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Twenty-five euros so that they will never again become pregnant: That's the equivalent sum that women in India receive from their government if they agree to be sterilized. It is seen as compensation for travel expenses and lost wages, but also as an incentive. The Indian government has had the program in place since the 1970s as a way of reducing population growth.
And it has been successful. Female sterilization is the most frequently used contraception method in the country and the national birth rate has dropped significantly. In a 2019 survey, almost 30 percent of Indian women of childbearing age reported that they had been sterilized. An additional 17 percent said they used other contraception methods, 45 percent said they don’t use contraception or have no need for it, and 8 percent said they would like to use contraception but have no access.
India is no exception. Across the globe, more women protect against pregnancy with sterilization than with condoms or the pill, making it one of the most frequently used contraception methods in the world – in part because it is widespread in populous countries like India and China. The United Nations estimates that more than 200 million women underwent the procedure in 2019 alone.
In countries around the world, including China, Puerto Rico, the United States and Canada, the share of sterilized women is between 18 and 31 percent, according to a meta-analysis performed as part of the World Bank’s Global Burden of Disease project and published in the medical journal The Lancet. One reason for the popularity of sterilization is that in many countries, other methods of contraception are either unavailable or too expensive. And because men rarely go through the process of sterilization themselves.
Some experts, though, are critical of the trend, in part because women often don’t have much of a choice in the matter and the procedure is subsidized in places like India for political reasons. "For politicians, contraception is primarily a means for controlling population growth," says Mona, a researcher who works on a sustainable development program for the Observer Research Foundation in Delhi. For personal reasons, she doesn’t want her last name to be published.
In India, the number of children per woman has dropped from 5.2 to 2.3 since 1971 – a positive development from the government’s perspective. Mona, though, says that such numbers often lead to an inadequate understanding among politicians of what sterilization means for women.
The procedure, during which the fallopian tubes are either severed or otherwise made unviable, generally can't be reversed. It is also far riskier than other options. "Contraception methods shouldn’t just work. They also must be safe and practical, and their use must not harm a woman’s dignity," says researcher Mona.
Because that isn’t always guaranteed, there has been frequent criticism of India’s sterilization program over the years. In addition to the compensation provided to women, the state also finances most of the clinics where the procedures are performed. In rural areas in particular, says Mona, such clinics often take the form of mass sterilization centers, and there have been repeated reports over the years of almost factory-like conditions, with some women not surviving the operation due to the poor medical attention they receive.
Women in a hospital in Bilaspur, India, in November 2014 recovering for sterilization proceduresFoto: AP
In 2016, the Supreme Court of India even ordered the government to close down such sterilization centers, a ruling that came in response to the deaths of more than 300 sterilization patients in the preceding three years. According to reports in the Indian media, however, such clinics continue to operate.
Still today, female sterilization is the most efficient method of birth control for the Indian government. On top of that, as Mona says: "Family planning in India is up to the woman." She says that campaigns for methods of contraception are almost always aimed at women, and even though financial compensation for vasectomies tends to be higher than it is for female sterilizations, hardly any men undergo the procedure.
In November 2014, New Delhi saw protests against the state-subsidized sterilization program after dozens of women died during the procedure.Foto: Manish Swarup / AP
There are historical reasons for this. During the period between 1975 and 1977 when a state of emergency was declared in India, millions of men were forcibly sterilized in an extremely brief period of time. Since then, vasectomies have become a political taboo in the country. "There is hardly any discussion of male sterilization," says Mona. "Part of that is because of history, but there is also a societal stigma which holds that the procedure harms manhood and virility."
But India is by no means the only place where vasectomies are stigmatized and contraception is almost entirely the responsibility of women.
"The popularity of female sterilization is an indicator for poverty and for limited access to adequate healthcare," says Laura Briggs, professor for international healthcare and reproduction policy at the University of Massachusetts Amherst. "Sterilization is often only the best contraception method when circumstances make it so."
