Given the increased demand for reproductive health services in India, more attention must be paid to the quality of care for these services. To assess the current state of care and patient satisfaction, The International Center for Research on Women (ICRW) and the Government of Bihar conducted research in Bihar, auditing 79 facilities (including district hospitals, sub-divisional hospitals, primary health centers, and private hospitals), and conducting interviews with 800 providers, female sterilization and IUD clients from January 2013 to mid-2014.
ICRW today released a new report, which details these findings, shedding light on how far too many women undergo sterilization procedures in inadequate environments in Bihar, India. The findings highlight that many health facilities, both public and private, are underprepared to perform such procedures.
The study was designed to assess the quality of care in the provision of female sterilization and IUD in Bihar, a northeastern state of India that is home to more than 103 million people, where there is a high unmet need for modern family planning methods.
The report indicates that while there have been some improvements to facilities’ infrastructure over the past few years, too many facilities did not have safe, clean spaces for women. Only one in ten health facilities provided every woman who had undergone sterilization with a bed. In many cases, women who were recovering had little choice but to lie either on mattresses or cotton mats on the floor, a breeding ground for infection. And recovery areas were often over-crowded, further compounding women’s risk of infection. Basic amenities were also missing: fewer than half of the facilities had a separate, functional toilet for women.
And while many health facilities indeed did not provide women with safe sanitary places to recover, many aspects of the facilities themselves were often in poor condition. We found that many facilities had broken windows, with some windows in operating theatres even broken. Blood-smeared walls were found in some facilities, and in one out of every three health center, used medical waste, including syringes, cotton swabs, and bandages were found scattered about. In a couple of facilities, medical staff was performing the sterilization procedure in an in-patient ward, not in operating theatres, violating safety guidelines set forth by the Government of India.
“This report highlights that despite the government’s recent commitment and efforts, health facilities are falling woefully short of meeting some requirements that are carefully crafted and implemented to protect women from infection and from harm,” says Pranita Achyut, lead researcher on the study.
Our data also shows that some facilities lacked even the most basic equipment, drugs and supplies, including emergency and post-surgery drugs, and gloves. In other facilities, there was a lack of qualified staff. And in these constrained environments, districts were mobilizing trained providers from different facilities to provide services.
Overall clients did not report that they were unsatisfied with the quality of care, but research showed that clients had limited time – and virtually no private spaces – to consult with their doctors about the procedure, including asking questions and voicing concerns and hearing about potential complications associated with the procedure. Consultations were often quick and cursory, which is further compounded by a high client load and limited waiting space. Additionally, many women report that they were not checked out by a doctor or nurse before being discharged and few were provided with additional advice. Generally, we found there was apathy towards clients in the health facilities.
These unsafe, unsanitary environments with limited interaction between clients and providers can seriously undermine both women’s needs and their trust in the health system. Negative experiences can stop women from returning for follow-up services and also from advocating family planning to their peers.
“The data is saddening, as women who seek these services deserve better,” says Achyut. “While we do recognize the constraints within which public health facilities operate, the facilities could do much better by demonstrating greater empathy for the clients and by providing adequate information and better services. Family planning services should be about empowering women, and not ‘how many’ women have accepted a method.”
ICRW puts forth a host of recommendations that must be implemented in order to improve the quality of care for women in Bihar, who undergo sterilization, including:
- All health facilities must have a clean, safe and designated waiting area, as well as clean and private recovery and consultative rooms to ensure clients’ comfort and that they are able to ask doctors and nurses questions about their reproductive health;
- Every health facility should be stocked with necessary, sanitary equipment, drugs, and supplies to effectively perform sterilization and IUD procedures;
- Health facilities must make sure they’re staffed with qualified health providers with gendered perspective to ensure they respect the rights of women undergoing procedures; and
- Women must be better educated on the care they should expect and know what they’re entitled to as a client.
Sterilization procedures and IUD insertion are routine procedures that, in and of themselves, don’t carry a high risk. However, when basic hygiene requirements are not met, staff is unprepared and overworked and post-operative drugs are missing, women’s lives are put at risk.
Just last year, 16 women died – and dozens more were sick – after undergoing sterilization procedures in Chhattisgarh, India.
Given the government’s efforts to address high fertility, in Bihar and around the rest of India, female sterilization and IUDs are expected to remain the mainstay of Bihar’s overall family planning strategy. As such, we must ensure that these services are provided safely and that facilities do everything they can to provide a sanitary environment with qualified, knowledgeable staff.