Originally published as part of Khabar Lahariya’s long-form series “Sound Fury & 4G“ ♦
In December 2018, Khabar Lahariya reporter Suneeta Prajapati arrived at the Community Health Centre in Kabrai, Mahoba to cover a sterilization camp, a routine feature of rural healthcare in these parts of Bundelkhand, especially during the winter. She was taken aback to see anaesthetised women being hoisted out of wheelchairs by their wrists and ankles, like sacks of potatoes, to be lowered into tight rows on the ground, packed under heavy blankets. (General anaesthesia is “rarely necessary” for laparoscopic tubectomy or minilaparotomy, according to the government of India’s own sterilization guidelines.) Family members sat wherever they could find an empty spot; children crawled, cried and played among their mothers.
The spectre of the deaths at a sterilization camp in Chhattisgarh in 2014 hangs over such scenes, which continue, despite the Supreme Court’s encouragement to wind up mass sterilization as a family planning method within three years (that was in 2016). In another room, Shivpati, a woman who had been sterilised two weeks earlier under similar conditions, awaited medical treatment for complications. “I have some kind of infection, water is coming out,” she said. “Yes, it’s painful. I can’t stand up.”
The next day, Suneeta interviewed Suman Singh, Mahoba’s Chief Medical Officer, who sheepishly tried to argue that “there are wards, beds,” available in the CHC for post-operative care. Sunita pointed out that she counted 15 women on the floor. “Look, we do make efforts to assign patients to different wards,” Suman said. “But I will check up on it.”
Mahoba, along with many of the other districts in which KL regularly reports, is one of the 146 “high fertility” districts covered by the Parivar Vikas Mission, one of an array of initiatives to lower population growth, which kicked off in November 2016. Always on the political agenda, family planning has moved up higher on the priority list in recent years. In his last Independence Day speech, Prime Minister Narendra Modi characterised “responsible parenting” as a cornerstone of patriotic duty. In Assam, which has become something of a testing ground for demographic experiments, as well as other states, certain laws shut families with more than two children out of government jobs. Similar policies have been proposed nationwide.
Calling attention to a “population explosion” might be a handy way to deflect criticism during an economic crisis, but the fact is fertility rates have been steadily declining across India for decades. Across geography and communities, these rates are mostly lower than they were before. But the one data point that remains frustratingly high is female sterilization; it’s still the most common form of birth control, accounting for 36 percent of all family planning measures, despite being the riskiest and most invasive of the available options (as of 2015-16). Yet data also consistently links lower fertility rates to increased literacy, education and empowerment of women. Setting aside the decision of how many children to have (or whether to have them at all), choosing a method of birth control isn’t a straightforward question even for highly educated and empowered women. There are always side effects, failure rates and social acceptability norms to contend with.
But tubectomy is not the ideal default option. Replacing female sterilization as the main method of family planning is the unspoken focus of many recent missions and schemes, and the ones they must work most urgently to address. The scene in Kabrai was all the more haunting because KL reporters have seen their own fair share of botched sterilization operations, resulting in pregnancy, illness or death. Half of the women who undergo sterilization have the operation before the age of 26, according to the latest National Family Health Survey.
Nasbandi #Fails
When it comes to sterilization, there’s a mandated amount of compensation for everything, from medical expenses incurred due to sterilization complications (up to Rs. 25,000, around $330), to death due to the surgery. In July 2019 in Jana Bazaar village, Tarun block, Ayodhya, we met Veena Soni, who’d had a tubectomy five years earlier but recently started having severe stomach aches and vomiting. At the Tarun CHC, the doctor looked at her ultrasound, said she had an ectopic pregnancy, and that it was nothing to worry about –– she would probably miscarry on her own. Her husband Surendra decided to get a second opinion, and the second doctor told the couple Veena’s life was in grave danger. But despite his letter recommending treatment for the government authorities and all the Aadhaar formalities, Veena was repeatedly told to seek treatment first and then compensation for the expense.
