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India: Sterlisation by default: Where’s choice in family planning?

Aug 23, 2013

Odisha is a specific instance where the state continues to piggyback on female sterilisation to meet its development agenda, writes Leena Uppal.

Khurda: World Population Day was marked by much fanfare in Odisha this year, with the state government publicly felicitating the ‘best performing’ districts for having achieved impressive family planning levels for the year 2012-2013.

Not surprisingly, the top three districts in this regard were all predominantly tribal – Malkangiri, Koraput and Anugul. Equally unsurprising was the fact that their impressive achievement was made possible because of a dependence on female sterlisations. While Malkangiri achieved a sterilisation level of 138.27 per cent, Koraput and Anugul notched sterilisation levels of 109.08 per cent and 106.09 per cent, respectively. What about breakthroughs in the propagation and delivery of other contraceptive methods, whether intrauterine devices, oral pills or condoms? Clearly, the less about this, the better!

The Government of India’s Ministry of Health and Family Welfare is working hard to project the fact that its family planning programme has changed tack from the sterilisation-centric approach of yore. Now, it claims, it is offering a basket of contraceptive choices for women and men in the reproductive age group. At the Family Planning Summit in London in 2012, it had talked about how different kinds of contraceptives are being made available through public health centres and with the help of accredited social health activists (ASHAs).

But such change is hard to find in the field. A permanent method of contraception like sterilisation clearly continues to be the mainstay of India’s family planning departments across Indian states, with female sterlisation emerging as the obvious favourite. This is in keeping with the historical perception, which continues to prevail in the country that it is women's ‘irresponsible breeding’ that is the single biggest factor for India’s ‘overpopulation’ and is the major barrier to its social and economic development.

Odisha is a specific instance where the state continues to piggyback on female sterilisation to meet its development agenda, despite faring quite well on social and economic indices of growth. A closer look at the relevant data is revealing: the state already has a total fertility rate of 2.3, with 10 of its districts having achieved the replacement level fertility rate of 2.1. It ranks eleventh among major states across India in the overall human development index. Yet, the Annual Health Survey, 2012, confirms the dark side of the state's family planning programme: female sterilisations account for 30.1 per cent of all contraceptives used.

In Odisha, the mega sterilisation camp approach that had brought such notoriety to the national family planning programme in the Seventies has been done away with. This would have been commendable if it had been replaced by a more consensual approach to female sterilisation. But that, unfortunately, is not in evidence. Most sterilisations in the state are conducted in hospitals through a fixed day static service. What actually happens, according to sources on the ground, is that women in labour are forced to agree to go in for tubal ligation, after they deliver their second child at a health facility.

This has implications that go beyond family planning. A glance at the family planning register being maintained at the district headquarters hospital at Khurda tells its own story. It shows that in the months March and June 2013, not a single couple who had undergone the steralisation procedure had had two daughters. All couples who had undergone the operation had either had a son and a daughter, or two sons. Sterlisations then could be an important factor for the declining sex ratio that is causing so much alarm in policy circles.

To understand why this happens, one just needs to speak with the ASHAs. One ASHA working in the region put it this way, "We are required to motivate and bring in couples for sterilisation, and we try our best to do this. We do not persuade those clients who have daughters to consider this option but prefer to focus on those who have already given birth to boys. They are much more receptive to the message. Sometimes we even motivate the woman’s mother-in-law to send her across for sterilisation and she immediately agrees because she too does not want granddaughters."

The ASHA’s words come as a reality check. The Ministry of Health and Family Welfare officials in New Delhi may insist that the government is not focusing on sterilisations but is interested in promoting a wide spectrum of contraceptive methods. They even claim that the number of sterilisations is now on the decline when compared to earlier years. But the ground realities in the hinterland seem to indicate otherwise, with female sterlisations still dominating the family planning landscape.

In fact, in some places female sterlisations have reached saturation point. An ASHA in Khurda district gives the game away when she innocently exclaims, “There are no more women left to sterilise in my village, I don’t know how I will reach my sterilisation target for next year!"

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