Jayeeta Chowdhury, Melissa Lairenlakpam, Abhijit Das - CHSJ Sakhi, Sancalp, Shaktivardhini – Bihar

1. Study on Quality of Care in Women’s Sterilization conducted in PHC, CHCs & District Hospitals in Select Districts of 5 States in India Jayeeta Chowdhury, Melissa Lairenlakpam, Abhijit Das - CHSJ Sakhi, Sancalp, Shaktivardhini – Bihar Grameen Punarnirman Sansthan – UP NAWO, Society for Developmental Action, Unnayan, Social Development Society – Orissa Agragati – Jharkhand Prayas, Shikshit Rojgar Prabandak Samiti - Rajasthan

2. Context • Tubectomy - 5 million women undergo sterilization, & 34.4% of all women in the age group 15 – 44 years had undergone sterilization. • 1998 – 99, GoI issued QoC parameters as standard operative procedures in doing sterilizations • 2002 HW UP-B conducted a detailed study of QoC in eleven camps. • On the basis of this report and a Maharastra study conducted earlier, HwF filed a writ petition in 2003 in the Supreme Court of India. • The SC heard the case and directed all states to follow these parameters. In March 2005 the Supreme Court gave its first direction to the GoI. Consequently Family Planning Insurance Scheme (FPIS) introduced in 2005.

3. Objectives of Study • Assess the implementation of the SC order and in a select districts in at least 5 states of India • Examine whether standard operating procedures as prescribed by the Manual on Female Sterilizations are being followed in regular sterilization camps/facilities that are organized in selected districts of these states • Understand women’s own experiences of quality of care and informed choice in the process of receiving sterilization services.

4. Methodology

5. Methodology • Orientation Workshop with study participants on objective and methodology of the study in January 2008 • Preparing Tools • Field Testing of Tools • Ethical Issues – Confidentiality maintained & Consent taken • Study Period -varied in different states. In some states between March-May 2008, while in other states in June-August. • Selecting women - those who had undergone sterilization at least 10 day before interview and within 30 days of sterilization. • Selecting surgeons – those who conducted the operations & were available

6. Limitations of Study • Conducted with a small sample size. • All the research tools could not be used in all sites, so could not reach the desirable number • In-depth interviews did not bring out very detailed responses. • Study period varied in different states resulting in process delay

7. Findings • Background of Women Pre-Surgery Care • Checklist – Surgeon: “Frankly speaking it is not followed before every surgery” • Waiting time before Surgery – 114/160 women: 2-5 hours • Counseling –17% were given information on other contraceptives. In 9/17 camps, women were being counseled. • Consent - 91% sign or thumb impression was taken - 63% - verbal consent taken - 6% - consent form read out. - 91% unaware of consent form. - 84% no coercion used. Rest did not answer. • Medical History – 28% women’s medical history taken. • Screening examination - Urine (73%), PR (51%), BP (61%), Fever (25%), Vaginal (15%), Blood Test (8%), Weight (8%) • Privacy during examination – 44% felt no privacy. 12/17 camps had separate exam. room

8. Findings - Post-Surgery Care • Discharge after Surgery – 84/160 said they were discharged in < 4 hours • Discharge slip -73% were not given any discharge slip • Surgeons on Certificates after Surgery - “No we are not giving any certificate to the sterilized women, only government employee are demanding from their sides and we are giving them only but not to the common. Now, in the last meeting we have planned to give to each individual who undergo sterilization”. • 84% were advised to resume light work > 2 days 11% of were not given any advice on it • Resuming sexual intercourse -34% were not given any advise. Most of them were advised to resume sexual intercourse nearly after 90-180 days • Post Surgery Health Problems– 54% faced some kind of health problems immediately & after few days & 34% didn’t seek medical help. 1 case of failure. • FPIS Knowledge – 83% women didn’t know. No claims. • Findings show most providers & Dist. Officials knew about SC guidelines, QAC. They face difficultyin following the guidelines.

9. Findings – Progress of Quality Assurance/Care • QAC formed in 5/9districts, not in 3 districts – District Officials & Providers • Panel of doctors – Only 1 District from Orissa has it • Sterilization Targets - Mixed responses by Surgeons & Officials • Behaviour & communication of providers were acceptable • Infrastructure still has huge gaps – examination room, recovery room, OT • Prevention against infection lacks complete measures • MIS – exists. Records of operations, failures & deaths are maintained but on counseling & consent, below the mark. • Complaint /Suggestion Mechanism –13 camps didn’t have complaint/suggestion box • IEC – Poor (Few camps had citizen’s charter, timings & charges displayed)

10. Costs • Surgery – In Bihar women spent in the wide range of Rs.20 to Rs.2500. 17 out of 31 women spent more than Rs.1000 on surgery and 5 among them had spent Rs. 2000 and more. • Medicines – In Bihar 18 out of 49 women had spent Rs. 1000 and above on buying medicines. 11 women among them had spent between Rs. 2000 and Rs. 5000 on the same. In Orissa - 3 out of 25 women spent Rs.1000 and above and 1 woman Rs. 4000 on medicines • Additional Expenses - food at facility, payment to health staff and removing stitches, blood and urine tests, medicine • Transport Costs • Compensation after sterilization

11. Conclusions • Introduction of Quality Standards & FPIS is laudable • Women’s experiences, camp observation show quality parameters are being followed only to a some extent & their information on FPIS is low • Surgeons & District level Officials reported challenges in meeting quality standards • Special attention should be given to educating and informing women about their entitlements and rights and mechanisms of remedy incase of denial of care • Improving quality of infrastructure, supplies, equipments, human resources and issues of ethical practices is an immediate necessity

12. Recommendations • Educating clients of their rights, entitlements & compensation mechanisms like FPIS, complaint mechanisms. • FPIS only include measures to address provider misbehaviour, cost related issues, poor quality of care. These issues should be addressed. • Investigating the high burden of costs related to sterilization. • Regular Monitoring of the implementation of SC guideline and Standards of GoI by activating the QAC with focus on Counseling and informed consent of clients. • VHSC, RKS may play an active role in bridging the gap between women & programme representatives.

13. Recommendation • Strengthening MIS at block & district level • Investigating more about sterilization related health problems among women and compensation claiming by them/families • Conducting training courses for service providers, District Officials on policies and quality standards with emphasis on human rights, women’s rights, discrimination, sexual and reproductive health and rights on the lines of ICPD+15 and Beijing Conference.

14. THANK YOU

15. Background of Women Return

16. Transport Costs Return

17. Compensation after sterilization Return

18. Health Problems after Sterilization Return • Head Spin • Abdominal Pain • Vomiting • “Gas” • Bleeding from incision • Infection • Fever • Urinary problems

19. Respondent No. 31’s Case Return “Pain in abdomen, had fever, menstrual problem and severe and recurring abdomen pain. After few months I got pregnant again. Strange !! I Spent Rs.4000 on medicine, Rs.300-400 for check up, test, transportation. I received only Rs.450 on the same day from facility but had to spent Rs.400. I did not know about FPIS, learnt today from you only. Till today I did not apply, only listening from you, so thinking of applying for failed operation. When I went to Doctor for check up, his behaviour was not good. He was only trying to hide his mistake, ie the failure case. I think No cheating/harrasment/negligency should mark in this sensitive issue. Proper information on time should be shared with the people. If there is so much facility and trained Doctor also, then how I face a case like failure of sterilization. What can you do now for me? Can I able to get the compensation?”