Sikha, a 27-year-old farmer from Shivpur village in Varanasi, does not want a third child. But since her husband has refused to get a vasectomy, Sikha has been taking contraceptives which trigger side effects – her medical complications have not allowed for a sterilisation surgery.
She still thinks sterilisation is the solution, and the burden to get it is only on her. “Why would my husband do it...I have to take these steps.”
It’s not just Sikha. In villages across Uttar Pradesh, hundreds of women like her bear the brunt of family planning – either due to patriarchal norms or the government’s push for female sterilisation.
Despite India declaring a numerical “target-free” approach to family planning in 1996, officials in UP have ostensibly been given targets – termed as “expected level of achievement” – for contraceptives and sterilisations, with a focus on women, show official documents for 2022-2023. Even the word “target” has been used in official communications between 2013 and 2016.
Around 25 health workers, accredited social health activists, auxiliary nurse midwives, primary health centre doctors and district family planning officials told Newslaundry that these “targets” are communicated to them by the Uttar Pradesh state health department, and alleged that they are often threatened with consequences if they fail to deliver these ELAs.
The approach is focused on women, despite female sterilisations being more complicated than vasectomies.
“We are pressured by the health department officials to achieve the ELAs. If we lag behind, we are threatened that our salaries will be held back or we’ll be transferred. We are compelled to do the same with the health workers on the ground,” said a family planning official at Ghazipur, wanting to remain anonymous.
The central government had declared a “target-free” approach to family planning in 1996. This was after international human rights organisations’ criticised the target approach as “coercive”. But despite official documents asserting that family planning in India is target-free, the practice of target-setting has allegedly continued at the state-level in Uttar Pradesh – with specific emphasis on female sterilisation.
The country, meanwhile, recorded 37.9 percent of female sterilisations in 2019-20 in comparison to 0.3 percent male sterilisation, as per the last NFHS report.
In UP, ‘pressure’ on rural workers
Family planning officials at Varanasi division – home to prime minister Narendra Modi’s Lok Sabha constituency – claimed that the state programme management unit of the UP health department shares these targets or ELAs with the district chief medical officers, who then distribute it among the family planning officials at an annual meeting.
For the districts under the Varanasi division – Chandauli, Gazipur, Jaunpur and Varanasi – the ELAs for female sterilisations for April 2022 to March 2023 period were 12,257, 11,824, 9,835 and 12,809, respectively. Meanwhile, for male sterilisations, the ELA was 69 in Chandauli, 55 in Gazipur, 38 in Jaunpur, and 180 in Varanasi, officials told Newslaundry. Meanwhile, for the entire state, the ELA was 3,50,000 for female sterilisation and 5,000 for vasectomy for 2022-23.
These data are also available on the website of the National Health Mission of Uttar Pradesh. An NHM circular issued in June last year, addressing chief medical officers on the state’s family planning initiatives for 2022-23, mentioned the expected level of achievement or ELAs for sterilisations and other contraceptives. Meanwhile, the NHM state programme implementation plans from 2013 to 2016 stated the “targets” for the same.
Notably, Uttar Pradesh saw 0.1 percent male sterilisations against 16.9 percent female sterilisations in 2019-20, as per NFHS data – corresponding to the figures recorded in the 2015-16 NFHS survey as well.
“There is a lot of pressure for sterilisation from higher authorities, and if any fortnightly or special programme is going on, the target is increased,” said a health worker at Varanasi’s urban public health centre. The PHC officials and other health workers are given the targets or ELAs by the family planning officials.
The mechanism for setting the ELA is shrouded in confidentiality. While family planning officials have vague ideas about the factors that influence the ELA, they do not know about the “exact mechanism”.
“These targets are set on the basis of the district population, but they also consider achievements of the past years. For example, in Balia, which is a bigger district than Chandauli, the ELA set for the past year was one male sterilisation. Contrarily, for Chandauli, it was 69. We are not told about the exact mechanism behind the ELA, but we reckon that the state increases the target by 10 percent every year,” Chandauli family planning expert Rajesh Rai told Newslaundry.
