"When we look at contraception, we also have to look at infection prevention. We should promote dual protection, which we completely ignore" - Dr R.C.M. Kaza, India's first no-scalpel vasectomy surgeon
April 1, 2015. 12:12am.
India’s population: 1,27,89,53,812.
Every second, one baby adds to the digit. Around 21 million babies are born every month in India, which is almost equal to the population of Australia. At this rate, India will be the most populous country by 2030, despite the fact that India launched its family planning programme in 1952.
It should, however, come as no surprise. As per the 2012 survey-based study by NGO Population Council, 75 per cent of women in Bihar and 54 per cent in Madhya Pradesh do not use any contraception. The situation is no different in villages of Rajasthan, Uttar Pradesh and Orissa.
“In Karhal, a small village in Madhya Pradesh, families don’t know anything about contraception. There is no sense of spacing, and women suffer from multiple miscarriages, which lead to severe anaemia in these women. These malnourished mothers give birth to malnourished babies, who die soon after their birth, and women are again forced to produce more children,” says Rohini Mukherjee, who works with Naandi Foundation, an NGO. “Every second child in India is malnourished, under-weight or stunted. We cannot build a strong nation with malnourished children.”
Take, for example, Sabri Devi, 35, who lives in Pabli Khas village in Meerut, barely 70km from the national capital. She has seven children―the eldest is 20 and married and the youngest, sitting in her lap, is 18 months old. Besides, she has had eight unsuccessful pregnancies. Sabri's frequent pregnancies have left her severely anaemic. Slim and swarthy, she looks older than her age. She asks this reporter, who she thinks is a doctor, for a way to stop getting pregnant. “Haven't you heard of condoms, copper T or sterilisation?” I ask. “No,” she says.
Even those who know about contraception don’t have access to it. Shamli, 23, went to another village to get an intrauterine contraceptive device (IUCD) implanted. She did not tell her family. A few days later, she contracted an infection. She had no choice but to suffer in silence as she couldn't go out of the village again.
The story of Sabri and Shamli represent the utter failure of the family planning programme in India. Millions of women here continue to have babies by chance, not by choice. In many villages, women get pregnant every year from the year of wedding. These are the women who are often herded like cattle to sterilisation camps.
“Sterilisation or tubectomy done in a camp setting is the worst thing to happen to women. It is done in the most unhygienic and inhumane conditions,” says Pratibha Demello of Human Right Law Network, New Delhi. “There are instances of pregnant women being operated upon at such camps, where chances of post-operative infection and other complication are also very high.”
She is not exaggerating. These sterilisation camps have been in news for all the wrong reasons. In November last year, 13 women died at one such sterilisation camp in Bilaspur, Chhattisgarh. Following the incident, the Union ministry of health and family welfare issued a circular asking state governments to limit the number of sterilisation surgeries to 30 a day. Yet, there are reports of doctors performing such surgeries with torchlight in Chatra district, Jharkhand; of doctors using cycle pump to fill carbon dioxide in the fallopian tube in Orissa and doctors performing surgeries in a school campus in Rajasthan. Also, the government’s inclination towards women's sterilisation is evident from the fact that Rs292.9 lakh of the Rs369 lakh sanctioned to family planning programme in Delhi in 2014 was for tubectomy.
Was this how the programme was planned to be executed? The family planning programme was launched with a view to address the health of a family―economic as well as physical. India was the first country to launch such a programme, and Rs6.5 million was sanctioned towards education, research and clinical services. It was promoted as a shared responsibility of a married couple. A number of family planning clinics were opened, and which increased from 147 to 4,165 during the second Five-Year Plan (1956-1961).
In 1962, it was found that the programme had failed to make any impact, and experts concluded it would require a dedicated human resource to be successful. An army of family planning workers was appointed for a door-to-door campaign, encouraging couples to accept family planning methods. Incentives were offered to women who opted for IUCD implants and men who went for vasectomy.
“In April 1965, I was appointed as Union health secretary and was given the task of making the family planning programme of India a success. In a meeting with the Planning Commission, it was made clear to me that funds would not be a problem,” says Kripa Narain, a retired IAS officer. “Prime Minister Indira Gandhi was determined to make this programme a huge success.”
