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.
According to Dr. Amarjit Singh, who heads the National Population Stabilization Fund, it is making progress in getting people to use alternative forms of birth control, like intrauterine devices — a form of birth control that uses an object inserted into the uterus to prevent fertilization — in traditional problem states like Bihar and Orissa, which now have effective and proactive governments.
In Bihar, for instance, the number of women using the devices — an essential part of the population program in China, where 60 percent of women use them — climbed from around 40,000 in 2009 to around 200,000 last year.
The fund has also leveraged India's recent Right to Education legislation with innovative schemes to encourage girls to stay in school, which not only means a delayed start to their childbearing years but also increases the likelihood that they will use birth control.
And private-public partnerships have helped reduce the number of home births by increasing the number of facilities available to poor women. But the general perception remains that uneducated villagers can't be trusted to use other birth control methods and female sterilization is the only foolproof solution.
"In certain states, it's still a very male-dominated society, so there's no certainty that women can ensure that a condom can be used. An IUD is a good alternative," said Singh, referring to the acronym for intrauterine devices. "But until we're able to increase use, then sterilization is the focus."
According to the latest National Family Health Survey, 37 percent of Indian women have undergone sterilization, compared with 1 percent of men, while just 3 percent are on the pill and only 5 percent use condoms.
The figures can be mind-boggling. Along with the 150,000-odd women who were fitted with intrauterine devices in Bihar last year, for instance, another 150,000 went for sterilization operations.
"Repeated surveys done in India say that in most cases sterilization is the first method [of birth control] people are using — which should not be the case," said Das. "About one-fourth of the people [in a recent national health survey] did not have any information about a second method and about a third of that one-fourth did not have any information about the safety of the sterilizaton procedure. So there is no informed choice."
That focus on sterilization has its own dangers.
Although activists pushed the Supreme Court to mandate minimum safety and quality standards for sterilization in 2005, there is no real monitoring mechanism to ensure that facilities adhere to the norms. Surgeries are no longer performed in cattle sheds. But Das said that infections and other complications are still common. All too often women die under the knife as tired surgeons rush through operations in hastily erected rural camps.
Although international figures suggest that about one in 200 female sterilization operations fail — resulting in unwanted pregnancies and other difficulties — in India that number is likely much higher.
Moreover, the focus on sterilization for birth control pushes women to have children early and then go for sterilization operations at 22 or 23 years old, which studies show makes them more vulnerable to various gynecological problems — and four times more likely to undergo a hysterectomy later in life.
As the world takes fearful stock of India's growing numbers, it should remember that those figures represent human beings, says the Population Foundation's Nanda. And focus on the progress that has been made and why it has been made, rather than putting the country in the cross-hairs again.
"No such scare mongering should be done," he said. "The fertility rate has come down. When we started, it was around six. It has come down to 2.5 or 2.4, and it will reach 2.1 in another five or 10 years, maximum. In some states it may go a little later, but that should not lead us to do things that will cause problems for women."
Editor's note: This story has been updated to reflect the fact that the population of India increases every year by that of Australia.