In mid September 2016, the Supreme Court of India pronounced a judgment in the case of Devika Biswas vs Union of India. Biswas, an activist, had approached the courts following an incident in January 2012, when, over the course of a few hours, a surgeon sterilised over 50 women in a mass camp Bihar’s Araria district. During the procedure, one woman suffered a miscarriage, and three others lost significant amounts of blood. Biswas’s petition highlighted the cruelty of such procedures. It also condemned the use of sterilisation as a measure of population control—a practice that has been ongoing since the 1980s. (India has a dark history of coercion when it comes to reproductive rights, underpinned by the Malthusian ideology that population growth is stunting development. After thousands of men died in sterilisation procedures during the Emergency, in the 1980s, female sterilisation began to be promoted. The state has adopted a targeted approach to it since.)
Further, the petition stated, camps such as the one in Bihar are in direct contravention of guidelines framed by the centre—in 2005, inRamakant Rai vs Union of India, the court directed the central government to issue guidelines for minimum standards to be followed when conducting sterilisation procedures. The court also directed states to set up quality-assurance committees to ensure the implementation of these guidelines. The standards issued by the central government mandate, among other things, the informed consent of the patient; a preoperative health assessment and counseling; and a review of the requirements for post-operative care.
In its judgment in Devika Biswas, the Supreme Court directed the central government to end all sterilisation camps within three years. It chastised the centre for having failed to monitor these procedures, and noted that it had “passed the buck” to state governments on accounting for the high numbers of deaths. (The largest number of such deaths took place while the case was ongoing, in 2014, at a camp in Bilaspur, Chhattisgarh.) The court likened mass sterilisation camps to coercion, and stated that they impinge upon the “reproductive freedoms of the most vulnerable groups of society.” The judgment was widely celebrated—many hailed it as a progressive step towards viewing contraception from a rights-based approach, a demand that feminist and public-health activists have long held.
Shaifali Agrawal, an independent reporter, spoke with Jashodhara Dasgupta, the founder of non-governmental organisation SAHAYOG, to discuss whether any changes have taken place on the ground since the 2016 judgment. Dasgupta, whose NGO works with maternal health and rights, is a senior policy advocate. She is part of several civil society alliances, including Healthwatch Forum—one of three groups that were involved in filing the writ petition in Ramakant Rai—and National Alliance on Maternal Health and Human Rights. She was involved in conducting the on-ground study and providing evidence in the case—of lack of counselling, informed consent, quality and accountability in thousands of female-sterilisation cases in Bihar, Uttar Pradesh, and Maharashtra.
Dasgupta told Agrawal that while the government rhetoric has changed since the September 2016 order, the camps continue, and targets for achieving sterilisation are still being enforced. According to her, incentives for sterilisation, which are still being offered to women in rural areas, are disguised forms of coercion, a fact that is compounded by the lack of other contraceptive choices.
Shaifali Agrawal: Have any changes taken place in the implementation of sterilisation since the Supreme Court order last year?
Jashodhara Dasgupta: We have been tracking what has been happening to the sterilisation services after the order—I actually have a quite long list of news reports from different states in the country. The picture that is emerging from these is that on ground, it is largely business as usual. Targets [for sterilisation] are still operating and they have not actually gone away as far as district and sub-district health managers are concerned. We may not hear about targets on the public platform—in the sense that the government rhetoric has definitely changed—but there are targets on the ground.
This Expected Level of Achievement, which is the euphemism that is used [to signify targets] is closely tied to the way budgeting is done, and it is also closely related to the kind of claims India is making at the FP2020 summit [a United Nations Foundation initiative, the Family Planning 2020 is an international group that, among other goals, aims to improve access to contraceptives for 120 million women by 2020, about 40 percent of whom will be from India]. India is making these tall claims of how many women, how many couples will be covered, and how many more women will have contraception, but India is not doing it from an approach of reproductive rights. It is still being done with either a “herd them into sterilisation camps” approach, or now—which is a little more insidious—women who come in for hospital delivery are getting a post-partum IUCD [intrauterine contraceptive device] inserted. We have cases where it has been done without their consent. In essence, even though they have refused, it has been done.
