Contra-indication: Examining the issue of reproductive rights in India

—In October, two tech giants announce they will pay women employees $20,000 (approx. Rs12,20,000) to freeze their eggs. They hope the move will attract more female staff and help retain them longer by taking off the pressure to have children by a certain age.

—On November, 13 women die and 49 are hospitalised after a botched-up sterilisation operation at a state-run camp in Chhattisgarh's Bilaspur district. A day later, on November 11, 60 women who underwent tubectomy at another camp nearby are admitted to hospital with post-operative complications.

Two events from two very different worlds, one representing the acme of a developed society and the other, the nadir of an underdeveloped one – do they have anything in common?
"Yes," says Dr Geeta Sethi, who heads the Family Planning Association of India, an NGO working in the area of sexual and reproductive health. "In both instances, one sees an external agency, the state or a corporation, seeking to exert control over a woman's fertility for its gain. This is often done through pressure of various kinds." Sethi cites the monetary incentives given to poor women for tubectomy. "Many of them are very poor, have little formal education and are often marginalised tribals and Dalits." She feels the tech majors have decided to let women employees undergo "highly invasive medical treatment in return for putting off family life" instead of saying "have children and we'll support you with well-paid maternity leave and subsidised childcare".
Dr Laxmi Lingam, Deputy Director of Tata Institute of Social Sciences (Hyderabad campus), agrees. "They are both part of the same exploitative continuum which seeks to control women's bodies, their sexuality and reproduction". The corporate sector, she adds, "fails to realise that great employees want to be able to blend work with family life".
Sethi raises another issue — what happens to the eggs if the woman quits? "Will the companies continue to bear the costs of preserving them or simply discard them?"
Oocyte cryopreservation or egg freezing is an expensive affair, costing about Rs2 lakh initially and Rs40,000 as annual fees. It is not foolproof, and a 2013 guideline from the American Society for Reproductive Medicine warns that "there is not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women because there is no data to support the safety, efficacy, ethics, emotional risks and cost-effectiveness".
On the flip side, the fact also is that egg freezing is becoming increasingly popular as it gives career women the option of delaying having a child until their 40s. "It offers reproductive autonomy to the smart woman who is making her own decisions. Why should a career or a baby be an either/or question for women? I have so many women in their 40s who come to me wanting to have a child, and they say they wish they had had access to this when they were 30," says Dr Aniruddha Malpani, a well-known infertility specialist in Mumbai.

Contraception in a man's world
In India, the entire debate is vitiated by the fact that the onus of 'family planning' seems to have fallen largely on women — ironic in a country still steeped in patriarchy, where women have little control over their sexual lives and where one woman dies of childbirth every eight minutes.
Female sterilisation constitutes as much as 74.4 per cent of India's sterilisation efforts, according to the February 2014 follow-up report of the 1994 International Conference on Population and Development (ICPD). Moreover, the relative use of male sterilisation in India declined by 2 per cent since 1994, the report says. ICPD was a landmark agreement which bound its signatories to making sure that "reproductive rights which women's groups have been advocating since the '80s, and not population control, would be the cornerstone of their respective family planning programmes". Implicit to reproductive health, was "the right of women and men to be informed and have access to safe, effective, affordable and acceptable methods of family planning of their choice".
India, a signatory to ICPD, is far from this ideal. According to data from the Ministry of Health and Family Welfare in Haryana, almost a quarter of married women aged 15-24 who want to limit or space pregnancies do not have access to contraceptive information or services. While there are targets for female sterilisation, data shows that knowledge of non-permanent contraceptive measures has actually decreased since 1998.
In November last year, the NGO Himmat Mahila Samooh filed a PIL in the Punjab & Haryana High Court demanding a woman's right to contraceptive information and services. "The state government's failure to do this, our petition argued, was a violation of Article 21, which guarantees women the fundamental right to life and health," says Samooh president Jugmati Sangwan. The matter is still undecided, with the state government being directed to respond to the petition.
In India, 'the cafeteria approach' — where couples are told about all the contraceptive options available to them and then allowed to decide — is non-existent, sociologist Mukul Joshi says. "It's like creating a menu full of non-vegetarian choices and adding one vegetarian item and calling it holistic".
Joshi is referring to the many contraceptive options available for women — tubectomy, intrauterine devices (IUDs), hormonal implants like Norplant, contraceptive injections, oral contraceptives, emergency after-intercourse pills and female condoms. Each of these, he says, has multiple problems.
"Tubectomy," he says, "is invasive and risky. Intrauterine devices often lead to infections and menstrual problems, hormonal implants and injectables can cause nausea, depression, extreme weight gain, irregular and/or heavy bleeding, osteoporosis, loss of sex drive, an increased risk of breast and cervical and uterine cancers. Oral pills also can play havoc with a woman's body, and the female condom is not easily available."
Ironic, isn't it, that it was the pill that was the harbinger of women's liberation? Introduced in 1960, the contraceptive pill gave women complete control over their lives by allowing them to choose when to have a child and work alongside men on a more equal footing.
The options for men — withdrawal (coitus interruptus), condoms or vasectomy — are less invasive and reversible, Joshi points out. "While withdrawal is the easiest, how many men want to do it? As for condoms, men are even given choices in terms of texture, flavour and improved longevity of performance!"
According to a senior executive in an advertising firm, women like her may feel that they can decide for themselves, but it's an illusory freedom in a conservative society like ours. "The decision to delay having a child was mine," says the 39-year-old. "But after using the condom for a few months, my husband decided he didn't like it and left the responsibility of birth control to me. I went on the pill and continued despite the physical problems. Now, we can't put off having a child any longer. I have started IVF treatment and the hormonal injections are taking a severe toll on me."
Geeta Sethi wonders why science hasn't been able to come up with more contraceptive options for men. "Researchers in this field are not applying their minds as much to men as women. Placing the responsibility for contraception decisions solely on women impedes efforts to promote male responsibility. In a culture like ours, men dominate reproductive decision-making. If partners disagree on the number of children or use of contraceptives, the man's views usually prevail."
Besides, there are social biases at work in the health delivery system. Young women from slum colonies — or in villages such as those in Chhattisgarh — are often pressured into sterilisation immediately after childbirth. "After my abortion the doctor at the municipal hospital said I should get a copper-T installed. They knew I was in no position to say no," remembers Mayawati Thorat, 29, who lives in the Shivaji Nagar slums in Govandi, Mumbai.

