India’s lethal contraception culture

Sterilization camps like the one Suryavanshi visited are regularly organized all across rural India, where hospitals are few and far between, and equipment scarce. To prevent women from relying on traditional contraceptive methods such as consuming herbs, the government organizes camps that attract women from neighboring villages, where doctors are brought in to perform the procedure free of cost.

The camps are part of a central-government program to control the population, currently 1.3 billion and projected to overtake China’s around 2028.

Here, the most common method of birth control is tubectomy, in which a woman’s fallopian tubes are surgically tied in a hospital procedure that ordinarily requires a day of bed rest. Reversing the procedure requires a separate operation. More than a third of Indian women undergo tubectomies, as compared to the 1 percent of men who undergo vasectomies — an outpatient procedure that is easier, cheaper and simpler to reverse. One reason for the disparity is social norms around masculinity, which equate manhood with sexual potency. The use of condoms — largely promoted to combat AIDS — is, for many Indians, associated with prostitution and the deadly disease; condom use stands at roughly 6 percent and is largely limited to cities.

Suryavanshi was one of 13 women who died after getting a tubectomy at that camp; more than 50 were hospitalized. The doctor, Rakesh Gupta, who had just a year to go before he retired, was arrested a few days after the deaths and charged with medical negligence.

Ironically, in January 2014, Gupta was the recipient of an award from the state government for “his contribution to rural health” and for having performed 100,000 laparoscopic tubectomies in his 30-odd years as a doctor.

Binayak Sen, a rural-health activist and doctor who focuses on public health, is one of many vocal critics of the government’s role in the women’s deaths. “It is all fine that the doctor was arrested in this incident, but establishing individual culpability is not enough,” he says. “The state — and the larger health system — is responsible for this. Laparoscopies are relatively complex and require stringent cleanliness guidelines. Why doesn’t the state provide people with contraceptive methods which are safe and inexpensive, like condoms?”

Government health workers in rural India are responsible for identifying women who are candidates for sterilization. Ideal candidates are between the ages of 18 and 29 who have had three children or more. The health workers are expected to bring a certain number of women to the camps each month. To recruit people, a health worker typically approaches families and talks to them about about the benefits of contraception. “We do not need to tell them that contraception means female sterilization,” says Rajim Yadav, because the assumption is that sterilization is always for women. Yadav is a health worker in Neertu village, where Ranjita Suryavanshi also lived.

For every woman who undergoes a tubectomy, which is provided by the government free of cost, the health worker gets paid about 200 rupees ($3.24) by the government, while the woman receives about 600 rupees. Vasectomies, on the other hand, aren’t free.

“This is not just a question of rural health but also a question of blatant gender discrimination against the women,” says Nandi, the nonprofit worker. “Men do not want to lose their ‘manhood.’ That is the only reason.”

Moreover, vasectomies carry fewer health risks and are inexpensive relative to tubectomies. “Male sterilization is not adequately promoted or easily available to a rural population,” says Sen.

But government officials say female sterilization is their only hope of success. “If we target men, the chances of our program succeeding is less,” says T. Sundaraman, a former director of the National Health Systems Resource Centre, a rural-health-research organization. “There needs to be social change before we tailor our sterilization programs towards men.”

“During my time, I didn’t know that even men could be sterilized,” says Meenakshi Oraon of Geniyari village, who is illiterate. “Today, my daughter-in-law knows that. She goes out, speaks to other women, and they tend to exchange notes.” Kavita Oraon, her daughter-in-law, did not study beyond the 10th grade. She has not gotten sterilized; she says she is not sure she wants it done.

Levels of literacy are directly proportional to contraception usage among married couples, according to human-rights lawyer and activist Sudha Bharadwaj. This matters more than whether a woman is economically independent or not, she adds. According to the 2011 national census, 65.5 percent of Indian women are literate, as compared with 82 percent of men.

Seven years ago, Santosh Suryavanshi and Ranjita were married in a small ceremony in their village; they had three children together. “When she entered the house for the first time in her embroidered red sari, she looked very beautiful,” he says now with a heavy voice. He is sitting on a cane cot in their small courtyard, with his mother, Bimla Bai, who now is the primary caregiver to the children. She puts a consolatory arm around her son’s shoulder and says, “She was a very loving women, yes, but you have to move on.”

Bimla Bai says that though her son is deeply shaken by his wife’s death, he will eventually remarry. At 57, she is unable to care for three young children and manage all the household chores alone; a new wife could help shoulder the workload.

“You will control [the] population better if you sterilize men,” says Gayatri Suman, a lawyer with the nonprofit Centre for Social Justice, who is planning to file a lawsuit against the state government on behalf of the families of the women who died in November. “Else,” she says, “it is easy for them to remarry and continue to add” to the population.

Ranjita Suryavanshi was discouraged by both her family and the local health worker from going to the sterilization camp since she had given birth less than a month earlier. “I told her that she should recuperate well first and eat wholesome food. She could always go to the next camp,” says Yadav, the health worker. “But she was scared that she couldn’t refuse sex to her husband and that she might have to carry an unplanned child. In trying to avoid another child, she has left her three children out in the cold.”

The families of the women who died have been given 400,000 rupees by the state government as compensation. And those who were hospitalized got 50,000 rupees. But, Nandi says, the government need not spend money on compensation at all if it would spend intelligently on public-health facilities.