From the Field to the Judge’s Bench: Developing Litigation Strategies to Improve the Lives of Women
24th – 25th November 2012 Assam Association A-14 B Qutab Institutional Area, New Delhi
IN COLLABORATION WITH
HEALTHWATCH FORUM – BIHAR INITIATIVE FOR HEALTH AND EQUITY IN SOCIETY WOMEN’S ASSOCIATION MARCHING AHEAD MANASI SWASTHYA SANSTHAN ALL INDIA DRUG ACTIONNETWORK JANADHIKAR MANCH - BIHAR
From the Field to the Judge’s Bench: Developing Litigation Strategies to Improve the Lives of Women
IN COLLABORATION WITH
HEALTHWATCH FORUM – BIHAR INITIATIVE FOR HEALTH AND EQUITY IN SOCIETY WOMEN’S ASSOCIATION MARCHING AHEAD MANASI SWASTHYA SANSTHAN ALL INDIA DRUG ACTIONNETWORK JANADHIKAR MANCH - BIHAR
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• To protect fundamental human rights, increase access to basic resources for marginalized communities, and eliminate discrimination.
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• To professionally train a new generation of public interest lawyers and paralegals to be comfortable in the world of law as well as in social movements and to learn from such movements to refine legal concepts and strategies.
FROM THE FIELD TO THE JUDGE’S BENCH: DEVELOPING LITIGATION STRATEGIES TO IMPROVE THE LIVES OF WOMEN January 2013
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Table of Contents
Introduction……………………………………………………………………………………………………………………………...1
Welcome Address……………………………………………………………………………………………………………………...2
Access to Sexual Health Education: Helping Youth Exercise their Rights………………………………………3
National Entitlements: There is No Benefit if There is No Implementation…………………………………...6
Access to Contraception: Supporting Women to Achieve the Highest Standard of Sexual and Reproductive Health………………………………………………………………………………………………………………..11
Skilled Birth Attendants in the Field: How a Shortage in Human Resources and Training Jeopardizes Women’s Maternal Health……………………………………………………………………………………..16
Child Marriage: Protecting the Rights and Lives of India’s Children……………………………………………18
Hysterectomies: Insurance Fraud and Reproductive Rights………………………………………………………23
Status of Family Planning in India………………………………………...... 27
Experiences from the Field: Francis Elliot’s Personal Recount………………………………………………...... 29
Devika Biswas vs. Union of India and Ors.: Female Sterilization in India………………………………………30
Female Sterilization in India: A State by State Recount from Uttar Pradesh, Rajsathan, Odisha, Madhya Pradesh, and New Delhi…………………………….………………………………………………………………..34
List of Participants………………………………………………………………………………………………………………...... 47
Introduction
Over two days, activists and advocates gathered to discuss some of the most pressing reproductive rights issues in India. Activist presented on a wide range of topics ranging from child marriage to sexual health education to female sterilization all with the aim to determine how these reproductive rights violations can be advanced through public interest interventions. Our purpose was to bring grassroots level activists, policy experts, and advocates together to bridge the gap between activists in the field and advocates in the courtroom. In this way, together, we can promote reproductive rights as human rights.
Reproductive rights violations in India are fomented and compounded by cultural, religious, and societal contexts. Any approach to address reproductive rights violations in India must be committed, crosscutting, and collaborative. There is no silver bullet to right these wrongs, just like there is also no panacean, hierarchical, or methodical method of bringing an end to them either. Instead, a comprehensive, multi-faceted approach to advocacy is necessary. This approach must embrace field level activism and litigation, policy advocacy and demonstrations; all efforts undertaken as pieces of a bigger, cohesive, picture to eradicate the ills of rampant reproductive rights violations.
Reproductive Rights in India
The 1994 Cairo International Conference on Population and Development (ICPD) defines reproductive rights as follows:
Reproductive Rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right of all to make decisions concerning reproduction free of discrimination, coercion and violence.1
In India today, women young and old are victims of one of the highest maternal mortality rates in the world, coercive population control policies, forced sterilization, a lack of comprehensive sexual health education, limited information regarding contraception, inadequate access to contraception, and persistent child marriages. All of these issues continue compromising the lives of millions of women, female adolescents, and girl children in violation of their reproductive rights.
The following paragraphs provide a short background on each reproductive rights issue discussed during our National Consultation. Following each issue is a summary of the information presented and the recommended ways forward.
1 Chapter VII, Reproductive Rights and Reproductive Health, International Conference on Population and 1 Welcome Address
Sonali Regmi, Center for Reproductive Rights (CRR)
Ms. Regmi presented on the work of her organization, the CRR. The CRR is an international NGO based in the United States, which has been working on reproductive rights for 20 years. The organization recently opened regional offices in Latin America, Africa, Europe, and Asia. Ms. Regmi is based at the Asian regional office, which is based in Kathmandu. Ms. Regmi began her presentation by stating that as reproductive rights are not fully recognized as human rights, the CRR works to connect reproductive rights to the larger human rights framework. She told the participants that there is a clear link to the right to life and the right to health but that reproductive rights also engage a myriad of other rights. She also stated that reproductive rights are inherently connected to women’s rights and that the CRR uses international standards such as the ICPD and the Beijing Declaration to promote women’s rights in the area of reproductive health law.
Ms. Regmi told the participants that the CRR focuses on reducing maternal mortality, increasing access to contraception, improving access to safe and affordable abortions, and, more recently, preventing harmful traditional practices including child marriage. Ms Regmi shared that the CRR is now focusing on child marriage, as there is a link between this practice and maternal deaths. She told the participants that CRR felt it was essential to begin working against child marriage, as when people are married at a young age, they generally do not know their rights. This means that young married people often have limited access to contraception and are unaware of their right to decide on number and spacing of children which in turn leads to greater maternal mortality.
The strategies employed by the CRR include litigation, amicus briefs, and advocacy before treaty committees. The CRR focuses on advocacy at both a national and international level by taking litigation to national courts but also appalling to international treaty monitoring bodies which offer an extra forum if domestic remedies fail to create change. Ms. Regmi told the participants that the CRR also works on policy reforms and initiatives where lacunas exist in reproductive rights.
Finally, Ms. Regmi shared that the CRR also conducts training for lawyers and judges to sensitize them to reproductive rights issues and the human rights framework. She told the participants that training helps ensure more comprehensive and supportive orders from the courts. She stated that they have spent ten years working with judges in Nepal, which has led to good judgments, such as the 2009 Lakshmi judgment. This case concerned a women who was pregnant for the fifth time and who wanted an abortion. Abortion is legal in Nepal but the women and her husband could not afford the 1,200 rupees that they were quoted at the public hospital for the procedure. She therefore had to continue her pregnancy against her will. In their judgment, the court utilized a reproductive rights framework and held that access to abortion was a constitutional right and directed that the government formulate a separate, rights based law for abortion. Ms. Regmi highlighted that this was a very good judgment, but stated that implementation was poor and that no law had so far been created. In order to combat this, the CRR had begun working with national human rights institutions in order to ensure implementation of judgments. In this case Ms. Regmi stated that the CRR was working with the National Women’s Commission in Nepal to produce a draft bill. She shared that working with such groups can often make it easier to get the legislation through for enactment.
2 Access to Sexual Health Education
Background Information
In its report on adolescent and youth development for the formulation of India’s 12th Five Year Plan, the Working Group on Adolescents and Youth Development listed the following as one of its objectives: “g) Facilitate access to all sections of youth to basic nutrition and health especially related to reproductive and sexual health information and facilities and services …”2 This is a not a new sentiment. The Working Group for the 11th Five Year Plan made a similar recommendation and stressed that a lack of information on sexual and reproductive health leads to early and unwanted pregnancies, the spread of HIV, sexually transmitted infections (STIs), and Reproductive Tract Infections (RTIs). The Working Group noted that although “adolescents want sexuality education,” there is “resistance from adults in the family and community,” adding that even teachers “feel inhibited to discuss issues related to sexuality and reproductive health.”3
The Ministry of Human Resource Development in collaboration with the National AIDS Control Organization developed the Adolescent Education Programme (AEP), a sexual health education curriculum. Although the drafters envisioned AEP as a nation-wide curriculum, several states including Rajasthan, Chhattisgarh, Madhya Pradesh, and Uttar Pradesh have rejected the AEP curriculum arguing that it leads to devious and harmful sexual activities. In addition to being banned in several states, several important NGOs criticized the AEP for being out of touch with the youth of today. The AEP suffered from serious flaws and focused on “abstinence only until marriage,” as a means of avoiding unplanned/early pregnancies, HIV, RTIs, and STIs.
An improved, comprehensive, sexual health education is essential to preventing early/unplanned pregnancies, the spread of HIV, RTIs, STDs, and to ensuring that women achieve the highest standard of sexual and reproductive health. Legal advocacy to pressure the Government to a) work with NGOs on developing a new and improved curriculum and b) implementing it on a national scale can be effective and will improve the lives of women in India.
Information Presented
Gopika Bashi, The YP Foundation (TYPF)
Representing TYPF, Projects Manager Ms. Gopika Bashi presented on TYPF’s work and aims. TYPF is a youth-run and led organization with partnerships in 18 Indian states. TYPF works to promote, protect, and advance young people’s health and human rights through youth-led leadership building, strengthening, and initiatives. Their target age groups are 5-9, 10-14, 15-19, and 20-25 (following the United Nations definition of youth). TYPF focuses on working with young people both in and out of school and collaborates with young people from lower income communities and youth from the disabled, LGBT, children of sex workers, living with HIV, and who have been orphaned, abandoned or live in government care.
2 Report of Working Group on Adolescents and Youth Development, Dept. Of Youth Affairs, M/o YA&S for Formulation of the 12th Five Year Plan (2012-2017), Ministry of Youth Affairs & Sports, 2011, p. 68. 3 Draft Final Report of the Working Group on Youth Affairs and Adolescents’ Development for Formulation of 11th Five Year Plan (2007-2012), p. 12. 3 Promoting Artist Rights & Livelihood Opportunities
Mental Health Digital Media, and Substance IT and Abuse Learning prevention.
Young People working with their Communities
Education Sexual and (Life Schools & Reproductive Formal Education) & Health and Health Rights (Hygiene & Sanitation)
Governance & Democracy (RTE & RTI)
Ms. Bashi noted the lack of knowledge on how to involve young people in policy making and national programmes and sees a need to create safe spaces for young people to communicate directly with decision makers. To strengthen youth leadership, TYPF engages youth in a constant dialogue on issues including child marriage, unsafe abortion, gender discrimination, HIV/AIDS, and a lack of youth-friendly health services. TYPF’s programme objectives between 2011-2013 include increasing young people’s understanding and awareness of their Sexual and Reproductive Health Rights (SRHR), advocating for the implementation of comprehensive sexual education (CSE) in Uttar Pradesh, National Capital Region, and Maharashtra, and mentoring 50 youth leaders to enable the implementation of CSE at the district level. To this end, partnership is vital to the campaign’s successful implementation.
Ms. Bashi’s presentation also highlighted the youth friendly monitoring and evaluation framework that TYPF employs. Additionally, Ms. Bashi shared several complimentary policy responses to TYPF’s approach to CSE promotion. These have included structuring the HIV Prevention for Youth and Adolescents Programme, serving on UNESCOs Global Advisory Group for Sexuality Education, producing data that is being used in a pilot to strengthen school mechanisms and train teachers in 12 zones of Delhi, and creating adolescent strategies to ensure CSE for out of school youth in UNFPA’s Country Programme 8.
TYPF has faced several challenges in implementing its organizational objectives. These include that a) it has multiple partners, which can make forward movement time consuming, b) its monitoring and evaluation process needs to work for young people and also create credible evidence from the field, c) its approach is a novel process for government agencies, which can take time to build trust, and d) its entry points for advocacy change constantly, requiring consistent monitoring and constant building of new relationships.
Dipa Nag Chowdhury, MacArthur Foundation
Ms. Nag Chowdhury spoke on the reality of policy and policy making in New Delhi. For example, policy makers in the capitol are unwilling to deal with child marriage. In states where child marriage is endemic, Ms. Nag Chowdhury stressed that advocacy is as important as law. As girls get married, they need specialized services that do not necessarily or always fall under women’s services. This is especially detrimental to women who depend on comprehensive health services in their teen and mature ages. Ensuring sexual health education is an important way of providing
4 young people, especially young girls, with the skills and tools to protect themselves and give them a happier, safer, and healthier life, particularly as regards to HIV/AIDS.
Shocking instances of gang rape of children can be used to highlight the need for and push for greater sexual health education. To this end, government services and education must complement each other. Ms. Nag Chowdhury also noted that even in states where sexual health education is being taught, it is not being taught well.
Senior Advocate Colin Gonsalves
Acting as facilitator and moderator, Mr. Gonsalves asked who amongst our participants saw the potential for a PIL in the presentation on access to sexual health education. One woman recognized that a PIL could be filed to make CSE compulsory in school. Another woman shared that often teachers feel uncomfortable teaching sexual health education to their students. She recommended a PIL that includes a request for a centre where students can speak to social workers and psychologists that offer sexual health counselling for children and parents. One man noted that developing a PIL first requires significant ‘homework’. He shared that female biology teachers are uncomfortable teaching male students about their reproductive systems and instead avoid the subject. Therefore, before a PIL can be filed, CSE and CSE instructors must be sensitised. Judges in particular must be sensitised. Another woman was of the opinion that sexual health education needs to happen within the sphere of the family: if parents are given the resources to teach their children about sexual health, there is no need for it to be taught outside of the home. Finally, one woman shared about the need for counselling of children who have suffered sexual violence.
