Of 13 505 women who underwent voluntary sterilisation procedures at eight clinics operated by DKT/Janani in the states of Bihar and Jharkhand, India in 2007, the average age of the sterilisation clients was 29 years. The average parity was 3.6. A very high percentage of these clients came from districts with relatively low literacy and high infant mortality, a reflection of the rural and underdeveloped nature of this part of the subcontinent.

Despite a controversial and chequered history of sterilisation generally, the sterilisation of women in India today represents the overwhelming choice of Indian couples. About 37% of married women of reproductive age have chosen sterilisation,1 representing a remarkable 77% of all persons practising modern methods of birth control in this country.

During the 1960s, several Indian states began providing compensation to cover the out-of-pocket costs for couples who accepted sterilisation. At that time, vasectomy was by far the more popular of the two sterilisation procedures. However with the introduction of quotas and incentive systems during the emergency period (1976), millions of men were sterilised, often with dubious consent. The result was a backlash against government-promoted vasectomy, but not against female sterilisation which, surprisingly, continued to gain popularity virtually without interruption.

In 2007, the Indian organisation Janani, an affiliate of DKT International (http://www.dktinterntional.org) operated 18 clinics in the states of Bihar and Jharkhand. Eight of the clinics were chosen for this review. The poverty levels in the districts where the clinics are located, especially the rural clinics, are extremely high. Literacy averages just over 60% vs 72% for India as a whole, and infant mortality averages 80 per 1000 as compared to an India-wide average of 57 per 1000.

Particularly given the relatively low socioeconomic status of these women, the average age for the sterilisation procedure seems remarkably low. Among all 13 505 clients, the average age at sterilisation is 28.7 years (Table 1). However, even at this age, parity of 3.6 suggests a completed family size. The total fertility rate for India is just 2.7 vs 4.0 for all of Bihar and 3.3 for Jharkhand.2

As expected, virtually none of these clients were without sons, however many daughters they may have had. Of those who had no daughter (16%), the great majority had two or more sons. Virtually none of these women presided over one-child families, and relatively few (17%) underwent sterilisation with only two children. Some 35% had three children, 29% had four and 18% had more than four (Table 1).

When interviewed about their use of family planning many of these clients revealed that they had never used it before. They and their families look on ‘the operation’ as a natural step in their reproductive lives, and many have never heard of any other contraceptive method.

While the average age and parity statistics for the urban and rural clients are not dramatically different, the child-bearing patterns vary considerably. Far more urban clients had no daughter (25% vs 10%), and more of the rural couples had four or more children than did the urban women (56% vs 33%; Table 1).

Except for sterilisation, fertility patterns in Bihar, especially in the rural areas, seem largely unchanged from centuries past. Women marry in their late teens, use little or no birth control, and bear three or four children before they attain the age of 30 years, spacing the births naturally through lactational amenorrhoea. Modernity intrudes only then, with the sterilisation procedure that has now become overwhelmingly popular among women throughout India.