In just a year, says Narain, medical services, public health services and family planning were brought together. Advertisement campaigns were launched to target the rural population. Male vasectomy, as it was a simpler procedure, was offered as a permanent contraception. And then, condoms made an entry. “I made a trip to Japan, the USA and Korea. I finally decided to collaborate with Japan for the condom-making technology. Japanese scientists came to India to set up the first machine and then we made many more units. By the end of 1969, 144 million pieces of condoms were manufactured,” says Narain.
But explaining how condoms worked proved difficult. Health workers used to demonstrate it using their thumbs. “But people often used to complain of pregnancy after a few months. Later, we found that people were using condoms over their thumb during the act,” says Dr A.R. Nanda, former secretary, ministry of health and family welfare.
The 1971 Census showed that the programme had failed to curb population growth despite government efforts. Population growth was seen as a reason for the country's slow economic development. The government then decided to organise vasectomy camps. In one such camp in Ernakulam, Kerala, more than 60,000 vasectomies were done in a week.
In April 1976, a national population policy was formulated and adopted by Parliament for the first time. It inspired state governments to pass suitable laws to make family planning compulsory for citizens and to stop child-bearing after three children, if the state so desires.
Then came the Emergency, and forced sterilisations became a norm. “It was crazy. Vasectomies were conducted at railway stations and educational institutes. The total number of sterilisation done in India from April 1976 to March 1977 was 8.26 million. It was more than those conducted in the previous five years,” says K. Srinivasan, former director and senior professor, International Institute for Population Sciences, Mumbai. After Indira Gandhi lost the elections in 1977, the new government changed the name of the programme to family welfare and adopted a softer policy.
From the 1980s, women's sterilisation or tubectomy was preferred. During the revised sixth Five-Year Plan (1980-85), the Planning Commission decided to set a long-term goal―achieving a crude birth rate of 21, a crude death rate of 9, an infant mortality rate of 60 and an expectancy of life at birth of 64, and to take contraceptive prevalence rate among the eligible married couples to 60 per cent. “Unfortunately, these targets still have not been achieved,” says Srinivasan.
The family planning programme of India faced major criticism from women activists at the International Conference on Population and Development at Cairo in 1994. The Indian government then adopted a revised policy promoting reproductive health.
Though the name and focus of the programme kept changing, not much has changed on the ground. Experts blame it on the complete lack of political will. “Policy makers are resistant to innovations. They have not expanded the basket of choices for women,” says Suneeta Mittal, former head of the department of gynaecology at All India Institute of Medical Sciences, New Delhi. “Besides, contraceptive choices on offer are provider-dependent―be it copper T or vaginal rings. In rural areas, where women have limited access to institutionalised health care, it is impossible for them to opt for methods that require a followup.”
Another major concern is that the family welfare programme doesn’t target unmarried people, youngsters and sex workers. “If young people have heard about the programme but don’t know how to use oral contraceptive pills or condoms, or where to get them, or if it is safe to use them and about their side-effects, we are not going to achieve our target,” says K.G. Santhya, a researcher with Population Council. “We need to promote safe sex concept among the young population.”
Dr M. Ayyappan, chairman, HLL Lifecare Limited, India's largest condom manufacturing company, agrees: “To understand the market for condoms, we carried out a survey-based study in Maduram Nagar, 60-70km from Chennai. We found that 60 per cent of users were people who have extramarital relationship and 30 per cent were unmarried people. This study was conducted 25 years ago. The need to address this group has grown manifold since then.”
In fact, even for married women, only limited choices are available. “The methods have to be age-appropriate. You simply cannot sterilise women in their early 20s. When we look at contraception, we also have to look at infection prevention. We should promote dual protection, which we completely ignore,” says Dr R.C.M. Kaza, India's first no-scalpel vasectomy (NSV) surgeon. There is a strong need to reintroduce NSV, he says, which failed largely because of lack of knowledge and communication. It is, therefore, time for India to have the talk.