KAMRORA, INDIA — The Globe and Mail

Noni Raja was married in 2004 at the age of 20, then gave birth to a son a year later. After having two more children – a girl and a boy – Ms. Raja did something unexpected. She caught a bus into Mahoba, the nearest town, and presented herself at the hospital for a tubal ligation. She spent a couple of hours recovering, took the bus home and informed her startled in-laws that she had had “the operation.” (Simon de Trey-White For The Globe and Mail)

Noni Raja did just what she was supposed to do. She married when she was 20, in 2004, and gave birth to a son a year later. In 2006, she had a daughter. And a year after that brought the second son she needed to fulfill her obligations in the eyes of her in-laws, farmers with a tiny plot in this hardscrabble hamlet in the Indian heartland.

Then Noni Raja did something rather less expected. She got up one day, caught a bus into Mahoba, the nearest town, and presented herself at the hospital for a tubal ligation.

She spent a couple of hours recovering, took the bus home and informed her startled in-laws that she had had “the operation.”

Years later, her mother-in-law is still affronted. “I didn’t like it,” Kiran Devi says as the two women sit in the spring sun on their front stoop. “She went against our wishes.”

At the time, Ms. Raja wanted the best for the children she already had, which meant ensuring there would be no more.

Being surgically sterilized seems an extreme form of contraception for such a young woman, but India’s approach to family planning left her with no other choice.

Even worse, her defiance would come back to haunt her.

India began grappling with the magnitude of its population even before it became independent in 1947; it was labelled a crisis in the 1970s when the government of Indira Gandhi carried out mandatory sterilizations, en masse.

But since those dark days, the country has emerged as a leader in the field, adopting the language of “reproductive health and rights.”

That means, in the words of the World Health Organization, that India is committed to ensuring its people have “the capability to reproduce and the freedom to decide if, when and how often to do so” – and that their decision be “free of discrimination, coercion and violence.”

This official position – which contrasts starkly with China’s strict one-child policy – has won India international plaudits; last year, it was invited to co-chair a prestigious international summit on family planning held in London, and feted for its progressive approach.

Yet spend some time talking to women in Kamrora – and dozens of villages like it in the “Hindi belt,” the poor states that span India’s middle bulge and are home to about 450 million people – and you learn something that never came up at the meeting in Britain: The policy this country has on paper is markedly different than what happens in real life.

The reality is harsh and repressive and targets the most marginalized, often the lowest-caste, women. It is also far from effective in areas with the highest birth rates, paradoxically driving the rate up and making poverty worse in the process.

Beijing has been widely criticized for limiting families to only one child, but India has adopted many aspects of its policy. With 1.2 billion people and on course to overtake China as the planet’s most populous country in about a decade, India is taking steps many consider nearly as harsh – but cloaking them in the far more benign-sounding “two-child norm.”

And despite all the government rhetoric about how its citizens have choices and condoms are brought right to village doorsteps, the truth is that, in the northern half of the country, the Indian health service consistently delivers only one form of contraception in the rural areas, where 70 per cent of the population lives.

That is tubal ligation, often performed at “camps,” where dozens of women are sterilized in a day; more than half of them are 25 or younger, and they are often illiterate and unclear about what the surgery means.

Unlike many women, Noni Raja knew exactly what she was doing when she got on the bus to the city: She has been trained in family planning, which she is charge of delivering in Kamrora, and is responsible for distributing a government-funded supply of condoms and oral contraceptives. It is the only access to birth control people here have, as most cannot afford a trip to the city. Yet, in a situation typical of India’s badly managed social schemes, it has been two years since Ms. Raja last received anything to dole out. Today, her kit contains one desiccated packet of prophylactics and an expired pregnancy test.

So, when a village woman confides that her in-laws have given her permission to stop having babies, Ms. Raja knows that the only option is sterilization. To make sure that she promotes it, the government pays her $3 for each woman she brings in – and, if she does not deliver as many as the government expects, she stands to lose the only wage-paying job in Kamrora, other than breaking stones in the quarry.

