Sumati Devi knew before she arrived at the grimy government clinic in northern India that she would be paid to be sterilized.
She didn’t know that she would lie on an operating table with bloody sheets, that the scalpel used to open her up would be stained with rust or that she was supposed to first get counseling on other birth-control methods before giving consent to have her fallopian tubes cut and tied.
The main reason Devi had agreed to be sterilized at all was because the $10 she received -- equivalent to about a week’s wages for a poor family -- would help feed her three children.
“I did it out of desperation,” said Devi, 25, as she lay on the concrete floor recuperating at the clinic in the state of Bihar. “We’re so poor, we need the money. Health officials came to our home. They told us it would be best.”
When it comes to family planning, women are on the front lines in India, which has carried out about 37 percent of the world’s female sterilizations. Government-imposed quotas and financial incentives for doctors mean 4.6 million women were sterilized last year, many for cash payments and many in the unsanitary and rudimentary conditions that greeted Devi. Vasectomies, by contrast, accounted for just 4 percent of all sterilizations.
“This is a sign of how downtrodden women are in India, that they don’t even have control of their reproductive rights,” said Kerry McBroom, the director of reproductive rights at the New Delhi-based Human Rights Law Network, which helped to file a court case against the government last year documenting abuse at sterilization camps. “Women are the easiest prey, whether it is government officials or their husbands asking them to undergo the operation.”
Devi’s plight also highlights the failings of India’s main method for reining in its population. Despite the coercive nature of the program, India has missed every target in the past five decades to reduce its populace, which at the current rate will eclipse China’s by 2021.
The emphasis on surgery is a deterrent for women unwilling to lose the option of having children when they are still young. Like Devi, the majority of women sterilized in Bihar have had three or more children. And India’s decision not to pursue the more expensive option of teaching often illiterate women how to use pills or contraceptives means only about half of couples of child-bearing age practice modern methods of birth control, United Nations data show.
India, which has 1.2 billion people, is adding on average 18 million more each year, more than the population of the Netherlands. One in five babies born globally starts life in India, straining supplies of land, food and water, and bloating an underemployed, poorly skilled workforce.
“A fast-growing population affects everything: the economy, the environment, quality of life,” said Vishwanath Koliwad, secretary general of the Mumbai-based Family Planning Association of India. “More people means the fruits of our development are further divided.”
At the clinic, held in mid-March in the town of Sonhoula, the 33 women who had registered for surgery lined up in the heat outside as guards carrying bamboo sticks watched over them. They were then led into a dimly lit room, with peeling paint on the walls and bare concrete floors, and placed on makeshift operating tables propped up with bricks.
Dressed in jeans and flip-flops, A.K. Das, the surgeon at the clinic, moved from one operating table to the next as he made an incision below the navel in each woman, then cut and tied their fallopian tubes. The patients were laid shoulder-to-shoulder on the floor in a separate room to recuperate.
Das, who spent three minutes on each operation, ran out of anesthetic with more than 10 patients to go, forcing him to use a weaker sedative. He said he’s paid an extra $2 per patient by the government for continuing to operate under these circumstances. In between each operation an assistant washed the scalpel in a tray filled with warm water.
“The surgical equipment is meant to be brand new, but look at this,” he said, pausing during an operation to hold up the rust-stained scalpel he was using. “This is dirty and that will significantly increase the chance of infection.”
According to United Nations data, 49 percent of all couples in India practice birth control. Of that group, about three-quarters do so by having the wife sterilized.
In neighboring China, the government has since 1979 used the threat of fines and the loss of social services to enforce rules that bar many urban couples from having more than one child. It now is beginning to ease the policy as the population ages and coastal regions face labor shortages.
A majority of those attending sterilization camps in India are lured by incentives such as payments or improved welfare benefits, offered by provincial officials under pressure to meet targets each year, said Abhijit Das, director of the Center for Health and Social Justice in New Delhi, an advocacy group. He isn’t related to the clinic doctor.
“India has the most coercive birth control methods in the world after China,” he said in an interview. “Family planning has become a system of quotas and human beings are the targets.”
While the federal government formally abandoned numerical targets for sterilizations in 1996, that hasn’t filtered down to all states. Most of the operations are performed in the first few months of the year -- a period dubbed “sterilization season” -- so as to fill quotas before the end of the financial year on March 31.