In 2018, a mother of six named Pinky in Karhiya, Banda told us she was six months pregnant, despite having had a tubectomy three years ago. Her husband had been chucked out of the local health center and wasn’t sure he’d have much success chasing the Rs. 30,000 Pinky was owed for the nasbandi fail. The CMO of Banda told us that “Usually when the sterilization fails, it is within three months that a woman reports pregnancy,” implying, preposterously, that Pinky was lying.
In November 2016, a woman named Shanti, left Nandan Kurmiyan in Chitrakoot for a sterilization surgery at the CHC in Ramnagar. “In the morning she got up and did her make-up, applied sindoor, did her shringar,” members of her family told us. “She walked off to the bus stop laughing, in a good mood.” But she never woke up, likely due to a reaction to the anaesthesia she was given. Without the facilities on hand to revive her, she was transferred to the district headquarters at Karwi, and then to a hospital in Allahabad, where she was declared dead.
The deputy chief medical officer, Narendra Kuraichya, was sombre but ready with excuses. “I’ve performed around 25 sterilizations over the past 16 years and this has never happened before,” he said. “All of these sarkari medicines, including allopathic ones, can cause a reaction. There is even a case of a surgeon who anaesthetised his own wife, and she died.” He wrapped up the interview, “They will get two lakh rupees ($2,600). That is the provision when a woman dies on the same day or within seven days of sterilization.”
For married couples who already have children, non-invasive, no-scalpel vasectomy would seem a solid choice. But somewhat surprisingly, at least in this part of India, wives are just as opposed to this procedure as their husbands, despite the fact that vasectomies are more highly incentivised (men get up to Rs. 1,000 more for undergoing the procedure than women do). Male sterilization remains dramatically low, accounting for only 0.3 percent of family planning nationwide, though the numbers have improved slightly.
In Mahoba last March, an ASHA worker explained that she had never managed to bring in a man for a vasectomy because “The men have to go to the quarries and do hard labour,” implying that the operation would reduce their physical fitness. Asha, a Primary Health Centre in-charge there elaborated: “Ninety-nine percent of operations are on women. They themselves think if a man has the operation he will become weak and not be able to work outside. They have to do labour, so they take the responsibility on themselves. Even if men agree, women don’t let them.”
What Women Want
Kiran Devi, an ASHA worker in Chitrakoot giggled, looking everywhere but at the camera as she told us condoms weren’t something she’d considered using herself. “Yes, the new generation is using them…” she admitted, “but men in my village are ignorant. They give it to children to play with them, so I stopped handing them out. I only give it to people who ask for it specifically.” The awkwardness probably goes both ways, and the government has tried to address this through various measures. In 2017, UP, along with other states, announced a program to distribute “shagun” kits to newly married couples, including condoms, pills and family planning information. Condom distribution boxes, have also been installed in government offices and other places, though they often lie empty). The joke at KL is that officials (or visiting reporters) either ransack them as soon as they are filled, or no one ever notices that they are empty.
On the other hand, condom ads are banned between 6am and 10pm, even though television was a frequently cited source of information on birth control among a few younger (but still married) women we spoke to earlier this year. Condom usage has declined, while the use of widely advertised emergency pills has gone up. If they did use condoms, their husbands typically bought them from medical stores.
Empty condom dispenser in a government office.
Women are still reluctant to use IUDs, though they are often urged to do so (specifically copper Ts) after giving birth. Last year, Sunita, a doctor at the Primary Health Centre at Jaitpur, in Mahoba district, told us that “people used to be quite scared of IUCDs – they worried that the device would go into their stomachs.” As an alternative, she and other practitioners around the state had started offering a birth control shot, branded Antara. “With this injection, people are quite comfortable,” she said. “I must have given 50-55 shots in the last two months.”
Since 2016, the government has positioned these progestin-based birth control injections as a replacement for sterilization camps. These injections are not without controversy –– though widely used in developing countries around the world (and available on a chargeable basis through private healthcare providers), they have a long and fraught history of opposition in India’s public health policy. However, the women in Mahoba who opted in for the shot were hardly aware of the politicised debate.
