Editorials

India’s latest sterilisation camp massacre

BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g7282 (Published 01 December 2014) Cite this as: BMJ 2014;349:g7282

The desire to apportion immediate blame should not detract from the urgent need to overhaul the country’s approach to family planning

The deaths of 13 women operated on at a sterilisation camp in Bilaspur, Chhattisgarh, have caused a stir in India and beyond.1 One surgeon conducted 83 sterilisations in six hours—much higher than the government limit of 30 a day.2 Speculations about who is responsible for these deaths abound. Amid the current media storm we should remember that complications and deaths resulting from poor quality of care in sterilisation camps are routine in India. The continued emphasis on mass female sterilisation, poor quality of services, and deep rooted coercion are all signs of a family planning programme that assigns little value to women’s lives, especially those of poor women, who are viewed as “irresponsible breeders.”

Fuelled by global propaganda about a “population explosion,” policy makers have long been concerned by India’s population. As a result, the family planning programme focuses on “population stabilisation” rather than providing couples with a range of contraceptive choices. Sterilisation, which is viewed as a foolproof method to ensure women do not reproduce, is given priority, accounting for 72% of use of modern contraception methods in India.3

In reality, however, population growth in India has been slowing over the past two decades. Many states have reached a replacement fertility rate of 2.1, which has long been seen as the holy grail of India’s population policy.4 Today, most babies are born to young people having their first, second, or, in very few cases, third child.5 These couples need temporary methods to either delay the birth of their first child or to ensure spacing between subsequent children. Yet, female sterilisation continues to be the mainstay of the family planning programme.

This programme is also riddled with prejudice—women bear the burden of family planning, whereas men’s responsibility is not addressed in a meaningful way. Tubal ligations, as a proportion of total annual sterilisation operations (male or female), have increased from 71% in the early 1980s to 98% in 2013.6

Coercive, target driven approach

After the Bilaspur incident the government repeatedly stated that the sterilisation programme was driven by demand rather than targets.7 But the enormous number of women who are sterilised should be regarded as an indicator of lack of choice rather than informed choice. Women are not always informed of other methods of contraception, and access to other services, such as abortion, is often made conditional on acceptance of sterilisation.8 In addition, incentives and disincentives are used to coerce women into accepting sterilisation (box). Although India has adopted a “target free approach” in its population policy,8 medical officers and health workers continue to receive targets as well as incentives for “good performance.”

Targets and incentives for sterilisation

  • In 2012 the chief minister of Madhya Pradesh announced a target of 750 000 sterilisations with incentives, such as cars and DVD players, for surgeons, motivators, and women who accepted sterilisation9

  • In Rajasthan in 2011 women who accepted sterilisation could win cars and bikes through a lottery10

  • On World Population Day in 2013 the government of Odisha doled out cash awards to service providers in districts with the highest number of sterilisations11

  • The plans for programme implementation in states such as Chhattisgarh clearly state targets for sterilisation, with greater targets for female sterilisation12

Poor quality of care

With targets the main concern, the quality of care has taken a back seat. In 2005 the Indian government issued standard operating procedures for sterilisations. Quality assurance committees were meant to monitor standards of care, and an insurance scheme was implemented to provide compensation in cases of failure or death. However, subsequent studies of women’s experience of family planning services show that quality standards continue to be poor.13 Incidents such as that in Kaparfora, Bihar, in 2012, where 53 women were sterilised in two hours in a school,14 and Malda, West Bengal, in 2013, where unconscious women were dumped in an open field after sterilisation,15 show scant regard for women in the approach to sterilisation. Camps continue to be held in blatant defiance of medical standards.

While women fight for their lives in intensive care units in Chhattisgarh, speculation is rife whether surgeon error, rusty instruments, or contaminated drugs are to blame. We may come to know the medical cause of these deaths in time, but this should not detract from the urgent need to overhaul India’s approach to family planning and contraception.

India recently signed the Family Planning 2020 agreement with a commitment to provide contraception to 48 million couples.16 This goal is ambitious, and given the current state of affairs it is difficult to imagine how it will be achieved without coercion and a compromise on quality. It is time to step back and think about the people behind these numbers. At the heart of the problem is the value that India places on women. It is time for policy makers to recognise that women deserve autonomy to make choices free from coercion, and it is the government’s duty to provide them with quality services, no matter which method of contraception they choose.

Notes

Cite this as: BMJ 2014;349:g7282

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant competing interests to declare.

  • Provenance and peer review: Commissioned, not externally peer reviewed.

References

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