Poor Quality Service in Sterilization Camps
Recent news reports of over dozen deaths in a sterilization camp in Bilaspur city of Chhattisgarh along with other reports of doctors doing sterilization procedure in non-serious manner or under unhygienic conditions from other parts of the country has once again highlighted the fact our bureaucratic machinery in the family planning department hasn’t given up its old mindset. The ‘target’ patients in the camps are brought from the poor communities whose social and health awareness is still very low. The ‘incentives’ attached to the sterilization procedure lure them to come forward, and the officials are only too happy to see their ‘targets’ achieved. Clearly, Babus responsible for the family planning program have no idea that the National Population Policy of 2000 has categorically rejected their old-fashioned ‘targeted approach’ of population control.
A Brief History of Family Planning Initiative in India
Let’s start with a brief historical perspective.
Sixty years ago, India started the first national family planning program in the world. It was certainly a different world with different realities. Indian population was only a third of what it is today and the average life expectancy was only 32 years (today it is 67 years). The average number of children per woman was about six and over one-fifth new-born infants did not survive for their first birthday. Compared with current scenario, the infant mortality rate was four times higher – 225 for 1000 live births. Interestingly, female sterilization, the most commonly employed birth control tool by the state machinery today, did not exist then.
In the years after the second WW, India’s family planning initiative was controlled by the Western aid givers, who were clearly in the Malthusian awe of the large Indian population and the very thought of its growth meant something like a ‘population explosion’ to them. Indian family planning initiatives were highly influenced by the global trends and the fear of “population explosion” got systematically ingrained in the public psyche. This fear expressed itself in a series of incentives and disincentives in the family planning programs in India. It was even introduced in the school curriculum and the later policy changes failed to completely rectify such references. [Read, History and Politics of Family Planning in India]
What was initially merely a maternal and child health program, grew into an overwhelming adventure as the fears of a “population explosion” gripped the planners – of course, promoted by the international aid agencies and the Western donors. Mid seventies saw a sudden twist in the family planning initiatives when Indian policy planners, from seeing development as the best contraceptive, moved to a dictatorial forced sterilization campaign. Over time it became an entirely ‘target’ driven number game and the government machinery, from top to bottom, began to be judged by the number of “tubectomies” delivered annually.
Some sanity was restored after the International Conference on Population and Development (ICPD) in Cairo in 1994. Its program of Action clearly stated that
‘…Government goals for family planning should be defined in terms of unmet needs for information and services. Demographic goals, while legitimately the subject of government development policies, should not be imposed on family planning providers in the form of targets or quotas for the recruitment of clients.’
India then began to shift into a target free, reproductive and child healthcare regime during 1996 – 97 and adopted a new National Population Policy in 2000, which called for an integrated approach that in a couple of years transformed into a more holistic National Rural Health Mission in 2005.
Women’s and civil society organizations have always demanded policies focused on the need for addressing women’s welfare and health concerns, rather than the narrow focus on sterilization. But as realities of sterilization camps reveal today, policy makers still fail to focus on quality of care and remain obsessed with the ‘targets’ of sterilization numbers.
New Realities, But Old Mindset
Ground reality of today’s sterilization camps tells that the government machinery is still dogged by the old understanding of the population issue and is still aiming to reduce family size through permanent termination of pregnancies. Despite the much changed demographic realities of today, the state bureaucrats also still harbor the ossified thinking that “female sterilization is the only means of population control.”
The policy makers sitting in State capitals set targets of sterilizations and the bureaucrats galvanize the state machinery to set up sterilization camps to achieve the goals. But the ground level health workers know “how these numbers are gathered” and goals achieved. Bureaucrats are, of course, unconcerned as long as they are given reports of targets achieved. They still take delight in achieving the ‘targets.’
Let us examine why the ‘target’ driven approach and the over-hyped female sterilization is not the correct solution to manage Indian population given the current demographic realities.
What is the Reason behind Population growth Today?
“You can solve a problem only if you understand it properly.” This is the age old wisdom our family planning officials are ignorant of.
Family planning bureaucrats’ primarily need is to reeducate themselves with the changed population dynamics of India. Today India’s population is growing not because families are getting bigger but because there are too many people in the reproductive age group – it is a ‘young’ India today. Such a growth is called population momentum. In fact, the Total Fertility Rate (TFR) has declined from over 6 in 1950s to 2.5 in 2014, reflecting desire for smaller families and is still falling. The message of “Hum Do Aur Hamare Do” has reached even to the most backward person.
