Introduction
The tragic death of 16 young women and the critical condition of several others following tubal sterilization at a camp in Bilaspur District, Chhattisgarh, has once again brought to fore the disregard for dignity of women and the dismal quality of care of India’s family planning programme. In recognition of the fact that violations of standard operating procedures and guidelines prescribed by the Ministry of Health and Family Welfare (MOHFW) are not limited to Bilaspur or Chhattisgarh, but are a grave concern across the country, a multi-organizational fact-finding team travelled to Bilaspur on 19–20 November 2014 to assess the situation and recommend corrective actions at national and state levels.
The Family Planning Programme is one of the oldest components of India’s health care system and has received focused attention over the last five decades. However, it has remained primarily a programme of controlling numbers rather than focussed on reproductive and human rights that India had affirmed at the International Conference on Population and Development (ICPD) in 1994 and in its National Population Policy 2000. However, the family planning programme in India has yet to conform to the principles agreed to under ICPD, especially in terms of doing away with targets and incentives. The quality of family planning services ranges from low to abysmally poor. Quality parameters include choice of method, dignity and comfort, privacy and confidentiality, safety of procedure, follow up and referral services as well as space for feedback. While the National Guidelines reflect almost all these components, in reality, most of these parameters are compromised.
The contraceptive choices available in the public sector have remained static over two decades. The choices available through the national programme are limited to: oral pills, condoms, the intra uterine contraceptive device (IUCD) and female sterilization. Non-scalpel vasectomy, though a part of the basket of choice, remains under-utilized. Moreover, supplies are irregular and users are forced to adopt provider-based methods like female sterilization, and at times the IUCD. The demand for sterilization services exists, but it is essentially a false demand as there are neither other long term suitable options available on a regular basis nor is there adequate access to information and counselling on all aspects related to sterilization.
Findings
The fact-finding team from four organizations working on public health has called for the setting up of an independent inquiry commission to inquire into the Bilaspur sterilization camp disaster and ascertain the facts regarding the deaths of 16 women. The team found that some of the critical cases admitted at Apollo Hospital showed raised levels of procalcitonin that suggests septicaemia. Post-mortem examinations of the first seven deaths at the Chhattisgarh Institute of Medical Sciences and the District Hospital had evidence of peritonitis and septic foci in the lungs and kidneys, also suggesting septicaemia. These indicate deaths by infection during or after the operation, and not just from spurious medicines, as is being made out to be the case. Further, according to forensic medicine and toxicology experts, the amount of zinc phosphide required to be lethal for women is 4.5 gms, which is much higher than what could possibly have been consumed by the women in 500 mg of Ciprofloxacin. This also strengthens the argument that it was not the medicines alone that caused these deaths.
The team — from the Population Foundation of India, Family Planning Association of India, Parivar Seva Sanstha and CommonHealth — surveyed the camp sites, interviewed doctors and support staff involved in the service delivery, as well as women who had been sterilized, and family members of those who had died.
The team has come up with a list of recommendations for Chhattisgarh and the country as a whole, in a 37-page report,Footnote1 excerpted here, that was released in New Delhi on 1 December 2014.
It has also urged the state government to immediately make public the post-mortem reports, laboratory reports on drug analysis and the state committee set up by it to probe the tragedy. The team found that the families of the deceased had not been given the hospital records, nor told about the possible cause(s) of death.
Analysing the expenditure on family planning, the team points out that for the year 2013–14, India spent Rs 396.97 crores on female sterilization, which constitutes 85% of the total expenditure. A chunk of this amount — Rs 324.49 crores was spent on incentives and compensation, and Rs 14.42 crores on the camps themselves. The amount spent as compensation for female sterilization was 2.5 times the untied grants given to primary health centres for infrastructure strengthening. The huge spends on compensation/incentives, only to bring women to non-functional facilities with poor quality services that are a health risk, is inappropriate and unacceptable.
