The much-heralded family planning programme is in its details little more than the mass sterilisation of mostly illiterate women to complete bureaucratic quotas, rather than safeguard their health.


“On one hand, Navaratri, and on the other, the match. Didn’t you get any other day for operation?” Nina, the nurse-intern asks the woman on the hospital bed as she gives her a local anaesthetic. The woman is here for a tubectomy.

This is the “recovery ward” of Badshah Khan hospital, Haryana’s Faridabad district’s biggest government facility. All the district’s family welfare programmes are conducted here. The ward is full, half are women who want a tubectomy and the rest their attendants and anganwadi sisters, or behenjis.

It’s March 26, and there’s a lot of excitement about the India-Australia World Cup semi-final. The radio jockey calls it “national illness day” because lots of people in this cricket-obsessed nation called in sick just to watch the match at home.

The ward was originally white, with new vitrified cream tiles, but they are splattered with countless stains. The ward and the corridor are full of noise—women chatting and laughing, phones ringing, waiting men discussing the score and Australia’s batting order.

In November last year, the ICU was shut for a month because of a shortage of trained paramedics and doctors. Close to 10 people who might have been saved if it had been open died in this period, according to local media reports. Even today some two-thirds of its 307 medical posts are vacant.

The ward has 11 beds and big windows that light up the whole space. The women—all between 20 and 26—lie on the beds, dressed in brightly coloured clothes. The last two beds are occupied by four women, one of whom is wearing a bold yellow sari. They’re all here for the same thing.

Nina says, “Didn’t you know that today was the surgery? You should have worn a suit.”  The woman looks at her mother-in-law sitting cross-legged on the next bed and replies, “We are from UP, not Haryana. So we are not allowed to.”

The stench from an attached bathroom chokes the room. Constructed two years ago, the ward is called “modern” and air-conditioned, which explains the lack of fans. However, the centralised air-conditioning plant has failed. The windows are sealed. There’s no way to escape the smell.

Kanta Rani, the head nurse, is middle-aged and dressed in a printed blue kurta, blue salwar, and half-sleeved lab coat. Her henna-dyed hair is pulled back in a bun. She wears pearl earrings and a small maroon bindi in the centre of her forehead. She is examining a patient named Ramvati when Ramvati’s sister-in-law Pushpa says, “Sister, it is impossible to sit here because of the stink. I’m feeling dizzy.”

“If you’re feeling dizzy, go and eat something,” Kanta replies.

“How can I eat? I’m fasting for Navaratri. I can only eat once I reach home,” Pushpa says.

Kanta looks at her for a moment and then walks toward the door. She steps out of the ward and yells, “Sanjay! Where are you?”

A short, stocky man in his late twenties with white earphones plugged into a big white smartphone is sitting outside the ICU on the visitor’s bench. This is Sanjay, the ward boy, in checked shirt and blue jeans. He removes an earphone from his right ear and answers, “Haan?”

“Clean the bathroom, Sanjay. Why aren’t you doing it? Told you twice already,” says Kanta with authority.

“Australia has already made 250 runs, sister. Kya yaar? Doing it!” he says, re-plugging the earphone and passing Kanta in the recovery ward to enter the adjoining operation theatre section.

Kanta looks at him for a few seconds and mutters “Can’t think of anything but the match.”

It’s now 1 p.m. and the eight women slated to be operated on haven’t eaten anything since morning. Patients are not allowed even water four hours before surgery.

Ramvati is worried about Babloo, her three-month-old youngest son. Anaesthesia is to be given at the operation table but it has been given outside already. An hour has passed and no one seems to know how much longer it will take. Pushpa had taken Babloo out into the corridor for a stroll but he wouldn’t stop crying. Three other toddlers are also in the ward, all dependent on breastfeeding.

Pushpa gives Ramvati the baby, saying, “Feed him; God knows when next you will be able to after the surgery.”

Ramvati was married at 18 and had her first child, a son, a year after. Next year, she had a daughter and two years later, one more. The village behenji (anganwadi worker) told her to get an operation done since she already had three children. “No more children,” she said.

Ramvati says every time the behenji saw her she promised to take her for the operation. “She wasn’t saying anything wrong. Even I didn’t want any more. But my husband wanted one more son. He said we must have “two eyes and two arms”. Ramvati got pregnant again and “fortunately” delivered a son. Three months later, she is here for the surgery.

It’s been five hours since she reached the hospital from Kheri Kalan village, 30 kilometres away, with her husband Sandeep and Pushpa, all on one motorcycle. But surgery hasn’t even begun. The ICU is still occupied. The doctor for the previous surgery reported late and so did the technician. Pre-operative procedures took time.