Recommended Ways Forward
The ban on sexual health education is the starting point for a PIL. While it is in place, it is arbitrary, discriminatory, and unconstitutional because it deprives the young people of India with education necessary for them to lead a healthy life. (Constitution of India: Right to life, Article 21). Mr. Gonsalves agreed that the ‘backward cultural angle’ must be handled sensitively. Mr. Gonsalves also suggested that to start a PIL, we must develop a sample to show what sexual health education means and what it comprises. In order to do so, Mr. Gonsalves counselled, we must look at successful international examples. He also stressed that there must be a coalition of groups backing the PIL. He agreed that caution must be taken to avoid filing a PIL that reaches farther than judges are willing to go sharing that perhaps there should be an attempt to reach out to and educate judges before a PIL is filed.
Issue PIL Status Complimentary Advocacy Partners Strategies
Sexual Health • Background • Sensitization • HRLN Education gathering workshops • The YP • Coalition • Youth Awareness Foundation building Raising • MacArthur • Drafting workshops Foundation
5 National Entitlements
Background Information
As last recorded, India’s Maternal Mortality Rate (MMR) is 212 deaths for every 100,000 live births. According to the United Nations Population Fund, as of 2010, one third of all maternal deaths in the world take place in India and Nigeria alone, 14% and 20% respectively. In order to address its high MMR, the Indian government developed several national benefit and incentive schemes to promote maternal health vis a vis institutional deliveries and ante- and post-natal care. Notwithstanding, these schemes have had moderate success due in large part to their lack of implementation. The following is a short description of some of the national entitlements available to pregnant and lactating women in India.
National Rural Health Mission (NRHM)
The National Rural Health Mission (NRHM) was launched to strengthen public health systems in rural areas. NRHM’s aim is to provide effective health care to India’s rural population with a special focus on states that have poor public health indicators and/or weak infrastructure.
Through NRHM, state governments are provided central government funds to improve the state’s public healthcare systems. In this way, states bear the responsibility of identifying and assisting their most broken district public healthcare systems.
Janani Shishu Suraksha Karyakram (JSSK)
JSSK is a scheme developed under NRHM. The scheme ensures free services to pregnant women including cashless delivery at a government centre, caesarean section if needed, medicines, drugs and consumables, diagnostics facilities including ultrasound, provision of blood units without payment of testing charges, exemption from all user charges and free diet during the stay at the facility (three days in case of normal delivery and seven days in case of a caesarean section) and free transportation home.
Janani Suraksha Yojana (JSY)
NRHM launched the JSY scheme to promote institutional delivery and to reduce neo-natal mortality. The JSY scheme entails specific guidelines for health care during pregnancy:
The scheme provides financial assistance to Below Poverty Line (BPL), Scheduled Caste (SC), and Scheduled Tribe (ST) pregnant women who obtain antenatal care, undergo institutionalized delivery, and seek postpartum care.
Under the JSY scheme, ASHAs are assigned to every village to serve as a link between the pregnant woman and governmetn schemes and facilities. The ASHA’s responsibilities include:
• Identifying pregnant women as a beneficiaries of the schemes and reporting or facilitating registration for ante-natal care (ANC); • Providing and/or helping women receive at least three ANC checkups including Tetanus injections and Iron Folic Acid tablets;
6 • Preparing a micro birth plan; • Identifying a functional government health center or an accredited private health institution for referral and delivery, immediately upon registration; • Counseling women for institutional delivery; • Escorting the beneficiary woman to the pre-determined health center and staying with her until she is discharged; • Arranging to immunize the newborn until the age of 14 weeks; • Informing the Auxilary Nurse Midwife (ANM)/Medical Officer (MO) about the birth or death of the child or mother; • Performing a post-natal visit within 7 days of delivery to track the mother’s health; • Counseling for initiation of breast-feeding to the newborn within one-month of delivery and its continuance until 3-6 months and promoting family planning; and • Facilitating the payment of financial assistance immediately following the delivery.
Additionally, the JSY scheme ensures that BPL women receive Rs. 500 for home delivery.
National Maternity Benefit Scheme (NMBS)
NMBS is a social assistance scheme meant to provide financial assistance to pregnant BPL women. The beneficiary woman must be a permanent resident of a village and the entitlement is valid up to any number of births. NMBS is the result of a 2001 Supreme Court order in PUCL vs. Union of India and Ors., (Writ (Civil) Petition No. 196 of 2001). Under NMBS:
• All BPL pregnant women should be paid Rs. 500, 8–12 weeks prior to delivery for each of the first two births; and • The benefit under NMBS must be paid irrespective of place of delivery and age.
The Supreme Court has said that the JSY and NMBS schemes are distinct and that women should have access to benefits under both schemes. In reality, unfortunately, they are interpreted as the same scheme and women usually only receive money under JSY.
Information Presented
Javid Chowdhury, Former Secretary of Health, Ministry of Health and Family Welfare
Mr. Chowdhury began by saying that there is no explicit right to health and no statutory right for anyone who wishes to access health rights in India. The Constitution covers the Right to Equality, Right to Public Discrimination, and Right to Life, but there is no explicit right to health.
Mr. Chowdhury shared that the Indian government had recently introduced a draft National Health Act, which sought to reduce the requirements for approaching the Appeals Courts through PILs. However, this effort proved ineffective because the Act tried to a) provide everything to everyone, which achieves nothing, and b) centralize the powers, which are state-bound. Therefore, a reasonable National Health Act should be formed through which citizens can approach subordinate authorities for implementation.
7 Mr. Chowdhury also suggested several issues to file a PIL on that could have far-reaching impacts. These included: • Great Deficiency of Statistical Data: o As Health Minister, when malaria cases were on the increase, Mr. Chowdhury struggled to ensure that the Ministry reported the true number of malaria cases. The clerk in the Ministry insisted that there be no variation in the figures for the same, so the official data indicated that deaths due to malaria were less than 1,000 even though the actual figure had gone up to several thousands. The honest thing for the Indian government to do in such cases is to accept that it does not have the appropriate and accurate statistics. o One great service NGOs have accomplished is that they have pushed for better statistics and demographic information via PILs. For example, if a PIL were raised on this issue to higher courts, these would in turn raise the issue to the government. There is no statistical base in the country and it is important to insist on one. Our national statistical organizations are some of the best in the world but unfortunately, this is not true where public health records are concerned. • Dismal Infrastructure in Health Care: o The underlying reason for this issue is a lack of resources, which is substantial and extremely damaging. Mr. Chowdhury called for PILs to be filed asking the government to allocate more resources in public health facilities. o Resources per capita for primary health care are approximated at Rs. 204 per health care facility. Under the current situation, it is impossible to ensure a person’s right to life through accessible, adequate health care.
The recent Supreme Court intervention in the Mid-Day Meal Scheme was important and helpful, but Mr. Chowdhury stressed that it is also important to interact and provide health education in rural areas. NRHM has been moderately successful, he admitted, because it has attempted to interact with villager and because, when NRHM provisions have not been implemented, PILs have been filed to ensure they are implemented. Unfortunately, through the years, important suggestions have not been implemented. The Planning Commission recently convened and issued an important report on the subject. For example, the Planning Commission recommended that 70% of health care resources be allocated for primary health care. This would ensure that 90% of health problems are dealt with at the primary level. Mr. Chowdhury urged legal activists to support the report.
NRHM called for a reduction in the gap between strong and weak states, but a review after six years of implementation shows that this has not been effective. Mr. Chowdhury suggested that PILs be filed to redirect more money to weaker areas.
Mr. Chowdhury noted that there is a tendency in the Indian government to demarcate NGO activities from government activities and stressed that it is time to do away with that.
Finally, Mr. Chowdhury re-focused on public health stating that although diseases like malaria can be treated symptomatically, this approach is not taken. Moreover, drugs should be made available free of cost to poorer sections of the society in order to increase the outreach of health services. Mr. Chowdhury stressed the necessity of public health access and proper implementation of corresponding schemes.
8
Jashodhara Das Gupta, SAHAYOG
Mrs. Das Gupta began by referring to a chapter in the Planning Commission Committee Report, which dealt with citizen engagement. In the past 7-8 years, she reported, many laws have been framed for uplifting the poor, including those targeting health, education, employment, and women’s rights. These laws have only been possible due to Jan Andolan i.e., People’s Movements.
The Movement for Food has been growing strong and many schemes including JSY and JSSK have been created to give entitlements to the poor. Had their intended beneficiaries actually accessed these entitlements, the Right to Food Commission, for example, would have proved more successful in its last 11 years of implementation. In many cases, complimentary successful judgments have also been issued. Nevertheless, the challenge of implementation still remains. According to Mrs. Das Gupta, there are two elements of implementation:
1. Making a facility available to the court: This would require infrastructure, resources, manpower, etc. Most recently, in the Planning Commission, a budget was created for providing universal health in the next few years. 2. Accountability: Even after obtaining judgments that are in favour of the public, if there is no accountability, judgments are ineffective.
Mrs. Das Gupta explored the meaning of accountability saying that it has two essential elements. The first is a hierarchical system for managerial accountability. Here, reporting to a higher authority is necessary. It is mandatory that a budget be made to account for expenses. However, this is not the kind of accountability Mrs. Das Gupta referred to. Instead, she wanted to talk about social accountability, which has more to do with the relationship between the implementers of these schemes and their intended beneficiaries. Mrs. Das Gupta shared that her last 26 years of experience in Uttar Pradesh with adivasis, Dalits, and other marginalized communities made her realize that India’s schemes system shows an unequal power struggle between the implementers and the beneficiaries. For example, remote areas do not benefit from these schemes because there is no parity in their implementation. Poor villagers do not know whom to approach if they want to obtain a BPL card or a Dalit certificate. Under JSY, pregnant women are told they will receive Rs. 2,400 if they deliver in public hospitals. Yet, once they go to public hospitals, they are treated roughly and rudely turned away.
Mrs. Das Gupta stressed that to file a PIL, we must make sure that we have the support of the People’s Movement. It is of no use to press for a change through litigation without their support. Women in poorer areas are not satisfied with the family planning schemes. Entitlements are available, but they do not reach the poor. Under JSSK, everything from transport, treatment, and post-operative checks are meant to be free of cost. Additionally, women are meant to receive Rs. 2,400 for institutional delivery under JSY. Instead, a recent survey reveals that women end up spending around Rs. 1,277 during their pregnancy and delivery. It is necessary, then, for people to claim the benefits to which they are entitled. If people remain unaware of these schemes, they are of no use. Mrs. Das Gupta noted that lawyers must form relationships with villagers with the help of the People’s Movement and NGOs working on these issues.
9 Mrs. Das Gupta concluded her remarks stating that judgments are of no use if they are limited to paper. Instead, we must all work together to ensure that these judgments reach their intended beneficiaries.
Advocate Shamik Naraian:
Mr. Naraian stressed that we need to be vigilant and make sure that the implementation of these schemes is being continuously measured. Advocates and NGOs should also work collaboratively to make sure positive judgments are implemented.
Recommended Ways Forward
Issue PIL Status Complimentary Advocacy Partners Strategies
Non-Implementation • Background • Monitoring • SAHAYOG of National gathering Committees to Entitlements • Coalition building oversee • Fact Finding implementation • Drafting • Impose fines on non-participating public health facilities
10 Access to Contraception
Background Information
Access to contraception in India is an essential element to improving women’s health. Nevertheless, Frederika Meijer, India’s representative to the United Nations Population Fund, recently revealed that the estimated number of women without access to contraceptives in India sits at 28 million, which accounts for 10% of the world’s unmet need. If access to contraceptives was provided to Indian women, Ms. Meijer noted, “unintended pregnancies would drop by two third[s] and…[it] would save [the] lives of thousands of women and newborns.” Nevertheless, according to the Annual Health Survey, “at least one-fifth of CMW [currently married women] are yet to meet their family planning requirement…”
Young women are also implicated in India’s unmet need. UNICEF recently reported that with 243 million adolescents, India has the highest number of adolescents in the world.4 A 2011 report revealed that condom use is staggeringly low among adolescents who engage in premarital sex; only an alarming 27% of young men have ever used a condom and just 7% of young women have used a condom.5
Information Presented
Dipika Jain, Professor Jindal School of Law, Centre for Health Law, Ethics and Technology (CHLET)
Ms. Jain shared that her organization, Centre for Health Law, Ethics and Technology (CHLET) has recently undertaken an evidence-based research project because she “ wanted to know what's going on in the field rather than depend entirely on theoretical data." CHLET began collecting data for its study in September 2012 by visiting 5 districts in Haryana to investigate women’s access to contraceptives. The study’s findings could then be used to gauge the availability of and access to contraceptives in Haryana districts and for a possible PIL on the issue.
Ms. Jain shared the following background information to provide context to the issue. There are 14 different varieties of contraceptives available in India, of which 10 have been scientifically declared 'effective'. The national list of essential medicines includes hormonal contraceptives, condoms, and copper-T. CHLET’s study was concerned with whether or not the medicines listed on the national list of effective medicines are readily available in hospitals and whether married women are aware of them. If they are, CHLET questioned why women do not avail themselves of them or know to avail themselves of them, CHLET wondered whether women failed to seek access to contraceptives because of socio-cultural barriers or whether there are other reasons.
