Female sterilisation: Last resort, only choice

At Sneha Tabussum’s* (29) house in Tumakuru, two of her daughters play in the fast-dimming evening light. Looking at them, she says, “We cannot afford any more kids.”

Both of Sneha’s deliveries were complicated. She experienced pre- and postpartum anaemia and even suffered from pregnancy-related seizures. The doctor she consults has strongly discouraged a tubectomy, yet she is adamant in her decision to go ahead with the procedure.

She is certain that her husband would not even consider the idea of a vasectomy. “He is scared of surgery. Also, he is the earning member and I cannot allow harm to come to him,” she says.

While women allow such factors to influence their decisions, men often choose to sit out of family planning, even if this means putting their partners through riskier surgeries.

It has been two years since Rakesh’s* (30) wife went through a tubectomy. “Our family was complete. I asked my wife to get the operation done so we can focus on raising our children,” he says.

Read | Shift from target-driven contraception policies

His doctor had suggested a vasectomy during a counselling session, explaining that the procedure was much easier. “I was afraid that I would not be able to work properly. Many women get the procedure, but I have not met any man who has had such an operation,” he explains.

Faced with misinformation, familial pressure, patriarchal ideas and skewed policy, millions of women in India are compelled to shoulder the burden of contraception.

Seven decades have passed since the inception of the National Programme for Family Planning, yet it has failed to raise awareness effectively about available contraceptives. As a result of its historical focus on women, many see tubectomies as the only viable option.

Without comprehensive information, informed consent remains mired in a grey area as women are often operated on before they become fully aware of the side effects. In this way, basic reproductive rights elude most women in the country.

It should come as no surprise that about 38% of women in the country and 57% in Karnataka have undergone sterilisation procedures, according to data from the National Family Health Survey (NFHS-5). In comparison, the male sterilisation rate between 2019 and 2021 is just 0.3% in the country and 0% in the state.

This disparity persists despite the simplicity and efficacy of vasectomies. “It is an outpatient department procedure and does not take more than 10-15 minutes,” explains Dr Susheela Rani, a gynaecologist in Bengaluru.

The procedure uses local anaesthesia. The no-scalpel technique, in particular, does not even require incisions or stitches. “It is also just one-tenth the cost of a tubectomy. Post completion of the vasectomy, recovery barely takes a week,” Dr Rani adds.

Read | Contraception is woman's business, say 45% Karnataka men

Tubectomies, on the other hand, are far more complicated. To begin with, these surgeries are lengthier and require the use of general anaesthesia, involving either open or keyhole incisions in the abdomen. “There could be surgery-related infections, injury to the bladder and intestinal bruising,” Dr Sanjeev Kulkarni, a Dharwad-based gynaecologist says. Women with pre-existing co-morbidities like diabetes or anaemia face twice the risk.

Post-surgery, women require longer to recover, taking from one to three weeks. However, as primary caregivers in their families, they are not afforded this luxury.

Sushma D, a housewife in Bengaluru, for instance, was fatigued and dizzy for an entire month after her laparoscopic tubectomy. Yet, she had "a thousand chores" to mind, which hampered her recovery.

Ever since her surgery a year ago, she has suffered from a disturbed menstrual cycle. “Cramps started about two to three weeks after surgery and have not yet receded,” she says. She now regrets the procedure as it has left her with chronic pain.

There is ample evidence to show that sterilisation procedures can haunt women with long-term side effects, including “heavy menstruation or menstrual disturbances and ectopic pregnancies. Blood supply to the ovaries can be interrupted or reduced,” says Dr Kulkarni.

The side effects and risks associated with tubectomies seldom find their way into counselling sessions between doctors and patients. Unsure of the consequences of the surgery, women’s consent is nebulous at best.

“There was no counselling before the surgery was performed,” says Shruthi K, a resident of Tumakuru. She was neither scheduled for follow-up nor was she informed about the aftercare. “I was completely alone. Someone else who underwent surgery told me what to do,” she adds.

Women are also in serious danger when such complicated procedures are conducted in set-ups with few resources. “In the absence of an expansive pool of choices in remote areas without enough surgeons, physicians and counsellors, poor quality of care becomes an acceptable standard,” explains Poonam Muttreja, executive director of the Population Foundation of India, New Delhi.