As Sanjay told Kanta, “Sister, if they love their country, they will be okay with a little delay today.”

The term “birth control” was coined by Margaret Sanger in 1914 to provide ways to poor women to avoid pregnancy. Decades later, when President Lyndon B. Johnson pushed for birth control in the US, it was seen as a part of “black genocide”. The targeted people were mostly blacks because of their poor socio-economic situation.

In 1962, human rights activist Malcolm X suggested that “it would be more successful if the term family planning is used instead of birth control.” Thus, what started as a reproductive right for women was appropriated within patriarchal norms in the years to come.

Matthew Connelly, a professor in Global history at Columbia University in his frequently referred paper, “Population Control in India: Prologue to the Emergency Period” mentions that in the pre-independence era, the Congress party’s National Planning Committee issued a report advising that all barriers—social and political—in inter-caste marriages between upper caste Hindus must be done away with to stretch upper caste Hindu reproduction to the best. The report suggested that government should start birth control campaigns for lower caste Hindus, Muslims and tribals to lower their population. The aim was to “prevent the deterioration of the racial makeup.” It did not materialise.

The sterilisation camp approach was introduced in the Fourth Five Year Plan (1969-74). The camp came in handy because birth control and condoms depend on the agency of the person to use them. The primary motive was to sterilise a large number at one go and meet targets. It became a symbol of the Indira Gandhi administration’s excesses during the Emergency, from June 1975 to January 1977. She implemented it in lieu of food aid from international lobbies which were paranoid because of the growing population of the developing world.

Her defeat, among other things, was attributed to the forced vasectomies during the period. The subsequent   governments, to avoid political ramifications, almost entirely focused Family Planning efforts—which have now been repackaged as Family Welfare—on women’s sterilisation.

According to government guidelines issued in 2006, the women patients should be between 22 and 46.  Counselling about sterilisation, its possible side effects and failures along with other methods of contraception is a must before the surgery. In addition, a health check up, record of last menstrual cycle and current pregnancy status is required. Information about health insurance is also mandatory.

The consent form should be signed before surgery when the patient is not under sedation and without any coercion.

Local anaesthesia should be given on the operation table and not outside.

After surgery, the pulse, respiration and blood pressure of the patient must be recorded every 15 minutes for one hour, or longer if the patient is not awake. The patient can be discharged four hours after surgery when she is fully awake, has passed urine, can walk, drink or talk and has been evaluated by the doctor. A sterilisation certificate is issued after a month of surgery or after the first menstrual period by the medical officer of the facility.

Ramvati was the first in the hospital at 8 a.m. with her BPL card as identification. The anganwadi worker had met her at the family welfare section, where two counsellors had told her “tubectomy is comfortable and hassle free”.

“Did she tell you anything else?” I ask.

“No. That was all,” she says.

After five more women gathered, the group was taken to a small, dingy section on the ground floor. One by one, they were given forms to sign and place their thumb impressions on.

“The form was in English. I didn’t ask (what it said) because the nurse was in a hurry,” Ramvati says.

Once the forms are stamped, they are asked to move to the laboratory. Blood samples are taken. Urine samples are required next, but “there were not enough containers for all of us, so only four gave samples,” says Ramvati.

All eight women are from the Jatav community, part of the Scheduled Caste.

The recovery ward on the second floor is next to the ICU. By the time the women reach, it’s already 11 a.m.

Two hours pass this way: nurses administering anaesthesia, demanding the bathroom be cleaned, Babloo being fed, patients dozing, Sanjay watching match updates on his phone. Finally, Dr. Sangeeta Agarwal, middle-aged, dressed in a yellow kurta with a red border and white tights, enters the ICU. The women are told to go for surgery five at a time. The other doctor, Dr. Sandeep, has left; he wants to watch India batting.

Kanta and another nurse do a quick head count and wake up the first five patients. “All of you go and urinate,” they are told. “The bladder should be empty.”

There is a bathroom at the other end of the floor, soiled and dirty. Its aluminium-framed main door and the doors inside have no glass at all. So the patients use the bathroom attached to the recovery ward, which Sanjay has still not cleaned.

Hardly able to walk because of drowsiness, the women are taken to a small waiting chamber with an L-shaped bench. A security guard, the only one on the floor, sits outside. The door is half-open.

Each woman holds a few sheets of paper stapled together: forms, photocopies of their identity proof, their BPL cards and others. A nurse examines their eyes and asks the first patient if she has had dengue, malaria or typhoid in the past. “I had fever a month back for two weeks. Don’t know what it was,” she says.