Less than 1.5% of the annual expenditure on family planning went towards spacing methods. The remaining 1.3% was spent on equipment, transport, IEC activities and staff expenses. Similarly, the figures for Chhattisgarh show that 85% of the Rs 15.59 crores spent on family planning went towards sterilizing women. Rs 12.76 crores were paid as compensation and incentives. Only 1% went towards spacing methods.
Recommendations
Based on the fact-finding mission, the Team recommends the following:
| 1. | Discontinue incentives for all service providers – doctors, nurses and support staff. Incentives lead the doctors to do more cases than the infrastructure can handle and in complete violation of protocols and quality norms. The team has proposed that only the acceptors be compensated for wage loss and transportation. The incentive amount should be diverted to strengthen the facilities and procure equipment for the health facilities. | ||||
| 2. | Promote spacing methods like oral pills, condoms and IUCDs, and add new methods. Ensure their uninterrupted supply and train health workers to counsel women so that they can make an informed choice. It has also strongly recommended expansion of contraceptive choices available in the public sector and extensive promotion of non-scalpel vasectomy as an easier, safer, permanent method. | ||||
| 3. | Stop sterilization targets as well as sterilization in camps across the country. The surgeon in Bilaspur had spent about a minute to a minute and half in each of the 83 surgeries he had conducted with inadequate basic facilities and manpower in an abandoned dirty hospital. The team noted the complete disregard for the dignity of the women at the camp, with the operation being carried out in an assembly line fashion with male ward boys positioning the women for surgery and then physically carrying them out of the operating theatre. The women had neither been counselled about spacing methods they could use, nor informed about the consequences of the surgery and possible side effects to enable them to make an informed choice. | ||||
| 4. | Carry out family planning services on fixed days at government facilities by suitably trained doctors and support staff with strict adherence to standards protocols and quality assurance guidelines. Meanwhile, public health centres should be strengthened and equipped to provide regular services based on demand. | ||||
| 5. | Plan and orient all officials at the block, district and state levels on sterilization procedures and quality assurance. District Quality Assurance Committees, as directed by the Supreme Court, should be made functional with a special role in assuring quality in family planning services. The Rogi Kalyan Samitis and the Village Health Sanitation and Nutrition Committees should be strengthened for community participation and monitoring. The quality of care guidelines of the Ministry of Health and Family Welfare (MoHFW) had been violated at every stage, the team points out. In fact, the staff were found to be ignorant of the safety and quality procedures and guidelines. | ||||
| 6. | Fill all posts of doctors lying vacant in the state and train more doctors in sterilization procedures in the state. The district of Bilaspur was found to have only three laparoscopic surgeons, of whom one had retired from government service. It has called for gynaecologists and surgeons at the District Hospital and the Community Health Centre to be trained in laparoscopic surgery, while doctors in these facilities could be trained in minilaparotomy sterilization and non-scalpel vasectomy, both simpler and less risky procedures. | ||||
| 7. | Strengthen the drug procurement policy and ensuring that the quality of drugs is regularly monitored for efficacy, toxicity, lethality and composition. | ||||
The women who died were young mothers and they leave behind toddlers and babies. The youngest is a baby barely a month old. While the state government has provided monetary support for the children left motherless, there is an immediate need to provide support to the affected families in terms of appropriate infant feeding practices. Many of the babies are now under the care of their grandparents who need to be guided on proper sterilization and hygiene practices of bottle feeding. The team has, therefore, proposed that the Anganwadi workers be suitably trained to follow up on the affected children on a regular basis.
The organizations have called for quick corrective action as the tragedy in Bilaspur has the potential of completely derailing the country’s family planning programme. To quote one ASHA, known as Mitanin in the state: “Abkis mooh se logon ko nasbandi ke liye bolenge? Ab to voh samne chal kar aayeintoh bhi hum khud hichkichayenge. (With what face we will tell people to go for sterilization? Now, even if they come to us for it, we will hesitate)”.
Acknowledgements
The Fact Finding was supported and coordinated by the Population Foundation of India. The team consisted of members from the Population Foundation of India, Family Planning Association of India, Parivar Seva Sanstha and CommonHealth.
Family members of one of the deceased women with the two-month old infant