Earlier this year in Chitrakoot, we met a few women who had tried Antara shots but abandoned them because their periods stopped and then went on for weeks once the effects had worn off. One woman told us she hadn’t told anyone that she had not got her period, but was worried that she may go blind as a result. Another pointed out that “inconsistent periods are a problem for us.” Irregular periods are a common early side-effect of the shot,but according to ASHA worker Pattu Devi, no amount of explanation could get this point across. “However much we explain this to women, they don’t understand it,” she claimed. Only one of the three women she’d signed up for the shot had continued to use it.
Looking around the districts over the past few years, we’ve seen some encouraging changes, and some persistent pockets of resistance. Even while one woman in Lalitpur told us very seriously that she and her husband never used a condom because he was away most of the time –– and that they never had sex during her period (the logic being that condoms prevent “infection” during this time) –- another in Belvi, Mahoba told us that all the information anyone needed was available at the Anganwadi. This woman recalled seeing “women literally bleeding and spending thousands of rupees on abortion, which is dangerous for her health and her family.”
Suman Singh, the CMO at Mahoba told us earlier this year that “Women are more aware now, but sometimes methods fail, like she forgets to take her pill, or the condom breaks. Then they have to get an abortion. For family planning, we have tablets, injection condoms, IUD and copper T. We have family planning counselors and other specialists, they hold meetings, they go to the field and speak with ASHA and anganwadi workers. There is a young women’s clinic where teens can go for menstruation and other issues. There is a change – the fertility rate has lowered.”
The younger reporters at KL can testify to this change. Their friends and acquaintances openly discuss birth control methods (anecdotally, the rhythm or standard days method is particularly popular, as it is elsewhere in the world), and groups of women are as comfortable discussing condoms as their mothers and grandmothers might have been discussing herbs like blue and black cohosh and bamboo leaves, traditionally used in birth control.
Closing the Awareness Gap
The “basket of options” available to women has a wide array of offerings. But rural women still have a hard time talking directly about these contraceptive methods, even with each other. Mobile technology is one of the quick fixes that is often offered to bridge the gap between distributing contraception and actually getting people to use it and understand it. There are too many app-based initiatives around the country to name, though most of them have sputtered out after a promising pilot test in one district or another. Some have focussed on promoting the standard days method of family planning via SMS, while others focus on disseminating information about sexual health.
The experience of ASHA workers using UP’s mSakhi and mSehat apps in 2015, however, is a cautionary tale. The mSehat app, ASHAs told us, were supposed to replace their physical health diaries. But the women said that without uninterrupted electricity and access to the internet, the app was useless. Not all of them had been adequately trained to use it either, underscoring the point that technology, without education, is as meaningless as distributing condoms that will later be blown up into balloons by children.
Above, a training for RKSK peer educators in Ayodhya. Below, a scene from the episode about the RKSK programme in edutainment show Main Bhi Kuchh Kar Sakti Hoon.
One initiative under the National Health Mission promises to actually address this gap, as well as extend access to sex education beyond the sphere of the biology textbook and the married couple. In March 2018, we sat in on a room full of teenagers gathered at the Bikapur, Ayodhya CHC, to learn about puberty, sexual health and other adolescent-related issues. The boys and girls, ages 10-19, were training in a six-day course to become peer counsellors, called Saathiyas, in the Rashtriya Kishore Swasthya Karyakram, an adolescent health program launched in 2014.
These counsellors (two boys and two girls chosen by each ASHA local worker) are tasked with taking the lessons they’ve learned back to their villages and teaching other peers about things like drug abuse or birth control. Through partnerships with NGOs like the Population Foundation of India and the Hindustan Latex Family Planning Promotional Trust, as well as support from institutions like the United Nations Population Fund (UNFPA), the program holds trainings, summits, and conducts other types of outreach. The PFI has even produced an edutainment television series with the Gates Foundation about a woman who returns to her village to practise as a doctor, Main Bhi Kuchh Kar Sakti Hoon. But its video dramatising the Saathiya programme is miles from the training we went to in Ayodhya district, and the counsellors we met are far from possessing the confidence of those depicted on a related “game show”.