The nurse says, “You don’t have it now, no?”

“No,” the woman says. She is sent to the ICU.

A patient—middle-aged, emaciated, dressed in green pyjamas and shirt—peeps into the ICU, where an operation is in progress. From the door, blood-soaked cotton and internal organs are visible.

The guard asks, “Why are you peeking inside?”

The man replies, “The next operation is mine.”

Five minutes later, the first woman comes out. Sanjay is pushing her on a wheelchair. She looks faint, dupatta trailing on the ground as he takes her into the recovery ward. Sanjay taps her shoulder. “Get up!”

He takes her arm and stands her next to the bed. An attendant makes her lie down and covers her with the dupatta to save her from the flies. There are no sheets to cover the patients.

The routine is repeated with the second patient.

The fifth patient has not signed her form. There is some commotion for a couple of minutes to find a stamp pad. The nurse helps the half-asleep woman put her thumb impression on the form before taking her into the ICU. A few minutes later, at 2 p.m., she returns.

When the next three women are taken to the waiting room, two more come into the ward. Kanta tells the interns, “Inject them and take them with the other three.”

Nina says, “Why more? I’m fasting today. Need to go home early.” Nevertheless, the last two women are efficiently given anaesthesia and taken along.

By 2.30 p.m., all 10 are done. The nurses pack their bags and proceed to the staircase.

The National Family and Health Survey-3 (NFHS-3) data show that in India three quarters of contraceptive users have undergone sterilisation. In the last two decades, female sterilisation has risen from 27 per cent to 37.3 percent. Male sterilisation accounts for just one per cent. Temporary contraceptive methods have hardly shown any change over years: the current use of condoms is 5.2 per cent. Nearly 45 lakh tubectomies have been performed each year since 2000.

Globally, one in 200 female sterilisations fails. One woman in 100 gets pregnant after surgery, complications are reported in one in 100 cases, and the risk of death is reported in three in 10,000 cases. There’s no scientific data in India for these parameters as there is no follow up of cases or qualitative survey.

If we plug in these data on an average of 47 lakh female sterilisations every year, a back-of-the-envelope calculation suggests 2.35 lakh failed procedures every year and 14,100 deaths. Experts estimate the number to be much higher.

Dr Sangeeta Agarwal explains the sterilisation procedure.“The procedure is to go to family welfare department, to the counselling centre. Once all formalities are done, they are operated here. Yesterday, there were six, sometimes there are 30-40 in a day. Today 10; two were not operated because one had ovarian cysts and the other one’s bladder was full. She has been told to come tomorrow.”

“What about tubectomy failures?”I ask.

Sangeeta says, “We have a committee. You can ask Dr Swamy. He is the head of the family welfare department. Everyone knows him.” She leaves.

“Did they tell you about insurance and compensation?” I ask Ramvati.

“No. What is that?”

Twenty minutes later, the chattering stops. The women leave the hospital with their discharge certificates.

Dr R. N. Swamy is the deputy civil surgeon and head of the family welfare department in Faridabad. His office is in the old building. The entrance is lined with cardboard boxes full of Nirodh condoms, awareness posters, and medicines. A board enumerates the achievements of Faridabad’s family welfare department. In 1991-92, the department met 51 per cent of the sterilisation target for the district. In 2013-14, the figure was 131 per cent.

Swamy’s office is at the end of a long passage divided into small cabins. The entry to his cabin is through a small room occupied by his attendants and assistants. I wait in the room as Swamy is in a meeting with two senior police officers. India is batting now; the assistants are busy refreshing scores on
the computer.

Twenty minutes later, the cops leave and I enter Swamy’s office. He is middle-aged and bespectacled, wearing a blue shirt. He asks his assistant, “What is the status now?”

The assistant replies, “140 for four wickets.”

Swamy turns to me. I say, “I wanted to know about the sterilisation process in the hospital. How many are conducted every day? What is the process? Are there any male sterilisations too?”

He says, “The ANM or ASHA worker brings them here. We counsel them and after medical tests perform the surgery, not more than 30 a day. Male sterilisations are very few. No one comes.”

“What about sterilisation failures? Are they given compensation?”

“There are very few. We have a committee to review the cases and then give them compensation,” he replies.

“What about Santosh’s case? It’s pending for two years now.” I show him a legal notice sent by Santosh to the hospital asking for a response to her compensation claim after a sterilisation failure in 2014.

Dr Swamy goes through the document and says, “I am aware of the case. I am from the same village. But I am sorry I cannot talk to a reporter about the status. Please give a written request and we will pass it on to our seniors who will respond after the financial year closing, in the second week of April.”

