The tragedy in a sterilisation camp in Chhattisgarh, where 14 women lost their lives post tubectomy conducted under horrific conditions, calls for a deeper look into the context. Such an exercise would reveal that this has been happening for decades ever since family planning strategies began focussing on women as targets of the government’s agenda on quantitative cutting down of population, with little or no regard to the quality of lives of the people targeted.

 India is the first country in the world to have introduced family planning as a national programme. It is also the first country that coined the phrase “Family Planning’ to replace the earlier term “birth control.” The word “welfare” was incorporated in 1977 and we had the new term “Family Welfare Planning.” 

 The word ‘welfare’ was meant to introduce quality-oriented programmes because till then, all family planning strategies had been admittedly targeted at quantity. What did the authorities mean by the word ‘quality’? Did they mean the quality of the future population? Or did this suggest a rise in the quality of the standard of living and healthcare for the poorest of the poor?

 Rural health activist Manisha Gupte in her unpublished paper A Feminist Understanding of Contraception (1986) writes: “Few topics related to the women’s health movement are as controversial as contraception. Liberating heterosexual women at one end by giving them the choice to control their own reproduction, at the other end, it snatches away the same control when many contraceptives are abrasive and harmful (but) come as a package deal with population control programmes that select, motivate and wherever necessary, coerce helpless targets. Male hegemony exists in medicine, in policy, in decision making and in research. Do women end up having lesser choice and lesser control over their bodies through the usage of existing contraceptives?”

A mother with her new-born baby in Patna, Bihar. Pic: The Bill & Melinda Gates Foundation

The answers to these questions sustain nearly three decades after Gupte raised them. Sterilisation performed in 2013-2014 exceeded four million according to the government. India now has the world’s third-highest female sterilisation rate after the Dominican Republic and Puerto Rico among more than 180 countries tracked by the United Nations.

Methods of Contraception

A closer look at different devices adopted to push family planning in India reveals that almost all programmes are tilted against women. Other than the male sterilisation scandal created by the ruling party in 1977, every single technology in the family planning programme has been targeted against women. Rural, poor and uneducated women have often been willing and often ignorant participants in the family planning process, submitting themselves unwittingly as guinea pigs to a larger aim that sacrifices them to a cause that is as self-defeating in its means as it is destructive in its ends.

The Oral Pill: Most of the oral pills used as a contraceptive device by women are Schedule L drugs, which are prohibited from being advertised. Yet, they have been advertised on television.

Besides, no woman who opts for the oral pill adheres to WHO directives such as (a) compulsory supervision by a medical expert, (b) a thorough screening of her system to rule out contra-indications, (c) periodic check-ups while on the pill, so that negative side-effects if any may be detected or (d) compulsory education on the importance of taking the pill every day. The WHO also lays down that the woman must be aware of the side effects that could ensue from continuous use of the pill and she must know what she should do if she has forgotten to take the pill – conditions that are certainly not met in a vast number of cases in the Indian context. 

To add to this, in 2006, the government permitted the ECP (Emergency Contraceptive Pill) to be used as a convenient form of contraception in case the woman or the girl has forgotten to take protection during sex. This is freely advertised across television screens in the country and young urban girls look at it as their freedom to choose ‘the morning after’ pill denied to them for so long.

“Girls are popping these pills like candies,” says Dr Abhijit Ghosh, a gynaecologist at the Bhagirathi Neotia Women and Child Care Centre, Calcutta. “They are not aware that multiple use of the pill in a menstrual cycle can lead to contraception failure which is quite difficult to diagnose. Frequent use can affect fertility in the long run,” he says.

Long-term overuse according to doctors, are still being studied. Besides, there are common side-effects like nausea, vomiting, headache, abdominal bleeding, irregular menstrual cycles. Long-term effects are still being studied.

IUDs: Intra-Uterine Device (IUD) was prescribed as a temporary fertility control measure developed by Dr. Jack Lippes who came to India to introduce and counsel on this method. In 1981, the Indian Council of Medical Research claimed that IUDs are effective, reversible and economical. But possible complications could be perforation of the uterus, pelvic inflammatory disease, spontaneous abortions and increasing chances of ectopic pregnancy.

