Eight women have died and two dozen are seriously ill after undergoing sterilization surgery at a government-run health camp in central India, according to reports.
Officials in the Bilaspur district of Chattisgarh said some 80 women had undergone the procedures and were sent home on Monday.
However, 24 of the patients were later hospitalized after reports of vomiting and other ailments.
Local governments offer financial incentives – the 83 women who underwent tubectomies at the camp received payments of 1,400 rupees (£14) to have the surgery – for sterilization as the country grapples with rampant population growth.
Campaigners and rights groups however, say that incentivizing population control is leading to “coercive”, target-driven sterilization practices which are putting thousands of women at risk.
The health workers involved in the tragedy were paid 200 rupees (£2) for each woman brought to the camp.
Officials in eastern India came under fire last year after a local news channel showed dozens of women, still unconscious after their surgeries, dumped in a field near a health camp.
Surgery involves a woman’s fallopian tubes cut and tied. Procedures take place in what campaigner say are often “medieval” conditions with little regard for hygiene or safety standards.
Whilst authorities are required to provide women counselling on birth control methods, many overlook advice in a bid to meet targets.
India carries out nearly half of the world’s female sterilizations but account for a tiny fraction of all vasectomies.
Experts say uneducated, vulnerable and impoverished women are an easy target, be it for health workers or husbands who pass on the responsibility.
Many women are often unaware that the procedure means that they will never bear children again.
Most operations are performed in the first months of the year – a period dubbed “sterilization season” – as the end of the fiscal year prompts quota-filling.
According to a report by Human Rights Watch, health workers in Gujarat were threatened last year by their supervisors with pay cuts or dismissal if they failed to meet targets.
The targets-driven approach is despite assurances by the central government which announced in 2012 a new strategy that encouraged birth control methods over automatic sterilization.
The Indian government’s promises to adopt a ‘target-free’ approach to family planning goes back to the aftermath of the 1994 International Conference on Population and Development when it ceased setting centralized targets and devolved power to local governments to establish their own quotas based on local realities.
However, many health workers – particularly in areas with large populations of adivasis or tribal people who are among the most impoverished in India – say that local authorities are merely perpetuating the target culture.
Health workers – called ‘Anganwadis’ – from two districts in Gujarat told Human Rights Watch that district and sub-district authorities assigned individual yearly targets for contraceptives, with a heavy focus on female sterilization.
Almost all said that their supervisors or other higher-ups threatened them with adverse consequences including reduction in salary, negative performance assessments and even dismissals.
Experts from across India have repeatedly voiced concerns about contraceptive targets leading to coercion and poor quality services.
“Information about contraceptive choice and quality of services should not be sacrificed for numbers,” Dr. SundariRavindran, from the campaign group CommonHealth Coalition, said.
“Hounding a poor woman to get sterilized without proper information and leaving her to deal with negative reproductive health consequences cannot be seen as success.”
State authorities in some parts of India also use incentives – including cars, gold coins, and drawings for prizes – to “promote” sterilization.
Because male sterilization is not well-accepted socially, this almost always means female sterilization.
Aside from family planning programs, sterilization is pursued through other programs that are entirely funded by state governments.
For example, five states have introduced “girl child promotion” programs, which provide monetary benefits to parents of girls, with a final cash benefit if she reaches the age of 18 unmarried.
But to receive benefits, a couple must produce a sterilization certificate.
Experts have also repeatedly called for the Indian central government to refashion its family planning program to take into account social factors related to childbearing, including early marriage, the preference for sons, infant and child mortality, and the country’s lack of social security for the elderly.
The Indian central government’s failure to implement social security programs has been a major deterrent to contraceptive use since many families say they rely on their children, especially sons, to care for them in old age.
India created a National Policy for Older Persons in 1999 and passed the Maintenance and Welfare of Parents and Senior Citizens Act, 2007.
But little has been done to implement the policy and law.
A further problem has been the country’s focus on women in its family planning program. At the same time, it is men who often decide when to have sex and how many children to have.
According to experts, there is also a lack of sex education in the country’s school curriculum.
India’s 2003 Youth Policy specifically recognized that that education relating to reproductive health should form part of the curriculum but more than a decade after the policy was introduced, sex education in schools is yet to be made compulsory.
“In sex education, there are no shortcuts to engaging with both adolescents and men,” Dr. Abhijit Das, of the National Coalition Against Two Child Norm, said.
“India should treat age-appropriate compulsory sex education – both inside and outside schools ¬as integral to its new chapter on family planning and find a way of engaging men effectively.”