Ms. Raja is the best-educated woman in the village – she finished 10th grade before her health-worker training – but she says with a sigh that it’s sometimes hard to explain the surgery to her neighbours. Research from the Centre for Health and Social Justice in Delhi shows that state governments aggressively target women from the poorest aboriginal and Dalit (once known as “untouchable”) communities.

Those who undergo the operation may not understand what is being done, but they know that there can be severe consequences if they do not comply with the two-child norm.

“We’re on the track to be just like China,” says Leena Uppal, an earnest activist who co-ordinates the National Coalition Against Two-Child Norm and Coercive Population Policies. “It’s entirely coercive – for the women, for the health worker, who will lose her job if she doesn’t bring in enough people. The whole focus is on closing off wombs, of making sure these women don’t have any more babies.”

China’s one-child campaign, adopted in 1979, forced women to have abortions if they conceived again without state approval, or fined couples heavily, especially in urban areas. India’s policy involves no such direct punishments, but its impact can be harsh in a place such as Kamrora.

Parents with more than two children are denied access to everything from a subsidy for babies delivered in hospital and school bursaries to the right to run for political office. A law now being considered would deny them access to subsidized food – a tactic The Times of India, the country’s largest newspaper, recently reported, favourably, on its front page.

The problem, says Abhijit Das, an obstetrician who runs the Centre for Health and Social Justice, is that, while the government’s policy has changed since Mrs. Gandhi’s era, when the rural poor were seen as strangling the country’s chances of progress, its mindset has not. There is a genuine commitment to ending poverty and a sincere desire to see families better able to care for their children. Yet officials based in air-conditioned offices in the capital still believe that ignorant rural poor people are dragging the country down by mindlessly having babies, and simply do not know what is best.

“The construction of the population problem is a middle-class creation,” Dr. Das says, “and it has caste and class distinctions: The ‘wrong’ people are the ones who have eight kids.”

In this, India is not unlike the West, where there is public debate about the higher birth rate of “welfare moms,” aboriginal people and immigrants. The idea is entrenched, and it results in policy entirely disconnected from the reality of life in a place such as Kamrora, where families have many good reasons for having more than two children.

First, mortality rates remain high – children, as Ms. Raja will tell you starkly, die here. Almost one in 10 do not live to see their fifth birthday. Subsistence agriculture remains the only employment option, so the young are needed to work in the fields and later, in the absence of any real social-welfare net, to care for their parents in old age.

And couples have children because there is no way not to have them: Those unwilling to undergo sterilization – newlyweds, for example – have access to no other form of birth control.

The two-child norm flies in the face of the idea of “reproductive rights,” Ms. Uppal notes. “What is a more basic right than deciding how many children to have – and when to have them?”

It also punishes women when the decision is not really theirs to make. Ms. Raja’s family expected her to have a third child, but when she did, she became ineligible for a central government allowance to provide extra food while pregnant and breastfeeding (a policy supposedly aimed at poor, Dalit women like her). As well, she lost the right to run for the local council, and her daughter was disqualified from a bursary program designed to boost girls’ education.

The policy is enforced by local-level officials, often haphazardly. As part of her health-worker job, Ms. Raja has succeeded in obtaining the bursary for having a baby in a maternity centre for a number of women with more than two children, even though it is theoretically denied. At the same time, she says, other women in Kamrora have been denied a state bonus for mothers who have daughters – a measure designed to discourage sex-selective abortion, an especially grim side effect of the two-child policy. The desire for sons, to carry on a family name and inherit land and assets, is so strong that families may abort girls to get the two boys they want and stay within the limit.

India already has one of the world’s more sharply skewed sex ratios. As in China, millions of women are “missing” from the normal population balance. And yet the mandarins in charge of its population policy reject any comparison with China.