Population control
Experts question another aspect of government-sponsored family planning programmes such as female sterilisation. The approach often seems aligned with eugenics, a belief widespread in the late 19th century — now completely discredited — that the human species could be "improved" by discouraging reproduction among persons with genetic defects or "undesirable" traits.
"The idea of population control first began as a way of limiting populations that were seen as 'overwhelming' other groups. That these were often poor, immigrants and from a section of society seen as 'the other' wasn't at all coincidental," Lingam says.
The restriction of women's rights is most glaring on the issue of abortion. The Roman Catholic Church is, of course, infamous for its opposition, but other religious groups too, says Joshi, have a pro-natalist agenda.
Anubha Singh, who has been researching women's reproductive rights among low-income communities in Delhi, says laws such as the Medical Termination of Pregnancy (MTP) Act restrict women's choice. "Abortion is not really a right in India. A woman cannot go to a doctor and ask to terminate a pregnancy. Safe legal abortions are allowed only if a physician authorises it. The MTP Act came out as a family control measure where abortion was seen as a secondary method of population control." Further, she adds, the act only applies to married women — the sexuality of an unmarried woman is not recognised. In many cases, health workers say, the husband's approval is sought before an abortion is allowed.
The husband, government and corporate policies, science, religion, and the law… the odds are against the woman and her right to choose when and how many children she wants to have. And while birth control measures are definitely her ticket to freedom and a career, the choice of contraception — sterilisation, egg-freezing or the pill — must be an informed one, taking in the upsides and downsides of each.

Male order
Males have fewer options of birth control compared to women. These comprise withdrawal, condoms and vasectomy. But a series of new generation male contraceptives are on trial. Of these, the most promising is Vasalgel in which a polymer gel is injected into the vas deferens, a duct through which sperms pass to reach the penis. The technique was developed by an IIT-Kharagpur professor Sujoy K Guha around 15 years ago but is only now clearing clinical trials

Contraception methods around the world
Female sterilisation is the dominant form of birth control in India, accounting for 74.4% of modern contraception methods used by women between the ages of 15 and 49. In Japan, the preferred method is male condom use, with 92% of couples using it.
In China, where population control is a government policy as in India, two methods of contraception predominate - intrauterine devices (IUDs), used by 48.3% and female sterilisation, which accounts for 34.2%. Contraceptive injections are favoured by 47.5% women in South Africa, and 52.9% in Kenya, with female sterilisation and pills accounting for the rest.