A US Food and Drug Administration panel recommended that both physicians and IUD users should be made thoroughly aware of the increased risk of inflammatory disease and possible interference with future fertility. In January 1986, both Copper-7 and Tatum T, two IUDs manufactured by pharmaceutical major G.D. Searle & Company were withdrawn from the US market but marketing overseas did not stop. Note that both these devices were meant exclusively for women.

A notorious IUD marketed by A.H. Robins Company, a US multinational, was the Dalkon Shield. The company marketed approximately 1.7 million Dalkon Shields to at least 80 countries. Dr. Hugh J. Davis of JohnHopkinsMedicalSchool in Baltimore invented the Dalkon Shield and claimed that the pregnancy rate with the use of this was only 1.1 per cent. It did not need FDA clearance because it was not a drug.

Women who got the Dalkon Shield inserted began to complain of serious discomfort such as pelvic inflammatory disease, sterility, spontaneous abortions, and loss of reproductive organs. 200,000 deaths were reported in the US alone. These facts were kept hidden by A.H. Robins and distribution continued. In 1974, the FDA stopped distribution until its safety was ascertained. Finally, the Dalkon Shield was recalled but the damage was done especially in Third World countries like India, where women were not able to identify the brand and type of IUD they were using. They neither had any prescription at hand to trace it back to the company.

The Sixth Five Year Plan that introduced IUD, oral pills and sterilisation as alternative methods of contraception and family planning earned notoriety through what came to be known as the Great Copper-T Fraud in Maharashtra. In 1983, public health officials operating in Sindhudurg and Thane districts in Maharashtra were hell bent on bagging the coveted Rs. 2.5 core first prize for the third year in succession initiated by the government for the district that reached the highest target.

Investigations revealed a massive scam of manufactured statistics of people who were acceptors of Copper-T insertions while in reality, the insertions had not taken place at all. The Copper-Ts scheduled to be inserted were misappropriated and to bag the prize, the public health officials claimed a 256 per cent success over the targeted figure!

Sterilisation: With the declaration of Emergency in 1976, a national target of 4.3 million sterilisations was announced by the government, ear-marked for the period between April 1976 and March 1977. The brunt of the male vasectomies was born by poor, illiterate, ignorant, low-caste and minority men involving coercion at the highest level. Several teenaged boys were also forced to undergo vasectomy. This scandal was partly the reason for the ruling party’s downfall in the following elections.

As a fall-out of that, the next government, and others thereafter, have deliberately and calculatedly reduced male vasectomy programmes over the decades. There has been a visible shift of the burden almost entirely on women. Then Health Minister, Mohsina Kidwai admitted in 1986 that over the past years, vasectomy cases had declined sharply.

A poster released by the Government of India on World Population Day. Pic:

The death chronicles began when in 1985, 44 women in Rajasthan died on the operation table while undergoing sterilisation for want of post-operative care. A few like Gita Rawal and Suman Sethia suffered a fate worse than death. After a tubectomy on 1 August 1985, Suman went into coma for three months. When she regained consciousness, she was paralysed from the waist down.

Gita Rawal had been tempted with the offer of a soft loan for a sewing machine in exchange for undergoing the operation. She went for a sterilisation operation on 7 July 1987, following which she had to be confined to the bed to prevent her limbs from getting completely gnarled.

Swapna Majumdar in an article for the Women’s Feature Service reports “About 2700 cases of failure, complication or death due to sterilisation were officially recorded in 2012. According to the Ministry of Health and Family Welfare, while Rajasthan recorded the highest number of failures in sterilisation cases at 772, Tamil Nadu accounted for the maximum number of deaths at 10, followed by Andhra Pradesh and Madhya Pradesh at eight deaths each, Bihar, Karnataka and Rajasthan at four deaths each and Assam, Gujarat and Uttar Pradesh at two deaths each. 40 per cent of the 225 million women sterilised worldwide live in India. More than half the women who get sterilised have had the operation before they reach 26 years of age.”

Other Methods: Other methods of long-term hormonal contraceptives include Dep Provera which was banned by the US but continued to be exported through manufacture by Upjohn Pharmaceuticals’ Belgian agencies outside the US to some countries including India. Thankfully, after the storm it created in the UK and the US, the Indian government decided not to allow its use and distribution in India.

