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India population: Is sterilization the answer?

Millennium Development Goals could push India back to a "sterilization first" policy.

Indian wrestler balancing baby
An Indian wrestler balances his baby during practice at Loknath Akhara wrestling school in Allahabad on April 19, 2010. (Diptendu Dutta/AFP/Getty Images)

NEW DELHI, India — Every year in India, shanty towns mushroom in the cities, cities sprawl into farmland and the country increases by the population of Australia.

Every day, every minute, on trains and buses, on sidewalks and streets, the country squeezes and shrinks and sucks in its breath to push too many people into too little space.

India has fallen behind in the race to meet the Millennium Development Goals for reducing its birth rate by 2015. Only about half of India's 26 states have reached the targeted level of two children per mother.

In large, economically depressed states like Bihar and Uttar Pradesh, an average woman still bears four children over her lifetime. This means India will surpass China to become the world's most populous country by 2030. The continuing swell threatens the environment and places a tremendous burden on government services.

But obsession with the Millennium Development targets is pushing India back to incentive-based family planning, something the country first visited in the 1970s — where dangerous sterilization operations for women are too often presented as the first, and sometimes only, option for birth control.

Critics of India's repackaged population control program say the cure may be worse than the disease. 

"There's a great hurry to again set targets from above to be followed by everyone. And that's again creating problems," said A.R. Nanda, executive director of NGO Population Foundation of India and the former health secretary who wrote India's population policy in 2000.

The main worry? India's National Population Stabilization Fund has brought back controversial, incentive-based sterilization, among other initiatives aimed at reducing the birth rate. 

While sterilization in and of itself isn't new to India, for the first time the country is outsourcing the work to private clinics — a move that has raised concerns about poor and illiterate women of rural India being pressured or fooled into going under the knife without fully understanding the risks, consequences and alternatives.

Cash rewards threaten to turn operating theaters into veritable assembly lines. The fund's Santushti scheme offers private sector payment of 15,000 rupees per operation and hospitals and clinics get 500 rupees extra per case if 30 cases are done on a single day in a fixed facility.

These factors make it more likely women will be denied their right to make informed choices about their medical care and increase the chances of surgical complications, said Abhijit Das, a former fellow in Population Innovations at the MacArthur Foundation who now heads an NGO called Healthwatch Uttar Pradesh.

"When you create an incentive system, it privileges one solution over the other and encourages them to cut corners," Das said. "And we've had very bad experiences with that in the past."

In the 1970s, the Indira Gandhi government pursued an aggressive, target-based sterilization program that featured similar incentives for participants, as well as compulsory vasectomies for men with two or more children. Because of widespread corruption and abuses, however, many other men were tricked or forced to get the operation, and many women, too, were compelled to undergo much more dangerous sterilization procedures.