“But why has she not received an acknowledgement of her notice?” “I cannot respond to that,” Swamy says.

Anangpur village is a few kilometres from Surajkund, the annual handicraft mela site in the National Capital Region. A well-constructed road lined with several real estate and housing projects leads to the village through a big gate. After the main square, the village is divided into several colonies.

“Where is Sant Lal’s house?” I ask a passerby. Sant Lal is Santosh’s husband.

“Which one? Just Sant Lal or Sant Lal from the Harijan basti?” asks the man.

“The one who works at the petrol pump?”

“The Harijan basti one, then. Go straight. There is a well. Ask anyone there,” he replies.

A few metres away, the well, surrounded by houses on all sides intersected by narrow lanes, almost blocks the entire passage. It has an iron grill over it with water pumps placed nearby. To its left is a building with a board saying “Ambedkar Kalyan Samiti” with Ambedkar’s picture above it. Santosh’s house is on the right.

Painted in blue, it looks massive. A small courtyard serves as the entrance, with several rooms around it. Santosh is away, but her sister-in-law Preeti sends a boy to look for her. A cluster of households live in the house; each room with a chulha outside is a family unit, with separate income and expenditure.

Meanwhile, a teenage girl in school uniform of grey salwar kameez and white dupatta with fresh chicken pox scars on her face walks in barefoot, pencil box and paper in hand. “This is Kajal, Santosh’s elder daughter. There are five siblings. One died last July. This one had mata 10 days back. Still recovering,” says Preeti. Mata is a local reference for chicken pox.

Kajal has three sisters and one brother. The third sister was born after Santosh’s tubectomy in April 2013. One brother was playing near the well and got electrocuted in July 2014. He died on the spot. “If a son had been born after the surgery it would have been still okay. What will she do with one more daughter?” says Preeti.

Kajal gets her mother’s documents from their house next door, a small eight-by-five foot room. They’re in a yellow plastic bag that she empties on the floor, swiftly separating the hospital documents from the others.

“Mummy has managed to get six out of seven papers from the hospital.”

According to the norms, any patient applying for compensation in case of sterilisation failure has to submit an array of documents: a claim form and medical certificate in original, signed and stamped by the designated officer at the district level; a copy of the consent form; a copy of the sterilisation certificate; and a copy of the discharge certificate. Additionally, a person must also provide medical bills in the event of complications, a death certificate in the event of death, or proof of pregnancy in a failed procedure.

“Her claim form is yet to be signed by the officer,” explains Kajal, arranging the documents in order—her mother’s sterilisation certificate, discharge certificate, pregnancy report, and ultrasound. She points out the blue marks on the sonogram pictures and says, “See, Anmol is here.”

Sant Lal, Kajal’s father, works at a petrol pump on the Surajkund road and is an alcoholic. He earns Rs 6,000 a month and does not let Santosh work outside the house. Santosh filed this complaint with the help of an uncle, Chavan Singh. He is a tall, lean man, with salt-and-pepper hair, and calls himself a social worker.

“There have been many cases in the village,” Singh says.“The first one was that of Rameshwari, 20-25 years back. She had to finally withdraw her complaint because her husband was a government servant.” It was not easy to work with the government and complain against it simultaneously.

Anangpur has a population of 5,000 with 2,500 votes. It is dominated by the Gujjar community with approximately 400 Jatav households in the Harijan basti and some Kumhars, Muslims and Pandits.

“She wanted to file a claim. They are very poor and I helped her.”

Singh says the Gujjar biradari panchayat asked the Ambedkar Samiti to tell Santosh to withdraw the complaint. There has been tension between the communities since last year. During chakbandi (land redistribution) the Gujjars took away all the land to be given to Dalits. “Not even 100 square yards was given to us,” says Singh.

“Since they have land, money and power, all officials listen to them. After her complaint, officials approached them to withdraw the complaint. The village pradhan is also a Gujjar. It has become an issue of honour for them. Plus, it is not a problem their caste women face.”

At this point, Santosh enters. Thirty-four years old, she is thin as a stick, short, and wearing a loose light green salwar kameez. She covers her face with her faded, torn white chunni on seeing Singh.

He ignores her and continues. “We had cattle but now there is no place to take them for grazing. We were anyway weak. Now unemployment has risen. All MLAs, all corporators, all pradhans listen to the powerful, not to us.”

Santosh asks me to join her in another room. That is her house. A dressing table with a broken mirror stands in one corner. There’s an old television and a bed. Santosh’s wedding photograph hangs on one wall next to a garlanded photo of her son Amit, who passed away.

