Moving targets: Routine IUD insertion in maternity wards in Tamil Nadu, India

Cecilia Van Hollen
1998 Reproductive Health Matters  
In 1995, nurses and doctors in many of the public maternity wards in the state of Tamil Nadu in India were routinely inserting IUDs immediately following childbirth and abortions, as part of the target-orientated family planning policy. This practice, sometimes carried out unbeknownst to women or against their will, has received little public attention. Tamil Nadu's success in reaching state targets for IUD acceptance far exceeded those of all other states and territories in India. This paper
more » ... India. This paper reports on an ethnographic study in 1995 of Tamil Nadu women's experience of routine IUD insertion and why health workers considered the policy necessary. Based on information from a followup visit in 1997, it describes how the change in national and state policy in 1996 to a target-free approach with local determination of needs, is being implemented, but only in some hospitals and by some health workers. Reproductive health policy in India has been dominated by family planning and driven by numerical targets for a long time; it will take more time to assess the effects of the new policy. SINCE 1995 India has been undergoing a transformation in the conceptualisation and implementation of its family planning policies and programmes, moving away from a target-based approach at central and state government levels towards a broader reproductive health agenda with the locus of decision-making moved to the local level. Under policies initiated in the late 1960s, government health workers have been required to 'motivate' set numbers of eligible men and women to 'accept' contraception. Similar numerical targets were established for public hospitals and district and state governments, creating an elaborate system of competition to attain the requisite number of acceptors. The All India Post-Partum Programme was established in 1970 as a 'maternity-centred hospital approach to family welfare' in national, state and district hospitals. The Programme was later extended to the sub-district (taluk) hospitals as well. The Programme's mandate was 'to motivate women within the reproductive age group 15-44 or their husbands to adopt the Small Family Norm (two-child family) particularly during the ante-natal, natal and postnatal periods.' This Programme was intended to supplement other maternal-child health (MCH) programmes such as immunisation and the distribution of iron pills in hospitals, but its primary goal was to involve all hospital staff attending births and abortions in the family planning campaign. It was within this Programme that contraceptive targets were set for post-partum and post-abortion women attending these hospitals. During the mid-70s, especially during the political emergency in India (1975-77), family planning became a priority at the top-most level of government. Public officials as well as public service employees of virtually every type were directed to fulfill family planning targets and were penalised for failing to do so. Many of them eventually resorted to coercive means in order to achieve these targets. The 'Emergency' is often remembered for the ways in which human rights were flouted, and particularly for the forced sterilisation of men. 2 Family planning tactics have not been as draconian since the Emergency; however, the system of targets continued until 1996, though confined to the health sector. Targets were set for many categories of health workers, and for hospitals, zones, districts and states. Punishments and rewards were meted out based on achievement rates. The Post-Partum Programme was able to be effective in Tamil Nadu because a high percentage of women in the state, unlike in other parts of India, give birth in hospitals. As part of a study on the medicalisation of childbirth in Tamil Nadu carried out in 1995, I asked women about the kind of care they and their families sought and about other practices during pregnancy, delivery and the post- Correspondence
doi:10.1016/s0968-8080(98)90086-6 fatcat:bbwzjnlszzdchogkdjww3punay