That is also true for the United States, she says. More and more people in the country are afflicted by poverty and poor medical care. "If regular doctor’s appointments for prescription contraceptives aren’t possible, then the probability is much higher that I will opt for a method that only requires a single appointment."
Women in San Juan, the capital of Puerto RicoFoto: Marica van der Meer / Arterra/Universal Images Group / Getty Images
Just how influential social and historical factors can be is also apparent in Puerto Rico, a country that for years has had the highest rate of sterilization in the world. "Women in Puerto Rico are so familiar with the procedure that it is simply referred to as 'La Operaciòn,'" says Iris Lopez, a sociology professor at City College in New York who specializes in the Puerto Rican diaspora and sterilization abuse.
A major factor in the high rate of sterilization is the colonization of the island by the U.S. Up until the 1970s, a third of the women in Puerto Rico were sterilized as part of a program financed by the United States. From the perspective of Washington, the Latin American island’s developmental problems were a direct consequence of its high birthrate. Many of the women who underwent the procedure did not receive sufficient information and thought it was reversible. Others were forced to submit to sterilization.
But it’s not just the consequences of the sterilization program that can still be felt today. U.S. pharmaceutical companies in the 1950s also tested high dosages of progesterone in Puerto Rico, the hormone in birth control pills. "Many women became ill and suffered from side effects," says Lopez, leading to a situation in which the pill and other modern contraceptive methods were long viewed with skepticism.
Only since the mid-2000s has the frequency of sterilization in Puerto Rico begun to fall. But high costs, bureaucracy and a lack of infrastructure continue to limit access to other contraceptives. For Iris Lopez, though, another question is also important: "In a colonial context in which sterilization was long promoted as the only method, can we really speak of a free decision?"
The Fight against Forced Sterilization
"When it comes to female sterilization, consent is often a gray area," says Mona, the researcher with the Delhi-based Observer Research Foundation. In India, she says, it is mostly poor women from lower castes who undergo the procedure, or women with mental disabilities. "Women aren't given the information they need to make an informed decision," she says.
In other countries, too, it is often socially disadvantaged women who are most affected. The procedure is frequently performed following Caesarian sections, at a time when the women are often exhausted and can hardly object. Sometimes, doctors sever the fallopian tubes simply because an incision has already been made.
Whereas forced sterilizations can be ordered by a court of law in the U.S., in Canada it is primarily members of the First Nations who report being sterilized against their will, even though the practice violates Canadian law. One woman told a Canadian parliamentary investigative committee: "I wasn’t at all aware of what had been done to me until I went to a fertility clinic to find out why I couldn’t get pregnant. I was then told that part of my uterus had been removed."
Still, such examples of coerced and forced sterilization do not explain the dominance of the practice. Iris Lopez, for her part, believes the discussion about the possible reasons for the widespread reliance on female sterilization to be unhelpfully polarized. Women, she says, are either portrayed as being completely free to do as they choose or as victims of the situation in which they find themselves. For Lopez, the truth is somewhere in between: "Women try to make the best decision they can for themselves under repressive conditions."
Laura Briggs holds a similar view: As long as countries restrict access to certain forms of contraception and people are left to deal with medical costs and childcare on their own, truly free choices in contraceptive matters will not be possible.
Note: Some of the data used for this story is from a meta-analysis performed by the Global Burden of Disease Project, which gets funding from the Bill & Melinda Gates Foundation.
This piece is part of the Global Societies series. The project runs for three years and is funded by the Bill & Melinda Gates Foundation.
The Global Societies series involves journalists reporting in Asia, Africa, Latin America and Europe on injustices, societal challenges and sustainable development in a globalized world. A selection of the features, analyses, photo essays, videos and podcasts, which originally appear in DER SPIEGEL’s Foreign Desk section, will also appear in the Global Societies section of DER SPIEGEL International. The project is initially scheduled to run for three years and receives financial support from the Bill & Melinda Gates Foundation.