She says, “I lost all strength after his death.”

After Santosh found out she was pregnant at a private clinic, she went to the B. K. hospital to get an abortion done. “They told me I was anaemic so they can’t do it. I asked them, why did they do a tubectomy? The doctor told me that when the child is born, give it to us. She will give it to her friend. I am not literate but tell me: who gives away their child like that? Would she have said this to a rich person?”

Santosh says Anita behenji, an anganwadi worker, took her for the tubectomy. “ After my fifth child Mayank was born—he is three now—I decided to get the surgery done. There was a lot of tension at home. My husband is an alcoholic. He does not beat me up but gives us hardly any money to run the house. So when I said that I want the operation, he didn’t object.”

“How did you get the sterilisation certificate if you did not have your period the following month?”

“I don’t know. One month later, I went to the hospital and got it. I found out in August that I was four months pregnant. Anita behenji said she will help me in following up the complaint. Now she has also been pressured by the Gujjars. If I had money I would have also gone to a private clinic, like the Gujjar women. ”

According to the government scheme, in a case of failed sterilisation (pregnancy)the compensation is Rs 30,000. In case of death within seven days of surgery, Rs 2 lakh. Within a month, it’s Rs 50,000 and for other health complications, Rs 25,000.

Santosh received nothing.

The “family planning festivals” that started in Kerala in the 1970s introduced the practice of “motivators”. Anyone who needed to get government work done was supposed to bring a sterilisation case. The present roles of motivators like ASHA and ANM workers, and incentive programmes, are inspired by this.

ASHA workers were appointed soon after the National Rural Health Mission (NRHM) was launched in 2005 to help vulnerable sections. They are considered honorary volunteers and paid Rs 600 for an institutional delivery, Rs 150 for immunising a child, and Rs 150 for family planning. There have been nationwide protests for the last two years, where ASHA workers have demanded permanent status in the health department. Currently they are contract workers and will be jobless when the NRHM closes in 2018.

Auxiliary Nurse and Midwife (ANM) workers are responsible for anganwadi centres, to take care of child and maternal health in a village. They also train ASHA workers and are paid a nominal salary by the Central government, about Rs 1,500 per month.

Anita behenji’s house is locked. Kajal looks for her at a neighbouring house where a group of women are huddled in a circle. A woman “possessed” by her dead husband’s spirit is issuing instructions through clouds of incense. Kajal walks up to one of the women in the group. This is Anita.

In her mid-30s, Anita is dressed in a peach salwar kameez with a green border and golden embroidery, and wears dark lipstick. She sits on a sofa in her house with a second woman, Pushpa, an ANM worker in the village.

“Navratras are on. You will find many such scenes in the village. We try to tell them it is mental illness, stop them. But who listens to us?”Pushpa says.

Anita looks at Kajal who is sitting nearby. “What happened with her mother was wrong. Doctors are careless and we have to suffer.”

“How?” I ask.

“Do you think women will come with us for operations? The village women don’t understand that we have no role in the failure. We can only take them to hospital and figure out medicines and documents for them,” says Anita.

Pushpa says, “Rich people go to private hospitals but not Harijans. They don’t have money to go to the doctor even for illness. The Gujjars are the ones who don’t even tell us about the pregnant women for immunisation and for our records in their houses. They say, ‘we go to private doctors, not consult behenji.’ We then tell them okay then, don’t come to us for pulse polio for the newly born child later. That medicine you can’t get privately. Then they send the pregnant women for immunisation.”

Anita didn’t find it easy to apply as an ANM worker. “No one in my family approved; I had to apply secretly. When my name appeared on the list, my father-in-law, brother-in-law, husband, everyone opposed it. They wanted to throw me out. Now, after five years, my husband roams around with my ATM card. In the past, he would say, is my money not enough? I really wanted to work and this is good work,” Anita says.

“How many male sterilisations happen in the village?” I ask.

“None. Who will talk to them? We have no male workers, and they aren’t bothered. The women tell us they don’t even want to use condoms. They force themselves even when women are advised abstinence after delivery or surgery. Does the husband ever listen?”

According to the family welfare programmes, the state government is supposed to pay half the salary of a Male Health Worker (MHW) in an anganwadi centre but estimates suggest that half the centres in the country do not have MHWs.

In the past few years, several state governments have announced additional incentives including DVD players, Tata Nano cars, and washing machines for doctors, motivators and women who undergo sterilisation to meet population control targets.

