Category: Family Planning

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Family Planning Medical Public Health

Condemn “Assembly Line” Sterilizations

News media focused in November on deaths in India after women had surgery at a sterilization “camp”. Authorities suspect that the surgeon caused more than a dozen deaths, so he is in prison.

More people are added to the population of India each year than to any other country. India has family planning programs, but abuses occur. This epidemic of deaths may have occurred because of disregard for established standards.

Indian gynecologist Pravin Mehta holds the world’s record for the number of tubal ligations that one doctor has done—over a quarter million. He told me how he could do 300 surgeries in one day; Henry Ford would have been amazed!

I didn’t realize how crude Mehta’s process was until I saw a movie of him working in a surgery camp. Operations were performed in a tent, and conditions were very primitive.

Nevertheless, Dr. Mehta’s safety record was remarkable. He offered a reward for anyone who reported a problem, including pregnancy, after his surgery, but gave out very few rewards. Indeed, I believe that his complication rate was lower than surgeons doing tubal ligations under modern conditions.

Were all these surgeries truly voluntary? During the era when Dr. Mehta worked—1970s and 1980s—India had aggressive sterilization programs for both men and women. Acceptors were given a small stipend if they agreed to the surgery. Recently the stipend for a person getting sterilized was equivalent to less than $10—a small sum by our standards but more than a villager might see in a month.

Reports of the recent sterilization tragedy frequently mention that women wanted to limit their family size, but that they were not given information about temporary methods of family planning. Even if women knew about temporary methods, they were not available.

Many problems were found after these Indian surgeries that killed many young mothers. The operating room was not clean, the staff were untrained, the medicine was contaminated. The same syringe and needle were used to inject local anesthesia for many women. Even worse were systemic problems: almost all of the funding was used for administration and too little paid for actual health care, there was little counseling or informed consent, no access to temporary contraceptive methods, and providers were pressured by numerical targets.

Two Americans are making a documentary about sterilization. Quartz published quotes from some of the Indian women they interviewed; here is the link: http://qz.com/299712/these-are-the-voices-you-did-not-hear-after-the-chhattisgarh-sterilization-tragedy/. One of the women, Archana, said:

“I was 19 when I got married and I have 3 kids. I don’t have much income, that’s why I got sterilized. When our income is limited what’s the use of having so many kids? ASHAs [Accredited Social Health Activists] came to visit me and told me about sterilization. When I got sterilized I went with my sister-in-law to the hospital and was given Rs600 in compensation. My husband and my mother-in-law were supportive. It took me about a month to recover fully. After a week I had to cook for my kids and take care of the house. I would have liked an entire month to recover, but we didn’t have anyone else to do the work. I chose this method because I had so many kids, and I didn’t know of other methods of contraception at that time. Now I’ve learned about more temporary methods. Copper T is not available here, you have to go to the cities, but you can get pills and condoms here.”

Please remember that conditions and standards in developing countries are different from what we know. Nevertheless, people must be respected and well informed about their health care.

Can family planning programs provide services to millions of people and yet assure that care is truly voluntary? Delegates at the International Conference on Population and Development 20 years ago felt that it is best if family planning were a part of comprehensive reproductive health programs. Since then our population has grown by 1,600 million people, with consequent increasing problems. Much of this growth is in developing countries, but remember that it is we in the rich countries who cause the worst impact because of our consumption!

Some of the family planning workers have real concern for the people they serve. After this tragedy one ASHA (health activist), Mitanin, is quoted as saying: “with what face we will tell people to go for sterilization?  Now, even if they come to us for it, we will hesitate.”

A new program, FP2020, is working to provide quality family planning services while respecting reproductive justice. More about FP2020 soon.

© Richard Grossman MD, 2014

Woman after sterilsation surgery in Bilaspur

Categories
Family Planning Population

Watch East Los High

There was an omission in my last article about the effectiveness of the media on teen pregnancy rates. Bill Ryerson, one of the world’s most effective population activists, kindly reminded me of my mistake in leaving out an important example of the use of modern media.
“East Los High” is an online TV series aimed at Hispanic teens. All the episodes of the 2013 season and several episodes for 2014 are available at www.hulu.com. Be prepared for an advertising blitz, and for an introduction to a very different lifestyle.
When I was in high school I knew that guns, shootings, teen pregnancies and drugs all existed, but I had no personal experience. Times have changed. I watched several episodes of “ELH” with real apprehension because of the problems these adolescents endure—and the excellent quality of the acting.
In between the violence and sex are some sweet but instructive scenes. Jacob is a football hero who discusses with his dad whether he should join the military or not. His father recommends that he take advantage of a sports scholarship and be the first in his family to go to college.
Jessie is a very good student who doesn’t date and belongs to the “Virgin Club”. She is a junior and so is amazed when Jacob, a senior, asks if she will help him study chemistry. The study session turns out to be more when he becomes amorous. She protests, pushes him away and says that she is still a virgin and needs more time.
“I totally understand if you think I’m lame and you don’t want to hang out no more,” she says.
“Hey, I don’t think your lame” Jacob replies.
In another episode a dancer announces to the dance team’s head that she is pregnant. “I thought that you were on the pill” was the angry reply.
“I am. Unless I forgot to take it.”
“Stupid, the pill won’t work if you don’t take it every day. Why didn’t you take the Plan B pills I gave you?”
“Do you have any on you?”
“It’s too late, pendeja. You have to take the pill within 3 days of having sex.”
Then comes reality testing about the future of the dancer—and of the pregnancy. Her boyfriend seems happy to become a dad, and invites the young woman to stay at his house after her aunt kicked her out. When he introduces the mother-to-be to his mother, the older woman tells him to throw her out.
“I can’t. She’s going to move in. She’s having my baby.”
“Again?” was the baby’s grandmother’s reply. Apparently this older man had caused more than the one unplanned pregnancy.
Has this program lowered teen pregnancy rates, reduced drug use or caused any other improvements? it is too soon to tell. However, ELH is under the watchful eyes of two communication professors, Drs. Arvind Singhal (University of Texas, El Paso) and Helen Wang (University of Buffalo). They have been using several techniques to measure the program’s impact. The results are very encouraging.
As expected, ELH is most popular in areas with the most Hispanics. Many people watched the show more than once because of the high appeal of the stories. This appeal has spread to Facebook, whose interactive properties engaged the audience even more. Furthermore, over 25,000 people have linked from one the show’s sites to reproductive health service providers in Los Angeles alone.
Closer to home, the teen pregnancy rate in Colorado has taken a nosedive. It has shot down 40% from what it was just 5 years ago. This decrease is important because, on the average, children born to teen moms don’t succeed as well in life. Furthermore, a teen mother’s chances of completing education are lessened and adolescent pregnancies are expensive to society. From a financial standpoint, every dollar spent on family planning saves $3.74 in Medicaid costs for maternal and newborn care. The human savings are much greater, of course.
Title X (ten) is a government program that works. It provides reproductive health services to women of any age who otherwise would have difficulty affording them. Here in La Plata and Archuleta Counties clinics offer women disease screening and their choice of family planning.
One of the reasons for the recent success of Title X clinics is that they are able to provide Long Acting Reversible Contraception (LARC), such as IUDs and Nexplanon®. Do you remember when you were a teen, how forgetful you were? LARCs remove the risk of forgetting to take “the pill”—the problem of the dancer in East Los High.

© Richard Grossman MD, 2014