From PRB

After the Tsunami‚ A Drive to Reverse Tubal Ligations in Tamil Nadu

by Margot Cohen

(July 2005) When India accelerated its nationwide family planning program in the 1970s, the southern state of Tamil Nadu was quick to respond. Government officials set up a wide network of primary health centers and spread the message that tubal ligation (also known as tubectomy) meant permanent birth control with no fuss.

The campaign brought dramatic results: By 2002, nearly 44 percent of Tamil Nadu's women had borne two children and been sterilized before their 27th birthday.¹ And the state's total fertility rate dropped from 3.8 in 1976 to 2.0 in 2002.²

But after last December's Indian Ocean tsunami killed over 2,300 children under age 18 in Tamil Nadu, the state government began offering free reversals of tubal ligation for women there who wish to conceive again. So far, 189 women have signed up for the microsurgery, which is known as recanalization.

"In countering the depression of losing a child, this is a very intelligent option," says Dr. J. Radhakrishnan, the district collector (or top civil servant) of Nagapattinam, a coastal district of 1.4 million people where the tsunami left 6,065 dead, including 1,776 children. "They feel guilty that they survived but could not save the child," he says of the bereaved parents.

The issues raised by Tamil Nadu's recanalization program, however, reach well beyond parents directly affected by the tsunami. Nationwide, more than two-thirds of India's female contraceptive users rely on tubectomy.³ And for some family planning experts, the new initiative is a stark reminder that India's health bureaucracy has failed to devote sufficient counseling and other resources to promote easily reversible contraceptive methods such as pills, IUDs, and condoms—especially for young women in their 20s.⁴

"Choice has been very limited for [India's] women," says Dr. Saroj Pachauri, regional director for South and East Asia at the New York-based Population Council.

No Hard Sell Needed for Tubectomies

In Tamil Nadu, just 3 percent of women are relying on IUDs, with 1 percent turning to the pill and 1.5 percent using condoms, according to a 2004 report from the Directorate of Family Welfare in Chennai, the state capital.⁵ But while annual targets for tubectomies have been officially abandoned, local governments such as Tamil Nadu's still strive to meet what they call each district's "expected demand" for sterilization. Between April 1, 2004 and April 1, 2005, doctors in Tamil Nadu performed more than 416,000 tubectomies, up from roughly 370,000 in the same period five years earlier.⁶

Dr. G. Venkatachalam, joint director of medical services at the government hospital in Nagapattinam, says Indian women are advised to undergo a tubectomy immediately after delivering their second child. "If prolonged for two or three months, the mother might not come to the hospital for sterilization,” he cautions. “Or she might conceive again."

After more than two decades of high-profile campaigns, though, the government no longer needs to make a hard sell for tubal ligation. "Women feel very comfortable with tubectomy," says Sheela Rani Chunkath, secretary of the Health and Family Welfare Department in Tamil Nadu. "They feel they don't want to mess with the hormones." Compounding the trend are continued complaints of excessive bleeding after IUD insertion and nationwide worries among women that pills bring side effects that include pronounced fatigue.

But Chunkath also emphasizes that the government is now seeking to promote vasectomies, which have only occurred sporadically in recent years due to broad male distaste for the method. "This gender imbalance, we really need to correct it," she says. "We think the man should also be responsible."

The Right of a Woman to Choose, or Just More Gender Discrimination?

More than a dozen tsumani survivors in Tamil Nadu have already had recanalization, but most of the other patients are expected to undergo the procedure in late June and July. Tamil Nadu's flamboyant chief minister, Selvi J. Jayalalithaa, added a political gloss to the drive by appearing on television to publicize an executive order that promised either free recanalizations at government hospitals or 25,000 rupees ($595) in compensation for those who opt for private clinics.

Some analysts think the initiative protects the reproductive rights of Tamil Nadu's women. "The recanalization approach is in fact in keeping with the right of women to choose the timing of the birth of their children as per their emotional needs,” says Madhu Bala Nath, South Asia regional director of the International Planned Parenthood Federation.

But other observers are expressing concern that the high-profile program feeds into broad cultural biases that only validate women if they bear children. In India, childless women generally live in fear that their husbands will remarry in the search to continue the family line—often at the prodding of their own mothers. Economic dependence only deepens such fears.

