Sterilisation as contraception is on the rise. For decades, India has relied on female sterilisation as its primary mode of contraception. Apart from vasectomies being safer and non-invasive, its reversal is also considerably safer than tubectomies.
As per NFHS-5, 37.9 per cent of women use sterilisation to prevent unwanted pregnancies, much higher than non-surgical methods like pills (5.1 per cent), injectables (0.6 per cent), condoms (9.5 per cent), IUDs (2.1 per cent) or even male sterilisations (0.3 per cent). Nearly 75 per cent of all female sterilisations occur in public institutions, and roughly one-third of them are done post-partum.
While condoms are the most commonly used technique in the northern and western regions, the north-east and eastern areas have a higher prevalence of pills. India shows heterogeneous geographical and socio-economic variation in the choice of contraceptive methods.
The data puts into perspective the striking gap between female and male sterilisations across States. Southern States/UTs like Andhra Pradesh, Telangana, Tamil Nadu, Puducherry and Karnataka lead in female sterilisations with more than 50 per cent coverage. But this is barely matched by the abysmally poor involvement (0-1 per cent) of male counterparts.
The focus on male sterilisation is theorised to have zoomed out of the Family Planning Programme post the 6.2 million forced sterilisations conducted during the 1975 Emergency period. Stigma, perception of sterilisation as emasculation, misinformation concerning the side-effects/complications and cultural and religious beliefs remain significant deterrents to the adoption of sterilisation for men. Between 2008 and 2019, only 3 per cent of all 51.6 million sterilisations done were vasectomies.
There is still a dire lack of awareness of alternative and reversible methods and knowledge of the side effects of surgical techniques for women. High unmet needs for modern contraception have been observed among poor and marginalised women leading to poor reproductive outcomes and unwanted pregnancies.
Side effects
Also, poor cognisance of the current contraception methods’ side effects was noted among women in the NFHS-5 (2019-21). Andhra Pradesh and Telangana rank lowest in terms of awareness of side-effects of the current methods of contraception used by women, despite having the highest female sterilisation coverage in the country.
Popular in rural areas, post-partum or post-abortion insertion of Copper-Ts (or Copper Intra-uterine Devices) is the only long-term reversible contraception method available in the country. Yet uterine bleeding and abdominal pain have been pervasive side effects, troublesome for both the women and the physicians.
In States like Bihar, with the highest Total Fertility Rate (TFR) of three children per woman in the country, the increased prevalence of unwanted pregnancies is attributed to an absolute lack of counselling for women on birth-spacing and alternative methods. Fear of side effects continues to be a major deterrent in opting for contraceptive as well as the choice of it, even after almost 70 years of the family planning programme running in India.
Other reasons are lack of knowledge, cultural beliefs, lack of decision-making power within intimate relationships and undesirable attitudes of service providers.
Apart from disquiet on the services delivery of these surgical procedures, there grim areas regarding the ethics of consent. Past instances of violation or non-agreement of consent have been reported, especially for uneducated, disabled, tribal/minority women. Several women have been either coerced into, misinformed about the surgery or even never told about the possible risks that it may entail.
Additionally, procedures like mini-laparotomy or laparoscopic tubectomy may easily be done without women being fully aware. Evidence indicates that over-emphasis on female sterilisation in family welfare programmes may discourage other methods.
Hence, in the absence of an expansive pool of choices in remote and rural areas or enough surgeons/physicians, poor quality of care becomes an acceptable standard. Chhattisgarh has been historically notorious for time-bound and targeted mass sterilisations in camps with cases of botched surgeries and inferior standard of care. Incidents in Surguja (2021) and Bilaspur (2014) are some infamous examples of blatant disarray of government regulations and prescribed standards.
The skewed burden of permanent family planning indicates larger trends of early marriage and childbearing along with health concerns of unmet adolescent needs. Studies across India, Brazil, and Bangladesh have found higher parity (more children) as a determining factor for female sterilisation. But notably, it is still driven by son-preference at lower parities (fewer children).
A significant gap in truly understanding contraceptive requirements of the country arises from the exclusion of unmarried women and adolescent girls who are not commonly included in research studies. Hence, these groups have rising and unrecorded unmet needs for birth planning. Surveys in Bihar reveal that more unmarried and sexually active women used contraceptives than married women in the 15-49 years age group.
With the push for a two-child policy in States like UP, Assam and Gujarat, sterilisation is further incentivised and propagated. But this thrust seems unnecessary as most States have nearly reached replacement level fertility rate. Four out of the seven initial target States for Mission Parivaar Vikas have already reached the goal of a fertility rate of 2 and below.
Being crucial to achieving the sustainable development goals, the government must ensure improved access to and strengthen family planning services. The family planning programme should ensure that it is voluntary, informed and dignified to women to truly empower women to make choices for themselves and involve men in the process.
The writer are with Observer Research Foundation