Women in India’s southern state of Tamil Nadu are finding their contraception choices wrested from them under pressures from health professionals and family, in a dark echo of earlier policies.
Ramya Rajishwari had her first, and so far only child just shy of her 19th birthday. But before she left the government hospital in southern India’s Tamil Nadu state, and without being fully consulted, she was fitted with an IUD contraceptive.
“The doctors talked to my mother-in-law, who said that because of my husband’s irregular wages and addiction to drugs and alcohol, it would be better not to have another child,” she says.
That conversation happened while she was in labour, and no one explained to her which type of contraceptive she would be getting. The doctors just told her she would not conceive again for at least five years.
A slight, dark-skinned woman who speaks in a low voice and rarely makes eye contact, Ramya is a member of an impoverished Dalit – or lower-caste – community relocated to tenements outside Chennai after the tsunami devastated coastal Tamil Nadu in 2004.
She is one of millions of women given an IUD, or intra-uterine device, by government health workers for long-term contraception. The device physically prevents embryo implantation, and some also release contraceptive hormones.
Citing the health benefits of birth spacing, the Ministry of Health and Family Welfare three years ago launched an initiative to institutionalize IUD insertion immediately after birth – a policy aimed especially at rural and poor women who only go to hospital for delivery.
Around 61 per cent of women in Tamil Nadu use contraception, according to a 2014 study. Since the government push, the proportion of those carrying an IUD has jumped from 3 per cent in 2004-2005 to 48 per cent in 2014-2015, according to government statistics.
The popularity of sterilization has remained stable at around 38 per cent of women using family planning.
But many of those with IUDs are poorly informed if at all about their options, campaigners say.
One researcher working with government hospitals found in a recent study of 221 women that 14 per cent reported some degree of coercion by health care providers to accept an IUD.
Fewer than a fifth were informed about other contraceptives prior to insertion, and just 5 per cent said they were told how an IUD works.
A “significant number” were fitted with an IUD without even being aware of it, she said, without quantifying further. The research has not been published.
“Some were refused immunization for their children if they didn’t agree. Unmarried women who went for abortions were rarely consulted. These are vulnerable moments in which women are expected to submit,” said the researcher on condition of anonymity.
When asked about the alleged lack of informed consent, an official from the Health Ministry said poor women, especially from “backward castes” – a byword for marginalized communities like Dalits – were deemed “irresponsible breeders.”
They were unable to provide a good quality of life for their children, he said on condition of anonymity. The ministry declined to comment in an official capacity.
“After decades of population control, health workers have internalized the need to restrict women to two children,” said the hospital researcher, who has written extensively on Tamil Nadu’s family planning policies.
“It is deeply embedded in the public psyche,” she said. “They feel they are doing good by preventing poor women from having children they cannot bring up.”
Family planning policy has a chequered history in India. During the 1970s Emergency, when civil liberties were suspended in response to perceived national security threats, 6.2 million men were forcibly sterilized, a move widely condemned nationally and abroad.
More recently, millions of women have received gifts or money from the government to undergo tubal ligation, a procedure to block the fallopian tubes.
Some are questioning whether such policies are still necessary in Tamil Nadu, where fertility has stabilized at the replacement rate of 2.1 children per woman – a rate reached by eight Indian states.
Experts say the policies survive as part of wider discrimination against women, especially from marginalized communities.
Women coerced in public hospitals have almost no legal recourse, according to Chennai-based lawyer R. Devika, who says “common expert opinion” is used to override informed consent.
The state is failing in its responsibility to protect women, says Subha Sri Balakrishnan, a gynaecologist who provides reproductive health training to rural women.
“A woman’s right to bodily integrity and autonomy is a non-negotiable human right – no group of experts can violate that,” she says.
In some cases, the IUDs can also cause health problems. When Ramya returned home, she started bleeding heavily and suffering abdominal pain.
“When I went back to the government hospital, they shouted at me and said I was imagining things,” she says. But another clinic found the doctor had put the IUD in without waiting for the placenta to be expelled, causing an infection.
Her private clinic treatment cost 2,500 rupees (38 dollars), about a quarter of her husband’s monthly wages.
She now receives a contraceptive injection every three months. She says her 22-year-old husband, Dharma, would not consider using contraception himself.
Neither would most husbands in India, where vasectomies account for just 1 per cent of contraception and condoms are unpopular, the researcher says.
“This is where the government should be focusing its efforts.”