In Ayodhya, the boys say on one side of the room and the girls on the other. They were were shy of talking about what they’d learned. Most girls answered that the main message they had picked up was “there should be no discrimination between boys and girls.” With difficulty, Nisha, a student from Atari told us “We are learning about the changes that happen during maturity.” A boy, Anupam Upadhyay, added “We’re learning things like when boys reach puberty they get facial hair.”
Despite the fact that the roll-out of the programme appears quite top-heavy (most of the material online has to do with various felicitation and inauguration events), the program does hold great promise as a public health intervention. Devprakash Verma, a health education official present at the training observed that “in this age group, adolescents go through so many changes and are unable to share their thoughts with anyone. Peer educators will help sort out these problems with them, with support from the ASHA. We will also check regularly to see if problems are getting solved or not.”
There’s an app for the Saathiya programme too, which launched in February 2017 but has fewer than 300 downloads so far. In Madhya Pradesh, the program seems to have gathered more steam. Some districts, like Chhatarpur, have a programme that at least has higher visibility on social media. And some peer counsellors are taking pride in their role, participating in Facebook groups and Whatsapp chats, and adding “RKSK” to their profiles. There are peer counsellors putting up videos of educational skits on YouTube in Bundelkhand, and others making their own channels. A lot of the content about the RKSK program is made by grown-ups, but one can imagine young creators becoming invested in social messaging through social media if given the right tools. The headline of IndiaSpend’s recent deep dive into the programme in Sitapur district, UP captured it perfectly: “National Teen Health Programme Could Help Millions – If They Knew About It”.
The article explains how “Nearly all the funds were spent on procuring weekly iron and folic acid supplements as part of the National Iron Plus Initiative,” and that “No expenditure was recorded on behavioral change or for creating awareness about the programme, which experts said are the core guiding principle for educating youth about adolescent health. This also explains, in part, why most children do not know about the programme or the clinics.” Using data from an Accountability Initiative report, IndiaSpend detailed how the money allocated to the programme has decreased, while much of it still remains unspent. A parallel initiative, the Kishori Balika Yojna, for adolescent girls, recently distributed ghee near Meerut, while in Chhatarpur a few years ago we found this initiative floundering.
KL’s reporters haven’t heard much buzz about the RKSK programme, even though it is technically up and running. Jagran reported that the Mahoba adolescent health clinics, which were closed during the lockdown, reopened in early June. Which brings up another point, namely that during times when access to even basic healthcare is severely limited ((like the past few months, with the Covid-19 pandemic), long-lasting, impactful education and awareness is more important than ever.
While the theory that the lockdowns would result in a spurt of babies in nine months time was put to rest, for India’s rural women, it may have had a detrimental effect on access to family planning and birth control measures. The Ipas Development Foundation estimated that “access to 1.85 million abortions (or 47% of the estimated 3.9 million abortions that would have taken place under normal circumstances) are likely to be compromised”. Nearly 80 percent of these, the foundation suggested, were due to lack of availability of medical abortion drugs, typically procured from pharmacies. Other reports echoed these findings around the country.
In most places access to condoms was limited during the lockdown. Bihar, the state with the highest fertility rate by far, decided to use the lockdown to its advantage, dispensing family planning advice and condoms to quarantined labourers who had returned from cities. The Week interviewed an ASHA worker who said, “Men are not used to being at home. The women complain of the physical demands their husbands make on them. Women come to me begging for condoms, asking me to buy some but I am helpless.”
Now that the restrictions have largely been lifted, there’s no doubt World Population Day 2020 will have been celebrated with speeches – it is always a popular day to announce new family planning initiatives. And this government has already demonstrated its interest in highlighting this area of its activities. That’s not a bad thing– just before the lockdown, the government passed much-needed progressive amendments to India’s abortion law. But birth rates fall as other development indicators rise. Adolescent Friendly Health Clinics aren’t a bad idea, but college dorms can perform many of their functions, and classmates can be peer educators too. With so many options for family planning out there, hopefully the funds and effort going forward emphasise education rather than sterilization, so women can make considered, safe choices no matter where they live.