Health workers in Gujarat were threatened with salary cuts or dismissal if they failed to meet targets, Human Rights Watch said in July. Women are pressured to undergo sterilization surgery without being told they will never again be able to have children, the group said after interviewing 50 health workers. Three calls and two e-mails to the office of Gujarat Health Minister Nitinbhai Patel weren’t answered.
States including Karnataka, Andhra Pradesh and Punjab give priority to couples willing to undergo sterilization when doling out some benefits, according to a 2012 study by the International Institute for Population Sciences.
“We can’t rely on just one weapon to win this battle,” said Naveen Jindal, a lawmaker with the ruling Congress party who has campaigned on family planning since entering parliament in 2004. “Sterilization is too ineffective. When I go traveling around my constituency, I hear lots of people say they don’t want the operation,” said Jindal, who controls one of the country’s largest steelmakers by value, Jindal Steel & Power Ltd.
S.K. Sikdar, who runs population control programs at the Ministry of Health and Family Welfare, rejects the idea that women attend the camps under duress.
“There’s no pressure, people are free to do whatever they like,” Sikdar said at his New Delhi office. “There may be some isolated districts where there are overeager officials, but they are rogue operators.”
Sikdar said sterilization is “one way” that the government is trying to reduce the population. “But we are promoting different birth control methods,” he said.
India was the first country in the world to introduce a policy to deliberately reduce population, beginning in 1952 as hunger mounted in the years following independence. A quarter of a century later, with the press censored and constitutional freedoms suspended by then-Prime Minister Indira Gandhi, a mass sterilization drive officially targeting men spurred allegations of abuse and coercion of the poor.
Women are the focus of the sterilization drive because India has a male-dominated culture, said Sona Sharma, joint director of the Population Foundation of India, an advocacy group. “Men fear they will lose their virility or they will become weak if they undergo the operation,” Sharma said. “As the breadwinners they make the decisions.”
Sterilization has helped slow the birth rate. India’s population grew 17.6 percent in the decade to 2011, according to Indian census data, four percentage points less than in the previous 10 years.
The data mask wide regional variations. The number of people living in Bihar and Uttar Pradesh surged 25 percent and 20 percent respectively in the same period.
States that have most successfully curbed population growth are those that have raised education levels, increased work opportunities for women and enabled access to a range of contraceptives, said Jindal.
In Kerala, where government policy has achieved almost total literacy, the population grew 4.9 percent, according to census data. Fertility has plunged in the past 40 years in the southern state to 1.7 children per woman from 4.1 children. The national rate is 2.6.
Interviews with medical personnel and non-governmental organizations show the extent to which state governments continue to pursue targets.
“At the end of the year we are judged on how many sterilizations we have done,” said M.A. Rashid, 63, the doctor in charge of the Sonhoula clinic. “If we don’t meet the target, we get a scolding. The government doesn’t want excuses.”
Farooq Khan, a government doctor in Sonhoula, said that financial reward was the main reason the women agreed to be sterilized. “It may only be a small amount, but for these poor people it’s enough that they are willing to give up their reproductive rights,” he said.
Bihar, where annual per-capita income is the lowest in the country at $420 and the illiteracy rate is the highest, intends to sterilize 650,000 women and 12,000 men annually, according to the state health ministry. This year the state is planning more than 13,000 female sterilization camps.
For cash-strapped Indian state governments, sterilization is a less costly option than funding birth control programs via trained counselors and regular medications. All of the country’s 28 states are estimated to have run fiscal deficits in the year that ended March 31, according to data from the Reserve Bank of India.
Federal budgets for education and welfare programs are also under pressure as India endures its weakest economic growth in a decade. The government says that by 2022, India needs 600 more universities and 35,000 more colleges, and must increase its power-generation capacity by 73 percent. A food program for the poor is being expanded at a cost of $22 billion a year.
Ahead of their operations at the clinic, a medical assistant pricked each woman’s finger, using the same needle on multiple patients, and squeezed out drops of blood to test for anemia. Each patient had a number written on her arm.
Flies swarmed through the windows of the Bihar clinic, landing on patients. Das, the surgeon, removed his surgical mask after several operations because of the heat. Health workers milled about without protective gloves, shoes or masks. When the electricity shut down, a generator was cranked up. Dogs walked down the corridors outside the recovery room.
The women had cotton wool taped over their wounds. Nurses stepped around those lying on the floor, offering painkillers to the ones who groaned in agony.
“The program should be voluntary,” said Das, the surgeon, his face dripping with sweat as he ended his day. “There shouldn’t be any targets. This isn’t why we entered medicine. The entire system needs to be changed.”