Rai said the district also received an ELA for dosage of contraceptive pills. “For the past year, the ELA for Antra injection was 12,250 doses, and for Mala M, it was 93,000 doses. The target was 12,116 doses for Chhaya pills and around 15,000 for IUCD and PPIUCD. We are yet to get the current year’s ELA and the review meeting is also pending.”
A review meeting on the ELAs fulfilled is held by the state health department officials by the end of the fiscal year.
“In case we miss targets, we are questioned about the impediments. Last year, we achieved our target, but in 2020-21 we did not because of Covid-19 and the vaccination drive. The state officials considered our situation then,” said Tabriz Ansari, Senior District Specialist for family planning, Gazipur,. “We distribute these targets among the primary health centres, ASHAs and ANMs as per the population of the area.”
Neelam Devi, an ASHA worker at Bhadeni village of Varanasi told Newslaundry, “Every year, I get some target for sterilisation and I am awarded Rs 300 for each sterilisation. I get Rs 150 per case for the postpartum intrauterine contraceptive device or PPIUCD and post abortion IUCD insertion, and Rs 100 for every dose of contraceptive pill.”
But these incentives are not finalised unless the ASHA workers achieve at least 60 percent of their target, she said.
Newslaundry reached out to Uttar Pradesh health minister Brajesh Pathak and the state health department principal secretary Parth Sarthi Sen Sharma with queries on methodology used for ELAs and the push for female sterilisation. This report will be updated if a response is received.
Unawareness about contraceptives, burden on women
Andhra Pradesh and Telangana have the highest female sterilisation rate at 69.6 percent and 61.9 percent, respectively. But both the states rank the lowest in awareness about the effects of the current methods of contraception.
As per the 2019-20 NFHS report, at least 62.4 percent users of contraceptives are uninformed about its side-effects, and most of the contraceptive users are women.
The doctors Newslaundry spoke to deemed condoms as the most simple contraception. But as per the last NFHS report, they are used only by 9.5 percent of people.
Dr Ruchi Tondon, a consultant gynaecologist at Delhi’s Apollo Cradle Royale, said male vasectomy is much simpler than female sterilisation, and that long-term and unsupervised use of contraceptives could trigger medical complications for women. She said that to achieve targets, health workers often do not inform women about the risk.
‘Men think sterilisation will make them weaker’
Rajiv Jha, a family planning consultant at Jaunpur, told Newslaundry there are “misconceptions that male sterilisation will affect the man’s masculinity”.
“They say men have to go out for work and can’t afford to be physically weak. That’s why there is a lot of resistance,” Jha said.
This resonated with the ANM and ASHA workers’ experience with men in the villages of Varanasi. Newslaundry spoke to 18 health workers in the Varanasi division, who asserted that misconceptions and lack of awareness about the effects of sterilisation on health and sex life were major roadblocks to more vasectomies. Some said men also resist because many of them do not know anyone else who has undergone sterilisation.
A health worker at an urban PHC in Varanasi said. “It is difficult to convince a man for sterilisation because of social stigma. During the last ‘Nasbandi Pakhwada’ programme, two men first agreed for a vasectomy, but on the day of the surgery they backed off.”
A majority of men think contraception is a woman’s responsibility, said researcher and policy engagement officer at YP Foundation Abhinav Panday, referring to the findings of his 2017 study on the reasons behind the unequal burden of family planning on women. The study was carried out by the Ministry of Women and Child Development with Panday leading a survey across 15 districts in Uttar Pradesh, Bihar, Madhya Pradesh, Chhattisgarh, and Rajasthan.
“Only two contraceptives are available in the market for men, of which one is condom and another is sterilisation. But for women, there are a lot of options. That is another factor for the unequal burden.”
In 2017, the Ministry of Health and Family Welfare launched two contraceptives: Antara, an injectable contraceptive, and Chhaya, a contraceptive pill. Both for women.