Sterilisation is also being carried more or less the same way [it was before]. There are operations happening late at night, there are operations happening without electricity, there are operations happening where 50–60 women are getting it done in around one and a half hours. Then, of course, [there is] the whole question of what level of sterility is being maintained in the operation theatre. That is a joke because the operations are done sometimes in halls where public is moving around; bicycle pumps are being used to blow air into the abdomen. Things which were happening 12 years ago are still happening, so there has not been change on the ground. We are getting news reports from across the country about this. And these are news reports—not researched studies. If research is done systematically, I think we’d come up with much more shocking figures.
SA: What do you think of the practice of offering incentives for adopting measures such as sterilisation?
JD: I think there are two problems: one is that when you give an incentive, you definitely shape somebody’s choice. An incentive is a disguised form of coercion. When you are giving something to someone who needs it, obviously you are trying to influence their decision. If you are giving money to a poor person, obviously you are, in a sense, bribing them to do what you want. Maybe what that person actually needs is not a sterilisation surgery but a spacing method, but because you are giving money for sterilisation surgery, they go into that. Also, for instance, [a woman] may be deeply anaemic, she may have a white-discharge problem, so sterilisation would not be the appropriate method for her, but you are giving her so much money that her family will say “no, no, go for it.” It is not free and informed choice. It is not absolute consent—it is manufactured consent. In a rights-based approach, we need to be very clear about these distinctions.
The second reason it’s problematic is that when you make a budget for incentives, you are making budget calculations. The minute you make calculations, you are deciding upon the number that has to be achieved—you are setting numerical targets for yourself willy-nilly. Suppose I tell you that I am giving you Rs 100 [to be paid to the woman as incentive] per sterilisation case, and I am giving you Rs 10,000 [in all], what is the pressure on you? You have to spend it, so you have to find 100 cases for me because you have this target, because you have a budget. You can give a positive incentive [to women], like [saying] your child will get a scholarship, or some other benefits. The minute you give cash, you are you are putting targets on the providers, and the managers. And that means that they will resort to coercion.
On the other hand, for the staff of the government health department, there is disincentive [for not meeting targets]—like punishments, like money being withheld, like promotions being stopped. All of this is still happening in the country; it is just that it’s not happening at the level of rhetoric. On paper—all of this has stopped. But in reality, it’s there as much as it was.
SA: Why do you think that deaths and complications in sterilisation procedures continue to take place? Is it because that there are sterilisation targets to be achieved?
JD: We have deaths and complications not just due to a targeted approach. It is also because there are too many numbers being performed in one single operation. That’s number one—you are not giving people a range of methods [of contraception]. Obviously, the number of users for this method is far higher than that for other methods.
The second reason is that too few surgeons are actually available in the public sector who can actually provide this sterilisation—which means that on the days they leave their hospital work and do this, they have a large number of cases to operate upon. Sometimes they drive from one hospital to another doing these camps. They would do 30 procedures then go somewhere else, then do another 40 procedures there. This means that they are always rushing. The surgery itself may be a short procedure but there are many preparatory and follow-up steps. Because the surgeon just zips in and out and goes away, there is no one taking adequate care with all the preparatory and follow-up steps. Other health team members such as the paramedics and the nurses do short preparation and almost no follow-ups. [For instance,] a woman after surgery will just be asked to lie on a rug on the ground. That is what thousands and tens of thousands of women are actually made to go through after surgery.
The system doesn’t care about them—there is nobody checking whether they are kept in a hygienic place, whether a doctor is examining them. [After the procedure] the body is completely vulnerable to infection. If after that there is such poor care and before that there is such poor preparation, definitely women are going to get an infection, which could turn fatal. Because the surgery is performed in a hurry, many things that should have been checked earlier may not have been checked up properly. Sometimes women are pregnant, sometimes women have given birth five days earlier and they are taken to a surgery camp because their doctor is only available that day.
