12 Nov 2014

An op every four minutes: inside the sterilisation factories

The death toll rises to 13 after a mass sterilisation in India, including a women who had just given birth. But health experts tell Channel 4 News the real shock is that it doesn’t happen more often.

Around 20 women are critically ill in hospital, and at least 13 have died, after a mass sterilisation in the central Chhattisgarh state over the weekend.

In just six hours, 83 women were operated on by one surgeon in Bilaspur city, who was paid per procedure.

Among the 13 women who have died so far, one was a new mother who had given birth just days before the operation. The brother-in-law of one of the victims said the patients were “herded like cattle”, while the husband of Nem Bai, 35, said she died in “tremendous” pain.

Contraceptives are not seen as a way to prevent pregnancy – it’s really seen as something you do when your family is ‘complete’ Kirsty McBloom

A team of doctors have been rushed to the hospitals to help out, and four officials have been fired, as the government tries to minimise the fall out. The cause of the deaths is thought to be either blood poisoning or haemorrhagic shock (which happens when someone has lost too much blood), said the state’s deputy health director.

But the deaths have thrown India’s practice of mass sterilisation – which has been criticised as rushed, unhygienic and cramped – into the spotlight.

To outsiders, the practice sounds like a dystopian horror show, but it is commonplace in India which has the highest rate of sterilisation among women in the world: 37 per cent of the country’s female population have been sterilised, and it is common for women to have the procedure after they have had the number of children they want – especially if this includes a boy.

In rural areas, where there are a lack of hospitals and access to health care, eligible women are mobilised and operated on on the same day. Doctors are supposed to be limited to 20 operations a day.

‘It’s only a matter of time before there are more deaths’

However deaths or injury following surgery are nothing new: the government paid compensation for 568 deaths resulting from sterilisation between 2009 and 2012, according to the health ministry.

Part of the problem is the unofficial target-driven culture. The government has pledged to do away with sterilisation targets for various states which had been in place in an attempt to curb the booming population, which currently stands at 1.26 billion.

But Human Rights Watch (HRW), which carried out a report in 2012 to assess the extent of the problem, said this hasn’t happened. “It’s all in theory. It hasn’t actually translated into practice, and everything remains target driven,” Aruna Kashyap from HRW’s Asia division told Channel 4 News.

“The way the system is geared, it’s only a matter of time before there are more deaths. You’re appalled every time it happens.”

The report read: “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 sterilisation without providing sufficient information.”

Catalogue of horrors

The Reproductive Rights Initiative (RRI), part of the Delhi-based Human Rights Law Network, has been documenting violations in sterilisations across India for the last two years.

Alongside multiple deaths, serious injuries, a lack of counselling or information before and after surgery, some of the most shocking findings are:

  • At one camp, there was no running water so doctors had to wash their hands in a tub of water that was not replaced for days,
  • In Jharkhand, a 16-year-old was sterilised and a neighbour allegedly pocketed the money,
  • Staff put a women with bleeding surgery incisions on the ground in a field post-surgery in Malda,
  • In several cases in New Delhi, women were asked to remove their own stitches,
  • At a camp in CHC Dhanupur, there were no theatre beds, no wash basins and 20-day-old blood stains on mattresses,
  • In Barwani, a surgeon operated on 100 women in two hours and they were left on the floor unconscious for four hours,
  • A woman in Satna died after receiving an injection at a sterilization camp. Her husband was promised money and a government job if he kept quiet,
  • In Odisha, 6 per cent of the physically disabled population was forcibly sterilised and 8 per cent of what the report calls “mentally challenged”.

Despite a Supreme Court ruling in 2005 that obliged states to have minimum levels of care in sterilisation procedures, RRI Director Kerry McBloom says there has not been enough action since then.

£14 for your fertility

Payments for patients and health workers have also become a form of coercion, she told Channel 4 News, and sterilisation camps are turned into “factories” where women are rushed through as fast as possible.

At the camp on Saturday, women reportedly received payments of 1,400 rupees (£14.33) after having laparoscopic tubectomy surgery. Health workers were also paid 200 rupees (£2.05) per patient, Reuters reported, while doctors and anaesthetists also receive payments.

In India the community health workers who take women to be sterilised have no medical training, and are often hugely overworked. “The only payment they get are incentive payments,” said Ms McBloom. HRW found that these workers risk losing their jobs if they don’t meet targets.

There is also a big demand for sterilisation, and health workers know that women will often want the procedure so don’t think they are necessarily acting against her interests. “Contraceptives are not seen as something to prevent pregnancy – it’s really seen as something you do when your family is ‘complete’,” said Ms McBloom. Rather, it is the conditions that the operation is carried out that causes the problem.

Alternatives to sterilisation

The government has pledged to create 48 million new contraceptive users as part of the global partnership for family planning (FP2020).

It has recently been trying to promote the use of copper based IUDs instead of sterilisation, which are inserted into a woman – in practice, often straight after she’s given birth – and prevent contraception for around three years.

But the underlying problems of unhygienic conditions, rushed procedures and unofficial targets remain, with IUDs being inserted en masse. Health experts in India are calling for a paradigm shift in the way the government approaches the issue of contraception altogether – especially after the tragedy in Chhattisgarh.

“We’ve never seen anything this bad,” said Ms McBloom. “I’m hoping it does push some change.”