On a cloudy April morning, a nervous Nisha Devi waited in the reception area of a family planning clinic run by the nonprofit Parivar Seva Sanstha in northwest Delhi. The staff called out numbers given to patients — women from nearby low-income neighborhoods — as they made their way inside to see the doctor, one by one. Devi, 34, was about to undergo a sterilization procedure. A mother of three children, she would have liked to have stopped at two but “the third was destined to come,” she said with a smile. She knew she wouldn’t be able to afford another slip-up. “If I get pregnant again, I will be the one bearing the consequences,” she said. She and her husband decided that she should get sterilized.
In the week of Devi’s appointment, India surpassed China to become the world’s most populous nation. Devi is just one of millions of Indian women who have undergone the surgical procedure to get their tubes tied, each individual decision contributing to a lower overall rate of population growth.
The United Nations projects that India’s population will continue to grow for several decades, before reaching a peak at some point around 2064. However, Indian women are having fewer children. Devi’s family is already larger than the average Indian family. According to the National Family Health Survey, between 2019 and 2021, India’s fertility rate was 2, below the replacement rate of 2.1. Though it is higher than China’s (1.2), it is much lower than the rate in India in 1992 (3.4) or 1950 (5.9). Over three decades, from the 1970s to the ’90s, India’s population grew at a steady 2.2% annually, and started to decline thereafter. In 2011, the growth rate was 1.6%.
In 1952, when Indian families were having about six children on average, the recently independent country became the first in the world to launch a nationwide family planning program and mass media campaigns about the importance of a small family size. Then, during the Emergency, when civil liberties were suspended for 21 months from 1975 to 1977 by Prime Minister Indira Gandhi, a coercive mass campaign to get men sterilized in a bid to control India’s population led to severe backlash. It made future governments fearful of focusing family planning initiatives on men, and so the onus for population control fell on women. India’s family planning program has since come to rely heavily, and unfairly, on one method: female sterilization. According to the National Family Health Survey in 2019-20, tubectomies account for 38% of all contraceptive methods.
“Female sterilization has been promoted as the most readily available method in the public health system,” Poonam Muttreja, executive director at the Population Foundation of India, a Delhi-based nongovernmental organization, told New Lines. Couples in India tend to adopt family planning methods when they feel they have completed their family size, and women prefer sterilization because it’s a one-time procedure. Guidelines stipulated by India’s National Health Mission state that sterilization, which involves laparoscopic surgery and a daylong procedure, can only be performed for women who are or have been married and have at least one child who is above the age of 1. The woman should be “in a sound state of mind” and aged 22 to 49.
But Dr. Sangeeta Prasad, who performs female sterilization at the Central Government Health Scheme Maternity and Gynae Hospital in New Delhi, told New Lines that many young women also opt for sterilization. She once had a 22-year-old patient who wanted to get sterilized. The woman’s youngest child was less than a year old but “she was hell-bent on getting it done,” the doctor said. She tries to counsel young women to opt for long-acting reversible contraceptives instead, in case they change their minds about having more children. And there are some who do later have regrets.
Amid anxiety about population explosion, the family planning policies of the 1960s and ’70s focused on population control rather than stabilization, said Debanjana Choudhuri, director of programs and partnerships at MSI Reproductive Choices, a nonprofit that provides contraception and safe abortion services. Family planning programs were driven by numerical targets at the state and federal levels.
“Rights and choice was something that was completely unheard-of,” she said.
In 1996, India adopted a “target-free approach” to family planning, but a 2012 report by Human Rights Watch found that “in practice, state-level authorities and district health officials assign targets for health workers for every contraceptive method, including female sterilization. In much of the country, authorities aggressively pursue targets, especially for female sterilization, by threatening health workers with salary cuts or dismissals.” These targets often led to coercion or poor quality services, the report said.
To meet these targets, India deploys a vast network of Accredited Social Health Activists (ASHA) — female community health workers — to educate citizens about contraception and distribute pills and condoms. They aren’t medical professionals but are entrusted to carry out a number of crucial duties, from advising expecting mothers about pregnancy dos and don’ts to making sure children receive all the necessary vaccinations. For many Indians, especially those in lower-income communities and rural areas, ASHA workers are the sole link to the public health system, including family planning resources.
