INDIA: Target-Driven Sterilization Harming Women

India should eliminate coercive female sterilization practices as it implements plans for the expanded contraceptive services it announced at an international conference in London, Human Rights Watch and two reproductive health rights networks, the Coalition Against Two Child Norm and Coercive Population Policies and CommonHealth Coalition for Maternal-Neonatal Health and Safe Abortions, said today.

The Indian government announced on July 11, 2012, at the London Summit for Family Planning that it has brought about “a paradigm shift” in its approach and will emphasize promotion and provision of contraceptives for birth spacing. The Indian government announced that its new strategy focuses on “making contraceptives available at the doorstep through 860,000 community health workers,” providing services for inserting intrauterine devices (IUDs) on fixed days in public health facilities, and improving post-natal services for IUDs, especially in those public health facilities that have large numbers of women coming to give birth. But the ongoing focus of the Indian central and state governments on achieving numerical targets for use of contraception, especially female sterilization, has contributed to a coercive environment for several decades, and should not be replicated going forward.

Unless India's approach to contraception is revised, community health workers may come under increased pressure to meet contraceptive targets, the rights groups said. The government's plans should ensure that all community health and nutrition workers give women adequate information about HIV prevention, sterilization, and other contraceptive choices.

Two years after the 1994 International Conference on Population and Development, India announced that it would take a “target-free” approach to family planning. Since then, the Indian government has stopped setting centralized targets. But in practice, state-level authorities and district health officials assign targets for health workers for every contraceptive method, including female sterilization.

In much of the country, authorities aggressively pursue targets, especially for female sterilization, by threatening health workers with salary cuts or dismissals. As a result, some health workers pressure women to undergo sterilization without providing sufficient information, either about possible complications, its irreversibility, or safer sex practices after the procedure.

“Health workers who miss sterilization targets because they give proper counseling and accurate information about contraception risk losing their jobs in many parts of the country,” said Aruna Kashyap, women's rights researcher at Human Rights Watch. “The Indian government should work with civil society to ensure that mechanisms to monitor progress in contraceptive use emphasize quality and respect for reproductive rights.”

In June, Human Rights Watch interviewed more than four dozen Female Health Workers and early childhood careand nutrition workers, called anganwadiworkers, andAccredited Social Health Activists (ASHA) from two districts in Gujarat state about their family planning work in rural areas, as well as various health experts. Both Gujarat districts have large adivasi(indigenous tribal) populations, which are among the most impoverished groups in the state.

More than 50 health workers told Human Rights Watch that district and sub-district authorities assigned individual yearly targets for contraceptives, with a heavy focus on female sterilization. Almost all said that their supervisors or other higher-ups threatened them with adverse consequences if they did not achieve their targets.

These included threats to withhold or reduce salary, negative performance assessment, or suspension and dismissals. In one case, a health worker reported that she was asked to falsify records to show she had met targets or else she would be reported for poor performance. One women's rights organization that has more than a decade of experience working with community health workers in various parts of Gujarat confirmed that state and district health authorities have consistently set such targets and threatened health workers.

Experts from across India have repeatedly voiced concerns about contraceptive targets leading to coercion and poor quality services. This was highlighted during state-level consultations and a national conference hosted by the Family Planning Association of India in New Delhi in June. At that conference, experts reiterated their decades-long demand for contraceptive choice and better quality services instead of a focus on numbers of people accessing contraceptives or undergoing female sterilization.

“Information about contraceptive choice and quality of services should not be sacrificed for numbers,” said Dr. SundariRavindran, steering committee member of the CommonHealth Coalition. “Hounding a poor woman to get sterilized without proper information and leaving her to deal with negative reproductive health consequences cannot be seen as success.”

State authorities in some parts of India also use incentives – including cars, gold coins, and drawings for prizes – to “promote” sterilization. Because male sterilization is not well-accepted socially, this almost always means female sterilization. The most recent District Level Household and Facility Survey from 2008shows that of the 54 percent of the population that reported using any method of contraception, female sterilization accounted for 34 percent and male sterilization accounted for 1 percent of contraceptive use.

Aside from family planning programs, sterilization is pursued through other programs that are entirely funded by state governments. For example, five states have introduced “girl child promotion” programs, which provide monetary benefits to parents of girls, with a final cash benefit if she reaches the age of 18 unmarried. But to receive benefits, a couple must produce a sterilization certificate.

Experts have repeatedly called for the Indian central government to refashion its family planning program to take into account social factors related to childbearing, including early marriage, the preference for sons, infant and child mortality, and the country's lack of social security for the elderly.

The Indian central government's failure to implement social security programs has been a major deterrent to contraceptive use since many families say they rely on their children, especially sons, to care for them in old age. India created a National Policy for Older Persons in 1999 and passed the Maintenance and Welfare of Parents and Senior Citizens Act, 2007. But little has been done to implement the policy and law.Indian experts participating in the Delhi conference pointed out that pursuing an agenda of sterilization without addressing old age security only increases the risk of illegal sex-selective abortions.

“Son preference and choices about birth are intrinsically linked to fears about old age insecurity,” said Dr. Subha Sri, steering committee member of CommonHealth coalition. “By failing to address old age security for the poor, India is both turning its back on families pressured to meet targets and increasing the likelihood of sex-selective abortions.”

India's family planning program focuses predominantly on women, with little interaction and engagement with men. At the same time, it is men who often decide when to have sex and how many children to produce. For India to be successful in its renewed efforts at family planning, it should engage effectively with men too, the rights groups said.

With early marriage prevalent in many areas and with India having the highest number of adolescents in the world, information about reproductive and sexual health should become an important part of both school curricula and health services for adolescents. India's 2003 Youth Policy specifically recognized that “information in respect of the reproductive health system should form part of the educational curriculum.” But nearly a decade after the Youth Policy was introduced India has yet to introduce compulsory sex education for adolescents.

“In sex education, there are no shortcuts to engaging with both adolescents and men,” said Dr. Abhijit Das, steering committee member of the National Coalition Against Two Child Norm. “India should treat age-appropriate compulsory sex education – both inside and outside schools as integral to its new chapter on family planning and find a way of engaging men effectively.”

As India moves into its new phase of contraceptive services, the Indian government should:

• Consult with health rights experts and create a panel to develop measureable indicators for monitoring access to and use of contraceptives beyond numerical targets, which focus on spacing between two consecutive births, informed decision-making, and quality care;
• Pilot test a minimum package of integrated sexual and reproductive health services that includes a range of contraceptives and compulsory age-appropriate sexuality education for adolescents in and out of schools;
• Set up an independent grievance redress system that includes civil society members to report coercion and poor quality contraceptive services and to facilitate remedial action;
• Give priority to training male workers to provide information and counselingto men about safer sex and contraceptive choice;
• Review all existing girl-child promotion schemes, direct state governments to revise these schemes to stop forcing sterilization as the primary contraceptive method, and develop guidelines for such schemes.
• Examine the issue of social security for the elderly as an issue of national priority and take measures to review and implement the National Policy on Older Persons.