"This is about societal pressure on a childless parent. And that's not the right reason to have a child," says Sujatha Natarajan, vice president of the Family Planning Association of India.

There is also no guarantee that all of these operations will result in healthy pregnancies: One public hospital in Chennai that specializes in the procedure reports that just 47 percent of its recanalization patients eventually gave birth again. In fact, Chunkath says that many reversals could be doomed because government doctors often cut too much of the fallopian tube during the original tubectomy in order to forestall legal claims of method failure.

'Without Children, We Feel So Lonely and Lost'

Still, officials believe that recanalization will bring fresh hope to bereaved couples. At Kilpauk Medical College Hospital in Chennai, surgeon A. Kalaichelvi considers 24-year old Sumathy, a fish vendor from the town of Mahabalipuram, one of the lucky ones. Sumathy, who lost her 7-year-old son to the tsunami, had her recanalization performed by Kalaichelvi a month ago.

"I feel at peace," says Sumathy, perched on a blue hospital mattress. "My mother-in-law said, in future, when you grow old, you need a child to be there."

Sumathy says she has no particular preference for a boy or a girl—feelings that are echoed by many other tsunami survivors, according to Dr. Pinagapany Manorama, director of the Community Health Education Society, a Chennai-based NGO that conducted counseling in tsunami-affected villages. Such sentiments are unusual in a country where couples have long harbored a strong preference for boys, who ultimately inherit property and perform last rites for their parents.

Indeed, India appears to be fighting a losing battle against abortions of female fetuses, despite a measure that outlaws doctors from disclosing the sex of a fetus following prenatal scans. Tamil Nadu is no exception: The state's sex ratio among children up to 6 years old was 939 girls per 1,000 boys—a significant drop from the 948 females per 1,000 males recorded in 1991. In seven of the state's districts, the ratio has dipped below 930, with Salem district reaching an alarming 826 girls ages 6 and under for every 1,000 boys.⁷

But in the ramshackle tsunami relief camps erected near the coast, some couples appear desperate for any sort of companionship. "Without children, we feel so lonely and lost," confesses Moorthy, a 29-year-old fisherman whose son and daughter died in the tsunami. His wife, 24-year old Indira, became in January one of the first survivors to undergo recanalization. But the couple is still restlessly awaiting pregnancy.

Like most other bereaved parents in this traditional coastal community, they have no interest in adopting any of the surviving orphans, reflecting the unpopularity of formal adoption in India. "It's nothing like having your own child," says Indira, who was feeding her toddlers when the waves swept over their coastal hut.

While many health experts doubt that the tsunami will significantly alter the Indian government's longstanding focus on tubectomy, they feel the disaster could prompt some second thoughts among coastal dwellers. Says Dr. Manorama: "They may think, why get sterilized? A tsunami might come again."

Margot Cohen is a journalist based in Bangalore, India.

References

1. Government of Tamil Nadu, Department of Health and Family Welfare, Directorate of Family Welfare, 2002 Annual Report (Chennai, India: Government of Tamil Nadu, 2003).
2. Office of the Registrar General, India, Sample Registration Statistical Report2002 (New Delhi, India, 2004).
3. International Institute for Population Sciences, National Family Health Survey (NFHS-2) 1998-99 (Mumbai, India: International Institute for Population Sciences and ORC Macro, 2000), accessed online at www.nfhsindia.org, on June 24, 2005.
4. Injectables do not feature on India's contraceptive menu, partly due to concerns raised by local women's groups six years ago that the national government was not obtaining informed consent for experimental trials for the drugs.
5. Government of Tamil Nadu, Department of Health and Family Welfare, Directorate of Family Welfare, 2004 Annual Report (Chennai, India: Government of Tamil Nadu, 2005).
6. Government of Tamil Nadu, Department of Health and Family Welfare, Directorate of Family Welfare, Monthly Bulletin On Family Welfare Performance Tamil Nadu April 2005 (Chennai, India: Government of Tamil Nadu).
7. Venkatesh Athreya, "Census 2001: The Tamil Nadu Picture," Frontline 18, no. 29 (May 11, 2001), accessed online at www.frontlineonnet.com, on June 24, 2005.