The first two-child norm was recommended by the National Development Council’s Committee on Population in 1992 to curb India’s reproduction rate by 2010. Since India started family planning programmes in 1952, the average number of children per couple or total fertility rate (TFR) has come down from 6 to 2.5.  The current population is growing because of momentum effect. That is, there are more reproducing couples compared to the 1960s and 1970s than the number of children being born now.

The National Development Council also recommended that any representative, from Panchayati Raj to Parliament, should forfeit their seat if they had more than two children while in office. Further, any Indian having more than two children after the policy’s implementation would be permanently denied the right to contest the election.

Since 2000, 11 states have adopted the two child norm. The idea was to make elected representatives “role models”. While Madhya Pradesh, Haryana, Himachal Pradesh and Chhattisgarh revoked the norm, five—Rajasthan, Gujarat, Maharashtra, Odisha, and Andhra Pradesh—continue with the policy.

On December 1, 2014, Manisha Patel, a 35-year-old BJP councillor at Gujarat’s Valsad Nagarpalika, lost her job after it was established that she had given birth to a third child after being elected to the post. Chief Officer of Valsad Nagarpalika J. U. Vasawa in a public statement said, “We have suspended Manisha Patel after finding (that) all the allegations made by (the) Congress leader were genuine and she had given birth to a third child.”

In 1996, India adopted a target-free approach and a National Population Policy. It aimed at the reproductive and health needs of young people, spacing methods, and number of contraceptive choices.

Yet targets continue to haunt poor communities across the country. According to a report by the Centre for Health and Social Justice, “In 2002, in Lakhimpur Kheri district of Uttar Pradesh, five farm labourers from the Dalit community, aged 18 to 32 years, were taken to a hospital by their upper caste landlord on the pretext of being inoculated against malaria and given injections and knocked out. They found out later that they were sterilised. Two of the five were not even married. The UP government in its zest to promote family planning offered gun licences to anyone who brought five cases. The farmer got the licence.”

The same happened in the Emergency when in several parts of Uttar Pradesh, gun licences were issued to men who underwent vasectomies.

A 2011 study by Surat-based Centre for Social Studies says the law is being used to settle personal scores and has no structured implementation mechanism. Action is only taken if someone complains about the third child. In Manisha’s case, it was the rival political party, the Congress.

Reports suggest the law, implemented in Odisha since 1994, affects women in the reproductive age more when the age for contesting elections was lowered to 21 years from 26 years. A two-child policy thus not only pressures women to undergo sterilisation but also leads to increased sex selective abortions to ensure male heirs.

A Mahila Chetna Manch study in 2002 revealed that 82 per cent of 113 disqualified persons in Panchayati Raj due to the two-child norm were from the SC/ST and OBC communities.

People who adopt the two-child norm get preference in land allotment, allotment of surplus agricultural land, assignment of house sites and houses and sanitation schemes. Other public benefits denied to families with more than three children in the five states include maternity and public distribution benefits. Thus, the law is further penalising marginalised communities in the name of population control.

This is Urmila Pal’s first journey outside Uttar Pradesh, arriving in Delhi from Mirzapur. Dressed in a synthetic saree with purple flowers on light pink background, a red cardigan, and socks, she doesn’t mind the cold on this smoggy winter morning on December 16, 2014.

Urmila is here to attend a public hearing on “Informed Choice and Quality of Care in Contraceptive Services in India”, organised by the Centre for Health and Social Justice and some other organisations, after the deaths of 11 Bilaspur women at a sterilisation camp in Chhattisgarh last November. She is here to talk about her botched tubectomy at the primary health centre in Mirzapur two years ago.

Urmila is 24 and the mother of three sons. She was married at 17 and delivered her first child a year later, in 2008. After numerous abortions, miscarriages and the death of one child three months after delivery, she delivered the second son in 2011. “I grew up in a large family in Allahabad. I didn’t want a big one for myself. Plus, two sons were enough to keep my mother-in-law from not asking for more,” she says.

Soon after the birth of her first son, Urmila had to replace her father-in-law, who died of silicosis, as a stone quarry labourer. Her husband’s family was indebted to the upper caste local landlord for a loan to buy a buffalo, roughly 30 years ago. It was called the kamiya-malik system where kamiya, the male member of the family along with his family, provide labour in the home and farms of the malik. No one remembers the initial amount but the next generation was still unable to repay. The family was then sold to the stone quarry owner in the late 1990s. The debt obligation was transferred along with that.

Urmila studied till Class 8. “I come from a bada ghar (well-off family) in Allahabad. I had never worked before my marriage but now there was no option. My father has a pucca house and land. But he married me and my sisters off to a landless family, saying we will build our own fortunes. How is it possible when he did not give us any land, and gave it all to my brothers?”