Ms. Jain reported that 29% of India’s MMR could be prevented if women had access to safe, effective contraceptives. Unfortunately, of the budget assigned to procurement and dissemination of contraceptives in India for 2012, about 68.75% was left unused. This led CHLET to conclude
4 UNICEF defines adolescents as those who are between the ages of 10 and 19. 5 K.G. Santhya, et. Al., Condom Use Before Marriage and Its Correlates: Evidence from India, International Perspectives on Sexual and Reproductive Health Vol. 37, No. 4, Guttmacher Institute, 2011. 11 that although the Indian government has sufficient resources to provide better access to contraception, these resources are being wasted.
Of CHLET’s findings, Ms. Jain presented only a “microcosm” of the study that is indicative of the study’s overall findings. The study focused on women, doctors, and ASHA workers. In the District of Sonipat, for example, Ms. Jain found that the civil hospitals she visited open and close erratically, at times only staying open for 2 hours at a time. Moreover, ASHA workers do not work in the reproductive or obstetric departments but instead confine their work to the hospital’s pharmacies. Moreover, the counseling on 'reproductive health' these hospitals provide rarely goes beyond HIV prevention. When the study group attempted to access medicines from the hospital’s pharmacies, the team was told that that contraceptive pills and medicines meant for free distribution were actually being sold. Moreover, the contraceptives were past their expiry date.
The team found a general shyness about contraception and reproductive health. No one the group spoke with knew about female condoms though most had an idea about male condoms and copper-Ts, which were the most common method of contraception used. The team also found that many people were reluctant to go to government hospitals because they were “mistreated” or kicked out. Instead, people preferred going to private clinics.
The group next visited colleges in the district to talk to unmarried women. The group found that 78% of them think that contraception is an issue of health rather than of sexuality. Although over 78% of them had some knowledge about contraceptives, most of them knew nothing about government entitlements in this regard. Of note, 98% of the girls the group spoke to said that there are some cultural or social barriers that prevent them from being upfront or frank about reproductive health or from approaching people for guidance or assistance in matters pertaining to the same. When asked how the girls knew of contraception methods, they responded: 44% from TV programs, 22% through friends and/or peers, and 5.5% (one girl) through books.
The group asked each hospital it visited what forms of contraception it made available. The study revealed that 87% of the hospitals had copper-Ts while only a few had birth control pills. None of the hospitals in the study gave birth control pills on prescription. Instead, they provided them over the counter. The group also found that none of the staff the group spoke to knew of injectable contraceptives. CHLET noted that this was especially surprising since, as observed in Nepal, Thailand, and other countries, injectable contraceptives are one of the most effective and hassle- free methods of contraception.
On speaking with healthcare workers, most stated that sterilization is the most effective method of contraception. They noted that it is widely recommended and extensively administered. When asked if they provided family counseling, the replies were mixed. Many healthcare staff workers do offer family planning counseling. Some, however, expressed that they are too shy to counsel patients and only give family counseling to fellow women. The staff asserted that they always take a woman’s consent before administering female sterilization. However, some personal accounts testify to the contrary. Female sterilization is the most common method of contraception in India and very few people know about female condoms as an alternative although they are non- permanent and inexpensive. Ms. Jain commented that most women prefer not to use contraceptives until they have had a son. Nevertheless, most women claimed they wanted to space their deliveries illustrating that there is a certain level of awareness about family planning.
12
Kalpana Mehta, Manasi Swasthya Sansthan
Ms. Mehta shared that in India, contraceptives were intended neither for health purposes nor sexual reasons, but simply for population control. The singular reason behind the whole initiative was to curb births. Since their introduction in India, drastic population control measures have been adopted including having men aged 16 to 60 forcefully sterilized.
Ms. Mehta questioned how a health mission, referring to NRHM, is expected to succeed when many people still lack basic food, nutrition, and sanitation provisions. So that distributing contraceptives to people without improving their standards of health is tantamount to spreading morbidity.
Ms. Mehta spoke of a memo, released in 1969, that revealed how given the current mortality rates, a couple needs to have at least six children to be sure that a single surviving son will survive into adulthood. Around this same time, technology for detecting the gender of the fetus, also known as amneocentisis, was developed. The government endorsed the practice, the idea being that it would give people the option of having a son and therefore limit reproduction. This would in turn reduce India’s birth rate and reign in India's population explosion. In other words, “[couples would have] a son without the unecessary reproduction of females.” According to Ms. Mehta, in the year after amniocentesis was introduced, 800 abortions were performed. She reported that of these, 799 were of female fetusus; one of the fetusus was actually a male fetus that was mistaken for a female fetus.
Ms. Mehta recalls that birth rates did initially decline. However, the sex ratio also declined. The sex ratio, she noted, is now so disturbingly skewed that in certain villages of Haryana, girls are kidnapped and brought from states like Kerala to become brides of Haryana men because there simply are not enough females left Haryana. Nevertheless, it took 10 years for the Indian government to develop any kind of law to address the issue of sex-selective abortion. Even today, with a law on the books, implementation remains a distant dream. Ms. Mehta shared that in her hometown, where sex-selection is a prolific trade, there has only been one case in which the Pre- Conception Pre-Natal Diagnotic Technologies Act (PCPNDT) has been implemented. In the case, six doctors who had been running an illicit ultrasound clinic were each fined Rs. 1,000 for violating the law.
Ms. Mehta spoke of how women who were provided with oral birth control pills as part of family planning in India would throw them into their fields because apparently the hormones in them facilitate robust plant growth. Ms. Mehta shared that birth control pills have been shown to slow down the libido, drastically increase the chances of all forms of cancer, cause blood pressure issues, and give rise to potentially lethal blood clots. Dependence on pills, she commented, encourages the spread of STDs and HIV/AIDS. She questioned: “why would men use condoms when a woman is already on the pill? What couple in their right mind would go for double contraception?”
Birth control pills market themselves as being 98% effective. Condoms hover around 80% effective. Although birth control pills are more effective than other forms of non-permanent contraception, because they are taken continously over a long period of time, sometimes from the onset of puberty to menopause, their adverse effects ought to be researched and taken very
13 seriously. In fact, some research has already been done. Ironically, however, this research is usually carried out by the very same drug manufactures that manufacture and market birth control pills.
Recently, the drug industry discovered that estrogen is the root cause of many of the side-effects associated with birth control pills. In 2002, the government of India assured the public that it would cease to allow the sale of birth control pills with such damaging hormones under the National Family Planning Scheme. Instead, the government began using contraceptive injections. These injectible contraceptives, however, carry more than 10 times as many hormones as contraceptive pills.
Ms. Mehta noted that injectible contraceptives are by and large provider-controlled. For example, a doctor may inject a woman who visits a hospital for other, non-reproductive health purposes. With birth control pills, however, a woman always has the option to throw them away if she would rather not take them. Injecting women with contraceptives means that reproducitve rights are being curtailed instead of being safeguarded.
Ms. Mehta noted that there is a certain level of coercion in the government's vehement patronage of drug companies and their products. The American government, together with the American corporate sector, is interested in maintaining a wide market for its products to ensure a hefty accumulation of profit. It is because of this push for profit that American drugs are so conspicuous in the market. What is more, the Indian government tries to hide the drugs’ negative side effects to keep women in the dark about the risks. Ms. Mehta recalls once comparing an Indian and American brand of the same generic birth control pill and finding that the Indian packaging had 19 listed side-effects where the American packaging listed 47 side-effects.
Ms. Mehta stressed that we need to understand the entity we are locking horns with because the authorities we need to fight in our battle for the protection and promotion of reproductive rights do not just include the Indian government.
On a personal note, Ms. Mehta shared that she found it “absurdly anticlimactic” when people talk of India’s “unmet needs of contraception.” She asked “What do we understand as 'needs'?” Especially in light of millions of people who lack access to food and potable water. She questioned how we can expect these same people to use government grants for contraceptive injections that cost upwards of Rs. 1,500. Ms. Mehta also shared that she resents the popular correlation made between contraception use and maternal mortality rates. Ms. Mehta commented, “women who die during childbirth, who go into labor in pithy environs outside of proper clinics, who do not receive proper aid and support during the process of child birth, they do not die for unwanted children. These women nearly always wanted the child they died delivering. Having handed them contraceptives would not have necessarily saved their life, when they after all, wanted to have a child.” Maternal mortality, Ms. Mehta suggested, is to be addressed using greater, more systematic measures and safeguards. To link it to access to contraception is tantamount to trivilalizing the whole issue.
14 Senior Advocate Colin Gonsalves, HRLN
Mr. Gonsalves began by outlining the issues needing the most attention saying, “firstly we need to talk about unmet needs,” stressing that in many areas poor men and women are seeking contraceptives but cannot access them. Next, Mr. Gonsalves underscored the need to discuss dangerous forms of contraception and the availability of contraception over the counter without the need of a prescription.
Mr. Gonsalves shared that only recently, HRLN had a case on drug prices in which the Supreme Court said that the government has to bring 348 essential medicines under price control ordering it to follow the 1995 cost-based method of price control. Currently, the drug market in India produces anywhere between a 200% and 800% profit.
Recommended Ways Forward
Issue PIL Status Complimentary Advocacy Partners Strategies
Access to • Background • Regulating the • HRLN Contraception gathering dispensing of • Dipika Jain - • Coalition building birth control pills Jindal Global • Fact Finding (i.e., only University • Drafting available with • Centre for Health prescription) Law, Ethics and • Research and Technology highlight • Kalpana Mehta – negative side- Manasi Swasthya effects of Sansthan contraceptives
15 Skilled Birth Attendants in the Field
Background Information
The status of skilled birth attendants in India is illustrative of the government’s disservice to the women of this country. A lack of human resources, training, and compensation leaves skilled birth attendants disenfranchised and ill-equipped to handle the medical needs of pregnant women the country over. A skilled birth attendant without proper training or compensation is a skilled birth attendant without agency or accountability. This is a dangerous combination, especially where the health of women and children are at stake. If India is to achieve its Millennium Development Goal on maternal mortality, it must invest in the proper sourcing, training, and compensation of skilled birth attendants.
Information Presented
Dr. Prakasamma, ANSWERS
Dr. Prakasamma presented on how an acute shortage and lack of patronage affect the quality of care women and their children receive. Dr. Prakasamma began by highlighting the recent governmental push for institutional delivery and explaining that of all pregnancies, only 15% result in complications. The push for institutional delivery was based on evidence showing that the presence of skilled birth attendants at the time of delivery reduced maternal mortality as did the availability of essential obstetric services provided to women near their home. Skilled birth attendants are accredited health professionals (e.g., midwives, doctors, nurses, and ANMS) who have been educated and trained to proficiency in skills necessary to manage uncomplicated pregnancies, deliveries, and post-natal care as well as in the identification, management, and referral of complications in women and newborns. This categorization does not include dais or ASHAs.
The current situation in the field sees an acute shortage at all levels of staffing, extremely unhygienic facilities, evidence of harmful practices, and anecdotal evidence of abuse. At the community level, a single ANM can optimally cater to 100 births per year. In practice, this number is so great that a single ANM is unable meet the needs of the women in her community. Moreover, even when a majority of women access institutions for health care, continuity of care requires a full time and dedicated provider. A continuity of care requires 7-10 antenatal check-ups, education on and preparation for delivery, at least one interaction with an obstetrician, and coordination for delivery. Moreover, comprehensive care requires coordinating with an ASHA, arranging for transport, receiving the required JSY payment, postnatal care and follow-up checkups at home. In the months following delivery, a mother and child also require panoply of services including immunizations, growth monitoring, infant illness treatment, contraceptive support for the mother, and infant and maternal nutrition and vitamin supplements.
According to a recent survey, India has more than 200,000 ANMS in the public health system, with most ANMs posted in sub-centres. However, there has been a steady decline in the number of facilities and the skill level and readiness of ANMs. In fact, ANMs are now becoming a rare sight in far-flung villages. In order to properly care for pregnant women and newborn children, India needs a minimum of 250,000 skilled ANMs providing services, following up with patients, and
16 documenting their services. More importantly, India needs ANMs that are dedicated and skilled maternal and child health providers, not multi-purpose providers.
A lack of ANMs and skilled birth attendants means that the health of pregnant women and newborn children is unnecessarily placed at risk. A low availability of facilities and providers means that infection prevention measures are ignored, facilities are poorly organized for routine deliveries and unprepared for complicated deliveries, and that patients are victimized by unsensitized staff. On a micro-level, this also means that many facilities operate under very unhygienic circumstances without disinfection practices, sterile labor sets, gloves or even hand- washing protocols. Dr. Prakasamma stressed that labour rooms, especially, should be as emergency-prepared as intensive care units (ICUs) stocked with adequate supplies of emergency drugs and equipment, blood supplies and blood storage units, and staffed with skilled personnel who are able to handle emergency situations.
The Indian government recently implemented a training program. However, the program, which lasted only two weeks, has been slow moving, ad hoc, and ineffective. Notably, the program did not incorporate a sensitization element. It is a lack of sensitization that spurs the neglect and physical and emotional abuse of women at public health facilities.
Advocate Sandhya Raju, HRLN
Advocate Raju stressed that there needs to be a strengthening of ASHAs in the field through training, skills building, and capacity building. Most importantly, skilled birth attendants must learn to be accountable for their training and the services they provide. Government hospitals, too, must ensure basic hygienic environments for their patients. To provide anything less gives rise to a strong PIL. Infrastructure must be bolstered in India’s public health facilities so that facilities adhere to NRHM and Indian Public Health Standards (IPHS) and provide all of the essential mandated services. Advocate Raju also stressed that public health facilities need to be held accountable for all of the funds and resources they receive, especially in light of the services they fail to provide.
