In India, Gaps in Quality of Care Leave Women Seeking Sterilization Vulnerable

Nearly six months ago, 16 women died - and scores more were hospitalized - after undergoing sterilization procedures in Chhattisgarh, India. Myriad factors contributed to this tragedy, including unsanitary conditions, potentially tainted drugs, clinic staff that was both overworked and under-qualified, and apathy from the health system as well as doctors and nurses.

While the exact cause of death remains murky, what has become clear is that no woman should have died while undergoing a routine procedure like sterilization. Given the increased demand for reproductive health services in India, more attention is needed to assess the quality of care that women and men are receiving in order to identify what's working and what can be improved. A new report from the International Center for Research on Women (ICRW) does exactly that. This study was carried out in collaboration with the government of Bihar in 79 public and private facilities during January 2013 to June 2014. The report sheds light on the state of health facilities and current client satisfaction in Bihar, finding that while there have been improvements to certain aspects of infrastructure, we have room to grow in ensuring we are providing safe, sanitary environments for women undergoing sterilization.

We found that both public and private health centers and hospitals were inadequate in meeting the needs of women. For instance, only one in ten primary health centers were able to provide beds to all clients post-surgery, with the vast majority of women lying on mattresses or cotton mats on the floor. What's more, limited space meant women who had just undergone sterilization were often placed in over-crowded areas, which can act as a breeding ground for infection.

While the facilities' infrastructure leaves much to be desired (indeed, only half of the facilities had a separate, functional toilet for women), we also found that even the most basic requirements to minimize the risk of infection were not followed in too many cases. Doctors, nurses and other visitors were found to be walking in and out of operating theatres in plain clothes at several facilities. And despite out-sourcing waste management, in one out of every three facilities, used syringes, cotton swabs, and bandages were found scattered around. Several facilities had blood-stained walls and dirty, crowded wards with flies around women in recovery.

Most worrying, however, was the apathy we found so prevalent among providers towards women and their needs. In several facilities, the whole process of sterilization was conducted like an assembly line, with virtually no human touch. Consent forms were given without making an effort to explain their contents, urine and blood tests were completed, but clients were rarely informed of the results, and often women were discharged post-surgery without basic check-ups or medical advice. Additionally, there was a perception that when you are paid for receiving a service -women in Bihar are paid Rs 600 to undergo the procedure - one should not expect quality.

Sterilization is a routine procedure, but like any other procedure, it also comes with risks if performed by staff who are not competent, with medical equipment that is not sterile, or if basic equipment and drugs are missing. Women have a right to understand the risks associated with the procedure and to have the peace of mind that comes alongside with knowing the health care staff that is knowledgeable and minimizing their risk of infection. Indeed, these very suggestions are outlined in the Government of India's standards on female and male sterilization, which are meant to guide health care providers to provide quality services.

And yet far too many women simply are not well aware of their rights and that they are entitled to ask questions and know more about their reproductive health. As a result, their dignity is often compromised.

With leaders recently gathering in Delhi to discuss FP2020, a global pact to tackle the unmet need for contraceptives around the world, we are reminded now, more than ever, that meeting women's needs means more than just providing a service, but should be about providing comprehensive options that fit their needs and lifestyles, and most of all, protecting their rights.

The good news is that when the government and civil society work together, with a targeted focus and small changes, we can actually improve services for women. These changes include designating safe, clean waiting and recovery areas for women; equipping facilities with the necessary, sanitary equipment, drugs, and supplies to effectively perform sterilization and IUD procedures; ensuring facilities have competent health providers with a gendered perspective who ensure the rights of women are respected; and educating women and communities on their right to safe health care procedures.

These steps are absolutely critical - both in protecting the rights of women and providing quality health care - and must be implemented today to ensure that no woman's dignity, health, or life is compromised as a result of unsafe care.