“There is no grounds to call [Indian policy] repressive,” says S.K. Sikdar, who heads the family-planning division at the national Ministry of Health in Delhi. “We learned our lesson [in the 1970s]. … This isn’t a population issue any more; it’s a mother-and-child health intervention.”

Energetic and driven, Dr. Sikdar insists that “we don’t have a two-child norm.” He says that the only message to women from government is about the benefit of having children later and at least two years apart.

“Our only intervention is to give people free access to [child] spacing. … I know our women are quite happy with what they have,” he says, adding that the government has had great success in delivering condoms and oral contraceptives directly to rural doorsteps – that kit of Ms. Raja should be replenished every month.

Many of the more punitive policies in place today have been set by state governments, but the two-child norm also applies to a number of benefits, such as nutritional support for pregnant women, that come from the national government. Dr. Sikdar acknowledges this, but he says that “low-performing states” (the poorest ones with highest fertility) are exempt.

That news has not reached Kamrora – or dozens of other areas where poor women, often Dalit, are denied access to school meals, clean-water schemes, the female-child bonus and the maternity-home payment because they have more than two children. All state family-planning programs are run on money from the central government.

A.R. Nanda, who was once in charge of population policy for India and established its family planning department, says that not only is there a two-child policy, it was explicitly borrowed from China: “The idea of withholding benefits comes from

China … ‘If China can do it.’”

After taking its hard line in 1979, China saw its population growth fall sharply, and many in the Indian government were impressed. But they failed to grasp the basics of population science, Mr. Nanda says: “The highest drop in Chinese population came before the one-child policy; it came from equitable access to education, health care, including family planning, and a rise in income” following the communist revolution. From 1952 to 1979, China’s fertility rate was more than cut in half, falling to 2.75 children per woman from 6.5.

“If you want to emulate, emulate the positive,” Mr. Nanda says. “We ought to focus on equity.”

In the 1990s, he oversaw the adoption of a rights-based approach – only to see it quickly and quietly usurped by politicians who still believed that the key was to move fast and stop the “backward classes” from breeding.

India’s population is rising, but because of what demographers call “momentum growth.” Sixty per cent of Indians are of reproducing age. Even if tomorrow India attained “replacement level” fertility – if people had only enough children to replace themselves when they died – the country’s overall population would keep growing because the number of people being born will exceed those dying for several decades.

Despite alarms raised regularly in the media, fertility rates are, in fact, falling, and have been for two decades. In 21 Indian states and territories – including all of the more prosperous south – average fertility is at or below replacement level of 2.1 children per couple. The problem would take care of itself, says Dr. Das of the Centre for Health and Social Justice, if people in the high-fertility areas had access to jobs, education and, in the short term, condoms, birth-control pills and intrauterine devices.

Sterilization actually pushes population growth, he notes. “The largest amount of reproduction now is young women having their first and second children; sterilization does nothing to change this.

“The message [from government] is, ‘Have your children quickly and terminate your reproduction.’ When you give that message, you speed up the rate of delivery and you speed up momentum.” You wind up with even more reproducing adults.

When India’s policy was overhauled after Mrs. Gandhi, eliminating government-set targets for contraception and sterilization was seen as key to being less repressive.

But bureaucrats and health officials did little more than change their terminology.

“Targets and camps are back with a vengeance,” according to Mr. Nanda, saying he has seen officials who meet their targets handsomely rewarded by, for example, having a government car at their disposal.

In 2011, Shivraj Singh Chauhan, the chief minister of the state of Madhya Pradesh, announced a drive to sterilize 750,000 people a year. Those who underwent the surgery or brought in new recruits were entered to win prizes, including washing machines, DVD players, gun licences and a Nano, the ultra-low-cost Indian car.

Often sterilizations are done at breathtaking speed, with a doctor performing as many as 35 a day; rates of failure and complications are much higher than the international norm.