Recommended Ways Forward
Issue PIL Status Complimentary Advocacy Partners Strategies
Shortage of Skilled • Background • Sensitization • HRLN Birth Attendants in gathering training of public • Dr. Prakasamma - the Field/Poor • Coalition building health facility ANSWERS Labour Rooms • Fact Finding staff • Drafting • Auditing of public health facility labour rooms
17 Child Marriage
Background Information
According to UNICEF, 47% of girls in India are married by age 18 and 18% of girls are married by age 15.6 Experts agree that child marriage contributes to poor health indicators, lower levels of education, high rates of maternal and infant mortality, and increased HIV infection rates. Data shows that girls between the ages of 15 and 19 are twice as likely as girls between the ages of 20 and 24 to die of pregnancy related complications.7
Child marriage persists in the face of the Prohibition of Child Marriage Act (2006). Tradition, honor, gender inequality, security, and socio economic instability perpetuate child marriage. Moreover, the government has done little to ensure implementation of the Prohibition of Child Marriage Act, including posting Child Marriage Prohibition Officers. In fact, tracking data between the first National Family Health Survey and its most recent iteration, there has been little difference in the percentage of women, age 20-24 who were married between the ages of 15 and 20 (NFHS-1, 45%, NFHS-2, 44%, and NFHS-3, 46%).8
Child marriage affects all women in India and especially those who are too young to advocate for their rights.
Information Presented
Dinesh Sharma, Rural Development Society and Vocational Training Organization (RUDSOVOT)
Mr. Sharma shared the experiences of his organization, the Rural Development Society and Vocational Training Organization (RUDSOVOT), during a three-year project in Sawai Madhopur, Rajasthan. RUDSOVOT conducted research on child marriage in five districts and 31 villages. RUDSOVOT selected the Sawai Madhopur area as Rajasthan has the second highest rate of child marriage in India; 82% of women in the State are married before they reach 18. In Sawai Madhopur, the average ages of marriage are 18.3 for men and 14.9 for women.
RUDSOVOT conducted their research through household surveys and through focus group discussions. Mr. Sharma also stressed the importance of advocacy and awareness campaigning during the project. In this vein, RUDSOVOT held meetings with key decision makers in children’s lives including parents, village heads, and schoolteachers. RUDSOVOT also held advocacy meetings and workshops and reached out to five local NGOs and several government departments to further spread awareness of the project. Furthermore, RUDSOVOT opened Youth Information Centres and Youth Groups to educate adolescents on child marriage. They also initiated a peer education programme where they trained selected girls and boys in the district so that they in turn could educate their peers. The project also led to the creation of immunization camps to vaccinate children with DT and TT injections. Finally, RUDSOVOT released a magazine called Yuva Ankur, which incorporated personal stories of problems faced by young adults.
6 UNICEF Statistics, India, 2010. 7 Pregnant Adolescents: Delivering on Global Promises of Hope, The World Health Organization, 2006. 8 National Family Health Survey (NFHS-3) 2005-2006, Ministry of Health and Family Welfare, p. 35. 18
Mr. Sharma shared the information gathered using social mapping in the project area. The social map showed that girls living the districts covered were rarely educated. Although there are accessible government schools in the area, girls are not being sent to school. When local people were asked about this, they said there was no point in educating their girls because, after marriage, the girls will be unable to financially help their parents. RUDSOVOT also spoke to girls in the region who were working in traditional roles including cattle or sheepherders or as helpers on their parent’s fields. When asked why they were not attending school, the girls answered that their parents tell them that they should take on the role of looking after the animals to allow their brothers to attend school. Soon after this investigation, RUDSOVOT opened night schools to allow girls who work during the day to attend school.
Mr. Sharma then shared his views on how to help eradicate child marriage. First, the government must promote a delay in the age of marriage. Second, we must create an environment that encourages a delay the age of a woman’s first pregnancy. Third, we must ensure that there is interactive and effective policy analysis and review of child marriage. Fourth, documentation of appropriate intervention designs must be guaranteed. Fifth, there must be education for young people on family, sexual, and reproductive health. Finally, Mr. Sharma stressed the importance of ensuring and enhancing youth participation in these projects.
Mr. Sharma shared some thoughts on the situation in the field as well as photos of recent child marriages. When asked about child marriage, he reported, people often say that since child marriages have been taking place for generations, the tradition cannot be stopped now. They also stress that generally, the bride remains with her family after marriage until she has matured. He also highlighted some new problems where the number of girls has decreased so much due to families choosing to have male children that parents in other areas have begun to take lakhs of money to send their daughters far away to be married. In some villages, all the brothers in a family will marry a single girl, sometimes with the proviso that the girl need not do any housework.
Mr. Sharma closed by sharing his sadness when he receives records from the peer educators trained by RUDSOVOT’s project of the children who are still getting married in the villages. Despite the District Collectors efforts, and due in part to the corruption of the police, not a single marriage in the area has been officially prevented.
Govind Beniwal, Member of Rajasthan Commission for Protection of Child Rights
Mr. Beniwal focused his presentation on the structural issues of child marriages, He said, “I feel it is important to look at it from the child rights perspective as well as the domestic rights perspective. I feel that most people think of domestic rights as limited to marital discords but this is not true. Domestic rights also include the treatment of children in a family.” As such, Mr. Beniwal explained, child marriage is an issue that falls under domestic rights.
To address this issue, the Indian Government passed the Prohibition of Child Marriage Act, 2006 (PCM). The law has four distinct aspects: Prevention, Protection, Rehabilitation, and Prosecution of offenders. In India, Mr. Beniwal explained, the Prevention aspect is the one that receives the most attention. Mr. Beniwal stressed that we must realize that the children who have already been married off also need care. Especially as many married children seek to annul their marriages. The
19 PCM Act has a provision that addresses this issue, Mr. Beniwal explained, but because of inadequate implementation, activists are not able to work on it. A second issue with the PCM Act is the lack of clarity in the role of stakeholders. The Act gives power to SGMs as stakeholders and mandates the appointment of Child Marriage Prevention Officers (CMPOs), but this power is frustratingly vague. Mr. Beniwal noted that India already has an Integrated Child Protection Scheme (ICPS), and stressed that officers appointed under that scheme should also be given agency under the PCM. Additionally, rehabilitation is unfortunately not given much importance.
Although India may sometimes be successful in preventing child marriages, the aftermath of existing child marriage also needs attention. As India does not ensure protection of married children under its Domestic Violence Act, 2005, Mr. Beniwal urged India to link India’s Protection of Children from Sexual Offence Act with the PCM Act to better protect children from child marriage, especially female children whose consent is not required under the age of 18.
Turning to what states can do to curb child marriages, Mr. Beniwal underscored that states provide no legal support to child marriage victims who wish to annul their marriage or receive counseling. Most girls want to get out of their marriages but do not know how to legally do so. Once a child marriage occurs, the child’s rights are consecutively violated and the child is deprived of many rights including his or her right to education. After marriage, children remain unaware of how to protect themselves from sexually transmitted diseases and infections (STDs and STIs) so that their right to health is also made vulnerable. Because many child marriages are never registered, it is difficult to really tackle the issue.
Mr. Beniwal shared that in Bundi District, Rajasthan, which sees a high number of child marriages every year, the infant mortality rate (IMR) is similarly very high. Mr. Beniwal urged that we focus on human trafficking, which has been on the rise in the current year. Most cases involve men over 50 years of age paying families an undisclosed figure to marry their minor daughters. This has been happening more frequently in the past few decades, a result of extreme poverty. Mr. Beniwal shared that only the previous day he had heard of a case where seven child marriages were scheduled to take place.
Mr. Beniwal pointed to the well-known case of Bhanwari Devi, who was gang raped by five men after she stopped the marriage of a child. This fear of retribution is another reason why people do not come forward to stop child marriages. To support whistle-blowers and child marriage activists, the Indian Government should declare monetary awards to whoever comes forward with a complaint of an impending child marriage. Additionally, we must focus on the prosecution of those who violate the PCM Act. In Rajasthan, only four offenders have been prosecuted since the Act was passed and all four cases have occurred only this year.
In response to criticism, supporters of child marriage claim that children consent to being married. This consent, however, is obtained illegally and under duress rendering the marriage invalid. Mr. Beniwal stressed that until we look at this issue from the child rights perspective, we will be unable to successfully implement the PCM Act. We need to develop appropriate mechanisms, monitoring systems, and rehabilitation systems in order to improve the condition of young child brides.
20 Advocate Anant Kumar Asthana, New Delhi
Mr. Asthana discussed the conflict between the rights of children and young people’s right to choose, particularly in light of the enactment of the new Protection of Children from Sexual Harassment Act. The age of consent has been rendered immaterial and this has caused a crisis because courts have been very consistent in acknowledging 16 years of age as the age of consent. Accordingly, if there is an allegation of rape due to sexual relations between young people below the age of 18 and if the girl states that she consented, state high courts can quash any First Instance report (FIR) filed against the accused. Due to this recent legislation, any sexual activity between people below the age of 18 is heavily punished and the accused can be booked under any of the Act’s five offences.
The issue, however, is much more complicated. The Delhi High Court has recently issued a comprehensive three-bench judgment based on the judgments of four previous cases: Lajja Devi (2008), Mahadev (2008), Devender (2010) and Laxmi Devi (2011). These cases each involved a minor girl who exercised her right to choice and married a man who was an adult. The consequences of these cases are very complicated. Under Hindu Law, the husband is the guardian. Therefore, if the marriage is lawful, how must one deal with the question of custody? The Delhi High Court judgments give a clue as to how Parliament has created contradictory laws. For example, a husband can rape his own wife without any legal consequence if the wife is above the age of 16. It is only if the wife is 15 years or younger that Section 375 of the Indian Penal Code (IPC) is enacted.
The Delhi High Court judgment also mentions that there is a lack of sexual education provided to young people, which means that young brides lack adequate knowledge about sexual relations, their bodies, and their reproductive systems. This denies girls the ability to make informed decisions about their sexual relations, family planning choices, and their health. This ultimately results in the girl leading a life over which she has no control.
Mr. Asthana explained that when we deal with child marriage, important human rights principles we uphold are pitted against each other. How, then, can we link the principles of reproductive rights with those of children’s rights?
Mr. Asthana next discussed India’s personal law. The Delhi High Court has recently declared that if a Muslim girl below the age of 15 decides to exercise her right to be with a man who is an adult, she may do so. “What then is the scope of secular law?” Mr. Asthana stressed. “Which law will prevail?” Mr. Asthana shared that there is no consistency in the application of these laws; sometimes it is secular law that prevails, while other times personal law prevails.
Mr. Asthana urged audience members to read the Criminal Miscellaneous Application No. 11101001 of 2011, saying, “on the second page, you will find Writ Petition Criminal No. 338 of 2008,” a 62-page long judgment that includes the four cases he had previously cited. The cases reveal that the High Court suggests that an Amendment of Section 375 of the IPC is required. In fact, the High Court has asked Parliament to amend that section and to examine several acts including the PMC Act and the Hindu Marriage Act to reach a clear position on the law. Mr. Asthana stressed that this must be done so that individuals know which options they can exercise. Moreover, a person should know if he/she will be prosecuted for opting to exercise or not exercise a given option. For example, the PMC Act does not say that marriage between minors is illegal. Yet
21 it simultaneously provides punishment for the same. Thus, we need to have in-depth dialogues about the glaring contradictions in these important laws and provisions.
Recommended Ways Forward
Issue PIL Status Complimentary Advocacy Partners Strategies
Child Marriage • Background • Sensitization • HRLN gathering training • RUDSOVOT • Coalition building • Comprehensive • Rajasthan • Drafting rehabilitation Commission for services to youth Protection of • Incentive/ Child Rights Support • Advocate Anant programmes for Asthana families with unmarried girls/boys
22 Hysterectomies
Background Information
Although technically, a hysterectomy refers to the removal of a woman’s uterus, doctors also perform the surgery to remove any portion of a woman’s reproductive organs. A hysterectomy requires invasive surgery under general anesthesia. Methods of hysterectomy include: abdominal; vaginal; werthium (a radical hysterectomy that includes the removal of a woman’s womb, uterus, cervix, upper part of the vagina, lymph nodes, fallopian tubes, peritoneium, and ovaries); oorphoractomy (removal of one or both ovaries); salpingotomy (removal of the fallopian tubes); and caesarian. Each of these methods involves varying post-surgical symptoms as well as post- surgical health risks ranging from fatigue and bleeding to developing cancer.
The reasons most commonly cited for a hysterectomy include fibroids, uterine health problems, uterus prolapse, pervasive infections, and cancer. It is often after a woman complains of abdominal pain, brought on by multiple pregnancies, early childbearing, and malnutrition, that a doctor recommends a hysterectomy to alleviate the pain. Like any invasive surgery, hysterectomies require extensive pre-surgery counseling, testing, and care.
Most recently, media reported an unnatural spike in hysterectomies performed at Rashtriya Swasthya Bima Yojna (RSBY) empaneled health facilities in Chhattisgarh. According to records, over the last two and a half years, doctors performed more than 7,000 hysterectomies in Chhattisgarh. Other sources quote a number closer to 50,000. More often than not, doctors and private hospitals target SC, ST, and BPL women.
Private hospitals in Chhattisgarh have reaped as much as 2 crore rupees performing hysterectomies under the RSBY scheme, which provides heavily subsidized health care coverage to BPLs. The scheme’s schedule of fees reimburses doctors depending on the method of hysterectomy. Data from journalists and activists indicates that a few private hospitals near Raipur District performed the bulk of hysterectomies in the state.