Mass sterilisation camps have notorious reputations for not following protocol. In 2014, 16 women died at a sterilisation camp in Bilaspur, Chhattisgarh, after botched sterilisation surgeries. Following this, the Supreme Court banned mass sterilisation camps in 2016. The court called for the central government to shut down all such camps in three years.

However, the government has made little progress in closing mass sterilisation camps. Further, there has been a failure to examine the standards followed in camps where sterilisation procedures are still being administered. As a consequence, four women in Telangana succumbed after undergoing a double-puncture laparoscopy at a camp conducted in a civil hospital in late August.

Given the multitude of risks associated with tubectomies, and the presence of a simple, safe and cost-effective alternative like vasectomy – why is there a gaping disparity between the two?

Patriarchy

Lakshmamma* has an answer. As an Accredited Social Health Activist (ASHA) worker with over a decade of experience, she has attempted to persuade hundreds of men to opt for vasectomies, but only one or two have gone through with her recommendation. “Most men are scared that it will leave them without strength and affect their work in the long run. There is also fear that it will impact their intimate relationship with their wives. No amount of persuasion works,” she explains.

Lakshmamma has been at the receiving end of such obstinacy from her own partner too. Without access to any short-term contraception, she was forced to get an abortion. She suffered from several painful miscarriages after. “I was heavily bleeding every time (I went through a miscarriage) and was emotionally exhausted. I tried to convince my husband to get a vasectomy. He did not agree and stopped talking to me for three months,” she says.

Left with no other option, Lakshmamma decided to get a tubectomy. “I could not convince my own husband,” she says.

Family structures that uphold patriarchal ideas also prioritise the health of men more than that of women. Sneha’s in-laws, for example, were consulted when the discussion of her surgery came up. “In the end, fear for my husband’s well-being won over fear for mine,” she says.

Health workers at a Primary Health Centre (PHC) in Tumakuru explain that even men who had previously acquiesced to undergo vasectomies, would often back out a day or two later, after talking to their families. “There is a lot of fear-mongering and a tendency for the family to view vasectomy as an assault on ‘masculinity’,” says Sharada Gopal, founder of Belagavi-based Jagruti Mahila Okkoota.

Such misconceptions are bound to emerge when 18% of men and 28% of women are unaware that ‘male sterilisation’ or vasectomies are even an option.

Policy

Most family planning programmes focus entirely on women, except for the coercive mass sterilisation drives of 1976. “Since then, policymakers seem to target women when it comes to sterilisation, which seems more politically prudent to them,” says Poonam.

In fact, a 2020 study by the International Centre for Research on Women (ICRW) found that public family planning awareness materials disseminated by the government were highly gendered. They regularly exonerate men from participating in family-planning-related decision-making. Nearly half of the men in Karnataka – about 45% – believe that ‘contraception is women’s business and a man should not have to worry about it’.

Rathnamma J*, the head nurse at a PHC in Tumakuru, explains why these regressive mindsets persist, “Most ASHAs are women, and men do not feel comfortable talking to them about contraception.”

ASHA workers tend to talk more to women, “Because men ignore health workers. They speak with men about vasectomies only when the woman is unable to undergo surgery,” she adds.

Despite high health worker engagement with women, there is an unmet need for contraception on the ground. Currently, about 9.4% of women in the country do not have access to any contraception. Ease of accessibility to temporary contraceptive methods would reduce compulsion to undergo methods as permanent as female sterilisation.

Vulnerable communities are especially affected by this lack of access. A 2018 study found that contraceptive use was the lowest among Scheduled Tribe families (48%), followed by Other Backward Caste (54%) and Scheduled Caste families (55%).

The way forward

In the present climate, women lack true agency to exercise their reproductive rights. Sterilisation, which is usually the last resort, is their only choice.

In order to ensure equitable participation of men in family planning, Poonam suggests, “Almost half of all Indian men think it is a woman’s responsibility to avoid getting pregnant. This needs to be addressed with focused social and behaviour change communication campaigns that challenge patriarchy and break regressive gender norms.” Both partners should have equal access to information about contraception, she adds.

Additionally, the recruitment of male health workers could help create communication channels with men about contraceptives, explains Anjali Bansal, a researcher. Out of 9,758 required male health workers in Karnataka, only 5,888 posts have been sanctioned and 3,401 posts are filled.

“It is also imperative that policy, which largely provides for female-focused contraceptive methods, corrects its skew,” says Anjali.

In the absence of concerted action, countless women like Sneha and Sushma will continue to traverse the one-way street of family planning in India and men will continue to sit out.