‘Need male family planning counsellors in villages’
The ASHA workers Newslaundry spoke to said that men hesitate to speak to them about the use of contraception and sterilisation.
“We educate both men and women about family planning. Women share their problems and questions with us comfortably as we are from the same locality, but men don’t. Most of the time, they don’t even share their problems with us. They convey their queries through their wives. It causes a communication gap,” said Sarita Chaudhary, an ASHA worker at Nagwa, Varanasi.
“We are asked to also deliver condoms at the door step for Rs 1, but people are shy. Men can’t open up to us because most of them are known to us, we live in the same locality.”
Notably, most healthcare workers, like ANM and ASHA, who are at the forefront of raising awareness about reproductive health and family planning are women.
“Most family planning outreach programs are women-centric and maximum promotional activities are mobilised through ASHA workers, who are female and are able to influence the women. But most times, they can’t instruct or influence men directly to use condoms or for sterilisation. That creates a huge gap,” said researcher Abhinav Panday.
“We need male ASHA workers in our villages. They can make other men aware of issues related to reproductive health, use of contraception, its side-effects, benefits, and family planning,” said Panday.
Initiatives for inclusive family planning
The initiatives to include men as equal partners in family planning are far and few, despite the staggering gap in male and female participation in India’s family planning initiatives.
As per the central government directives, all states hold an annual ‘vasectomy fortnight’ to raise awareness about male sterilisation. Additionally, a person who adopts vasectomy receives Rs 1,500 in comparison to Rs 1,000 given to women who opt for sterilisation. An NGO or private facility that enables male sterilisation also receives Rs 1,300 for each case.
In 2017, the Uttar Pradesh government hiked the financial incentive for female sterilisation to Rs 2,000 and for male sterilisation to Rs 3,000, under the state’s new family planning scheme, ‘Mission Parivar Vikas’. About four years later, the state initiated the ‘Saas-Bahu-Beta Sammelan’ programme in September 2021 to involve both the partners, and the woman’s mother-in-law, in discussions on reproductive health and family planning.
The programme was in furtherance of the centre’s ‘Saas-Bahu Sammelan’, started in November 2016, under which the health workers would educate newly-married women and their mothers-in-law on family planning.
Rajesh Rai, family planning expert at Chandauli district, said that with the introduction of ‘Saas-Bahu-Beta Sammelan’, the onus of family planning is shifting on the district’s men. “Last year the target for male sterilisation was marginally increased to 69. In the year before that it was 47.”
However, Kavita Krishnan, the secretary of All India Progressive Women's Association, told Newslaundry that the governments’ initiatives for family planning were “not enough” and the policies need to be “restructured” with focus on health and not morality or population.
“First of all, we have to see family planning from a health perspective, instead of morality or population control, because when it comes to morality the whole burden is on the female...But male sterilisation has less health impact on the body in comparison to women,” she said. “In rural areas, there are only female health workers, and both male and female are not very comfortable talking to each other about these issues. We are not an open society. Where are the male health workers to motivate men?”
Krishnan said the government has to work on “changing the mentality of the society towards sterilisation, instead of approaching it as a target.”
Newslaundry sent queries to the principal secretary of UP’s medical health and family welfare department, and the state mission director of the national health mission. The report will be updated if a response is received.
Female sterilisation is the most common contraceptive across the world; but India leads in its use, making up 48 percent of the total female sterilisations across the globe. It is followed by countries such as El Salvador, Mexico, Dominican Republic and Nicaragua, as per the United Nations. In contrast, most of the developed countries, such as Finland and Sweden, report corresponding numbers of female and male sterilisations – comprising a small share of their total contraceptive use.
While male sterilisation rates are low across the globe, with only countries such as the UK, Canada, and New Zealand as exceptions, the use of male condoms is fairly common. Across the globe, male condoms are the most popular method of contraception after female sterilisation. Its use has more than doubled worldwide from 4.5 percent in 1994 to 10.0 percent in 2019, however, India is yet to catch up to this trend.
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