March 15, 2013,http://www.island.lk/
I was appalled to read a recent newspaper article that reported a government ban on irreversible methods of contraception. Later I learned that the ban prohibits non-governmental organizations (NGOs) from the provision of sterilization services. According to reliable sources, sterilization services continue to be available through the public sector albeit with additional counseling requirements implemented at some points of access. As this newspaper item coincided with protests against ‘family planning’ held by extremist Buddhist factions concerned about the diminishing ‘Sinhala race’, it is surprising that neither the government nor the Ministry of Health has thus far provided clarification on this issue. In this article, I would like to highlight a few problems with the existing sterilization policy that are unlikely to be resolved through bans or other forms of restriction. Rather than restricting women’s access to contraception to accommodate the views of reactionary groups, it might be more useful to focus our efforts on addressing some of the issues outlined below.
General Circular No. 1586 issued by the Office of the Director General of Health Services (1988) includes the following eligibility criteria for sterilization procedures: “1) The clients should be over 26 years of age and should have at least 2 living children; the younger being over 2 years of age. Confirmation of mother’s age should be done by checking the Birth Certificate, Identity Card or any other valid document, which is available; 2) Clients who are over 26 years of age and having 3 or more living children could be sterilized at any time; 3) A client under 26 years of age, and his/her spouse insist on a sterilization, the Medical Officer concerned could use his/her discretion, and perform the sterilization provided the couple has a minimum of 3 living children. In such a situation the officer concerned should personally check the validity of the information provided, in respect of the number of living children, prior to performing the sterilization; and 4) In the event of any medical indication, which warrants sterilization, the client should be referred to a specialist in the relevant field who should make the final decision.”
As the subtext of the circular implies, like most contraceptive programmes offered through Ministry of Health, the criteria for sterilization target women. For instance, references to the “mother’s age” and the insistent appeal of the spouse (when the ‘client’ is under 26 years) suggest that women are primary targets of the sterilization programme. In my experience of working for the Ministry of Health, sterilization procedures were, in fact, freely available and did target women, both in terms of availability and accessibility. This is confirmed by data from the most recent Demographic and Health Survey (2006/7): 16.9 % of ‘currently married women’ were sterilized compared with 0.7% of women whose husbands were sterilized (the Demographic and Health Survey is administered to married women and specifies these categories). These statistics must also be considered in light of the fact that the sterilization procedure for men is ‘simpler, safer, easier, and less expensive’ than the procedure for women (WHO, 2007).
Importantly, the criteria listed on the circular do not require the ‘client’ to obtain her/his partner’s consent to undergo sterilization (although spousal insistence may add weight to requests from those who are under 26 years of age). Nevertheless, spousal consent is routinely obtained in government institutions before providing sterilization procedures to women (my experience; see also CEDAW Shadow Report, 2010). In my work, I witnessed numerous instances when women’s pleas for sterilization were rejected during Caesarean section simply because the spouse was unavailable to sign a consent form. If these women decide to undergo sterilization on a later date, they are exposed unnecessarily to a second surgical procedure. In this way, doctors take on the role of gatekeepers to contraceptives services, restricting women’s access based on their own gendered presumptions.
The Circular of 1988 referenced above was introduced because “[it had] been observed that a significant proportion of females who [underwent] sterilization [were] under 25 years of age, with a notable number being less than 20 years” (General Circular No. 1586). These concerns were valid in the 1980s, a time when coercive tactics were being used as part of the population control agenda imposed on the third world. In 1980, a monetary incentive of Rs. 100 per sterilization procedure was introduced and was subsequently increased to Rs. 500. Surprisingly, this monetary incentive was not omitted in the Circular of 1988 and remains in place today. In fact, another circular was introduced in 2007 in order to “streamline” the payment process so that ‘clients’ would be able to obtain this payment from the institution that provided the sterilization procedure (General Circular No. 01-09/2007). Furthermore, healthcare providers (including the surgeon, anaesthetist and assisting nurses) can still claim, if they so do wish, a negligible sum for sterilization. While Rs. 500 may seem trivial to some of us, continuing to provide incentives for sterilization is problematic and warrants omission.
The provision of incentives can be interpreted in many ways, especially when sterilization procedures are mostly sought by particular groups of women. Sterilization is most popular among women in the plantation sector (presumably not Sinhala contradicting the claim of extremist factions in Colombo). According to the Demographic and Health Survey (2006/7), 61% of estate women used a modern method of contraception (including sterilization, contraceptive pills, intra-uterine devices, Depo-Provera, implants, condoms and complete breastfeeding) and 41% resorted to sterilization. In contrast, 54% and 44% of rural and urban women used modern methods of contraception, while 16% and 13% resorted to sterilization (the survey used urban, rural and estate as distinct categories). This set of data completely debunks the proclamations of extremist Buddhist groups who are hell bent on protecting Sinhala women from coercive sterilization. It also makes it incumbent on us to ensure that plantation workers are not coerced into sterilization. On the other hand, the large numbers of estate women accessing sterilization may signify a lack of access to temporary contraceptive options.
Imposing restrictions on sterilization may have other implications for women’s health. For instance, it is likely to increase the incidence of unplanned pregnancies. According to the Demographic and Health Survey (2006/7), sterilization is popular among the following categories of women: estate women, women above 35 years of age, women with lower levels of education and women with three or more children. While these associations may point to a need to ensure that these particular groups of women are not coerced into sterilization, it also reflects on who will be most affected by restrictions on sterilization. Not surprisingly, this profile bears similarity to that of women seeking abortion services; induced abortion is most common among rural, married women with at least two children (Senanayake & Willatgamuwa, 2009). Then restrictions on sterilization could result in more women resorting to unsafe abortion, a service that has moved underground since the government led shut down of abortion clinics in 2007.
Religious extremism is frequently accompanied by restrictions on access to reproductive health services for women. Although the existing policy is problematic for the reason that in targeting women it burdens them with the responsibility of adopting contraceptive measures, the policy does ensure that sterilization is quite easily accessible to women through the public sector. While there is much room for improvement around health policies governing contraceptive services, such as the removal of incentives and the unofficial requirement of spousal consent for sterilization, imposing restrictions or banning sterilization altogether is hardly the solution. Such restrictions are not only an extension of policies that assume that women are incapable of making decisions concerning their health, but may well be interpreted as an attempt by the state to regulate women’s reproduction in the service of a retrograde agenda of nationalism.
Ramya Kumar, MBBS
Kandy
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