Female sterilisation in India: Prevalence, informed choice and regret
Contraceptive use in India has been increasing in recent decades, but much of the increase can be attributed to the increase in the adoption of one particular method – female sterilisation
Key highlights
- In 1992-93, 40.7 percent of Indians were using some form of contraception. This had increased to 66.7 percent by 2019-21
- Much of this increase can be attributed to increase in the share of women who had undergone a sterilisation procedure
- Only 58.7 percent of women who had undergone a sterilisation in 2019-21 said they had been informed about the possible side-effects or problems of the method
- Nearly five percent of women who had undergone a sterilisation procedure said they regretted it
- Regret rates vary greatly between states with Ladakh, Meghalaya and Manipur reporting the highest shares of female sterilisation regret
Contraception has many benefits, from helping people limit and plan pregnancies to delaying pregnancies among young girls and reducing the transmission of HIV and other sexually transmitted diseases. It also has many non-health benefits, most notably, improving access to educational and economic opportunities for women. In fact, the World Health Organisation (WHO) argues that “contraceptive information and services are fundamental to the health and human rights of all individuals”. Improving access to contraceptive use is also envisaged under the Sustainable Development Goals.
For contraceptives to be effective, it is important that people have adequate information about them, and can access them in safe, affordable and convenient ways. Since some methods can be permanent or have possible limitations, the role of proper information and informed choice become critical. In the absence of these, people may not feel comfortable to use these methods, or worse, regret their decision to do so.
In this analysis, we look at the prevalence of contraception in India, with a focus on female sterilisation – how many women have undergone the procedure, how this varies by social groups, and how many women regret the same. The analysis is based on data from various rounds of the National Family Health Survey (NFHS), and unless otherwise specified, pertains to women aged 15-49 years.
A steady rise in the use of contraceptives in India
The use of contraceptive methods in India has seen a steady increase in the past three decades, data from various rounds of the National Family Health Survey (NFHS) shows. While in 1992-93, 40.7 percent of women (aged 15-49) reported that they (or their partners) were using some form of contraception, by 2019-21, this share had increased to 66.7 percent.
There are multiple contraceptive methods available to people. Birth control pills, condoms, emergency contraception pills, intrauterine devices (IUDs)/postpartum intrauterine devices (PPIUDs) are usually categorised as “modern” methods, while others such as rhythm and withdrawal are considered “traditional” methods.
The increase in the use of contraceptives is largely on the account of female sterilisation
Much of the increase in contraception use in India in the past three decades can be attributed to the increase in the adoption of one particular method: female sterilisation.
Sterilisation is a surgical procedure and a permanent method of birth control. While for men, the procedure is called a vasectomy, the corresponding procedure for women is a tubal sterilisation. Both are one-time and permanent procedures, and while both are effective and safe, male sterilisation is considered slightly more effective and safer in comparison.
Sterilisation remains the most common contraceptive method in India, with women comprising a bulk of those undergoing the procedure. Between 1992-93 and 2019-21, the share of women (aged 15-49) who had undergone sterilisation increased from 26.8 percent to 37.9 percent. The use of condoms also saw a notable increase in this period (from 2.4 percent in 1992-93 to 9.5 percent in 2019-21). On the contrary, the prevalence of male sterilisation, already low, had reduced further in the past three decades. Only 0.3 percent of women reported that their male partners had undergone sterilisation in 2019-21, as compared to 3.5 percent in 1992-93.
In some states, especially in southern India, the shares of women who had undergone a sterilisation were significantly higher. In Andhra Pradesh, 69.6 percent of women had undergone this procedure in 2019-21, the highest among all states. It was followed by Telangana (61.9 per cent), Tamil Nadu (57.8 per cent) and Karnataka (57.4). Research studies have attributed this higher prevalence of sterilization to a multitude of factors, including the prevailing social and cultural norms as well as, higher demand for limiting fertility, better network of family planning services and better quality of care in South Indian states. There is also evidence of higher post-sterilization autonomy among these women. On the other end of the spectrum, states in the north-eastern region had some of the lowest shares of women who had undergone sterilisation. In Manipur, only 3.7 percent of women were sterilised in 2019-21, and in Meghalaya and Assam, the corresponding shares were 5.6 percent and 9 percent respectively.
Figure 3
India has the highest shares and numbers of women who have undergone sterilisation globally. In fact, in its report on World Family Planning 2022, the United Nations Department of Economic and Social Affairs noted that female sterilisation was the most commonly used contraceptive method globally, “largely due to its extensive use in India, which accounts for 48 per cent of the global number of women who use female sterilisation. Female sterilisation would be the fourth most used method…worldwide if India were not included in the calculation”, the report noted further.
A large share of women who undergo a sterilisation do not receive proper information about side effects and other contraceptive methods
Unlike some other contraceptive methods such as condoms or birth control pills, sterilisation is intended to be a permanent method with reversals being a rare possibility. This makes it a convenient method as it is a one-time procedure on the one hand, but it means that once done, the person will not be able to have children. Therefore, making an informed decision about the process becomes all the more critical.