All the rules and regulations and procedures are violated constantly—that is why there are so many complications and deaths. Everything is not about targets. It’s because of the disproportionate number of sterilisations that are being performed. And that you can relate to the fact that sterilisation targets are very high, whereas there are very low or no targets for other methods.
SA: Is there an unmet need for contraception in India right now? Do we need more contraceptives in the public healthcare system?
JD: If you look at the data from the fourth National Family Health Survey [held in 2014–15], the figures are there—both state- and district-wise. You can see exactly in every district of the country what proportion of women have an unmet need. And you can make your own estimate of what kind of services would be appropriate to offer to these women.
There is also an unmet need for having information about their options. If the people in this country who use public-health services—and these are not the rich people, nor the upper-middle class, it is the poorest classes of this country—can get services which are of good quality, if they are educated about their options, they will make very sensible decisions about what contraceptive to use at what time. You are not giving them information about their options, you are pushing them to use one method instead of another, which may be more appropriate for them. [Maybe a woman thinks:] “I have had one kid, I don’t want another kid immediately for next 3-4 years, so I need spacing method. I don’t need to get pregnant immediately within one year, and then have 2 children, and then ASHA worker chasing me, saying why don’t I get sterilisation. I didn’t want that—I wanted my body to get rest, I want that gap of three-four years to bring up the first child properly.” But we are not letting them do that. [ASHA, or Accredited Social Health Activists are designated community health workers that were instituted as part of the central government’s health mission, in 2005. Appointed from among the residents of a village, ASHAs act as educators for women in that village on subjects such as contraception, birth, and pre- and post-natal care.]
In a very perverse way, we are actually contributing to population growth. If you are giving people information, choices, spacing methods, they would have delayed their pregnancy—instead of having two children within a space of two years, they would have had two children within the space of six years, which would have actually slowed down population growth. But unfortunately, nobody seems to be thinking of that.
SA: Many public-health initiatives put the burden of contraception on women. Do you think the government is doing enough to encourage men to participate in family planning as well, such as promoting the use of condoms?
JD: No. One of the big barriers is the fact that not all state governments actually have male multi-purpose workers for whom the state is supposed to pay. The ANM and the ASHA are paid from the central government funds. [An ANM, or Auxiliary nurse midwife, is also a village-level health worker, and is responsible for advising ASHAs on issues of healthcare.] But the male worker would have to be paid by the state government. So that is something that they are not doing. It’s very difficult for ASHAs to do so much condom-counselling with men. They have to understand the social position of the ASHA—it is unfair to expect that she would be able to tell women, and women would then convince their husbands, given that the gender relations in this country.
SA: What improvements or measures do you think need to be enacted in order for access to contraception to be improved and to become more rights-based?
JD: The Supreme Court has made a lot of suggestions [on sterilisation practices and policy]. In the Ramakant Rai case, we got the government to give orders about the system of ensuring quality control. Quality-assurance committees were supposed to be formed at the district and the state level, and were supposed to monitor how the services are being provided. Basically, they were supposed to increase the accountability.
Twelve years down the road, after the Bilaspur incident happened and all the court cases and affidavits from everybody, we are realising that none of the states actually bothered to implement those orders of the Supreme Court. The government never budgeted for those committees to actually work, have regular meetings—because it was not in the budget so no one ever bothered to do anything about it.
Just to begin with, if the orders of the honourable Supreme Court can actually be implemented in letter and spirit, that itself would be a good step forward.
From the civil society point of view, the experience with National Rural Health Mission had shown that when we are looking at poor people accessing these services, it does not work until the people are informed and are themselves empowered to actively monitor whether these services are working or not. That is the only danda that actually works—that the public should be informed and there should be a strong public pressure to make the public services work. That is also needed in the case of family-planning: all the women’s groups and self-help groups, and whatever else we have across the country, should be informed about their choices and they should be actively encouraged to monitor whether their front-line providers are actually supplying these services to them or not.
This interview has been edited and condensed.