Scenario of Sterilisation Camps in Madhya Pradesh: Are Court directives enough to bring an end to the camp approach?

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Even after a year of the landmark judgment by the Supreme Court, (Devika Biswas vs Union of India and Ors.) directing the state governments to put an end to the camp approach for sterilisation, operations still continue unabated in appalling conditions in these camps. Conducting sterilisations camps especially targeting women has been a common practice in the Family Planning Programme in India since decades. Even with standards for procedure of sterilization available since 1989, the focus has remained especially on female sterilisation and on fulfilling targets to control population.

The poor state of affairs in the female sterilisation camps has been time and again brought to fore by different Public Interest Litigations (PIL’s) filed by activists and civil society members, for example a petition by activist Ramakant Rai as part of Health Watch Forum UP Bihar was filed in the Supreme Court in 2003. The judgment for this PIL in 2005 directed all states to adhere to the guidelines of the ministry for such operations. Part of the order also directed to introduce a system of having an approved panel of doctors entitled to carry on sterilization procedures, set up Quality Assurance Committees, collect and publish reports of the number of persons sterilised as well as the number of deaths or complications arising out of the sterilisation and bring into effect an insurance policy to compensate for death of the patient sterilised, in case of post–operative complications.

Following this PIL, new guidelines were formulated and older ones revised[1], and on a positive note the Government also brought in the Family Planning Insurance Scheme in November 2005. The various guidelines provide detailed guide to ensuring standards of quality regarding the place and timings of where the camp must be conducted, number of operations allowed in a day by one surgeon, women’s eligibility criteria, pre-operative counselling and tests and post-operative check-ups and overall care, taking informed consent of the women etc.

Even with multitude guidelines in place, there is continued negligence on part of the states in implementing them in the camps. A glaring example of the utter neglect in camps came to light in Araria district of Bihar where 53 women were sterilised within 2 hours by a single surgeon in unhygienic and dire conditions. After witnessing the horrific negligence in this sterilisation camp, Devika Biswas a social activist filed a PIL on the gross violations in 2012. Even during the hearing of the case, news reports of violation came from the state of Chhattisgarh, where 13 women had died in Bilaspur after undergoing sterilisation operation in a camp, due to neglect in quality of the services provided by the health system. The historic judgment which came on the petition of Biswas in September 2016 was well received as it vociferously highlighted the end to the camp approach within three years and outlined to strictly adhere to guidelines for all procedures.

Conditions in Camps of Madhya Pradesh after the Biswas PIL Judgement

Following the judgment on the Biswas PIL, Maternal Health Rights Campaign (MHRC), a rights based network of more than 50 organisations based in the state of Madhya Pradesh (MP) took the responsibility to observe 35 camps across 11 districts to understand the compliance of guidelines in the camps. As part of this observation exercise, evidence was generated using an observation checklist, by capturing photographs of the ongoing activity and situation, and through conversations with beneficiaries about their experience with the services and facilities they received and behaviour of the healthcare providers. The observations were made during the winter months of December 2016 and January 2017, which fall under the peak season for sterilization. The observation and analysis has been done keeping in alignment with the prescribed standards in the guidelines issues by ministry of health and family welfare (MOHFW).

The observations and statistics from the exercise undertaken by MHRC reveal that even after the directives, the camp approach continues to violate the rights of the women and camps continue to be conducted in poor conditions.

Timing and Information Regarding the Procedures:

Women were brought in groups to the camps during morning hours, were made to wait for long hours before the arrival of the doctors. The arrival time of the doctors was unknown in many camps and reason quoted for the same was scarcity of human resource. Due to the late arrival of doctors and their determination to complete their workload of ‘reaching the target’, the operations took place outside of the prescribed hours which is from 9 am to 5pm as mentioned in the guidelines set by the MOHFW. In around 18 camps out of 35, the prescribed timing was not followed and some operations went on till as late as 11.30 in the night, indicating the importance given to