ASHA workers are encouraged to bring women for sterilization or insertion of an intrauterine device. “Instead of receiving a fixed-rate salary, ASHA workers receive incentive-based payments which are heavily geared towards encouraging female sterilization procedures over spacing methods,” according to a 2018 report by the Human Rights Law Network (HRLN). Sudha Rani, a Delhi-based ASHA worker, told New Lines that she receives an incentive of 1,000 rupees ($12) for sterilization, while an IUD insertion fetches $6 and an injectable contraceptive is about $1. In some states, women who opt for sterilization also receive financial compensation.
“Incentive-based policies for female sterilization undercut the reproductive autonomy of the woman and, in substance, amount to coercive population practices,” HRLN stated.
According to data made available by the Indian Parliament, 1,434 women died because of botched sterilization procedures between 2003 and 2012, largely because of poor conditions in sterilization camps. Doctors had been using unhygienic equipment and administering expired drugs. A court ruling noted that a doctor in the state of Bihar had conducted 53 sterilizations in two hours. It made national headlines when eight women died and 25 others were left in critical condition after a botched mass sterilization campaign organized by the state health ministry in Chhattisgarh, one of the poorest states in India, with a huge tribal population.
Although India’s supreme court banned mass sterilization camps in 2016, two-weeklong family planning camps are held every year at government health facilities, where dozens of women are sterilized in quick succession within hours. Government guidelines clearly state that women must be counseled about the procedure and told about possible complications and other alternatives before the surgery, but news reports have stated that women are not informed adequately about either.
“In a patriarchal society such as India, the burden of family planning is borne by women even when vasectomy is a far simpler procedure than tubectomy or female sterilization,” Muttreja said. “There is also a prevalent myth that men may lose their ‘virility’ and strength if they undergo vasectomy.” Many women, too, discourage their husbands from getting a vasectomy. Renu Devi (no relation to Nisha Devi), 35, said she decided she would undergo sterilization because she’s a housewife, whereas her husband has to go outside for work and “can’t afford to become weak because of a vasectomy.” ASHA workers also said that men think a vasectomy will be “a blow to their ego.”
The negative attitudes toward vasectomy in India can be traced back to the 1970s and the government-sanctioned campaign of forced mass sterilization that took place in the country during the state of emergency declared by Indira Gandhi in 1975. Gandhi’s younger son, Sanjay Gandhi, embarked on the aggressive campaign targeting men, especially from low-income households, who were often sterilized against their will. Rewards were offered in exchange for reporting noncompliance and men had to produce sterilization certificates to renew their driving licenses. The campaign also led to violent clashes in the town of Muzaffarnagar, Uttar Pradesh, when the police opened fire on protesters, killing 25 of them.
A major impetus behind this campaign was also the mounting pressure from the West on India to control its population. In his book “The Sanjay Story,” the Indian journalist and political commentator Vinod Mehta explained that the West, through the International Monetary Fund, the World Bank and the Aid India Consortium, had been advocating a sterilization-based crash family planning program because “valuable time had been squandered since 1947.” According to Mara Hvistendahl’s “Unnatural Selection: Choosing Boys Over Girls and the Consequences of a World Full of Men,” the World Bank doled out $66 million in loans for this purpose from 1972 to 1980.
Raj Narain, who became India’s health minister after the defeat of Gandhi in the 1977 elections, told The Washington Post that over 200 men died following vasectomies during that period, but other estimates put the number closer to 2,000. Narain became a folk hero after using the sterilization issue to defeat Gandhi, but family planning, sterilization and contraception had become dirty words in post-Emergency India. It even prompted the government to change the name of the Ministry of Health and Family Planning to Health and Family Welfare. The new government also offered monetary compensation to men who wanted to undergo recanalization surgery to restore reproductive capacity.
Since then, men have been virtually absent from India’s family planning program. Despite cash incentives, male sterilization is the least popular method of contraception in India, representing just 0.3% of the total. None of the five ASHA workers New Lines spoke to at the Delhi clinic, some of whom had been working for more than 15 years, have been able to persuade a single man to get a vasectomy. Some said that men don’t even agree to talk to them about it and quickly refer them to their wives.
Women have been burdened with the sole responsibility of contraception and often must resort to abortion as a proxy, Muttreja said. A 2015 Lancet study estimated that 15.6 million abortions occurred in India that year. “The incidence of unintended pregnancies and incidence of abortion are consistent with the level of unmet need for contraception among women in India and underscore the need for further investment to meet women and couples’ contraceptive needs and ensure access to safe abortion services,” the study said.
