As a gynaecologist, I find this hard to defend on medical grounds. The simpler and safer operation is the one we almost never perform.

Two operations, compared

A tubectomy closes the fallopian tubes so that the egg and sperm cannot meet. To reach the tubes, the surgeon has to enter the abdomen. In a minilaparotomy (“minilap”) this is done through a small cut in the lower abdomen, usually under local anaesthesia with sedation. In laparoscopic sterilisation a thin telescope is passed through a small cut near the navel after the abdomen is filled with gas, and a ring or clip is placed on each tube. Both are short and safe in trained hands, but they are –still—an abdominal surgery. The risks, though uncommon, include infection, bleeding, injury to the bowel or bladder, and problems with anaesthesia.

A vasectomy closes the two thin tubes that carry sperm. These lie just under the skin of the scrotum. In no-scalpel vasectomy the doctor reaches them through a single tiny puncture, under local anaesthesia. There is no entry into the abdomen and usually no stitch. The man walks home and can return to light work within a couple of days. Complications are mostly minor, such as bruising, swelling or a small infection. It does not affect erections, sexual desire or physical strength. One point needs honest counselling: a vasectomy does not work at once, and the couple needs another method (of contraception) for about three months afterwards.

Both operations are highly effective. The World Health Organisation (WHO)-supported family planning handbook puts first-year failure at about 0.5 per 100 for female sterilisation and about 0.15 per 100 for vasectomy. Both should be treated as permanent.

On every count, vasectomy is the lighter procedure. Yet the heavier one is done over a hundred times more often.

Camps, Targets and Bilaspur

This did not happen by accident. For decades the programme was run on numerical targets. After the coercive vasectomy drives of the Emergency in the mid-1970s, sterilising men became politically untouchable, and the targets shifted to women. The 1994 International Conference on Population and Development in Cairo moved the world from population control towards reproductive rights, and in 1996 India announced a Target Free Approach. On paper, targets ended. In practice “expected levels of achievement”, incentive payments to acceptors and motivators, and pressure on frontline workers kept much of the old logic going.

Its cost became impossible to ignore in November 2014. At a sterilisation camp in Takhatpur, in Bilaspur district of Chhattisgarh, 83 women were sterilised at a single camp. Thirteen of them died in the days that followed.

In September 2016, in Devika Biswas v Union of India, the Supreme Court held that what was happening in such camps violated women’s right to health and reproductive freedom. The court directed the Union government to phase out sterilisation camps within three years and to strengthen regular health facilities instead. It also said states must not set even informal targets, that consent must be explained in a language the woman understands, that deaths and failures must be audited and reported, and that compensation should be raised.

The standards were already there. The Ministry of Health and Family Welfare publishes manuals on standards and quality assurance in sterilisation services, covering screening, asepsis, the number of cases a team may do in a day, and follow-up. The Family Planning Indemnity Scheme provides compensation for death, complications and failure after sterilisation. What has been missing is consistent practice.

Why the gap persists

Myths come first. Many men, and many families, believe vasectomy causes weakness, ends a man’s capacity for hard labour or damages his sexual life. None of this is true, but families who depend on his wages often share the fear. NFHS-5 found that about 35% of men agreed that contraception is women’s business and a man should not have to worry about it.

Then there is timing. A woman meets the health system at delivery, and sterilisation is often offered soon after childbirth or with a caesarean section. That suits the system, but it is not always a good moment for a permanent decision. NFHS-5 gives the median age at sterilisation as 25.7 years. A decision made at 25, sometimes within days of a birth, has to last a lifetime.

Counselling is thin. Among sterilised women in NFHS-5, only about 65% said they had been told about other methods, and about 59% had been told about possible side effects. The public sector now offers a wider range: the intrauterine device (IUCD), including after delivery; the injectable contraceptive MPA under the Antara programme; the non-hormonal weekly pill Chhaya; condoms and daily pills. A woman who has never been offered these has not really chosen sterilisation.

Every year from November 21 to December 4, the government observes a Vasectomy Fortnight to encourage men to come forward. It is welcome, but a fortnight cannot undo a year of silence.

What needs to Change

Counselling must be real: unhurried, in the woman’s own language, without the husband or the motivator answering for her, and never in the labour room. Reversible methods should be offered first to young couples, with steady supplies so that a missed injection does not become an unwanted pregnancy.

Quality standards must apply in every facility, with follow-up visits that actually take place. States should publish what the Supreme Court asked for: how many procedures, how many complications, how many deaths, how many failures, and what was done about each.

Men need to be reached directly. ASHAs and ANMs speak mostly to women. We need male health workers, satisfied vasectomy users and trained no-scalpel vasectomy providers at district level, speaking to men where they work.

Finally, a woman must be free to say no, to sterilisation or to any method, without losing a benefit or the goodwill of the health worker she will need again. Family planning was meant to give women control over their bodies. A programme where one sex does nearly all the bleeding has not yet done that.

(The author holds a degree in medicine, an MBBS, MS [Obstetrics and Gynaecology], is an obstetrician-gynaecologist from Assam and is also a medical reviewer at abortion-riyadh.com)

Sources

1. NFHS-5 (2019–21), India Fact Sheet, IIPS and MoHFW: https://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf
   2. NFHS-5 (2019–21), India National Report, IIPS and ICF: https://dhsprogram.com/pubs/pdf/FR375/FR375.pdf
   3. Devika Biswas v Union of India & Ors, Writ Petition (Civil) No. 95 of 2012, Supreme Court of India, judgment of 14 September 2016 (summary, Human Rights Law Network): https://www.hrln.org/litigation/devika-biswas-versus-union-of-india-and-ors-writ-petition-c-no-95-of-2012-the-supreme-court-of-india
   4. National Health Mission, MoHFW, Family Planning programme, guidelines and manuals: https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=821&lid=222
   5. WHO, Family planning/contraception methods fact sheet: https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception
   6. WHO/Johns Hopkins, Family Planning: A Global Handbook for Providers, contraceptive effectiveness: https://fphandbook.org/sites/default/files/legacy/book/fph_appendix_a/index.shtml
   7. Centre for Economic Data and Analysis, Ashoka University, “Female sterilisation in India: prevalence, informed choice and regret” (2024): https://ceda.ashoka.edu.in/female-sterilisation-in-india-prevalence-informed-choice-and-regret/
   8. UNFPA, International Conference on Population and Development (Cairo, 1994): https://www.unfpa.org/icpd

Related:

Menstrual health of women in shambles: Surveys highlight need for inclusive and accessible healthcare services

Human rights of Women in mental health institutions violated: SC

India’s Poorest Women Benefit Less From Public Health, Nutrition Services

The post Health: Why do women in India still carry the burden of sterilisation? appeared first on SabrangIndia.