Family Planning In Kilinochchi Under Scrutiny
By Megara Tegal
A controversial report titled ‘Coercive Population Control in Kilinochchi’ by an anonymous group known as The Social Architects (TSA) has incited public uproar not only in Sri Lanka but in the international arena as well. Last week, the President of Pasumai Tayagam and former Health Minister of India, Dr. Anbumani Ramadoss, termed the incident ‘genocide’ and urged the UN to carry out an investigation, while speaking at the UN 68th Annual General Meeting in New York.
The Sunday Leader travelled to Kilinochchi to investigate the claims that women in three villages in Kilinochchi viz Veravil, Valaipaddu and Keranchi, were gathered at clinics and schools, where a Progesterone-only-subdermal implant (POSDI) was inserted into their upper-arms.
The TSA report
According to the report many of the women claim to have been taken to these clinics under false claims that the clinics were to conduct nutrition check-ups for their children. Once they arrived at the clinic they were informed about the contraception and told that they needed it as it is in their medical interest to not have more children. The women felt coerced into it as they did not have time to think it through or consult their husbands.
When the women expressed that they did not want the contraception, the medical staff, comprising doctors and midwives, had responded menacingly that their husbands would have to undergo the procedure instead. The women then felt compelled to give in.
The TSA report quotes a few of the women, one of whom is a 36 year old mother: “my youngest child is eight months old and my older child is three years old. The health volunteers asked me to come with the clinic card to weigh my children. They also said specialists are coming from the Kilinochchi district hospital.
I was excited to see big doctors who are knowledgeable. I went to the hospital and they weighed my children, but then they made us wait. When my turn came they spoke to me about the pros of not having any more children and told me that I am better off with only two children. I was of two minds and they sent me to the doctor.
The doctor spoke to me nicely and told me that rich and educated people in Sri Lanka and America use this method. This way my two children will be better off. How can I argue with such educated people? I hesitantly went ahead. But a few days later, I developed this pain and I went to the hospital. They treated me but I wanted to see the doctor who did this to me, but he wasn’t there, and the other doctor told me that he doesn’t know anything about this. The other doctor told me that I will be okay, but now I am not okay. How can these educated people do this to us? I wish they gave me time to think about this. They forced us to make a decision on the spot. I couldn’t speak to my husband or anyone that I knew. These doctors are not nice people. They cheated me”.
The report further stated that some women said they informed their husbands about it once they returned home; and their husbands reacted furiously, accusing their women of infidelity. Others complained about feeling ill during the days following the insertion of the POSDI.
What is POSDI
POSDI is a relatively new form of reversible contraception. The implant is a small rod that is inserted under the skin of the upper-arm of the woman, and it prevents ovulation for 3 to 5 years. The particular POSDI given to the women in Kilinochchi is expected to function up to 5 years, according to the medical staff that administered the contraception.
The WHO states: “Subdermal implantable contraceptives are highly effective, easy to use and carry a low risk of side-effects. These features make them a good option for women in under-resourced settings. However, data are lacking on the performance of contraceptive implants compared with other contraceptive methods”.
POSDI is also said to be an extremely costly form on contraception as well. The medical staff in Kilinochchi estimated that it would cost roughly Rs 5,000 to Rs 8,000, making it inaccessible to those who live in the fishing villages of Kilinochchi as they are low income earners.
The side-effects of using POSDI include hypertension, weight gain, irregular periods, and hormonal imbalance, which the TSA report charges were not explained to the women by the medical professionals in Kilinochchi. It goes on to say that after-insertion care information provided by the doctors and nurses was false and misleading.
Side-effects rare but low chance of removal
Sources close to the medical staff that conducted the contraception insertion, told The Sunday Leader side-effects are rare, but they include spotting. “Spotting is when a few spots of blood appear when it isn’t expected in the cycle. Most women find this irritating as in our community women usually cannot enter temples during their period and right after their period they need to have a (ritualistic) bath. So the women find this troublesome.”
However, when asked about the high cost of POSDI and whether the removal of the rod will be carried out, the source responded that removal is not something they take lightly because of the high cost and unavailability of the contraception. “It’s the best form of contraception for the women who want contraception here in Kilinochchi. We’ve come across many husbands who find all sort of problems with the more common forms of contraception – from the condom to the loop- and the women don’t take the pill regularly.
In fact if they forget to take the pill on one day, the next day they take two pills. This method of contraception will function naturally for five years. It is also very expensive so and the government will not be purchasing anymore POSDIs in future. Once it’s been inserted it cannot be used again and must be discarded,” he added suggesting it would be wasteful to extract the rod.
Medical staff speak
The Sunday Leader spoke to women in Veravil in groups, outside their houses and at small clinics located in the village. Within these groups of women some admitted to having heard about the contraception that was carried out, a few women oddly said they did not know about it. One of the women who admitted to having heard about it said that she too had been called to the clinic for a nutrition check-up for her child.