NET_EN is another long-term hormonal contraceptive whose implementation and use fizzled out after women and health activists questioned the use of clinical trials of NET-EN conducted by the Indian Council of Medical Research, in which WHO rules of experiments were violated with impunity.

Needless to mention that men do not feature in any of these methods. It is almost as if research in medical technology and medicine has forgotten that men exist and also need to participate in controlling the size of their respective families.

Motivators and health workers

In India, motivators are also poor women who have to reach targeted results. “Though in principle, the government adopted a target-free approach in 1995, targets continue to haunt the service providers. Governments and camps are organised to achieve the targets. India’s promise at the July 2012 Family Planning 2020 Summit to increase access to 200 million couples and adolescents will reinforce the pressures of targets furthermore in coming years,” says Dr. A.L. Sharada, Director, Population First, a Mumbai-based NGO that works for the girl-child.

In the mid-eighties, the government decided to disband male community health volunteers in the family planning project because it was increasingly felt that in the Indian social climate, rural women rejected male volunteers and health workers. But has the induction of women helped in any way? Not if one takes cognizance of the many incidents of botched sterilisation operations, rat-poison in anaesthesia and two minutes for each surgery.

Coercion has been the most common feature of the family planning programmes in the Five Year Plans. The deployment of women instead of men, in fact, makes coercion easy, quick and convenient. Says Gupte, “When motivators are women, whether they are health staff or primary school teachers, they are constantly threatened with dire consequences such as job transfer, sexual harassment, humiliation and delayed money if they fail to fulfil their targets.”

One must also remember that many among the motivators are women from very poor backgrounds. In a hurry to fulfil targets, they motivate as many women as they can to attend each sterilisation camp. Initially it was a precondition that women heath workers or motivators must first become acceptors themselves so that their methods of persuasion are backed by experience. But there is hardly enough evidence to suggest that this practice was monitored and supervised.

The perverse outcomes of a target-driven policy became evident once more in March 1986, when Manda Padwal, a female health worker in Talaseri Primary Health Centre in Thane, Maharashtra, committed suicide after being reprimanded by the doctor-in-charge of the PMC for not fulfilling the specified target of sterilising 20 tribals in the area.

Interestingly, the bias is also evident when one looks at the amounts paid to health workers. For a tubectomy, a woman motivator is paid Rs 150 per case, while the surgeon gets Rs 75. The anaesthetist gets Rs 25, the staff nurse or helper and OT technician get Rs 15 each. If the woman undergoing the procedure belongs to the BPL category, or to the Scheduled Caste or Tribes, she is paid Rs.600. If she is not from these categories, she is paid Rs.250. Compare this with the fact that a man agreeing to a vasectomy is paid Rs.1100 and the motivator is paid Rs.200, and you will know!

Beyond boundaries

In Choice and CoercionBirth Control, Sterilization and Abortion in Public Health and Welfare, by Johanna Schoen, the author’s statement emphasises how universal this strategy is. She writes that in August 2003, North Carolina became the first US state to offer restitution to victims of state-ordered sterilisations carried out by its eugenics programme between 1929 and 1975. The decision was prompted, she adds, largely by a series of articles in The Winston-Salem Journal.

These stories were inspired in part by the author’s research, when she was granted unique access to summaries of 7500 case histories and papers of the North Carolina Eugenics Board. Schoen widens her focus to include birth control, sterilisation and abortion policies across the nation and demonstrates how each method of limiting unwanted pregnancies had the potential both to expand and to limit women’s productive choices. Such programmes overwhelmingly targeted poor and non-white population, yet they also extended a measure of reproductive control to poor women.

To sum up, it would be apt to quote from health journalist Vimal Balasubramaniam’s article Towards a Woman’s Perspective on Family Planning in The Economic and Political Weekly : “The paradox which characterises the family planning scene in India is this – on the one hand, women are the major targets of the FP programme with both messages and methods beamed intensively at them; on the other hand, the felt contraception needs of these women who predominantly belong to the lower socio-economic class, are not adequately catered to. In a country like India, women can be doubly victimised: by the patriarchal family which refuses to allow them to use contraception and by the population controllers who make them targets of unsafe contraceptive programmes.”