Dr. Sikdar, as chief of national policy, says the camps are supposed to take place in medical facilities, and organizers of those that don’t face criminal prosecution. But last year in Kaparfora in the state of Bihar, a doctor sterilized 53 women lying on benches in a school without electricity, and charges have yet to be laid.

Research by Dr. Das’s centre consistently finds that it is women from the poorest communities, usually aboriginal people and those at the bottom of the caste system, who are targeted when a region needs to reach its quota. They may have no idea that the procedure is permanent, he says.

Navin Kumar, the health information officer who supervises Kamrora, says the state government gave him a target (for the 875,000 residents of Mahoba district) last year of 4,100 women and 400 men.

And yet, Dr. Sikdar insists: “We do not give targets – we have … ‘estimated levels of achievement’ … It’s a management tool. A doctor has to make a plan based on numbers.”

If local officials, such as Mr. Kumar, are being told otherwise, and health workers, such as Ms. Raja, are pushed to meet quotas, he says, it’s a local aberration: A district politician may be keen to boost his reputation and “if, in his over-enthusiasm, he does something …”

Anjali Sen, director for South Asia with the International Planned Parenthood Federation, says India’s policy was drafted with the best of intentions, but she does not buy Dr. Sikdar’s claim that there are no targets. State family-planning budgets come from Delhi, she explains, and “cash incentives are tacit acceptance [of targets] from the central government.”

Ms. Uppal, the activist, says national officials could easily make sure the system is target-free: “They’re the cops.”

Dr. Sikdar says India is launching a new incentive program under which 860,000 health workers such as Ms. Raja will be paid $10 for every woman persuaded to delay her first child for two years after marriage, and another $10 if she waits two years before having a second.

Left unexplained is just how the women are supposed to avoid getting pregnant.

Certainly no one is relying on husbands to sort it out. During the Indira Gandhi era, most sterilizations were performed on men – there was no way to do a tubal ligation without invasive surgery, and female doctors, whom women patients prefer, were rare.

Vasectomies are still less complicated, but 95 per cent of the operations are now on women. Mr. Kumar says Mahoba district achieved 80 per cent of its target for women last year – but sterilized none of the 400 men.

There is a widespread belief, rarely challenged by doctors, that sterilization weakens a man and “robs him of his powers,” as women in Kamrora say.

All of the government outreach about family planning – all the home visits and chat circles Ms. Raja organizes – focus on women. But ask the women if they actually make the decisions about children and birth control, and they burst into laughter.

Even Dr. Sikdar acknowledges the problem – he oversees a $20-million program that distributes free condoms to women who have “no control over fertility.”

Or as Ms. Uppal puts it: “These completely disempowered women take condoms home to their husbands as if somehow they are going to be able to convince them to use them.”

Dr. Das says the service delivery will not change as long as policy springs from a belief that the “wrong” people are having children.

“Our development priority is not to reduce family size, it’s to raise income. We’re not ashamed of the inequalities, of low education attainment, of poverty – why are we ashamed of population growth?”

Noni Raja has thought a lot about choices, and who gets to make them. Two years after her bold decision to have a tubal ligation, she received a brutal reminder of her place in the family hierarchy.

In 2008, her younger son died at the age of 1 from pneumonia that the local health centre failed to treat. She lost her bold, chattering boy – and something else. Her in-laws were unwilling to accept a daughter-in-law they felt had failed in her most important responsibility.

So they scraped together a small fortune, and took Ms. Raja to Jhansi, a city about eight hours away by bus, where they paid a surgeon to reverse her tubal ligation – a rare and complicated surgery.

The operation went badly. “I nearly bled to death,” Ms. Raja recalls flatly. But she came home and, two years later, produced that mandatory second son. Her place in the family was once more secure.

Today, that last baby is everyone’s mop-haired pet; mother and grandmother compete over whose lap he will lounge in.

Ms. Devi is defensive – but unrepentant about the extreme lengths they went to in the quest for another boy. “All the neighbours said it was not done, to have only one son,” she explains. “We were under pressure.”