Noida: After Geeta Devi* (32) had her second child in 2014, she decided that she did not want any more children. With the help of an accredited social health activist (ASHA), she approached a primary health centre (PHC) in Rajasthan’s Pratapgarh to get sterilised.

Despite going through the procedure, she got pregnant again in 2021 and gave birth to her third child. About 100 km away in Rajasthan’s Chittor, Mohini Devi (36) who belongs to the Bhil tribe also gave birth a year after getting sterilised.

The Family Planning Indemnity Scheme entitles them to a compensation of Rs 30,000 for a failed sterilisation procedure. While Geeta is in the process of filing the paperwork to claim the amount, Mohini went to the Rajasthan High Court in Jodhpur to get her compensation. “Since more than 90 days had passed after she notified the anganwadi about her pregnancy, the district officials told her that she could not get the compensation, so we were left with no option but to go to court,” said Madhav Meghwal, a social worker with Prayas who helped Mohini with the paperwork.

Official data from 2020-21 show that 51 deaths were attributable to sterilisations and India recorded 3,354 claims of sterilisation failure. This was a 32% decline in deaths and failures reported in 2019-20, when 75 people died and 4,895 operations had failed. However, mobility restrictions due to nationwide Covid-19 lockdowns meant female sterilisations fell by a quarter and male sterilisations by half from 2019-20, the annual report of the Family Planning Division under the health ministry noted.

Most of these are women: Nearly two in five Indian women of childbearing age were sterilised compared to three in 1,000 men, data from the fifth National Family Health Survey show.

The guidelines for sterilisation say that women who undergo the procedure need to visit the healthcare centre a month later and to notify the officials if they suspect being pregnant. They are also to avoid strenuous activity up to 48 hours after the surgery. However, these guidelines leave out pain management after the monitoring period, according to Meghwal.

“If we insist on using this as a policy measure, we must know how successful it is and monitor women for the risk involved,” said Dileep Mavalankar, a doctor of preventive and social medicine and former chair of the Union government’s Technical Working Group on Maternal Health and member of the Mission Steering Group of the National Rural Health Mission.

On World Population Day observed on July 11, as India takes up awareness programmes on family planning methods, we speak to women who avail of this method of family planning, and to doctors and social workers who work in reproductive choice. Their accounts make a case for reviewing the protocol to be followed, increasing the compensation to be awarded in the case of failure and making more options available to couples who want to put a cap on the number of children they have.

Risky, irreversible, not fail-safe, yet most popular

Women bear the brunt of contraception in India, as IndiaSpend reported in 2020. Tubal ligation, or female sterilisation, is a surgical procedure in which the fallopian tube is sealed (or tied) using a metal ring, or cauterised. It is performed under local anaesthetic, and women can go home on the day of the procedure itself.

However, even when performed under the best conditions, long term injury or death cannot be ruled out. “All the risks associated with an abdominal surgery apply: perforation, internal organ damage, local infection, etc.,” explained Mavalankar.

Female sterilisation is the most popular form of contraception in India, as we said. While two in three women reported using any form of family planning methods in the National Family Health Survey for 2019-21, more than half of them--or 37.9% of married women in the reproductive age group--chose sterilisation. The procedure is effective in preventing up to 99% of pregnancies. Its popularity is the highest among women belonging to the middle of the income distribution table and is lowest among women from affluent households.

If all the guidelines and due precautions are followed, the chances of dying are slim, one in a 1,000, as per Mavalankar, but he does not rule out the possibility of death.

In 2013, 13 women died after surgical sterilisation in Chhattisgarh, and autopsies performed on seven of them revealed that they had septicaemia, which is caused by poor hygiene following surgery. Following a public interest litigation filed by Devika Biswas, an activist from Auraria in Bihar, against the practice of performing these procedures under unsanitary conditions, the Supreme Court directed the Union Government to put an end to the practice of conducting sterilisation camps in September 2016 and asked the Ministry of Health and Family Welfare to develop guidelines to be followed while conducting these procedures in public facilities.

In one case last year, the Madras High Court ordered the government to pay a woman a compensation of Rs 3 lakh, which is 10 times the amount she is entitled to under the Family Planning Indemnity Scheme. The court also ordered the government to bear the expenses of educating the child.

“We know of one woman who died after getting this operation because her intestine was ruptured,” said Chhaya Pachauli, a social worker with Prayas, an organisation that works for health equity in Rajasthan. Guidelines are rarely followed in “fixed day static” that have replaced camps, and the women are not counselled adequately, she added.