Dorpradi, who lives in Dongatarai Village, Raipur District and had a hysterectomy in 2011 at a private facility empanelled under Chhattisgarh’s RSBY scheme
23
The situation of women in Chhattisgarh is not unique, as large-scale unnecessary hysterectomies have also been reported in Odisha and Rajasthan. It is important that we appreciate the unchallenged and continued violation of these women’s basic human rights.
Information Presented
Dr. Narendra Gupta, PRAYAS
Dr. Gupta presented a joint study between PRAYAS and JSA on women’s experiences with hysterectomies in Dausa District, Rajasthan. A hysterectomy requires the surgical removal of a woman’s uterus and prevents the women from conceiving in the future. There are several methods to perform a hysterectomy and these include vaginal and abdominal. A woman may seek a hysterectomy for several reasons including uterine prolapse, cancer of the uterus, cervix or ovaries, abdominal vaginal bleeding, chronic pelvic pain, and endometriosis.
In April 2011, several national and regional newspapers reported that around 226 women from Dausa District had had their uteruses removed at private nursing homes/hospitals after seeking treatment for severe abdominal pain and menstrual irregularities. Several civil society groups conducted an investigative mission shortly after these figures were reported. These groups filed a Right to Information (RTI) application to get a list of all of the women in the Dousa District who had received a hysterectomy. The groups then met with 16 of these women and documented their accounts. Dr. Gupta presented these accounts, some of which are shared below:
• Gulab w/o Ram Avtar, age unknown, mother of three: o Had her fallopian tubes litigated at a sterilization camp 10 years before; o Has experienced abdominal and general body pain the past 6 years; o Initially sought treatment at government hospital in Jaipur; o After she was referred to Manhur Hospital, a private hospital in Banikui, the doctor advised a sonography and informed Gulab that her uterus had to be removed because “it had swollen and there was danger of cancer happening later on.” Gulab underwent a hysterectomy a few days later; o Gulab stayed in the hospital 7 days and was charged Rs. 20,000. • Sunita w/o Ram Khiladii, mother of three: o Was sterilized after the birth of her third child; o Has experienced abdominal pain and an irregular menstrual cycle since she was sterilized; o In 2011, sought the services of a doctor at Madan Hospital in Banikui. The doctor advised her to get a sonography and later told Sunita that her “uterus has been decaying and required to be removed.” Dr. Madan urged her to have the surgery immediately and “didn’t give [Sunita] any time to think.” Sunita underwent her hysterectomy that same day; o Was discharged 7 days later, charged Rs. 20,000, and told to get medicine costing between Rs. 1,000 and 1,500 for post-operative care; o To this day, she suffers from abdominal pain and general weakness.
24 Dr. Gupta stressed that a hysterectomy is usually considered only after all other treatment approaches have been tried without success. However, in all of the cases he documented, no pre- surgery treatment was given and women were not given either enough information or time to make an informed decision regarding their reproductive rights. The testimonies of most of the women interviewed revealed that most hysterectomies were performed in private hospitals. The pattern of events usually involved a visit to a private hospital, a sonography, and a doctor’s strong medical advice to have a hysterectomy citing emergency circumstances. Neither the pain these women complained of nor their irregular cycles were ever investigated.
Bhupendra Pareek, Independent Health Activist
Dr. Pareek presented on a RTI he filed on hysterectomies in Dausa District, Rajasthan and subsequent investigations into their prevalence there. He began by sharing that the entire process began when it was reported that in one village in Dausa, almost every women had had her uterus surgically removed. These women reportedly suffered from many problems including vomiting, dizziness, and other similar grievances.
As a result of this report, Dr. Pareek filed an RTI application to find out how many operations had been performed in the district’s five hospitals and how many of these operations had been related to any problem with the uterus. The RTI revealed that 90% of the women who had undergone operations in the district had had their uteruses removed. Moreover, doctors justified these hysterectomies by citing their worries about the women’s health.
Dr. Pareek shared that the RTI revealed that even where women reported to the hospitals with simple cases of stomach ache or back pains, doctors claimed that the women could have cancer and that, if not operated on immediately, they could be in danger of dying. In these cases a thumbprint was taken for consent and the women were rushed into surgery. He highlighted that women were charged between Rs. 5,000 and 15,000 for the operation. Dr. Pareek also shared that three private hospitals had particularly high numbers of hysterectomies. In one example, data revealed that of the 30 operations performed at the private institution Vijay Hospital in April 2012, 27 of them had been hysterectomies.
As a result of this information, a fact-finding team, which included HRLN activists, travelled to Dausa district to look into the matter. The team found that even women who had not yet had children reported having had their uteruses removed. Dr. Pareek told that the team approached the District Collector and asked him to organize an investigation into why everyone went to private hospitals and whether the doctors at these hospitals had the training and skills to perform hysterectomies. This request led to the creation of a district level committee committed to monitoring the situation.
Dr. Pareek stated that he was not happy with the committee and its findings. While the committee report revealed that there was only one government anaesthetist who covered all the private hospitals, Dr. Pareek claimed that the committee was subject to outside influence and failed to admit to any wrongly performed operations. In addition, the report erroneously concluded that the government did not have control over the functioning of private hospitals.
25 Dr. Pareek then turned to the status of the Clinical Establishment Act, which has been approved in draft form but has not yet been implemented. No enquiries have been made about the activities of private hospitals and the government will not cancel their registration. A PIL regarding this is currently being filed.
Dr. Pareek also discussed the need for a finished version of the Clinical Establishment Act. The fact-finding team found that government hospitals lack sufficient medical officers. In particular, a lack of anaesthetists leads to people going to private hospitals for treatment. There is also a lack of female doctors at every hospital level. This information has been published in newspapers nationwide and on television in Rajasthan, but nothing has been done to improve the situation. Dr. Pareek highlighted again that the committee’s report was subject to outside influence and that, therefore, its claims that the doctors had not performed any unnecessary procedures and that 52 out of 58 women were satisfied with their operation cannot be taken at face value. He also shared that the six women who reported dissatisfaction had complained that they still suffered from the original symptoms that had led them to seek medical advice in the first place. Moreover, they reported that they only agreed to the operation after their doctors had scared them by telling them they were at risk of dying from cancer if they did not opt for surgical intervention.
Dr. Pareek shared that despite meetings with both the Chief Minister and the State Minister for Health and public assurances that a committee would be formed to look into why such unnecessary operations were being carried out over one year ago, no such committee has been formed. He said that activists’ attempts to raise the issue in the media led to district doctors claiming that there was a conspiracy against them and subsequently going on a two-day strike.
Dr. Pareek then drew attention to the PCPNDT Act, which is effective against private practitioners because it allows for charges against individual doctors. If a charge is brought under the PCPNDT Act, the State Medical Council will suspend the doctor’s license to practice within 30 days. Dr. Pareek argued that this shows that government legislation can be effective against private practitioners who commit medical/ethical violations. Dr. Pareek stressed that there is an urgent need for a functioning Clinical Establishment Act in order to hold private hospitals accountable for their actions.
Recommended Ways Forward
Issue PIL Status Complimentary Advocacy Partners Strategies
Unnecessary • Will be filed in • Monitoring of • HRLN Hysterectomies January 2012 RSBY scheme • Dr. Narendra • Coalition building hysterectomy Gupta – PRAYAS claims • Dr. Bhupendra Pareek
26 Family Planning in India
Dr. Abhijit Das, Centre for Health and Social Justice
Before delving into the subject of family planning and female sterilization in India, Dr. Das asked the audience how many believed that population is a pressing concern in India. After fewer than 10 hands were raised, Dr. Das noted that if he polled the general public he would likely find thousands, if not lakhs, of people who believe that population is a genuine concern in India.
Before acknowledging population as a problem, Dr. Das probed, “we first need to analyze why we consider it one. Do we believe that population in our country has started touching explosive magnitudes? Do we believe that the population of our country has risen so much that it poses a mortal threat to the environment, and that the news about global warming that we encounter every now and then- that population explosion has a direct bearing on that? Is it the infrastructure in our cities that makes us think so?” Dr. Das pointed to the roads in Delhi that are so overburdened it takes an unnaturally long amount of time to traverse relatively short distances.
Dr. Das pointed to myriad worries centered on the issue of population and stressed that it is important to put them to rest. If we look at the statistics, Dr. Das cautioned, we get a different take on the population “explosion.” Population growth has been decreasing over the past few decades. India’s population has been growing at progressively slower and slower rates. Why then does the number of people only seem to be growing? Dr. Das offered that the reason the overall population is expanding in number is because the number of childbearing women is rising.
In previous generations, Dr. Das explained, the population grew because the number of children per household was higher. That same group of children is today reaching its childbearing age. Looking at current statistics, the number of childbearing women is “colossal.” If in previous generations there were 100 childbearing women for each 1,000 people in India, today that number is closer to 200.
Changing Demographics
2010
1990
27 Dr. Das next turned to a frequently quoted adage that India adds the equivalent of Australia’s population to itself each year. The majority of population explosion related issues are due in part to the fact that this “explosion” is happening among the poor. That is, the number of children born to India’s poor population is growing disproportionately as compared to birthrates amongst middle and upper class Indians.
Dr. Das drew attention to the fact that if we look at a graph of annual increase, the overall production of edibles and economic turnout in India is increasing at a much faster pace than its population. However, the number of destitute people in India is also expanding at a rapid rate. This, Dr. Das underscored, points to the increasing disparity between the rich and the poor in India. Even if the total amount of resources is increasing, these are all being concentrated in India’s upper-class population.
Dr. Das next addressed the advocates present saying “it is important to understand what the issue actually is… we need to be clear as to what the issue is that we seek to address.” Dr. Das pointed to the landmark case of Jahada vs. Union of India, where the Supreme Court could not ascertain what the ‘greatest issue in contemporary India´ is – whether population or poverty.
It was Paul Lenning’s who first proposed the idea of a moribund population bomb in the 1960s after he landed in Delhi and drove through Connaught Place. He commented on how he could ‘see nothing but a deluge of people in each direction’ - a great mass of humanity, a great mass of poverty. Dr. Das stressed that Mr. Lenning’s issue seemed to be more with the poverty he witnessed than with population explosion per se. At any point in time there is much more of a crowd in New York’s Time Square than at the New Delhi Railway Station. However, the Times Square crowd would not leave Mr. Lenning very unsettled.
Dr. Das offered that the obvious answer to why India has a population explosion is that people do not have any economic facility – there is no occasion for them to earn a livelihood in the villages and they are therefore drawn to the cities. These same cities, however, have no infrastructure to accommodate the masses of people who migrate there – there is no sanitation, housing or transportation system that can adequately accommodate them.
Dr. Das explained that population explosion has become shorthand for describing a much more complex and multifaceted issue. If a person produces more resources and contributes more to the world than what he or she consumes, then his existence cannot be a burden on the world. If we contribute to the world more than we consume – be it by intellectual, physical or other means - then we, Dr. Das asserted, are an asset to the world, not a burden.
Dr. Das highlighted that the problem originates with a general lack of education saying, “in order to bring our productivity to the prime, a crucial required investment is education. It is the government’s responsibility to provide education. Unfortunately, it has slowly been veering away from this crucial responsibility and instead placing a greater priority on healthcare. We, as Indians, Dr. Das explained, have gotten into the habit of viewing the poor as an issue, a problem, rather than working productively towards their benefit. The problem really is, Dr. Das underscored, India’s inequity of distribution; some people in our nation have far too much while others have too little. This is especially egregious in Bihar, Rajasthan, Madhya Pradesh, and Uttar Pradesh. Dr. Das concluded by expressing that litigation should be used as a method of last resort after policy initiatives and grassroots level advocacy have failed to create positive change.
28 Experiences from the Field: Francis Elliot’s Personal Recount
Francis Elliot, The Times UK
Mr. Elliott began with the story of how he came to be newsgathering in a village in Bihar. He had read an article in The Hindu written by Mr. Shoumojit Banerjee, that to him, seemed to establish beyond a doubt that something extraordinarily ghastly, but well documented, had happened in this village. Mr. Elliot explained that, generally, journalists often have problems finding the evidence for such stories. This story, however, seemed to him to be solid and well founded.
He explained that he first met Ms. Devika Biswas after Ms. Leena Uppal from the National Coalition Against Two Child Norm and Population Control Policies put him in touch with her. Ms. Biswas volunteered to help him visit the female sterilization camp, which had happened in her home area of Araria. Mr. Elliot recalled that there was some resistance to having a journalist along with a fact- finding team and that at one point he was told he could not go.
Once reaching Patna, Mr. Elliot met with Ms. Biswas who introduced him to Mr. Lande, the Superintendent of Police at Patna. Mr. Elliot noted that the story would not have been possible without the involvement of Mr. Lande because it was the people’s confidence in Mr. Lande that lead them to share details of the camp with him.
After meeting with Mr. Lande, Mr. Elliot and Ms. Devika visited the village where all the women from the sterilization camp and locals showed them the school and classrooms where the camp took place. A total of 150 local people met with Mr. Elliot and Ms. Biswas. Of these, they were able to interview 15 women who had been sterilized. Although none of the women said they had been coerced into the surgery, none of them had been offered pre-operative counseling. The only thing the women had been offered before their surgery was painkillers, which, Mr. Elliot and Ms. Devika discovered, had all been out of date.