It is important to invest in targeted programs which promote men’s role in planning families, both as enablers and beneficiaries, Muttreja said. There also needs to be innovation in the types of contraception available to them, apart from condoms and vasectomies, said Choudhuri. Scientists are looking into the possibility of an on-demand male contraceptive, which could be taken a few hours before sex and could immobilize the sperm temporarily.
There is also a need to promote and push for temporary contraceptive methods. In 2017, the Indian government introduced three new methods — an injectable contraceptive, weekly pills and progestin-only pills.
“It was a step towards a much-needed shift from terminal methods to more modern spacing methods of contraception,” Muttreja said. But restricted access to these temporary methods and a lack of awareness about how to manage their side effects has meant that their uptake has been very low. Only 2.1% of women use IUDs, 5.1% use pills and 0.6% use injectables.
All of the five women whom New Lines spoke to at the family health clinic in Delhi had either never used any of the temporary methods or had given up on them after a short period. Nisha Gupta, a 31-year-old mother of three, had an IUD inserted a few years ago but later had it removed after experiencing prolonged weakness and heavy bleeding during her menstrual cycle.
Even the ASHA workers said that such complaints are routine. “Even if one woman in the neighborhood has a negative experience, the word spreads and no one comes forward to try temporary methods,” Rani said. Some women are worried about IUD displacement, added Ramrati Chauhan, another ASHA worker who encounters a lot of myths about it — that the IUD can make you permanently infertile or that it can migrate all the way up to the throat. “There needs to be a massive behavioral change campaign,” Choudhuri said. Women’s agency is also crucial, as men are the decision-makers for a large population, especially in rural areas and smaller cities, she added.
Gupta said her husband never uses a condom because “it feels strange.” Other women at the clinic agreed and said their husbands used them on and off depending on their mood. As a result, condoms make up less than 10% of all contraceptive use. Moreover, the men control what contraceptives their wives use. Chauhan, the ASHA worker, said sometimes men don’t allow their wives to have IUDs because they worry it will prick them during sex and ruin the experience. On another occasion, a woman’s family didn’t want her to take an injectable contraceptive even though she wanted to, so Chauhan was compelled to take her secretly to the public health facility to get it. As for oral contraceptives, women often forget to take them or say that the tablets “don’t suit” them.
“All contraceptives have side effects and the management of side effects has not been given priority and attention, which is much needed,” Muttreja said.
The use of temporary contraceptive methods reduces the risk of maternal and infant deaths, since it ensures adequate gaps between children. While the infant mortality rate in India is declining — it dropped by almost 70% in the last three decades, from 89 deaths per 1,000 live births in 1990 to 27 deaths in 2020, it is still 18 times higher than that of Finland. According to the Indian government, the maternal mortality rate has also dropped significantly. In 1990, it was 556 women per 100,000 live births, which was reduced to 97 by 2020.
It could also be a better choice for India’s upcoming generation of parents. Andrea Wojnar, India Representative at the United Nations Population Fund, explained that young people are now delaying marriage, often to focus on education and getting a job before considering marriage and parenthood.
“It’s really important for the government to make sure that there is a full range of family planning options,” she said.
Moreover, experts stress that family planning services should not be limited to families alone. “There’s a huge group of adolescents and people who are unmarried, who are left out of the conversation,” Choudhuri said. The phrase “family planning” itself can be alienating, added social scientist Kuhika Seth, as the mass media campaigns are not as appealing to younger couples. “The language has to change. If your language is dated, and does not really address the sensibility of the people you’re engaging with, then it loses its purpose,” she said. Family planning policies also need to pivot toward a rights-based and choice-based narrative and away from one of population control, said Choudhuri.
Education can also act as a contraceptive. “Access to education plays a crucial role in empowering women to make informed decisions about their reproductive health,” said Muttreja, as women with fewer than five years of education or no education are more than twice as likely to undergo sterilization compared to women with 12 or more years of education. It could also change attitudes in Indian families, which still have a strong preference for sons. This is one of the reasons why Indian couples have more than two children. Renu Devi has three daughters but “always wanted a son.” So when she finally gave birth to one a few years ago, she was ready to adopt a family planning method.
Gupta, the mother of three, said she had not planned or thought about the number of children she would like to have. It had not occurred to her that she should or could have a say in the size of her family.
“I wasn’t aware of all this when I got married, I only studied till fifth or sixth grade,” she admits. She underwent sterilization recently because her family could not afford to raise another child. “Today, even if we can educate one child properly, that is a big deal.”
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