Through their mathematical analysis, Indian population experts have discovered that today the most dominating factor is the population momentum. They estimated that about 70 percent population growth comes from the population momentum and about 24 percent from unwanted fertility or non availability of contraceptives (unmet need). Only a tiny 6 percent growth comes from the desire for larger families. Thus, today over 95 percent people of India don’t want larger families. It is really a great success for the awareness campaign of the past decades.
This analysis also points to the best course of action for our population planners. Their traditional obsession with sterilization as the primary tool for birth control puts them focusing all their energies in eliminating wanted fertility that contributes just 6% to population growth! Therefore, they must re-educate themselves with the new demographic realities.
So, What should be Done
The current realities demand that the family planning battle has to be fought not in the sterilization clinics but on the social plane. The fight against population momentum, the leading cause of population growth today, demands delaying all pregnancies. It provides three clear strategies:
- Discourage and prevent early marriages. Although the average age at marriage is increasing slowly, marriages at younger ages are still quite common: In many states, almost fifty percent girls are already married and many are already mothers at 18.
- Encourage delaying first pregnancy by two-three years after marriage and then delay further pregnancies. It demands easy availability of contraceptives as well the knowledge of reproductive health.
- Increase availability of contraceptives for spacing births
About a quarter births take place due to unwanted and unplanned pregnancies, measured as “unmet need” for contraceptives – this is, due to poor availability of contraceptives. Condom awareness campaign should not be limited to HIV and STD prevention only. Easy availability of condoms and other contraceptives will also help the needs of the educated and liberal youth who now have more opportunities of proximity and contact.
Additional Desired Steps
Additionally, the following steps would also go a long way in rationalizing the family planning efforts in the country:
- Strengthen the family planning healthcare system so that people get complete knowledge of possible contraceptive methods including IUCDs, pills, etc and turn sterilization into just another option. Anganwadis in the rural areas are the ideal places for such educational efforts, particularly of rural young women.
- Need to think contraceptive needs beyond marriage: The sphere of contraceptives for family planning and infection prevention is too small to accommodate the changing requirement of contraceptives for people not in marriage. This requires addressing the issues of sexuality and pleasure along with sexual violence and coercion.
- If at all incentives have to be given, they should go to the people availing services and never to the bureaucrats in any form. After all they are merely doing their job!
- Allow sterilization camps only by NGOs and civil social organizations with complete freedom about pre- and post-operative care and camp duration.
- Monitor the quality of family planning healthcare through a set of quality parameters, as oppose to the current fashion of counting sterilization numbers.
- Female education and empowerment is the best contraceptive; counseling on these issues should be included into programs designed for rural areas.
- Motivate men to get involved in the family planning program: Men can play a vital role in propagation of awareness on above issues. A good suggestion is to engage male volunteers to operate alongside ASHAs to work with men.
Why too much focus on female sterilization and sterilization camps are bad?
Making only females responsible for family size is a striking example of gender bias in India. Men should also be made equally responsible for fertility and child care related activities. Gender bias apart, there are other compelling reasons why focus on permanent sterilization method is a wrong prescription to check population growth.
- When sterilization is the only available method to prevent pregnancy, it leads to several distortions. For example, people tend to go for quick pregnancies before sterilization. This actually adds to population momentum which is the prime cause of population growth. Reducing population momentum demands delaying pregnancies.
- Experts advice against female sterilization below the age of 27 because it leads to higher complication and failure rates. NFHS – 3 data clearly indicate that most of the sterilizations are done at younger age – sometimes as young as 20 year or even younger. Moreover, female sterilization also increases the risks of hysterectomy by four times. Therefore, heavy dependence on sterilization is not only putting young women to future health risks, but also depriving them of other contraceptive choices – better suited to their needs.
- Encouraging sterilization camps is bad for two reasons: One, it encourages government bureaucrats to adopt coercive means to get people to the camp, neglecting proper screening for the sterilization operation. Second, camp conditions badly compromise quality of healthcare. Women also need pre- and post-operative care which is rarely provided. A lot of NGOs and other organizations familiar with the realities of camps even question the quality of operative conditions of the camp. They mention that most sterilization camps become active only during November to March, with the accompanying mania to meet the targeted numbers. Some activists even report death during or after such operations; fortunately such incidents rare but are fully preventable with proper care.
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