a hard look at India’s population control policies from the perspective
of the women who are forced to suffer its
consequences.
Take the case of 30-year-old Rajkumari from New Delhi, who underwent
tubectomy five years ago. In five years
of marriage, she had three children, followed by three abortions. A social health
worker appointed by the state government had convinced her that this was
the only way to avoid pregnancy, while
her husband was never counselled to use
contraception.
Since the surgery, Rajkumari has not
been able to sleep peacefully on most
nights. She often suffers from recurring
headaches, hot flashes, night sweats and
stabbing pain in her abdomen. In the
month following her surgery, she visited
the government hospital several times,
but the doctors only prescribed her medicines to control the symptoms. “The medicines only offered temporary relief. My
life has been a curse for the past five years
with constant suffering,” she says.
Her neighbour, 23-year-old Pushpa,
also narrates a similar tale of pain. The
nurse at a public health facility inserted
her with an iud after she delivered her
first child. Her consent was not sought.
The procedure was done after getting the
consent form signed by her husband, a
daily wage labourer who had studied up
• Post-operative hell Sterilisation camps for women are often conducted without proper medical infrastructure like operation theatres, in a hurry to meet targets
photo: down To earth
11 october 2014 tehelka
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Women’s health
to Class V. He wasn’t explained what an
iud is and what the form was for.
Pushpa was dizzy when she returned
home. She bled profusely, became pale
over time and stayed bed-ridden. Her periods lasted up to two weeks sometimes.
She lost her appetite, became weak and
was unable to feed her baby on most days.
When she went back to the hospital, she
was prescribed antibiotics and painkillers. But she continued to bleed and suffered from pain in her abdomen. It took
her three months to save enough money
to get the iud removed at a private clinic.
The common known side-effects of
iuds are nausea, changes in menstrual
bleeding and severe cramps. Sterilisation,
on the other hand, is a risky surgery that
may lead to internal infection or bleeding,
injury to internal organs and even death.
There are thousands of women like
Rajkumari and Pushpa who have suffered
the terrible side-effects of tubectomy
and iuds.
Stuck on a wall in the lobby of the office of New Delhi-based ngo Centre for
Health and Social Justice (chsj) is a clipping of a June 2013 article by the Bloomberg news service headlined ‘Pushing Indian Women toward Sterilisation’. It tells
the story of Sumati Devi, who underwent
sterilisation on an “operating table with
bloody sheets”. The operation was done
with a rusted scalpel and she was neither
counselled nor asked for her consent.
Instead, she was given some cash as an
“incentive”.
The article threw light on how
10 times more women than men undergo
sterilisation surgeries in filthy “sterilisation camps”, even though female sterili-
Population Control
Contraception prevalence in India
versus rest of the world
India ranks the highest in risky contraception and the lowest
in safe contraception
Female
Male
sterilisation sterilisation
World
India
Africa
China
Europe
North America
sation involves a more complicated operation than male vasectomy.
Another clipping from February 2012
headlined ‘Pregnant woman bleeds to
death after sterilisation’ (The Times of India) told the story of a 35-year-old pregnant woman who bled to death in Balaghat district of Madhya Pradesh while
the doctors were trying to sterilise her.
She had been pregnant with twins — both
girls — for 12 weeks when the operation
was conducted. She died a few hours after she began bleeding on the operation
table because the doctors did not follow
the basic protocol of medically screening
Disadvantages and side-effects of various
contraceptive methods
tehelka 11 october 2014
2.8%
1%
0%
6.9%
2.6%
11%
Condom
8.8%
3.1%
7.8%
Not known
20.3%
18.6%
6.1%
1.2%
1.7%
4.4%
14.3%
12.5%
(Source: UN World Contraceptive Report 2009)
The downside of
contraception
00
20%
37%
1.5%
33%
3.8%
21%
Pill
women before the sterilisation operation.
