• sterilisation
• India
• service delivery

Despite being the first country to launch a family planning (FP) programme, India is currently the world’s second most populous country and will soon surpass China to become the most populated country in the world.1 2 To stabilise its population, India needs to achieve a norm of two children per couple.1 As a step towards this goal, India has expanded the range of contraceptives included in its national FP basket in order to allow couples to choose the method best suited to their needs. Despite the availability of various methods, female sterilisation is the most common method adopted by couples,3 regardless of the fact that sterilisation is promoted as an irreversible procedure.4 The success rate of reversal procedures is variable (42% to 69% pregnancy rate according to a recent systematic review) and reversal surgery is costly and is available only at a few public health facilities in India.4 5

Two decades ago, the government of India adopted a ‘target-free’ approach to its family planning programme. However, the day-to-day reality of the Indian healthcare system is in stark contrast to the government’s claims.1 6 7 Annual Program Implementation Plans (PIPs) prepared by each administrative block, district, and state of India include fixed, predetermined numerical targets of prospective contraceptive users to be added in a given year.8 Moreover, frontline community health workers are given annual targets for persuading eligible couples to adopt at least one of the available FP methods.6–8 Because of the widespread acceptance of female sterilisation among Indian couples, the predetermined targets and the financial incentives for motivating couples, community health workers are pressured into recommending sterilisation to couples who have two or more children. In addition, surgeons are also pressured to perform an increasing number of sterilisations, with the aim of meeting those predetermined targets.6–8

Although goal-oriented towards stabilising India’s population, this ‘target-based’ approach does not always have a happy ending for the individuals, men or women, who opt for sterilisation, nor for the healthcare workers who promote sterilisation. Unfortunate circumstances such as earthquakes, floods, tsunamis or accidents, do occur, resulting in the loss of children or even entire families.9 In addition, neonatal, infant, and under-5-year-old child mortality rates in India are significantly higher than those in many other parts of the world.10 Consequently it is not rare that couples who choose sterilisation as a means to limit their family size lose a child or children. While such loss is a cataclysmic life event that could happen to anyone, the consequences of such a tragedy are worse for sterilised persons, as it would be a gruelling process, if not utterly impossible, for them to bear any additional offspring. The subsequent mental and emotional trauma is not restricted to the grieving individuals. The community health workers who advocated sterilisation as well as the doctors who performed the surgery also bear a heavy mental and emotional burden in such cases, as these are often the very first people approached by the affected individuals.

Irrespective of the circumstances under which a sterilised person loses their child, it is crucial for the government to support them. A large number of people who adopt sterilisation are illiterate, reside in remote areas and do not have access to advanced healthcare facilities. Furthermore, many of these individuals have insufficient resources and are unable to bear the expenditure associated with a corrective procedure. Another factor contributing to the need for government intervention is the gender bias so prevalent in Indian society, which renders infertile women vulnerable to domestic violence, abuse, and neglect. Thus, the government of India should formulate and implement policy and interventions for those so impacted. To begin with, those affected should be counselled on the options available to them. A package could include child adoption services, reversal surgery and assisted reproductive technology (ART).

I propose that reversal of female sterilisation should be offered as the first choice for those wanting more children as it does not require repeated visits to hospitals, is cost-effective (in comparison to ART) and has a low risk of side effects.5 ART can be reserved as an alternative for those women for whom reversal surgery is unsuccessful.5 Through a public–private partnership model, the government could make effective use of the gynaecologists available in India’s private health sector for providing these services. Moreover, the Indian government should initiate a programme to train surgeons in microsurgical reversal techniques so that the reversal procedure is at least provided by every medical college in India. In addition, the government could modify existing FP indemnity schemes to include couples encountering child loss after sterilisation so as to provide some financial compensation towards the expenditure associated with reversal procedures. Formulation of policy and announcement of intervention plans for couples who have faced family loss after sterilisation would help to encourage more people to adopt effective alternative FP methods, thus ensuring the welfare of all.

Finally, in addition to addressing the devastation of child loss after sterilisation, the Indian government should work towards reducing the incidence of such tragic events. While we cannot prevent loss of life from natural calamities, improving child healthcare across the country can definitely reduce the rate of death due to common childhood illnesses. Most importantly, existing eligibility criteria for sterilisation should be modified, first and foremost with respect to the minimum age for undergoing sterilisation (22 years), which should be raised.4 Moreover, the government should begin advocating for couples to use effective spacing methods such as intrauterine devices (IUDs) (the rate of postpartum acceptance of IUDs in India increased from 1.7% in 2013–2014 to 12.8% in 2016–2017) and depot medroxyprogesterone acetate injections (or any other effective spacing method of their choice) for the first few years after the birth of their second child. Furthermore, the government should look at other types of long-acting reversible contraceptives such as implants to be included in the national FP basket, to reduce dependency on sterilisation as a FP method.