Urmila is paid Rs 80 a day, her husband Rs 140. The UP government rate for unskilled labour in stone quarries is Rs 250. The combination of backbreaking work at the quarry, meagre wages, and frequent health problems because of repeated pregnancies drove her to choose sterilisation.

Urmila approached the ASHA worker in her village—who had been advising her to go for the surgery—to take her to the hospital for a tubectomy. “It was like they catch monkeys in the Mathura temples and dump them all the way in the Mirzapur jungles. And when the number grows, they catch hold of them and sterilise them. That is how ASHA volunteers keep tabs on us. Like a bandariya!”

Urmila knows the ways of the jungle too well. She is from the Kol community, originally a forest dwelling tribe that is being consistently stripped of its livelihood because of increasingly restricted access to the jungles by the forest department. It is classified as a Scheduled Tribe in the bordering state of Madhya Pradesh but as Scheduled Caste in Uttar Pradesh.

The sterilisation camp was at the primary health centre in Padari, Mirzapur. Even when the government restricted the number of surgeries in camps to 30 per day, this isn’t always followed: in Bilaspur, 200 women were operated upon in a single day. The Padari camp was smaller, between 50 and 60 women. She was operated on without anaesthesia, without medical check-up,without privacy. After the surgery she and several other women lay on the bare floor. An hour later she was handed Rs 600 as an incentive from the government and let off.

Before the surgery, Urmila was neither given a consent form to sign nor a no-objection certificate later to prove that she underwent tubectomy.

Two months after the surgery, she discovered she was four months pregnant. The tubectomy was performed while she was pregnant. The doctor was never traced since he was not from the primary health centre. “The health staff said ‘What has happened? Have you been raped? Eat the pill and get rid of it’,” recalls Urmila.

The ASHA volunteer was initially supportive but switched sides after the health centre staff’s denial to help. She gave Urmila medicines and told her to abort the child. “Aborting the child meant taking a few days’ rest. I could not afford to take leave. Delivering the child was easier than aborting.”

That is how the third son was born in September 2012.

“There are so many women who die after such surgeries. This morning I met Wakim bhaisahab from Purnea in Bihar whose wife died in a sterilisation camp. The doctor, instead of informing him about her death, transfused one unit of blood and two glucose bottles in the dead body and directed him to take it to the bigger hospital, only to find she had died long back,” she tells me.

Wakim is also fighting a case in Bihar and is one of the participants in the conference. Three hundred women were operated upon in that camp and the doctor took no responsibility.

Mirzapur is one of 51 districts in India which has more than 26 per cent Scheduled Caste population. Most of the people rendered ineligible if Uttar Pradesh starts following the two-child norm will be from marginalised sections.

Ramakant Rai, a man in his 50s at the same conference said, “The Supreme Court has said sterilisation is not a disease but a therapeutic intervention and that is why it should be 100 per cent safe.” Rai filed a petition in the Supreme Court in 2003 on unsafe female sterilisation practices which violated patients’ “reproductive rights, women’s rights, and health rights”.

In 2005, the court gave a landmark judgment with strict guidelines to state governments on female sterilisation. It directed states to set up a family planning insurance scheme to support victims of poor procedural quality and adverse outcome in a sterilisation surgery.

Urmila got the tubectomy seven years after this judgment. A bicycle pump instead of high-precision pneumoperitoneum insufflation equipment was used to pump air into her and other womens’ abdomens for laparoscopic sterilisation. The midwife attached the tube of the pump to the laparoscope and pumped, giving no thought to pressure, speed, quality and quantity of air pumped into the abdomen.

Many women complained of cramps and pain for months but no one had the time or inclination to enquire into the after-effects. Their pelvic regions were examined openly in the presence of several men and women in the room. The doctor even used the same pair of rubber gloves while operating on 50 women.

The nurse injected all the women with the same needle, using only a cotton swab to disinfect it once in a while. After surgery, the women were laid on the bare floor in the corridor which serves as a post-operative care hall. Within half an hour of surgery, they left for home.

This is a clear violation of protocols but until today no medical staff or doctors have been penalised, except for temporary suspension for botched tubectomies.

Rai says, “The government has tied up with private insurance companies who reject the claims of women who underwent a botched-up sterilisation surgery on grounds as flimsy as the quality of food patients eat.”

The same practice was seen recently in the Bilaspur case, where a lot of patients are being blamed for not maintaining “hygiene” after the surgery.

