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 Policiesand 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.”