Sterilization challenges

Female sterilization is estimated to be the current method of birth control in over 30 percent of households in India. The method, however, has been criticized by activists for causing health complications in women. In some instances, women have even lost their lives following sterilization procedures. In November last year, 15 women in the central state of Chhattisgarh died after a botched sterilization surgery at a government-run health camp.

The incident sparked outrage across the South Asian nation and grabbed media headlines around the world. However, such cases are nothing new in India – a country of more than 1.2 billion people where the authorities have been encouraging birth control for several decades.

The International Center for Research on Women (ICRW), a global research institute, recently reviewed the quality of female sterilization services in India's third most populous state, Bihar, and concluded that despite some infrastructure improvements, major problems continue to exist.

In a DW interview, Ravi Verma, head of ICRW's Asia Regional Office in New Delhi, says that despite some improvements in the quality of sterilization services offered in India, there are also problems involving logistics and attitudes of health care providers towards women undergoing sterilization.

DW: Just months after 15 women died following surgery, what are the main results of your study in terms of the quality of female sterilization services carried out in India?

Ravi Verma: These specific findings from our Bihar study can't provide reasons behind the deaths in Bilaspur, where 15 women died following surgery. Our study was carried out much before the tragic sterilization death incident and, importantly, within a different state with different populations and contexts.

Nevertheless, our research found that overall, the quality of sterilization procedures is fairly reasonable, given the limited resources that constrain health facilities and health professionals. We did, however, also find that there are localized problems of logistics and attitudes of health care providers toward women undergoing sterilization.

The findings indicate that while improvements to facilities have been made, challenges remain. For example, while almost every single facility had 24/7 running water and electricity, fewer than 50 percent of facilities had separate, running toilets for women. Additionally, while public-private partnerships have helped in pathological tests and diagnostics, much more could be done to speed up the delivery of results.

Health delivery facilities could also do much more to ensure privacy to women while seeking services and also improve post-surgery counseling and follow up.

India is the world's top sterilizer of women. What are the reasons behind Indians choosing this option over others for family planning?

India has pockets of very high fertility and the demand for terminal methods is high in these pockets. For example, in Bihar the total fertility rate is 3.7, which is among the highest in the country. Additionally, many women believe that a one-time method, including sterilization, is far more desirable than other less reliable contraceptives.

The government, however, is emphasizing on intrauterine contraceptive devices (IUCD) as well, and there is a strong post-partum IUCD program in the country. In our study, almost 80 percent of the women who underwent sterilization had three or more children. According to National Family Health Survey (2005-06), 37 percent of currently married women in the age group 15-49 years were sterilized.

What are the reasons for a lack of adequate medical infrastructure to conduct sterilizations in a safe environment?

India is a hugely diverse country in more ways than one, including on social and economic aspects. Like many other facilities, medical facilities are not uniformly distributed and can range in terms of the quality of care they deliver.

The public health system has improved over the years but much more needs to be done, both to ensure safer facilities and to ensure that patients, especially women, are receiving care that fits their needs and that is delivered with respect to their dignity.

What has the Indian government done so far to tackle the issue?

India's National Health Mission allows for community engagement and participatory planning process. It also encourages private partnership in health delivery system. Government has implemented health insurance schemes like Rashtriya Swasthya Bima Yojana (RSBY) for people living below poverty lines.

However, there is a need to enhance the uptake of health insurance schemes through awareness raising and high quality service back up.

What measures should the government take to ensure women receive proper medical care and that sterilizations are carried out without endangering their lives?

First and foremost, women should understand their rights. Utimately they are entitled to safe, effective choices about their reproductive health, and that they have the right to demand quality care and ask questions about their health care providers, as well as have their concerns addressed.

Second, the government should ensure they are more closely monitoring health care facilities and efforts. Setting up an accountability mechanism both within the system and outside in the community will go a long way to ensure improved implementation.

Ravi Verma is head of International Center for Research on Women's Asia Regional Office in New Delhi.