Number of Procedures

As per the guidelines, for maintaining quality services, each surgeon should restrict to conducting a maximum of 30 procedures a day spread across 8 hours (9am- 5pm) with the availability of 2 laproscopes. The findings however highlight contrary observations as only 9 camps followed this criteria. Even in these 9 camps, the number of procedures were conducted between 25 minutes to 2 hour 30 mins, which is otherwise recommended to be spread during the 8 hours allotted time, therefore raising questions on the quality maintained during the procedure. Doing excess procedures is strictly prohibited by the Supreme Court yet they were carried on, in some of the camps around 60-80 women underwent the procedure in a single day. It was also reported that in one of the camps, officials entered only enough names so as to not go beyond the cap, and other names were entered on other dates or not entered at all indicating a malpractice. This purposeful act can complicate the lives of the woman for future reference in case of complications or failure and also provides a false database.

Pre-Operative Procedures

Counselling, voluntary consent and undergoing tests before the procedure are a pre -requisite as per the guidelines. Every woman has a right to receiving all the required information about the procedure and also about the consequences in order to make an informed decision. The observations from the camps highlight that there were no rooms for counselling ensuring confidentiality as only in 11camps out of 35, women were given information on other contraceptive methods, only in 9 women were explained about the ill effects and complications post sterilization and in 8 camps were told about management and compensation in case of complication, failure or death. In regard to taking informed consent, in 25 camps, no woman were read to or explained about the content of the consent forms, and women were made to sign them without them knowing what was written on in. Similarly, a set of mandatory tests like blood, urine, blood pressure, weight and abdomen check-up are to be done before the surgery which will ensure the eligibility for the procedure. Considering the status of anaemia among women in MP, not conducting a blood test and also a pregnancy test before the procedure puts the woman at great risk often leading to complications and sometimes even death.

Makeshift OTs

The guidelines state no sterilisation procedure can be conducted in a non-functional OT, but this mandate was overlooked and 5 out of 35 camps had makeshift OTs in the hall of the hospitals. Also the rooms had no privacy, it was flooded with the women being operated on, women waiting for their turn along with relative and doctors. Another practice observed was the use of cycle pumps in 11 camps to inflate the abdomen, which is a gross violation of the standards of care which have previously been reiterated in court judgments.

 Post-Operative Procedure

The sterilisation procedure ends with ensuring that women are not going through complications, immediately after the procedure and months after it. While long term follow up was not part of this exercise, the immediate care and follow up by the nurses and doctors was not be seen in the camps. On the contrary, due to inadequate beds, women had to sleep on the floor, only 4 camps provided mattress and a blanket, considering that it was winter months, no effort was made to feel women feel warm and comfortable. Even at the time of discharge when adequate information needs to be given about care and follow up, it was observed that in around 20 camps women were not checked for recovery and stability by the doctor or a nurse until 4 hours nor were they given information on follow up and care before discharge.

Conclusion

The overall scenario of the camps through observations made by MHRC, suggests a dismal picture. Not even a single camp qualified following the standards and procedures. These are just 35 camps which have shown the gruesome reality, however the findings from these observations are enough to understand the commitment of the state to improve women’s reproductive health. As the judgement completes one year, the Government still does not have a plan to end the current approach. Though the government has introduced the Mission Parivar Vikas to ensure that services reach out to every couple, quality of care in each of the services remain a matter of concern. It is thus important to discuss the pathways of the current programme and a commitment from the state to learn from the past experiences and come up with strategies which will ensure informed decision making by women, remove social barriers to bring men to the forefront to take equal or even greater responsibility in using contraception, focus on the highest attainable quality of care in delivering all contraceptive method with special attention to spacing methods, steadfast action to bring an end to all camps and most importantly on this run ensuring women’s empowerment to decide for their own reproductive health, care and fertility. Without such deliberation and an increasing demand to limit fertility, women’s health and life will continue to be at risk.

[1] All family planning related guidelines can be found on ministry’s website – http://nhm.gov.in/nhm/nrhm/guidelines/nrhm-guidelines/family-planning-guidelines.html