There was also a clipping of a January
2012 story titled ‘Barrack-room surgery in
Bihar’s backwaters’ about a sterilisation
camp conducted by an ngo in a hamlet in
Araria district without any operation theatre, where 61 tubectomy surgeries were
carried out at a breakneck speed using expired medicines.
Another clipping on display was of a
March 2012 article titled ‘Freebies lengthen sterilisation queues’ (The Deccan Herald) talked of how a district administration won a Tata Nano car for meeting
sterilisation targets. Giving lpg connec-
Oral Contraceptive Pill
Nausea, mild headaches, tender breasts, spotting between
periods, irregular bleeding,
moodiness, vomiting within
two hours of taking a pill, severe diarrhoea and vomiting
for more than 24 hours
Copper-bearing IUDs
Menstrual changes in early
months, longer and heavy
menstrual periods, bleeding
or spotting between periods,
more cramps or pain during
period. Uncommon sideeffects include severe cramps
and pain beyond first threefive days of insertion, heavy
menstrual bleeding or bleeding between periods, possibly
contributing to anaemia and
possibility of perforation if
not inserted properly. It does
tions to every family from which a woman
underwent tubectomy, the administration
had got over 2,000 tubectomy surgeries
carried out in just three days.
According to the most recent data collected in 2012-13 under the District Level Household and Facility Survey, state
governments increasingly prefer female
sterilisation as a mode of family planning even though it is one of the most
risky contraception methods. In Andhra
Pradesh, for example, 63 percent women
in the fertile age range had been operated upon in 2012-13 as compared to 60 percent in 2007-08. During the same period,
the number of men who underwent sterilisation dropped from 4 to 2 percent. Similarly, in Maharashtra, the percentage of
women who underwent sterilisation increased from 52 to 54 percent, while the
corresponding figure for men dropped
from 3 to 1 percent. In Haryana and Punjab, one-third of the women in the reproductive age range have been sterilised.
Although tubectomies involve a serious chance of surgical infections and
post-operative complications, state governments continue to promote “camps”
where these are conducted on thousands
of women without any proper health infrastructure and in unsanitary conditions,
in a hurry to meet targets. This is despite
the fact that vasectomy for men is a relatively non-invasive procedure with little risk of surgical infections and the men
undergoing the procedure are usually fit
enough to walk only minutes later.
“The government’s focus is only on
terminal methods targeted at women.
Men are hardly involved in the family
planning programme. They need to be in-
not protect against sexually
transmitted diseases (stds)
including hiv/aids. Medical
procedure, including pelvic
examination, is needed to
insert the iud. Occasionally, a woman faints during
the insertion procedure. A
trained healthcare provider
must remove the iud. The iud
may come out of the uterus
possibly without the woman
photo: vijay pandey
• Unending curse Rajkumari, 30, has had recurring health problems since undergoing tubectomy 5 years ago
volved, not as targets for non-scalpel vasectomy but as partners within a genderequality paradigm,” says Dr Abhijeet Das,
director of chsj and an assistant professor at the Department of Global Health,
University of Washington, Seattle, USA.
For the past two decades, Das has been
observing persuasive population control
programmes, advising the government
and is also part of various national and international networks, including the National Alliance on Maternal Health and
Human Rights, Healthwatch Forum and
MenEngage, a global alliance on men and
gender equality.
knowing about it (more common when the iud is inserted
soon after childbirth)
Vasectomy Uncomfortable
for two or three days, pain
in scrotum, swelling and
bruising and brief feeling of
faintness after the procedure.
Rare complications of surgery
include bleeding or infection
at the incision site or inside
The 2012-13 survey also shows indicators that define the “quality of family
planning services” remain abysmally low.
Most women are unaware of other means
of contraception and the known side-effects of sterilisation. Even when they are
counselled, the counselling is manipulative as the staff has already decided which
contraceptive method a woman needs. In
Maharashtra, only 17 percent of the women were told about the side-effects, while
the figure was 14 percent in Punjab and 11
percent in Andhra Pradesh and Haryana.