Apoorva Gupta, a Delhi-based gynaecologist, says, “In an entire year I get only two to three per cent middle- and upper-class patients wanting a tubectomy. Most prefer pills or other temporary methods.” These decisions can be directly related to higher education levels in upper classes.

Female sterilisation in private clinics costs Rs 30,000 to Rs 40,000. Gupta says, “That is because not all private clinics have facilities for laparoscopic sterilisation and women who can afford do not want to go to government hospitals because of poor reputation.

Dr Abhijit Das, a health activist at the Centre for Health and Social Justice, says, “A sterilisation-focused approach, which India continues to adopt, leads to a fear psychosis where families quickly complete their desired family size through multiple pregnancies and miscarriages and then opt for terminal sterilisation. This speeds up population growth instead of slowing it down.”

According to NFHS-3, in India, 46 per cent of females in the six to 50 age group are illiterate. Female sterilisation is highest—47 per cent—for women with less than five years of education, and decreases steadily with education. This makes them more vulnerable to early marriage and repeated pregnancy.

With a family planning programme driven by female sterilisation, it is not surprising that more than half the women who get sterilised have the operation before 26. Early sterilisation is common in Andhra Pradesh where 50 percent of the patients are under 23.

NFHS data suggest that 45 per cent of young women marry before 18 and 63 per cent by 20. Like Urmila, about 25 per cent of girls in the 15-19 age group have their first child before 19. In May 2014, Karnataka chief minister Siddaramaiah reportedly attended a mass marriage of 42 couples where 16 girls were child brides under 18.

Das says, “Women who undergo sterilisation before the age of 30 face four times the risk of hysterectomy and higher risk of menstrual dysfunction and dysmenorrhea.”

It is important to remember that 13-15 million children die before five as high risk births lead to high child mortality. If children were born two years apart, three to five million of these deaths could be avoided. Had Urmila got access to spacing methods she might have managed to avoid multiple pregnancies and the death of one of her children before finally going for sterilisation.

Moreover, government family planning schemes are only focused on “eligible couples”. Twenty-eight per cent of India’s population is 10-24 years old. A 2005 survey conducted by the Population Council for boys and girls aged 15-24 in Pune concludes that one in five young men and one in 20 young women have premarital sex. In urban areas, youngsters are more sexually active.

Importantly, most of the budget approved for family planning under the NRHM launched in 2005 is directed towards female sterilisation. In 2013-14, Madhya Pradesh approved a budget of  Rs 8,417 lakh for family planning services out of which Rs 7,835 lakh was meant for terminal methods (sterilisation) and only Rs 87 lakh for spacing methods, which includes condoms, intra-uterine devices, contraceptive pills and others.

“After my first child, I asked my husband to use condoms. I heard about it at the primary health centre. Sometimes he would, sometimes he forgot. I didn’t want it to continue forever,” says Urmila.

Once, a co-worker was beaten up by her husband when he came to know that she was pregnant. Three months before the incident, the husband had undergone a vasectomy. The man accused his wife of having a loose character. When health activists intervened, they found out that his surgery was botched, too.

“I didn’t want to take that chance, at any cost,” Urmila says.

It is also telling that only 27 per cent of married women decide about their health care by themselves and only 11 per cent decide about visits to their family or relatives themselves, according to NFHS-3 data. Studies show that most men approve of contraception only after having a second or third child and that the husband’s approval of a particular method is critical.

The idea that poor people with more children consume more of the nation’s wealth has also been challenged, both nationally and globally. The increasing divide between rich and poor in India has to be addressed while rethinking population policies.

Das says, “A simple check on how much water, electricity and food is used by a middle-class family with two children and a set of parents in comparison to a poor family with five children in an urban slum will give you the answer.”

International researches also suggest that a strain on natural resources has been typically seen in urban areas. Sana contractor, a feminist health activist says, “The state must address issues like migration and rural infrastructure instead of brazen short cuts like female sterilisation for sustainable growth.”

Muslim women, for whom contraception is a religious taboo, are not considered while forming population policies, leading to questions around equity in access to contraceptives for minority communities.

Matthew Connelly, who has extensively worked on population policies across the world, writes in Salon that the idea of ticking population bombs in developing countries needs to be thought through in much greater detail. In the present form it is only penalising the poor.

NHRC member Cyriac Joseph who attended the conference says, “It is sad to hear the testimony of so many people who have been wronged. They should post a letter of complaint to their respective State Human Rights Commission. That will build pressure against coercive tactics.”

The conference Urmila attended had invited a number of people from the Health Ministry and Women and Child Development Ministry.

Not one turned up.