Sterilization as a method of contraception is on the rise. For decades, India has relied on female sterilization as the primary method of contraception. Apart from the fact that vasectomies are safer and non-invasive, its reversal is also considerably safer than tubectomies.
According to NFHS-5, 37.9% of women use sterilization to prevent unwanted pregnancies, far more than non-surgical methods like pills (5.1%), injectables (0.6%), condoms ( 9.5%), IUDs (2.1%). percent) or male sterilizations (0.3 percent). Nearly 75% of all female sterilizations take place in public institutions, and about a third of them are carried out after childbirth.
While condoms are the most commonly used technique in the northern and western regions, the northeast and eastern regions have a higher prevalence of pills. India exhibits heterogeneous geographical and socio-economic variations in the choice of contraceptive methods.
The data puts into perspective the stark discrepancy between female and male sterilizations in the states. Southern/UT states like Andhra Pradesh, Telangana, Tamil Nadu, Pondicherry and Karnataka lead in female sterilizations with over 50% coverage. But this is barely matched by the extremely low participation (0-1%) of male counterparts.
The focus on male sterilization is theorized to have zoomed out of the family planning program after the 6.2 million forced sterilizations carried out during the 1975 emergency period. Stigma, the perception of sterilization as emasculation, misinformation regarding side effects/complications, and cultural and religious beliefs remain significant barriers to uptake of male sterilization. Between 2008 and 2019, only 3% of the 51.6 million sterilizations performed were vasectomies.
There is still a critical lack of awareness of alternative and reversible methods and knowledge of the side effects of surgical techniques for women. High unmet need for modern contraception has been observed among poor and marginalized women, leading to poor reproductive outcomes and unwanted pregnancies.
Additionally, poor knowledge of side effects of current contraceptive methods was noted among women in the NFHS-5 (2019-21). Andhra Pradesh and Telangana rank last in terms of awareness of the side effects of current contraceptive methods used by women, despite having the highest female sterilization coverage in the country.
Popular in rural areas, postpartum or post-abortion insertion of Copper-Ts (or copper intrauterine devices) is the only long-term reversible contraceptive method available in the country. Yet uterine bleeding and abdominal pain have been pervasive side effects, bothersome to women and doctors.
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 counseling for women on child spacing. births and alternative methods. Fear of side effects continues to be a major deterrent to contraceptive and contraceptive choice, even after nearly 70 years of India’s ongoing family planning program.
Other reasons are lack of knowledge, cultural beliefs, lack of decision-making power in intimate relationships, and undesirable attitudes of service providers.
Besides the concern about the service delivery of these surgeries, there are gray areas regarding the ethics of consent. Past cases of violation or non-granting of consent have been reported, particularly for uneducated, disabled, tribal/minority women. Many women have been coerced, misinformed about the surgery or even never informed of the possible risks it could entail.
Additionally, procedures such as mini-laparotomy or laparoscopic tubectomy can easily be performed without women being fully aware of it. Evidence indicates that an overemphasis on female sterilization in family welfare programs may discourage other methods.
Therefore, in the absence of a wide range of choices in remote and rural areas or a sufficient number of surgeons/doctors, poor quality of care becomes an acceptable norm. Chhattisgarh is historically notorious for targeted and time-limited mass sterilizations in camps with cases of botched surgeries and substandard standards of care. The Surguja (2021) and Bilaspur (2014) incidents are some infamous examples of the blatant disarray of government regulations and prescribed standards.
The biased burden of permanent family planning points to greater trends in early marriage and childbearing as well as health problems related to unmet needs in adolescents. Studies in India, Brazil, and Bangladesh found that higher parity (more children) was a determining factor for female sterilization. But notably, it is still motivated by the preference for boys at lower parities (fewer children).
A significant gap in the actual understanding of the country’s contraceptive needs stems from the exclusion of unmarried women and adolescent girls who are typically not included in research studies. Consequently, these groups have growing unmet and unrecorded needs for family planning. Surveys in Bihar reveal that more unmarried and sexually active women used contraceptives than married women in the 15-49 age group.
With the push for a two-child policy in states like UP, Assam and Gujarat, sterilization is further encouraged and propagated. But that push seems unnecessary because most states are near replacement-level fertility. Four of Mission Parivaar Vikas’ original seven target states have already achieved the goal of a fertility rate of 2 or less.
Crucial to achieving the Sustainable Development Goals, the government must ensure better access to and scale up family planning services. The family planning program must ensure that it is voluntary, informed, and dignified for women to enable them to make choices for themselves and involve men in the process.
The author is with Observer Research Foundation
April 12, 2022