And yet, only 58.7 percent of women who had undergone a sterilisation in 2019-21 said they had been informed about the possible side-effects or problems of the method. Further, half (50.8 percent) were informed about what to do in case they experienced a side-effect. Two-thirds of women (65 percent) were also informed about other contraceptive methods. The prevalence of being given this information was higher among women who were either using a contraceptive pill or an IUD/PPUID.
Almost five percent of women who had been sterilised reported regret
The NFHS also asks women who have undergone a sterilisation whether they regret it. In 2019-21, 4.9 per cent of women who had undergone sterilisation said they regretted the sterilisation. The corresponding shares in 2004-05 and 2014-15 were 4.4 and 6.9 per cent. (Male sterilisation regret figures are unavailable, hence, ascertaining the gender gap within sterilisation regret rates is not possible).
In rural areas, five percent of women who had undergone sterilisation said they regretted it, while in urban areas, this share was 4.7 percent. Rural women were slightly more likely to have undergone sterilisation than their urban counterparts. In 2019-21, 30 percent of women living in rural areas had undergone a sterilisation procedure while in urban areas, the corresponding share was 27.1 per cent.
The prevalence of sterilisation varies with the levels of education for women. Women with no or little schooling are significantly more likely to have undergone a sterilisation procedure vis-a-vis woman who have had more years of schooling. However, roughly a similar proportion of women across education levels report regret.
A reduction in fertility rates is usually linked to the improved ability of women to participate in the labour force. Over half of currently married women (51.6 percent) who were employed for cash in 2019-21 had undergone sterilisation. In contrast, among those who were not employed, the share of women who had undergone a sterilisation was 31.9 percent. But a slightly higher share of women who were not employed reported higher rates of regret (6.3 percent) as compared to those who were employed (4.9 percent).
A reduction in fertility rates is usually linked to the improved ability of women to participate in the labour force. While 42.7 percent of ever-married women who were employed in the preceding 12 months reported that they had undergone a sterilisation procedure, less than a quarter (23.7 percent) of women who were not employed in the preceding 12 months reported the same in 2019-21. But a slightly higher share of women who were not employed reported regret (6.3 percent) as compared to those who were employed (4.9 percent).
Sterilisation and regret rates vary among communities and regions
Sterilisation rates vary across religious communities. Women from Buddhist, Jain, Hindu and Christian communities were more likely to have undergone a sterilisation procedure in 2019-21, while Muslim and Sikh women were the least likely to. Muslim women were also marginally more likely to report regret when compared to women from other religious communities – while 6.4 percent of Muslim women who had undergone sterilisation said they regretted it, among Christian and Hindu women, these shares were 5.3 per cent and 4.3 per cent respectively.
However, there was much more variation among states when it comes to regret. In Ladakh, 19.1 percent of women who had undergone a sterilisation procedure said they regretted it, data from NFHS Round 5 shows. It was followed by Meghalaya and Manipur with 15.2 percent and 15.1 percent of sterilised women reporting regret. Jammu and Kashmir too had high shares of women reporting regret (13.7 percent).
Figure 6
States in the North-Eastern region have comparatively lower shares of women who had undergone a sterilisation procedure but higher shares of women who report sterilisation regret. Research studies attribute this to a multitude of factors, especially the religious and traditional beliefs of the population in these states leading to lower belief in contraception and/or a higher preference for traditional family planning methods. Indeed, data from the NFHS 2019-21 shows that Assam, Tripura and Manipur are among the top five states in terms of the share of individuals using traditional contraceptive methods.
Beyond specific groups and regions, it is important to establish that ‘regret’ is a complex concept. It can vary over time and depends on a host of factors, many of which may be unobservable. However, some factors have been shown to help – from access to proper information on all aspects of a sterilisation to enable a genuinely informed choice, improving access to other forms of contraceptives, and quality of care extended during the sterilisation procedure, can all play a role.
Further, research evidence indicates the age at sterilisation is an important factor driving regret, with women who undergo a sterilisation procedure at a younger age significantly more likely to report regret. The median age of female sterilisation in India was only 25.7 years in 2019-21, and 39.6 percent of the women had undergone a sterilisation procedure at the age of 25 or earlier. In comparison, the median age of female sterilisation in 1992-93 was 26.6 years, implying that on average, women are undergoing sterilisation procedures earlier than they were in the early years of the 1990s.
Moreover, sterilization rates and regret also vary vastly among women who have already had children – only 0.5 percent of women with no children alive were sterilized in 2019-21, and this share was higher among women who had 2, 3 and 4 or more children alive (50 percent, 56.2 percent and 48 percent respectively). It is the women with no children or only one child alive who regret their sterilization the most (17.7 percent and 11 percent respectively, compared to 4.8 percent of women with 2 children, 4.3 percent with 3 children and 4.7 percent of women with four or more children).
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