The Indian government’s family planning initiative ‘Mission Parivar Vikas’ (MPV), now in its seventh year, has achieved some success in 146 districts that were originally identified as “high fertility” areas with a Total Fertility Rate (TFR) of more than three. The districts are spread across seven states, namely Rajasthan, Assam, Uttar Pradesh, Bihar, Madhya Pradesh, Chhattisgarh and Jharkhand.  MPV hopes to reduce the TFR in these high-focus areas to 2.1 by 2025.

The focused efforts are yielding results that can be seen in the numbers, but they come with hidden problems that the numbers do not or cannot capture. For example, contraceptive use has picked up in these areas following the government’s efforts to increase access to family planning services.  However the most popular method of contraception is the irreversible method of family planning involving surgery. This is good from the point of view of outcomes but not always good from the point of view of the women. The popularity of the permanent method mirrors the national preference, where 36.3% (NFHS-5 numbers) of currently married women took the option – making it the most popular of all choices. Across States with the MPV districts, many more women opted for the permanent method. But because the MPV runs essentially in districts with an overall higher level of backwardness, signaling weaker communications and poorer delivery of healthcare, the downsides of female sterilisation will be more pronounced here.   

A permanent method like female sterilisation is usually adopted when the couple has had the number of children they wanted and opt to have no more. But in rural India, the death of children and young adults is not unusual, particularly in tribal communities where many unexpected incidents happen, including snake bites and panther bites, falls from a tree, drowning in the village pond, and many caused by preventable or treatable diseases. Not having timely access to care often leads to the death of the child. There have been cases where women who opted for the permanent method after two or three children find themselves suddenly with fewer children, or without a son, after mishaps in the family. In such cases, reversal of surgery is very difficult, if not impossible, and the trauma for the family is endless. 

These are the unfortunate consequences of the growing acceptance of female sterilisation in rural India. They also highlight the uniquely Indian problems of irreversible methods of contraception, given the poor health infrastructure that leads to preventable complications and even deaths during the surgery and a bigger trauma if the woman survives surgery, then goes on to lose her children and can’t have anymore.

A total of 358 deaths in the years 2014-2017 were reported after sterilisation, the Minister of State for Health & Family Welfare Anupriya Patel told the Lok Sabha in March 2018. The minister told the Lok Sabha that “prescribed norms have been laid down in the Standards & Quality Assurance in Sterilization Services, 2014, published by the Government of India and made available to all States and service providers in order to ensure quality standards in service provision while performing sterilization procedures.”

In terms of numbers alone, female sterilisation in rural areas (as a percentage of currently married women) grew from 32.2% to 44.5% in Rajasthan 22.6% to 35.3% in Bihar, 39.8% to 47.6% in Chhattisgarh, 19.8% to 37.4% in Jharkhand, and 46.9% to 55.7% in Madhya Pradesh in the period from NFHS-3 to NFHS-5

How has this change happened?

Three recent developments have possibly contributed to the steady increase in sterilisation numbers. First, the presence of ASHAs (Accredited Social Health Activists) in every village has given a human face to the system, built credibility and trust, and has taken system-driven persuasion to the last household in the village. Second, the arrival of smartphones and high connectivity in villages has upped aspirations. DJs at rural marriages, birthday celebrations, and the changing attire of rural girls, are cases in point.

Rural families are also noting the small family size and lifestyle in cities and are ready to adopt it for themselves as well. The third factor contributing to increasing tubectomy numbers is the growing trend of male migration from rural areas to cities for work: in southern Rajasthan itself, some 70% of the households see at least one male member migrating to cities in Gujarat, or Maharashtra, or elsewhere for their livelihood. In the absence of the husband, it becomes doubly difficult for the woman to bring up children. An operation then seems a win-win for everyone. 

The need to look beyond sterlisation

Senior obstetricians recommend that operations should be the last option as opening the body has its risks. So other methods available that are safer should be used. Complications and fatalities from female sterilisation are not uncommon but appear not to impact the number of women opting for this method (or lured into the method with appropriate incentives). 

Yet, we cannot run away from the problem: The entire burden of population control in India has been borne and continues to be borne by women. And this is especially the case with sterilisations. This has remained true over ten years, from the last NHFS in 2005-2006, all the way to the survey by the government for 2015-2016.

Saying ‘no’ to tubectomy is much more possible today with the emergence of several choices for women that work almost like a permanent method: intrauterine contraceptive devices (IUCD) such as Copper-T or other hormonal devices, which are effective for long durations. Using these once or twice may be sufficient to prevent pregnancy for the entire reproductive cycle of the woman, thus also acting as a permanent method. 

The onus on our healthcare systems

Where PHCs are not regularly open, doctors and nurses not fully present, and people have little trust in the public health systems, tubectomy is a sure-fire way to ensure birth control. The alternative will require training of our doctors and nurses, making these methods available, and strengthening communication to dispel fears and myths associated with the different methods. As an example, a common fear that exists with Copper-T is that “it will move up in the abdomen”.

Overcoming this will require listening and acknowledging their fears, and helping them understand why these may be unfounded. It will also require the primary healthcare facilities to be open 24X7 and the healthcare workers to be present, to be able to manage any side effects of the other methods such as bleeding and abdominal pain.

The renewed emphasis on primary healthcare, emergence of the health and wellness centres, growing numbers of doctors and skilled staff across the PHCs and sub-centres are welcome steps that can make this paradigm shift possible.

 (The lead author is a doctor and co-founder of Basic Healthcare Services, a Rajasthan-based non-profit that runs primary healthcare centres. Lekha Rattanani is the Managing Editor of The Billion Press. Views are personal. By special arrangement with The Billion Press)