Dr. Sikdar, as chief of national policy, says the camps are supposed to take place in medical facilities, and organizers of those that don’t face criminal prosecution. But last year in Kaparfora in the state of Bihar, a doctor sterilized 53 women lying on benches in a school without electricity, and charges have yet to be laid.
Research by Dr. Das’s centre consistently finds that it is women from the poorest communities, usually aboriginal people and those at the bottom of the caste system, who are targeted when a region needs to reach its quota. They may have no idea that the procedure is permanent, he says.
Navin Kumar, the health information officer who supervises Kamrora, says the state government gave him a target (for the 875,000 residents of Mahoba district) last year of 4,100 women and 400 men.
And yet, Dr. Sikdar insists: “We do not give targets – we have ... ‘estimated levels of achievement’ … It’s a management tool. A doctor has to make a plan based on numbers.”
If local officials, such as Mr. Kumar, are being told otherwise, and health workers, such as Ms. Raja, are pushed to meet quotas, he says, it’s a local aberration: A district politician may be keen to boost his reputation and “if, in his over-enthusiasm, he does something …”
Anjali Sen, director for South Asia with the International Planned Parenthood Federation, says India’s policy was drafted with the best of intentions, but she does not buy Dr. Sikdar’s claim that there are no targets. State family-planning budgets come from Delhi, she explains, and “cash incentives are tacit acceptance [of targets] from the central government.”
Ms. Uppal, the activist, says national officials could easily make sure the system is target-free: “They’re the cops.”
Dr. Sikdar says India is launching a new incentive program under which 860,000 health workers such as Ms. Raja will be paid $10 for every woman persuaded to delay her first child for two years after marriage, and another $10 if she waits two years before having a second.
Left unexplained is just how the women are supposed to avoid getting pregnant.
Certainly no one is relying on husbands to sort it out. During the Indira Gandhi era, most sterilizations were performed on men – there was no way to do a tubal ligation without invasive surgery, and female doctors, whom women patients prefer, were rare.
Vasectomies are still less complicated, but 95 per cent of the operations are now on women. Mr. Kumar says Mahoba district achieved 80 per cent of its target for women last year – but sterilized none of the 400 men.
There is a widespread belief, rarely challenged by doctors, that sterilization weakens a man and “robs him of his powers,” as women in Kamrora say.
All of the government outreach about family planning – all the home visits and chat circles Ms. Raja organizes – focus on women. But ask the women if they actually make the decisions about children and birth control, and they burst into laughter.
Even Dr. Sikdar acknowledges the problem – he oversees a $20-million program that distributes free condoms to women who have “no control over fertility.”
Or as Ms. Uppal puts it: “These completely disempowered women take condoms home to their husbands as if somehow they are going to be able to convince them to use them.”
Dr. Das says the service delivery will not change as long as policy springs from a belief that the “wrong” people are having children.
“Our development priority is not to reduce family size, it’s to raise income. We’re not ashamed of the inequalities, of low education attainment, of poverty – why are we ashamed of population growth?”
Noni Raja has thought a lot about choices, and who gets to make them. Two years after her bold decision to have a tubal ligation, she received a brutal reminder of her place in the family hierarchy.
In 2008, her younger son died at the age of 1 from pneumonia that the local health centre failed to treat. She lost her bold, chattering boy – and something else. Her in-laws were unwilling to accept a daughter-in-law they felt had failed in her most important responsibility.
So they scraped together a small fortune, and took Ms. Raja to Jhansi, a city about eight hours away by bus, where they paid a surgeon to reverse her tubal ligation – a rare and complicated surgery.
The operation went badly. “I nearly bled to death,” Ms. Raja recalls flatly. But she came home and, two years later, produced that mandatory second son. Her place in the family was once more secure.
Today, that last baby is everyone’s mop-haired pet; mother and grandmother compete over whose lap he will lounge in.
Ms. Devi is defensive – but unrepentant about the extreme lengths they went to in the quest for another boy. “All the neighbours said it was not done, to have only one son,” she explains. “We were under pressure.”