The 20th Congress of the International Federation of Gynecology and Obstetrics (FIGO) in Rome featured a panel entitled “New FIGO Guidelines on Female Contraceptive Sterilization and Informed Consent: How to Comply”, which was the opening session of the conference in the area designated for Sexual and Reproductive Health issues. Below are my notes from the panel.
The 20th Congress was attended by at total of 8,000 people over one week. The full program is available at http://www.figo2012.org/scientific-programme/
The 21st Congress will take place in Vancouver in 2015, see http://figo2015.org/
Dr. Abhijit Das spoke on incentive systems and the new ethical guidelines on sterilization. He reported that nearly 20 % of women aged 15 -49 (225 million women worldwide) are sterilized and that 40 % of them live in India. Roughly 80 % of all women in India use sterilization as their contraceptive method, which raises the question of whether they are being sufficiently provided with alternatives and options.
The history of female sterilization in India was summarized as follows: From 1975-77, during the Emergency, about 12 million vasectomies were performed under increasingly inhumane conditions. After the fall of Indira Gandhi’s government (in part as a result of these excesses), the approach of “family planning” was replaced by an approach termed “family welfare”. In 1982 Indira Gandhi returned to power, and from 1982 – 1986, there was increased coercion of women to undergo tubectomy as part of family planning. In 1996, after Cairo (1994), India announced it would be taking a “Target-Free Approach” to family planning (again because of the previous excesses). In the year 2000, India announced its National Population Policy, and in 2005 it announced the National Rural Health Mission, which now focuses on Maternal Health and Institutional Delivery. Female sterilization rates are continuing to rise today.
Dr. Abhijit then screened clips from “Something Like a War”, an Indian film about sterilization made in the late 1980s which showed how promises of cash and land were made to women to undergo sterilization and then were not kept. Today, the news schemes involve providing women with blenders, cars, DVD players, etc.
Dr. Abhijit also noted that the Indian authorities are currently claiming that India is undergoing a “population explosion” despite the fact that its population growth rate is currently the lowest it has been for 50 years. “India adds an Australia every year” is the slogan being used to describe this supposed “explosion”. The language of “targets” has recurred, with the Chief Minister of Madhya Pradesh announcing a state level target of 700 000 sterilizations for 2011-2012.
What has not changed: In 2008, incentives were reintroduced. Quality of care continues to be very poor. There were reports from Bihar of “sterilization camps” being conducted in school buildings in early 2012, and of similar coercion in Madhar Pradesh in 2012. Deaths from improperly performed sterilizations have been occurring since 2010, and insurance compensation to the victims’ families has been delayed.
Continuing Concerns: Policy makers are taking a neo-Malthusian population control approach. There is little appreciation of the concept of population momentum (to which this “sterilization-only” program and decreasing family sizes are contributing) and little awareness that the full range of contraceptive services is not reaching the people. Politicians in impoverished states are now keen to become “developed”. There is also a new focus on immediate post-partum sterilization since a larger number of women than ever before are now delivering in an institution. Technocrats see sterilization as being simpler in management terms than any other contraceptive method. There is near-total ignorance about the FIGO ethical guidelines.
Coercion and poor quality of care: Coercion of sterilization is occurring through the provision of incentives. There is a lack of choice, as providers focus on sterilization only, and women accept it as the “best” option. No information is provided about other options or about the side-effects of this or any other contraceptive method. There is also a lack of understanding of potential adverse outcomes for sterilizations. The poor technical quality of the services provided is leading to increased deaths, increased failures, and morbidities.
Dr. Abhijit said he interviewed 7 gynecologists and 3 surgeons regarding the FIGO Guidelines and India’s contemporary context; 6 of the gynecologists were FOCSI members. The public-sector doctors he interviewed felt that the ethical guidelines were essentially harassment. The private-sector doctors he interviewed said they tell rural women to be sterilized and urban women to use less permanent contraceptive methods. For disabled women, their guardians’ consent is considered sufficient.
Dr. Das called on FIGO members to actively participate in the formulation of governmental policies and programs around family planning, in the implementation of the policies and programs, and in reviewing their implementation.