Mr. Elliot shared the story of Jitni Devi who was told she was pregnant while she was undergoing her surgery and subsequently miscarried. After the PIL was filed, the state denied that she had been pregnant and claimed that she had made it up in return for incentives offered by the fact- finding team. In fact, Jitni Devi had shared her story of her own volition and had been offered no incentives. The state also claimed that because its own investigative team could not find Jitni Devi to corroborate her story, her story was invalid. Mr. Elliot stressed that he would be happy to testify as to the voluntariness of the information Jitni Devi and the other women shared with the fact-finding team. He also shared that there were other women with terrible stories including that some of them had actually woken up during their procedure.
The fact-finding team next visited the nearby medical office of a doctor who had issued a report on the camp saying that it was properly conducted. When asked why she had issued such a patently false report, Mr. Elliot noted that the doctor lacked any control over the their meeting. In fact, there were many men in senior positions responding to his questions without the doctor’s input. Mr. Elliot had previously learned that these same senior officials were under severe pressure to meet their female sterilization targets. This information was especially important, Mr. Elliot stressed, because Bihar claimed that this had been a “one-off” incident. Mr. Elliot, however, was wary of this claim.
29 The state of Bihar has been, and is still being, praised by international organizations including the World Health Organization (WHO) for its use of Public Private Partnerships (PPPs) in the healthcare sector. This situation, accordingly, was very embarrassing for the state as it showed the failings of the very policy for which it was being praised. The evidence collected by the superintendent included CDs of previous camps that had been conducted by the same NGO that conducted the one Mr. Elliot investigated. Records also showed that the NGO was claiming payment for sterilizations that were never carried out.
Mr. Elliot also shared information that he was not able to corroborate and, therefore, could not print. One such allegation was that that there was some link between the NGOs that had had approval to carry out such camps and senior Bihar politicians. Additionally, there were allegations that NGOs were lying about the number of operations they conducted. Mr. Elliot noted the allegation’s probable truth since NGOs claimed twice as many female sterilizations than had the state government.
Finally, Mr. Elliot urged that journalists and field workers should be more organized and focused in collecting evidence for the courts alongside promoting their news gathering/activist activities. Moreover, there should be more use of smartphones to record statements and footage – video footage was key in this case as it provides both immediate coverage and strong evidence in a legal case.
30 Female Sterilization
Background Information
In India, ‘family planning’ is used as a euphemism for female sterilization. According to the most recent District Household Survey of 2008, only 54% of the population surveyed used contraceptives. Female sterilization accounted for a shocking 34% of the contraceptive methods used.9 Data from the 2005-2006 National Family Health Survey of 2005-2006 revealed that permanent birth control through female sterilization comprises about 75% of all modern sterilization use for married women age 15-49. 10 In fact, the three modern spacing methods (birth control pills, intra-uterine devices, condoms) only account for 10% of all contraceptives. Although governments deny a sterilization target, the number of women participating in daily or weekly family planning camps remains high and a spike in numbers is most evident in February and March when sterilization targets are due. Moreover, both field workers who recruit women for sterilization and women who undergo sterilization receive cash incentive payments for agreeing to the surgery.
Female Sterilisation in India 6000000 120
5000000 100
4000000 80
3000000 60 % Ster
Total No of Cases 2000000 40 F Ster
1000000 20
0 0
Robbing women of their right to decide the number and spacing of their children and to protect their body is indicative of the poor state of reproductive rights in India and underscores the need for stronger civil society engagement, innovative legal advocacy, and ultimately sweeping change.
9 District Level Household and Facility Survey (DLHS-3) 2007-2008, Ministry of Health and Family Welfare Government of India, p. v. 10 National Family Health Survey (NFHS-3) 2005-2006, Ministry of Health and Family Welfare, p. 8. 31
Information Presented
Devika Biswas, HealthWatch Forum, Bihar and Advocate Jayshree Satpute, HRLN
Ms. Biswas and Ms. Satpute presented on a case before the Supreme Court on female sterilization in Bihar and throughout India. The facts of the case are reported below.
On the night of 7th of January 2012, in the space of two hours, the Government of India sponsored the sterilization of fifty-three women in a Government Middle School building in the state of Bihar. All of the women come from marginalised groups (Below the Poverty Line (BPL), scheduled castes, or other backward castes.) A single surgeon carried out all fifty-three sterilisations in just two hours with the help of only a handful of medically unqualified NGO staff. The operations were carried out at night, with only one generator-powered lamp and a few torches to illuminate the classroom cum operating theatre. The doctor used classroom desks as operating tables and after each surgery; the untrained NGO workers laid the women on straw strewn on the ground. The women did not receive medical assistance or post-operative care. Meanwhile, the surgeon, Dr. Chowdhary, immediately left the premises.
While she was lying on the operating table in semi-consciousness, Dr. Chowdhary told Jitni Devi that she was three months pregnant. He told her that her current pregnancy would be her last, but Jitni Devi subsequently miscarried 18 days after the procedure. Another woman, Rehka Devi, was operated on despite the fact that she was conscious and suffering from severe pain. As a result of these sterilisations, three women were left bleeding profusely and one woman, Saraswati Devi had to be admitted to a hospital for 8 days following the procedure.
In 2005, in the case of Ramakant Rai vs. Union of India and Ors. (Writ Petition (Civil) 209 of 2003), the Supreme Court directed States to follow minimum standards when conducting sterilisation procedures. The Court also directed states to set up Quality Assurance Committees to ensure the implementation of these guidelines. To comply with these directives, the Central Government of India issued standards for sterilisation services in 2006. The standards mandate pre-operative counselling, the informed consent of the patient, certain pre-operative instructions including a pre-operation health assessment, a review of the surgical procedure, and the requirements for post operative care. Furthermore, the standards detail the equipment and facilities deemed necessary to carry out a sterilisation procedure.
The sterilisation procedures that were carried out on the women in Bihar fell far below the standards mandated by both the Supreme Court and the government standards. The women did not receive any pre-operative counselling or medical examination. Moreover, the doctor did not seek any of the female patients’ informed consent. The women, who were left without any medical help or information about post-operative care, had to have their stitches removed by private facilities at their own expense.
32
Women waiting to be sterilized at family planning camp in Barwani District, MP
The PIL Ms. Biswas subsequently filed argues that the NGO, surgeon, and government violated the women’s reproductive rights, their right to health, and their right to be free from inhuman, cruel and degrading treatment. Furthermore, the petition argues that the government failed to provide the women with adequate health services in a non-discriminatory manner as the majority of female sterilisation camps take place in rural areas. The shocking conditions in these camps amounts to discrimination against rural, poor, and marginalised women.
The petition seeks compensation for the women in Bihar and for an order directing the respondent states to file status reports on the implementation of the Supreme Court’s directions in the case of Ramakant Rai as well as the Guidelines for Female and Male Sterilisation in order to ensure that these guidelines are adhered to throughout India.
33 State Presentations on Sterilization
Information Presented
Rajdev Chaturvedi, GPS, Azamgarh (Uttar Pradesh)
Mr. Chaturvedi shared that his investigations revealed 11 female sterilization camps in Uttar Pradesh. These camps had no oxygen cylinders, no provision of rooms for changing clothes, and no provision of separate operation coats for the doctors to wear in the Operation Theatre. Only two camps had clean clothes for the staff and only six camps enforced changing clothes and medical instruments after each surgery. Additionally, there was no provision of toilets in any of the camps Mr. Chaturvedi visited.
It is a medical norm to carry out a check-up before operating, but this norm was violated in the camps. When check-ups were enforced, they were only done for blood pressure. While some of the doctors were competent to perform the surgeries, most had no expertise in the matter. Additionally, counseling ought to be provided to patients regarding the usage of and the various types of contraception options before sterilization surgeries. This mandate was also commonly ignored. Mr. Chaturvedi noted that most women are forcibly sterilized and that screaming and yelling can often be heard from the operating theatre during sterilization surgeries.
In reference to the Standards for Sterilization set out in Ramakant Rai, Mr. Chaturvedi stressed that they are not being implemented.
After their operation, women should be kept under care by the medical staff in the hospitals, but they are generally sent home immediately after their surgery. Doctors rarely conduct follow-ups with the women after their operation. In 12 out of 18 cases, women suffered from various problems after their operation, including dizziness, body ache, and low haemoglobin levels. Women have complained that there is a lack of good hospitals in nearby areas and they cannot approach hospital staff with their post-operative problems. Patients also complain about having to pay for their surgery and post-operative care when they suffer from complications. Other issues include the ill treatment the women receive at the hands of the doctors, the impolite and rude behavior of the staff, and the lack of contraceptives available in the hospitals.
Mr. Chaturvedi reported that women prefer going to private hospitals because they are nearer to their homes - government doctors in Uttar Pradesh can sometimes only be found 25 km away from the women’s homes.
Today, women are still being forcefully sterilized and left to suffer from various post-operative complications. All of this without any compensation, contrary to the government’s incentive programme. Doctors are usually unaware that their patients are entitled to compensation and even when they are, they do not act on it because they think that giving women compensation is tantamount to admitting that they performed the operation inefficiently.
Mr. Chaturvedi cautioned that a target-free approach should be employed. Recently, the arrival of the Rashtriya Gramin Swasthiya Mission has meant that no incentives are provided to doctors or medical staff for performing sterilization operations. However, targets are still created and
34 adhered to. In the Azamgarh District of Uttar Pradesh, the target has been kept at 30,777 female sterilization surgeries per year.
Swarup Pal, Manjari, Bundi (Rajasthan)
Mr. Pal presented on a female sterilization study his organization, Manjari Bundi, carried out in Rajasthan in 2009 - 2010. The organization spoke to 749 women who had undergone sterilization that year. Mr. Pal stated that in Rajasthan, prior to a woman undergoing sterilization, some care is taken of her, but that after the operation has been carried out, no one cares for the woman. He stated that his organization undertook the study in order to find out the levels of care provided to women before and after their operation. The women involved in the study had an average age of 29 and were mainly illiterate and belonged to other backward classes. Mr. Pal stated that of the women surveyed, almost all of them had only consented to sterilization if they had two or more sons regardless of how many daughters they had. Only one woman reported having undergone sterilization with only one son.
Mr. Pal shared some of the data gathered by the study. The study found that only 20% of women had received checkups prior to their operation and that, of the prescribed pre-procedure checkups, only three were carried out; blood pressure tests, haemoglobin levels, and pregnancy tests. The study also showed that counseling was either not provided to the women or where it was provided, government health workers gave misleading information about the alternatives to sterilization and aftercare. Mr. Pal shared that around 90% of the women were discharged from the hospital within 30 minutes of their operation and that 8% of the women were still unconscious when they were sent home.
Mr. Pal discussed the problems that women often face after their sterilization procedures and shared that around 60% of the women interviewed reported complications after their operations. Complications ranged from abdominal pain to back pain or pain while walking to irregularities in their menstrual cycle. Furthermore, the study found 17 cases of failed sterilization – meaning that the failure rate in the surveyed are was five times higher than the international standard. Mr. Pal stated these women whose sterilizations failed, had suffered mental trauma, physical distress and, in some cases, had been ostracized by their community or family.
Mr. Pal then highlighted the main problems the study uncovered. First, there is no proper reporting of failed sterilizations or post-surgery complications. Second, although there are compensation schemes for women whose sterilizations fail, women often do not know about the schemes and the medical staff generally do not inform them. Third, the data maintenance system is faulty. In this case, faulty recording resulted in the records of about 200 women who had undergone sterilization going missing. Therefore, these women could not be traced. Finally, Mr. Pal talked about the target system for sterilizations. He shared that officials set targets for the numbers of sterilizations they will perform each year. Reports on the number of sterilizations carried out are given to the government in mid-July, which results in a larger number of female sterilizations in the months leading up to the deadline. He shared that the women in the area are so used to this that they sometimes take advantage of the targets and wait until the last push to meet targets before asking for higher monetary incentives to undergo sterilization.
35 Mr. Pal stressed that currently in Rajasthan, women are pressured into undergoing sterilization yet as soon as the procedure is over, even if the women suffer from complications, they are ignored.
Advocate Rudra Prasad Mishra, HRLN
Chitrakoot is the most backward part of the Bundelkhand area, and has a high number of Dalits (backward classes) and financially crippled citizens. The issue of health has been addressed by NRHM, but it has still not improved sufficiently. Doctors do not wish to come to this area and those who do, do not wish to stay for long. This is because there is a staggering amount of corruption in the area. Nobody dares to speak out against such corruption as goons usually punish complainants.
As soon as a woman reaches the hospital, she must pay everyone, starting with the ASHA worker, nurse, and finally the doctor. If she resists, she is shooed away from the hospital with excuses ranging from the unavailability of blood to a lack of medical equipment in the hospital. Mr. Mishra shared that the previous week, a pregnant woman was refused treatment in a hospital after she refused to pay the staff a bribe. In response, she was told that she had miscarried and that her child had died. However, as soon as she exited the hospital, she went into labour and gave birth to her child.
If a woman dies of hunger, officials assign it to disease and do not investigate further. If a person dies because she has not had food for 7-8 days and contracted a disease as a result, health officials must investigate rampant malnourishment and undernourishment. In such circumstances, Mr. Mishra urged, we have no other option but to approach the Consumer Forum, file a case, and demonstrate on the issues.
The hospitals available to many women in rural areas are situated so far away from the settlement areas that women need to walk 20-22 km before they reach them. Even after travelling so far, women find that only a midwife or a staff without child birth training is present. There have even been times when not a single medical staff is present.
Citizens who are aware of the problems and are willing to fight against them, face consistent resistance from influential people. If PILs or cases are filed against such doctors, the officials try to suppress the issue.