A common side effect of the procedure is back ache, which can be treated with a week of rest, something that Geeta Devi cannot afford as she and her household depend on her daily labour to eat, according to Vijay Pal, a social worker from Pratapgarh. “Protocol for post-operative care needs to be updated to include issues like chronic back pain and pain in the limbs, increase the number of follow up visits, etc.,” he added.

Failure of sterilisation can be discovered up to 20 years after the initial surgery. “Recanalisation, or the natural easing of the constriction in the fallopian tubes, is a process that takes years,” according to Mavalankar.

“There is a correct procedure to be followed to prevent recanalisation--you have to cauterise the cut end of the tubes, make the loop in the middle third of the fallopian tube, add a linen suture inside, etc. All this can minimise the chance of failure to up to two in 1,000,” explained Suchitra Pandit, a gynaecologist and former president of the Federation of Obstetric and Gynaecological Societies of India.

Recanalisation can also result in ectopic pregnancies, which is a cause of maternal death in India, although the exact number of deaths caused by it is unknown. A small sample study published in 2019 found that abdominal tubectomy was a risk factor for ectopic pregnancy.

IndiaSpend has sought data from the Ministry of Health and Family Welfare as well as the Rajasthan government on the number of men and women who availed of sterilisation procedures in the last year and how many of them sustained long term injuries and/or died, or the number of instances in which the procedure failed. This story will be updated when we get a response.

One-step solution to women’s problems

Mohini Devi’s fifth child, after four daughters, was a son. That’s when she and her husband Nandlal, residents of Chittor in Rajasthan, decided to get her sterilised, in 2020. A year later, she was pregnant with her sixth child.

The only use case of this procedure, according to Pandit, is if a woman has had three or more caesarean deliveries, “because each birth causes significant blood loss of the woman, and it puts her and the rest of the family at risk”.

The guidelines laid down by the health ministry specify that only married women between the age of 22 and 49 (for men, the age limit is 22-60 years) with at least one surviving child can get the procedure. They need to be counselled about the procedure and their consent is required. They must also be advised to visit the doctor up to a month following the procedure

Geeta Devi opted for sterilisation over pills and injectables because she was not sure for how long these would be available to her. “Baar baar nahi jana parta hai,(I don’t need to go to the PHC every time I need the pills),” she explained her decision.

That the procedure is popular is not a cause for concern, “so long as the women opt for it out of choice”, according to Pachauli. “Women get to make a firm stand on an issue that affects them and the family has to obey.”

Sterilisation is touted as a permanent method and is provided for free under the government’s programme, as IndiaSpend reported in 2017. Women from below poverty line families, such as Geeta Devi and Mohini Devi, are paid a sum of Rs 600 for accepting to get sterilised. The ASHAs are also paid an incentive to bring the women to the PHC.

However, not all women are pleased with the loss of fertility: over 5% of women who were sterilised reported feeling regret over the procedure. The procedure is theoretically reversible, which means that the physical process of “untying” the tube can be performed. “However, the chances of a woman getting pregnant after that is negligible,” said Mavalankar.

No takers for pills, IUDs, vasectomies in India

Vasectomy, or male sterilisation, is safer, more effective and less expensive than female sterilisation. However, less than 1% of the married women reported that their family used this method of contraception. “It is such a safe method, but I do not know why men tend to think they will lose their virility,” explained Pandit.

Men were afraid of the sterilisation procedure, as IndiaSpend reported in 2022. While it is also theoretically possible to reverse a vasectomy, it is a difficult procedure with no results guaranteed, Pandit added.

There are several long-acting reversible contraceptive methods available to women even in the public health system that do not result in a permanent loss of fertility. The current basket contains condoms, contraceptive pills, hormone injections and intrauterine devices. One of them, called the DMPA, has several side effects, as IndiaSpend reported in 2017. Offering incentives for delaying pregnancies is cheaper and offers more benefits than sterilisation to the household, as we reported in 2017.

“A novel method called the implant, in which the hormone is placed in a plastic cylinder in the arm of a woman, can prevent pregnancies for up to three years,” explained Pandit.

“In addition to the side effects of the procedure, women need more counselling on the alternatives available to sterilisation,” said Pachauli. “The point of family planning is to give the families a choice, so that they can choose the desired option.”

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