According to the District Level Household & Facility Survey 2007-08, 40 per-
the incision, blood clots in
the scrotum. No protection
against stds, including hiv/
aids
Tubectomy Uncommon
complications include
infection or bleeding at the
incision, internal infection or
bleeding, injury to internal
organs and anaesthesia risk.
No protection against stds
Male Condom Latex condoms may cause itching for a
few people who are allergic to
latex. Also, some people may
be allergic to the lubricant
on some brands of condoms.
Small possibility that condom
might slip off or break during
sexual intercourse
(Source: Government reference
manual)
11 october 2014 tehelka
00
Women’s health
Population Control
cent of the women who underwent tubectomy in public health facilities across
India were illiterate, indicating that
tubectomy was not the “chosen” form of
contraception.
Despite the problems associated with
tubectomies, state governments continue to set targets for sterilisation surgeries. The reply to an rti query showed
that around 1,000 women were targeted
for tubectomy in just west Delhi over the
months of January, February and March
this year.
T
he two extremes of the debate on how
to stabilise the population are represented by the coercive sterilisation drive
associated with Indira Gandhi’s son Sanjay Gandhi during the Emergency, on the
one hand, and senior Congress politician Karan Singh’s statement at the 1974
World Population Conference in Bucharest, Romania, that “development is the
best contraceptive”, on the other. For a
long time, the dominant thinking globally
was in favour of coercive policies.
Internationally, this debate came to
rest at the International Conference on
Population and Development 1994 (icpd
94) in Cairo, Egypt. At icpd 94, civil society activists from around the world shared
experiences of coercive population policies and convinced 179 national governments to see “population” as people, not
a number. Economists like Amartya Sen
had also proved by then that improvements in women’s education and healthcare automatically result in smaller families without any need for authoritative
population control policies.
icpd 94 brought about a “paradigm
shift”. The governments agreed to abide
by reproductive rights and honour gender
equality while providing universal access
to family planning, sexual and reproductive health services. The Indian government, too, grudgingly committed to place
individuals at the centre of development.
However, the state governments in India
by and large do not follow this principle in
practice and it is not uncommon for politicians, bureaucrats, judges and the educated, urban middle class to blame India’s
large population for nearly all the problems plaguing the country and favour
force over cooperation.
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tehelka 11 october 2014
• No consent No one sought the permission of Pushpa, 23, before inserting her with an IUD
Until icpd 94, population was considered a dirty word — a dangerous “bomb”
that would explode if not controlled. In
the early 1950s, more babies were surviving in the newly-independent countries and fewer children were being born
in the richer countries, leading to a fear
of “overpopulation” in the Global South.
This led to the formation in 1952 of two
ngos — the Population Council and the
International Planned Parenthood Federation (ippf) — in New York and Bombay, respectively. They were set up with
the purpose of influencing the US government to orient the US Agency for International Development (usaid) towards
population control in the Third World,
alerting Americans to the danger of population “explosion” and raising funds for
international birth control programmes.
An advertisement for a joint campaign
by the two ngos read: “A world of mass
starvation in underdeveloped countries
will be a world of chaos, riots and war.
And a perfect breeding ground for communism… Our own national interests demand that we go all out to help the underdeveloped countries control their
populations.”
The political agenda was reinforced
and validated by Stanford University Professor Paul R Ehrlich, who authored The
photo: vijay pandey
Population Bomb in 1968. He emphasised
birth control at any cost with the use of
contraceptives, mass sterilisation and
pre-natal sex determination (so that parents can design the family sex composition). The US government was soon convinced. In 1974, National Security Study
Memorandum 200 of the National Security Council asserted that population
growth in poor countries posed a problem for the security of the US. That is how
the US and other industrialised countries,
which had achieved lower birth rates due
to improvements in education, healthcare
and incomes, without any coercive population control policies, became the biggest
proponents of the latter.