Mr. Mishra concluded by sharing the recent case of a woman who visited her nearest government hospital seeking treatment for her son, who suffered from a hearing problem. The doctor they saw gave them some medicines and additionally poured some medicine into the boy’s ear. Two hours after they returned home, the mother found that her son had lost his sight. When she went back to the doctor, he claimed that it was a slight reaction to the medicine and gave her other medicines. When she approached him again the next day, she was directed to another hospital – a private hospital, where she received more medicine. After 4-5 days of this, Mr. Mishra and HRLN approached the District Magistrate but the doctors refused to take responsibility for the boy’s loss of sight. Instead, they claimed that the boy had been blind before his treatment. Mr. Mishra and HRLN then approached the Consumer Forum. The matter is still being argued today. Mr. Mishra and HRLN also approached the court meant for addressing the issues faced by Dalits but the
36 matter was suppressed there as well. Meanwhile, the woman was repeatedly told to accept money from the doctor and drop the case against him.
Laws and forums exist in society but they are of no use to the backward classes, or Dalits, and the downtrodden poor. Mr. Mishra urged everyone that this issue necessitates our attention.
Dr. Manmath Mohanty, Human Development Foundation (HDF) (Odisha)
Dr. Mohanty presented an evaluation of the Green Card Scheme (GCS) in Odisha. The scheme was started in 1983 in order to promote two-child families. To do this, the scheme offered six benefits to those who had two children or less. The benefits included 5% quotas for Green Card holders in housing and certain university and college courses, land free from certain taxes, access to certain loans, and a lottery with a cash prize of Rs. 10,000. The lottery system was discontinued in 1994, but due to a demand for financial benefits the Health and Family Welfare Department was advised to undertake an evaluation of the lottery system and reintroduced it with a greater cash prize.
Dr. Mohanty presented an HDF study that reviewed GCSs compatibility with the Reproductive and Child Health Programme (RCH). The study assessed the influence of the GSC on reproductive rights, whether the GCS has influenced the prevalence of sterilization in the state, the level of benefits received by Green Card holders, the importance of the lottery scheme to those accepting a Green Card, and assessed the impact of the GCS on reducing the unmet need for contraception. The study consisted of research and a primary survey in two districts. Dr. Mohanty highlighted that due to a lack of data from the Department of Health and Family Welfare, it was difficult to ascertain the number of cards issued under the scheme.
Dr. Mohanty shared that 91% of those who participated in the study were female and that only 1.1% of respondents reported male sterilization. The study also showed a twofold increase in the percentage of women who were sterilized when they had two or less children but showed a decrease in the total numbers of sterilizations overall. However, the study showed there was no definite correlation between sterilization increase or decrease and the GCS.
Dr. Mohanty highlighted that the GCS was not in step with international thinking on family planning. In particular, he stated that it conflicted with the ICPD and its focus on preventing the use of coercion, incentives or disincentives to achieve family planning targets. Dr. Mohanty further stated that a higher percentage of couples who accepted sterilizations under the scheme were unhappy with their decision compared to the general percentage. He also highlighted that over a quarter of sterilized women under the scheme reported that their husbands made the decision for them and 50% of women felt pressure from outside their family to undergo sterilization. Dr. Mohanty stated that 66.7% of respondents were influenced by the benefits under the GCS when they were considering sterilization.
37 *Source: Demography and Evaluation Cell of Directorate of Family Welfare, Government of Odisha Trends in Sterilization: A review of last thirty years performances in Odisha
Financial Year Total Sterilization No. Sterilized with % of Sterilization with Two or less children Two or less children to total Sterilization* 1980-81 92989 16750 18.01 1981-82 110130 15567 14.14 1982-83 146693 22607 15.41 Total upto 1983-84 349812 54924 15.70 Total since 1983-84 3062389 890302 29.07 *Source: Demography and Evaluation Cell of DFW, GOO Figure-3.5: % of Sterilization with Two or less children Twofold increase in % of sterilization to total Sterilization with two or less children 45 Lottery draw 40 Green card discontinued 35 introduction Period upto 1982-83 (15.70%) and 1983- 30 25 84 onwards till 2006-07 (29.07%) 20 15 Percentage of Sterilizations 10 5 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 ------1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Financial years
Dr. Mohanty then turned to the influence of the GCS among scheduled castes (SC), scheduled tribes (ST), illiterate people and the poor. He stated that there were higher percentages of green card holders among all these groups than among the total respondents. He also stated that people who belong to these groups are easy targets for health workers and often will choose sterilization even without the GCS. However, despite the higher numbers of Green Card holders among these groups, they are unlikely to be able to fully access or enjoy the benefits. For example, Dr. Mohanty raised the question of the likelihood of someone from these groups having the money to pay the fees for their reserved university course. Furthermore, some of the benefits, such as access to urban housing, are not useful to the rural poor of Odisha. Dr. Mohanty also shared that only 11% of the Green Card holders in the districts surveyed had received any benefits under the scheme. He also stated that there was no systematic tracking of benefits distributed under the scheme and that only 16% of those who were sterilized were aware of some of the benefits available under the GCS, particularly the lottery scheme. He stated that until 1994, only 0.2% of those who have undergone sterilization under the GCS have received any benefit under the lottery scheme.
The study revealed that the GCS is in conflict with ICPD principles and domestic population strategies, that there was no consistency in the trends of increase or decrease in sterilization since its introduction until 2007 and that SC, ST, poor people and those who are illiterate are easy targets for the scheme but are unable to realize the majority of the benefits offered under it. These conclusions led the HDF to make a number of recommendations. The provision of incentives or disincentives in family planning amounts to coercion and, thus, the HDF recommended that the government of Odisha refrain from using such methods. The HDF also recommended that the greatest need in Odisha is for spacing methods to allow people to choose when and how many children to have. Finally, as there was no correlation shown between sterilization numbers and the influence of the GCS, HDF recommended that the state divert the resources used on the scheme to strengthen the health system and promote informed choice instead.
Dr. Mohanty concluded by sharing that a presentation of the study was made to the Director of Family Welfare in Odisha and as a result, the GCS was withdrawn on the 8th of November 2012. 38 Now, HDF is pushing for several other reforms including the repeal of the law disqualifying people with more than two children from contesting PRI elections, implementation of community based distribution of contraceptives, ensuring male involvement in decreasing the unmet need for contraception, and creating a unified strategy to lodge PILs for cases where there is a denial of health rights, particularly where such a denial has resulted in death or permanent disability.
Sashi Bindhani, SWAVINANEE (Odisha)
Ms. Bindhani began by reaffirming the right of women to decide freely whether or when to have children and stating that this includes the right to information, education, and accessible and affordable services, all of which are necessary for the protection of reproductive health, safe motherhood, and safe abortion. With this in mind, Ms. Bindhani turned to reflect on the family planning policies in Odisha.
Ms. Bindhani shared that the median age at marriage for women in Odisha is 17.9, a year younger than the Indian average, and that the total fertility rate (TFR) of the state is 2.37. This is lower than the national average, but she highlighted that among the Scheduled Tribes in Odisha, the TFR rose to 3.1, well above the national average of 2.7. Ms. Bindhani also highlighted that 14% of girls in Odisha between 15 and 19 years old, were already having children and that the contraceptive prevalence rate amongst currently married women is only 50.4% which is lower than the national average of 56.3%. She also stated that the unmet need for family planning in Odisha at 15% was higher than the India-wide average of 12.8%. The unmet need for family planning, particularly for the purposes of spacing births, was highest among women aged 15 – 24.
Unmet need for FP by age group (NFHS-III)
Unmet need of Family Planning in Orissa 25
21.8
20 18.3
15 14.3
12.1 11.5
10 8.7 8.1
5
2.2 1.5 0.6 0 15-19 20-24 25-29 30-34 35+ Spacing Limiting
Ms. Bindhani stated that 79% of women access their contraceptives from the public medical sector with 15% going through the private medical section and 5% gaining access through other sources. 34.1% of people in Odisha use sterilization as their method of family planning and male sterilization accounts for only 1% of contraceptive use. Ms. Bindhani stated that the other modern methods of contraception were not as common as only 7% of women used the oral birth control pill, 3.2% used condoms, and 0.6% used intra-uterine contraceptive devices (IUCDs). In addition
39 to these modern forms of contraception, Ms. Bindhani stated that 5.8% of people in Odisha still use traditional or natural forms of family planning.
Ms. Bindhani then turned to discuss the challenges that Odisha faces in delivering government programmes aimed at addressing the unmet need for contraception by assuring delivery of services, increasing male sterilization, promoting the use of IUDs and emergency contraceptive pills, and increasing contraceptive choice. She highlighted that Odisha has a high rural population at 86%, which can create problems due the difficult geographical terrain of the state. Ms. Bindhani also stated that there is inadequate attention paid to family welfare programmes in the state, that service provision for limiting methods of family planning are seasonal, and that Odisha does not focus on offering spacing methods of contraception. She also highlighted that the state has a large young population that is now entering reproductive age. Furthermore, low male participation in contraception options, low age at marriage and first child bearing, insufficient spacing between pregnancies, a strong preference for male children, and low female literacy rates and empowerment all contribute to Odisha’s family planning problem. However, Ms. Bindhani also raised some encouraging facts, which she argued would create opportunities for better family planning in Odisha. She reported that as 66% of households rely on the public health system for healthcare, 80% of contraceptives are accessed through the public system and more than 80% of deliveries are institutional, the state could reach a lot of people with their services if they were improved.
Finally, Ms. Bindhani turned to discuss the state level family planning programme now in place in Odisha. Under the programme the state has six priorities. First, to strengthen the system through bolstering the State and District Family Welfare Bureau to improve management, strengthening the Quality Assurance Mechanism to improve the monitoring and feedback system, promoting facility based monitoring, and institutionalizing the review mechanisms. Second, to increase the range and reach of family planning services by starting Fixed Day Centres for family planning, promoting the use of IUCD, increasing the focus on vasectomies, particularly in tribal districts, and by promoting post partum and post abortion family planning services. Third, to address the unmet need for contraception by promoting ASHAs and staff nurses as family planning counselors, implementing the home delivery of contraceptives by ASHAs, and by using MAMTA Divas platforms to provide information and supplies for family planning. Fourth, to address the needs of young couples by training and capacity building with AHSA and staff nurses and by ensuring that other schemes also address young couples. Fifth, by promoting contraceptive security by streamlining the supply management system for contraceptives in the state. The final objective is to create an enabling environment by offering family planning trainings and capacity building sessions for medical staff and ensuring a supply of necessary instruments, equipment, and consumables.
Ms. Bindhani concluded by sharing a letter of appreciation from the Chief Minister of Odisha to the Minister of Health and Family Welfare stating that there had been significant improvements in the provision of spacing methods in Odisha and asking him to ensure the programme was continued.
Karla Torres, Reproductive Rights Initiative, HRLN – Delhi
Ms. Torres presented on her fact-finding mission to Barwani District, Madhya Pradesh. She visited the district in late August to gather evidence on the implementation of NRHM and IPHS norms in
40 support of the ongoing litigation Duna Bai vs. State Madhya Pradesh and Others. With the guidance of local activist Madhuri Krishnaswarma, Ms. Torres visited 12 public health facilities in 11 villages over a one-week period.
Ms. Torres found female sterilization was rampantly practiced at every facility visited. One doctor she spoke to at Rajpur Community Health Centre (CHC) confirmed that the district had a female sterilization target equal to 1% of the district’s female population. At the same CHC, Ms. Torres witnessed over 50 women sterilized. The women arrived at the CHC in the early morning only to be made to wait for the surgeon until the late afternoon. When Ms. Krishnaswarma asked the women how long they had been waiting, they responded that they had been waiting for over five hours. They also complained that many sterilized women never received their incentive payment as promised. ASHAs present at the CHC complained of the same.
Generally, women are pressured to opt for sterilization after they have had two children, assuming that one of the children is male. This pressure also extends to ASHAs and hospital staff in order to meet their yearly target. Women are seldom counseled on alternative forms of contraception and lack access to the same.
All of the facilities Ms. Torres visited were egregiously unhygienic and many lacked a medical officer on staff. All of the PHCs and CHCs visited only had labour rooms in which sterilizations were performed, sometimes without reliable power. Because these facilities lacked a medical officer, a single surgeon from the District Hospital spends much of each month traveling to numerous health facilities to perform female sterilizations. Most harrowing, the average time spent on sterilizing 50 or more women is only two hours. This means that each woman receives less than two minutes worth of medical care. The surgeon usually uses local anesthesia that leaves the women unconscious for up to four hours. The women Ms. Torres spoke to at Rajpur and other facilities where family planning camps take place expressed frustration with having to return home without follow-up care, transportation services, and in some cases, without fully recovering consciousness.
Women in corridor at CHC Rajpur, Barwani District, after their sterilization surgery
41 Although family planning camps are not isolated to Barwani District, Madhya Pradesh, the predatory nature of these camps is most keenly felt in “backward” districts like Barwani. This case, then, merits special attention and advocacy.
Kerry McBroom, Reproductive Rights Initiative, HRLN – Delhi
Ms. McBroom presented on a recent family planning camp fact-finding in New Delhi. The team visited two slum areas, two government hospitals, a private charity hospital, and spoke with government staff and community members alike. According to the 2007-2008 District Level Household and Facility Survey (DLHS-3), 35% of women between 35-49 years of age in Delhi are sterilized. Of these 59.4% received their promised incentive payment. Of note, only 22.6% of these women received counseling on the potential side effects of their sterilization surgery.