“My child was weighed and they told me how to feed him properly, but I wasn’t asked to take any form of contraception,” she recalled. This corresponds with explanations given by medical staff sources who said that only women with two or more children, both of whom (as well as the mother) were undernourished, were administered the POSDIs.
Menaka is a local from Veravil who has been volunteering at the Kilinochchi hospital. She told The Sunday Leader, that she identified large families who suffered from acute malnutrition.
“While visiting the women, I’ve noticed that they usually have one child on the hip, another at the breast and another crawling behind them. With so many young children to take care of, the mother becomes under-nourished, and then her children become under-nourished. It becomes difficult to feed the children on the husband’s salary. The women themselves found it difficult and asked me to help them find a good form of contraception,” she said. “I then brought it to the attention of the Ministry of Health (MoH) in the area”.
She explained that people in rural villages do use protection such as the condom or the pill, since acquiring them requires travelling for four hours, on a bus on dirt roads.
“There were one or two women who grumbled after the insertion of the POSDI because their husbands were against it. But apart from those few cases, most of the women are fine,” Menaka said.
She went on to explain that women in the village are not new to using contraception. Many take the pill or use condoms. One of the women in the village who is a mother of four young children revealed, “On the day of the nutrition check up, I was told about the contraception but I didn’t want it and I told them that. I’ve told my husband to use condoms and I felt there was no need for this new form of contraception. They didn’t press on it and let me go with no issues”.
Small families are better nourished
One of the key problems identified by the doctors in Kilinochchi is that the families are undernourished. Typically, these were families with four or five children who could not be fed regularly on their father’s income.
The mothers were also severely undernourished as well.
Without the use of contraception, or the use of pills which were not taken regularly, many of the women who got pregnant, who already had more children than they can could for, or who are in their 40s or older, would seek to have a septic abortion as they could not provide for another child. The septic method often leads to infections and the mothers do not come to the hospital until they are in the terminal stage, and even the doctors are unable to save them.
In their research, which was carried out prior to the administration of the POSDI, the MoH determined that 30.7% of the Veravil population had unmet needs (in this case contraception). The population of Veravil is 1779, and the MoH identified 289 families that were eligible for contraception (malnourished children and mothers, and more than three children in a family were some of the criteria). Out of the 289 families 89 were in need of contraception. Keranchi has a population of 1608, of which 257 families were found to be eligible for contraception. Out of the 257, eleven (4.2%) were identified as families in need of contraception.
According to the sources, these were the families that received the contraception from the MoH.
However, POSDI were not the only form of contraception that was distributed. Overall, 50 families were administered Jadelle (POSDI), two were opposed to the POSDI and were instead given the loop, and one Oral Contraceptive Pill.
Maternal mortality rate records of the Family Health Bureau show that in 2006 the percentage was at 102.8% in Kilinochchi, while it was 39.3% islandwide. In 2008, the maternal mortality rate in Kilinochchi dropped to 24.9%, and 33.5% islandwide. In 2009 and 2010, the maternal mortality rate in Kilinochchi was found to be 0%.
The doctors expressed that they hoped to maintain the 0% maternal mortality rate.
Sources close to the team that carried out the contraception clinics, stated that the head midwife who oversaw distribution of contraception has been a midwife in North since 1982, and has delivered children during the war, they also stated that the doctors were all Tamil and from the North, refuting claims that programme was a deliberate attempt at population control in Kilinochchi.
The Sunday Leader emailed TSA to find out more details. The team refused to be interviewed over email, understandably stating, “I would like to help you, unfortunately I can’t reveal my sources but please go to these three areas and ask around. Everyone knows.
The nuns know it, the priest know it and you can contact them. I hope you understand our plight, as we have to be anonymous.”
TSA word against MoH
The Sunday Leader was informed by an activist based in Kilinochchi, that one of the women who voluntarily had the POSDI inserted into her arm, later complained of irregular periods, and feeling ill and uncomfortable. She was aware that the POSDI was a reversible form of contraception, and sought to have it removed at the hospital.
The hospital staff had refused to extract the rod from her arm. She then went to a private hospital that quoted more that Rs 20,000 – a sum she could not afford – to have it removed.
When The Sunday Leader spoke to the military’s Civil Society Camp in Veravil, the officer said that while they make a record of all that occurs in the village, there were unable to make a report on the contraception controversy as they were busy attending to matters regarding the elections.
However, during the investigation conducted by The Sunday Leader on the 22 and 23 of September, none of the women who were interviewed complained about the contraception that was distributed during the nutritional programme (an annual programme that is held in July in Kilinochchi for those who cannot afford medical care).
From cries of coerced population control to genocide, the incident has now reached the international community. If, as the Regional District Health Services of Kilinochchi states, the incident has been blown out of proportion then a timely explanation is required from the government.