India could not remain unaffected by
the discourse. In 1970, JRD Tata formed
the Population Foundation of India with
money from the Ford Foundation for population control advocacy in India. While
the country’s population initially focussed on vasectomy of men and stayed
clear of female sterilisation, considering
the risk of infection, the tide had turned
by the 1980s. The infamous coercive male
sterilisation drives of the Emergency period gave way to the setting of targets for
female sterilisation, which continues to
dominate the population control policy.
In 1992, a study by Dr Rani Bang and
Dr Abhay Bang demonstrated that women had more faith in indigenous methods of contraception than the modern
ones because they commonly associated the latter with adverse effects such
as backache, abdominal pain, weakness
and irregular or excessive menstruation.
Women also found that healthcare professionals were often insensitive to these
complaints and regarded them as minor
and insignificant side-effects that should
be ignored.
I
CPD 94 was the culmination of the coming
together of academics, activists and the
medical community in efforts to propose
an alternative perspective on population
control policies. They showed how a policy of targets, incentives and disincentives
under the National Family Planning Programme had made women mute recipients suffering quietly.
Among the participants at icpd 94 was
an ias officer, AR Nanda, who was then
the secretary at the Union Ministry of
Health. After he returned from Cairo, he
took up the mantle to reorient the population policy. The second half of the 1990s
saw a new target-free approach, which
focussed on combining contraception
needs with providing reproductive and
child health. Nanda also drafted the landmark National Population Policy (npp)
2000, which stressed on improvements
in human development, gender equality
and reproductive health to stabilise population growth.
“In 1999, when I proposed the npp, a
few mps supported the two pillars of the
policy — informed choice and informed
consent — but it was largely criticised in
Parliament,” says Nanda, who has since
retired from the government, but continues to advise the National Coalition
Against Two-Child Norm, an advocacy
group of ngos, academics and activists
concerned with promoting policies that
empower people to exercise their reproductive rights and choice.
State governments
have often promoted
population control
methods that go against
the spirit of NPP 2000
The npp 2000 begins with a statement
that “the overriding objective of economic and social development is to improve
(the) quality of life that people lead, to
enhance their well-being and to provide
them with opportunities and choices to
become productive assets in society”.
The policy recommended the empowerment of women through enhanced access
to education, employment opportunities
and quality healthcare.
The policy, however, failed to influence a large section of politicians who
continued to see population as a problem. In May 2000, when India’s population crossed the one-billion mark, the
then prime minister Atal Bihari Vajpayee
said: “This is a serious matter that is both
cause for concern and introspection —
concern over the impact that a runaway
population growth is bound to have on
the nation’s economic, natural and other
resources; introspection over where we
went wrong and how we can stabilise our
population… If the present growth rate of
our population remains unchecked, India will become the world’s most populous country by the middle of this century, with people clamouring for a share of
shrinking natural resources.”
Opposition to npp 2000 continued
even after it was adopted. Population being a subject on the Concurrent List, the
state governments are not obliged to follow anything that the Centre prescribes
on population control. They have their
own policies that in most cases go against
npp 2000. For instance, Uttar Pradesh
introduced contraceptives such as injectables and implants, which are proven to
be unsafe for women; Rajasthan promoted a lottery scheme for those who opt for
sterilisation; and Bihar contracted out
tubectomy surgeries to private operators
and ngos.
“The language used in talking about
population stabilisation changed after
icpd 94 but the mindset remained more
or less the same,” says Nanda. “Even at
the national level, male responsibility and
gender equity were largely ignored. The
state governments favour setting of targets and promoting terminal methods because the results are easy to measure.”
Clearly, despite all the talk of empowering women, their reproductive autonomy — the right to choose whether to have
children or not and the freedom to choose
the methods of fertility management
based on access to proper information —
has been largely ignored in the policies
and practices promoted by various governments in India.
Unfortunately, India has seen a reduced prevalence of condom use with
women remaining unequal targets of the
family planning burden. As the dominant,
irreversible methods of population control take a toll on women’s health, there
is indeed a need for reorienting it towards
the promotion of temporary and reversible methods such as condoms, which also
provide a barrier against sexually transmitted diseases.
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