Under Devika Biswas vs. Union of India and Ors., each respondent state was ordered to submit a response to the petition’s allegations. In its response, the National Capital Territory (NCT) stated that the facts in the case did “not apply” and that Delhi “fully complied” with the Supreme Court’s previous Ramakant Rai order. It further stated “no ‘rights’ of sterilization seeking clients are jeopardized and health care personnel are bound by professional ethics to treat their clients with dignity.” The fact-finding, however, proved otherwise.
The fact-finding team found a severe shortage of facilities, especially sub-centers, and specialized medical officers including gynecologists, pediatricians, and pharmacists at the CHC and PHC level. The team visited Jagiwan Ram Memorial hospital, a government health facility, and found it to be unclean and its labour room to have unclean, old mattresses with multiple women for every bed. One of the doctors the team spoke to stated, “women have many children because they are uneducated.” Doctors, then, bear the burden of “convincing” women to use contraception. However, the staff does not encourage birth control pills or other forms of temporary contraceptives because woman “do not obey” their directions. The staff also admitted that women are not counseled on family planning because the hospital is understaffed: four doctors service about 300 ante-natal patients per day.
Crowded ward in Jagiwan Ram Hospital
42 The team next visited Jahangir Puri K Block Hospital, also a government health facility, and interviewed 23 women about their family planning experiences. Most of the women said that after their first child, they received pressure to use the Copper-T contraceptive. However, when any of them suffered from complications or sought follow-up care, they were refused medical service and had to have the Copper-T removed elsewhere. Women also shared that they were pressured to opt for sterilization after they had had two children. In fact, women with three or more children are often turned away and never receive their incentive payment if they opt for sterilization.
One woman the team spoke to, Saroj, said that she had been sterilized in 2009 after having her third child. She told the team that the doctor did not carry out any tests or provide any counseling. Moreover, it was Saroj’s husband who provided consent to have Saroj sterilized. She remembered saying to the doctor, “I’m scared. I don’t want to do this.” A man who was walking around the room in which she was sterilized told her not to worry and gave her a shot in the arm. The next thing Saroj remembered was waking up in a room on a mat on top of several other women and feeling pained, nauseous, and drugged. The only staff in the room was a cleaning person. She later left without any medicine, instructions or certifications of her sterilization surgery. Saroj later had to remove her own stitches. When she visited the hospital seeking her incentive payment, she was denied any payment and to this day has never received her incentive. Saroj with her children
Saroj’s story is not unique. Many women in Delhi share harrowing stories where women are operated on without pre-operative check ups, counseling, or post-operative medical care. These women are operated on under unhygienic circumstances and are sometimes sterilized in only a matter of minutes. They are then left to regain consciousness while lying on the floor of a dirty room without any medical attention. Finally, they are forced to leave the medical facility because hospital staff complains of overcrowding.
This inhumane and degrading treatment of women is endemic of a society that devalues women and denies their reproductive rights as human rights. The disregard for the autonomy of indigent women in slum areas is especially shocking. These women place their trust in medical professional who mislead them, take advantage of their ignorance about health issues, and ultimately place their lives in jeopardy in order to meet a state mandated sterilization target.
43 Recommended Ways Forward
The following are prayers participants suggested:
• “Sterilization camps do not exist in isolation, so I think we should focus on health care in general and take a step back from sterilization, because it does not exist in a vacuum.”
• “We should discuss the Right to Privacy and Confidentiality, because the women come in for treatment, and everyone knows what you are doing. Many times, one does not want anyone else to know, so this is a right that should be given to people. We could connect it to Article 21 of The Constitution and make the Prayer stronger.” • “An independent body should be formed in order to provide women who are having problems after sterilization operations with compensation. The body should also have power to act against doctors who treat women negligently.”
• “We have to delete the word ‘compensation’. We should focus on ‘medical after-care’, as women end up spending money from their own pockets following the procedure. o Secondly, laparoscopy, as a method, was adopted to fool people in order to make them believe that the woman will only need 4 hours of rest. So families are happy believing that the woman will be back at work in the house and doctors are happy as they can discharge the women quickly. Even if women opt for sterilization because they have finished their childbearing, they should be given an option of Tubectomy. Everybody should not rush to laparoscopy. Tubectomy is safer because the doctor can see everything, so the doctor operates better. It requires hospitalization, so it is more expensive for the government, as it requires hospitalization for 8 days. Secondly, the doctors should also be held responsible for the problems faced after the operations. o About incentives, we should be very careful, as the poor people, especially during times of drought, accept these incentives.”
• (Addressing the previous suggestions) “The committee should be made up of renowned persons who are activists so that they can interfere, with the consent of doctors, in order to get a straight approach to what the patient needs for solving her problem, post her operation.”
• “In Bihar, one case of failure has come to our notice, and we find that the government never issues a certificate for compensation. I read in the book that it can be given after a month. Secondly, whenever anyone asks for the certificate, they are told to come themselves, and are told that the certificates are just pieces of paper of no value. Therefore, they cannot ask for compensation.”
• One needs to file for compensation within a month, but most people don’t know they can get compensation and even officials don’t know how much compensation to give. The period during which compensation can be asked should be extended, as a woman might start getting complications even 10 months after the operation. Also, the amount of compensation to be received should be mentioned on the back of the certificate. The 44 Government should also issue notices in the newspaper. Regarding the informed choice given to the patients, information should be provided in the local language. Mostly, the women are forced to make their thumb impressions. This needs to be tackled.”
• “There should be a record with the woman, stating how much she is to receive for compensation. Similarly, there should be a public board that declares that if a woman gets pregnant after sterilization, she can file a complaint for compensation.”
• “Talking about uniform consent forms and checklists, we need to realize that how these forms will serve their purpose depends on how these forms are designed. Instead of leaving it to the government to design the forms, the standard designs of the forms should be suggested by us.”
• “I feel that if we add our suggestions towards the drafting of the forms, in the Annex of the Petition, we should do this with the consultation of the government and National Human Rights Institutions, in order to add validity to the drafting suggestions, so the Court takes it more seriously.”
• “We should talk about how pre-sterilization and post-sterilization health care should be strictly followed, and there should be a follow-up of the woman after 3 months, or any particular period. Also, the woman should sign the consent letter only after she is made aware of the operational procedure and the after-effects of the sterilization. The doctor should not perform continuous sterilization operations (i.e., operations performed one after the other) within a short period of time. The Doctor’s Panel should ensure the availability of proper health-care facilities. Counseling should be provided to the women. The Panel of Doctors should be specifically numbered, something that is not mentioned in Ramakant Rai.”
• “The number of sterilization operations, the number of failure cases, and the number of cases where women are facing complications post-operation should be made available in the Public Domain.”
• “There are a lot of organizations and activists who are pushing for guidelines that look into the human rights perspective of the ethical aspects of sterilization, which the Ministry of Health Guidelines do not focus on. I feel we should create space to discuss these issues.”
• “We can discuss how sterilization programs focus predominantly on females.”
• “I think that what the speaker who spoke last wants to say is that ultimately, we need to talk about how this is a practice that targets women, and affects women. So we need to recognize and announce that this is a discriminatory practice.”
• “I feel that there is a different angle to the problems faced due to sterilization. The failure of sterilization as an effective procedure is a direct result of the cancellation of the 45 registration of clinics and surgeons. Because the medical council of India has set very clear guidelines about surgical medical procedures. Once the doctor operates, he is immediately individually responsible for follow-up check-ups. Secondly, the organization under which the entire process takes place is also responsible. Thirdly, if the person facing post- operative problems does not report the matter to the authorities, it also results in various problems.”
All of these suggestions were taken note of and the HRLN legal team is currently developing rejoinders to all responding states, conducting fact-findings to increase information and awareness, and developing a more comprehensive advocacy plan.
Issue PIL Status Complimentary Advocacy Partners Strategies
Female Sterilization • Filing response • Fact findings • HRLN • Awaiting further • Devika Biswas state responses • Using some of the suggested prayers
46
LIST OF PARTICIPANTS
Ramatai Ahire Arpita Choudhary Navsarjan Proletariats and Tinkers Horde (PATH) New Maharashtra Delhi
Junaid Alam Javid Chowdhury Chapal Gram International Former Secretary, Ministry of Health and Bihar Family Welfare
Adv. Shadab Ansari Sushil Kumar Das HRLN Prerana Bharati Jharkhand Jharkhand
Afreen Asrar Dr. Abhijit Das Mamta Health Institute for Mother and Centre for Health and Social Justice (CHSJ) Child New Delhi New Delhi
Adv. Anant Kumar Asthana Jashodhara Dasgupta Independent Advocate SAHAYOG New Delhi New Delhi
Raj Kumar Awasthi Aarti Dhar Bharat Seva Sansthan The Hindu
Gopika Bashi Dr. Bhaskar Dwivedi The YP Foundation (TYPF) Chhattisgarh Voluntary Health Association New Delhi (CARDS) Chhattisgarh
Govind Beniwal Francis Elliot Rajasthan Commission for the Protection of The Times Child Rights London, UK Rajasthan
B Bhattacherya Pushplata Ganvir The Academy of Nursing Studies and Navsarjan Women’s Empowerment and Research Chhattisgarh Studies (ANSWERS) Andra Pradesh
Ajit Sunder Bilung Katy Gilmour Chhattisgarh Voluntary Health Association HRLN (Intern) (CARDS) New Delhi Chhattisgarh
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Sashiprava Bindhani Senior Adv. Colin Gonsalves SODA HRLN Odisha New Delhi
Devika Biswas Dr. Narendra Gupta HealthWatch Forum - Bihar PRAYAS Rajasthan
Rajdev Chaturvedi Jashodhara Das Gupta GPS SAHAYOG Uttar Pradesh New Delhi
Kalpana Indu Adv. Kishore Narayan Manasi Swasthya Sansthan HRLN New Delhi Chhattisgarh
Dipika Jain Dr. Manmath Mohanty Centre for Health Law, Ethics and Human Development Foundation Technology (CHLET) Odisha New Delhi
Shafiq ur-Rhman Khan Swarup Pal Empower People Manjari Haryana and Assam Rajasthan
Adv. Shanno Shagufta Khan Bhupendra Pareek HRLN Akhil Bhariya Gisiahak Panchayat Madhya Pradesh Rajasthan
Radhey Krishna Phillip Perl Samarpan Jan Kaylan Samiti Centre for Health and Social Justice (CHSJ) Uttar Pradesh New Delhi
Manoj Kumar Manjula Pradeep LAKSHYA Navsarjan Bihar Gujarat
Tarun Kumar Dr. M. Prakasamma AANSVA The Academy of Nursing Studies and Bihar Women’s Empowerment and Research Studies (ANSWERS) Andra Pradesh
Swapna Majunbar Sudipta Purkayastha Freelance Journalist HRLN (Intern) New Delhi
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Sunita Malviya Dr. Shakeel Ur Rahman Betul DLN Society (BTNP) Centre for Health and Resource Management Madhya Pradesh (CHARM) Bihar
Kerry McBroom Ashutosh Rai HRLN Satya Nonayam Seva Sansthan (SNSS) New Delhi Uttar Pradesh
Lavanya Mehra Narendra Kumar Rai Centre for Health and Social Justice (CHSJ) Ashok Sansthan New Delhi Uttar Pradesh
Smriti Minocha Dinesh Kumar Rai HRLN Satya Narayan Sewa Sansthan (SNSS) New Delhi Uttar Pradesh
S N Misra Adv. Sandhya Raju Brij Bal Vikas Kendra HRLN Uttar Pradesh Kerala
Rudra Prasad Mishra Adv. Manas Ranjan Pragati Sheel Manch HRLN Odisha
Mazhar Rashidi Manish Sharma Association of Minorities Action for Nation Ujjain (AMAN) Madhya Pradesh Uttar Pradesh
Ankita Rawat Sanjai Sharma The YP Foundation (TYPF) HRLN New Delhi New Delhi
Adv. Ahmed Raza Sona Sharma HRLN Population Foundation of India (PFI) Jharkhand New Delhi
Sonali Regmi Vishwa Vaibhav Sharma Center for Reproductive Rights – Asia SAFE Society Nepal
49 Natassia Rosario Parmendra Sisodiy Fulbright Scholar Ratlam Jila Network of People Living with HIV/AIDS Society (RNPPLUS) Madhya Pradesh
Adv. KK Roy Dr. Raju SMG HRLN HRLN (Volunteer) Gujarat New Delhi
Kundan Lal Sah Aditi Sood CHARM SAHAYOG Bihar New Delhi YK Sandhya Dr. Prasanth Subrahmanian SAHAYOG NHSRC New Delhi New Delhi
Adv. Jayshree Satpute Adv. Rohit Thakur HRLN HRLN Delhi Jharkhand
Rajkumari Sen Adv. Namrita Tiwari Sagar Network Sagar DLN HRLN Madhya Pradesh Uttar Pradesh
Disha Sethi Adv. Alban Toppo The YP Foundation (TYPF) HRLN New Delhi Chhattisgarh
Neetu Singh Karla Torres Gramya HRLN Uttar Pradesh New Delhi
Rakesh Kumar Sinha Kartik Tripathi BREAD HRLN (Intern) New Delhi
Dinesh Sharma Leena Uppal Rural Development Society and Vocational Centre for Health and Social Justice (CHSJ) Training Organization (RUDSOVOT) (Delhi) and National Coalition against the Rajasthan Two Child Norm and Coercive Population Policies New Delhi
50