Access to Contraception and Women s Experiences with the Public Health System: Fact Finding at Mewat, Haryana

Transcription

1 Access to Contraception and Women s Experiences with the Public Health System: Fact Finding at Mewat, Haryana February 2014 Human Rights Law Network 1

2 Executive Summary In February 2014 a health rights activist and two advocates from the New Delhi based Human Rights Law Network (HRLN) traveled to three villages in Mewat District, Haryana to investigate women s access to contraceptive information and services and state implementation of reproductive health schemes. The current unmet need, or the percentage of married women who wish to delay or prevent pregnancy and do not have access to contraception is 35.8% in Mewat. This is much higher than Haryana s unmet need of 15.4%. The team conducted focus group discussions in three villages with a total of 57 women. As a result of these conversations, the fact-finding team has identified the following major issues of concern: (1) Women in Mewat do not have access to the information or contraceptive services that facilitate autonomous decisions about pregnancy and reproduction. (2) The public health system does provide women access to adequate, acceptable, quality reproductive health care or to trained medical professionals and equipped facilities. (3) Inadequate access to quality contraceptives results in unwanted pregnancies that create immense financial strain for women who either pay for medical termination of pregnancy out of pocket or struggle to provide for their large families. (4) Religious and cultural norms prevent women from obtaining contraceptive information and services. The state has not taken action to address these prevailing norms. (5) The state s singular focus on sterilization limits women s access to nonpermanent forms of contraception. This report also includes individual testimonies to illustrate the impacts of the state s failure to implement reproductive and maternal health schemes and to ensure the fundamental rights to life, health, dignity, and equality enshrined in the Constitution of India. Ultimately, the fact-finding team urges immediate state action to address the myriad forms of discrimination against women that persist in Mewat. 2

3 Table of Contents I. Fact-Finding team and design 4 II. Mewat District..4 III. Findings: issues of concern.6 IV. Findings: focus group discussions 11 V. Conclusion and acknowledgments

4 I. Fact-Finding team and design- Pratibha D mello, Social Activist, Reshma S. Jaffrey and Abhiti Gupta, advocates at Human Rights Law Network (HRLN), Deen Mohammad, local leader, and Mid Day Meal Workers Association representative from Akheda village conducted meetings with women in three villages in the Nuh, Mewat area and visited one Community Health Centre (CHC) in February Visit Itinerary: Date Timing Activity Place 8 th Feb 2014 Morning Meeting with women Akheda village Afternoon Meeting with women Khelra village 9 th Feb 2014 Morning CHC visit Nuh Mewat area Afternoon Meeting with women Ghasera village II. Mewat District Mewat District Population 2011 In 2011, Mewat had population of 1,089,263 including 571,162 males and 518,101 females. According to the 2001 census, Mewat had a population of 789,750 including 415,947 males and 373,803 females. Mewat Literacy Rate 2011 Mewat s average literacy rate in 2011 is as compared to in Gender wise, male and female literacy stand at and respectively. 4

5 Mewat Sex Ratio 2011 The 2011 child sex ratio for Mewat is 903 females per 1000 males. In 2001 the child ratio was 893 girls per 1000 boys. According to census 2011 directorate, the average child sex ratio in India is 940 girls for every 1000 boys. Maternal Health in Mewat The state of Haryana has failed to ensure basic maternal health care in Mewat. Only 17.4% of pregnant women registered their pregnancies in the first trimester. Only 16.4% of women had 3 antenatal visits during their last pregnancy and just 52.6% of women received at least one Tetanus Toxoid (TT) injection. Despite government incentive schemes, institutional deliveries remain low in Mewat at just 14.8%. The institutional delivery rate for the state is just 23%. Contraceptive Information and Services Information as per National Family Health Survey (NFHS-3) and District Level Household Survey (DLHS-3): In Mewat District, 48.5% women marry under the age of 18 and in rural Mewat 50% of women marry before 18. Of all married women, only 27.9% use contraception. In rural areas of Mewat just 25.5% of married women use contraception. Female sterilization is the most common method of preventing pregnancy in Mewat. Data shows that women clearly bear the burden of the state s family planning policies. While 12.7% of women in Mewat have had sterilization 5

6 surgeries, only 0.4% men have had a vasectomy. Intrauterine Devices (IUDs), including Copper-Ts are used by 1.7% of married women in Mewat and 1.3% of rural married women in Mewat. Only 1% of married women in Mewat use birth control pills. Married men using condoms constitute only 2.9% of contraceptive users and 1.8% of contraceptive users in rural areas. As per NFHS-3, the total unmet need for contraceptives in Mewat is 35.8%. In rural areas of Mewat the unmet need is 37.0%. This means that 35.8% of married women in Mewat who do not want additional children or who want to space births are not using any form of contraception. The NFHS does not include sexually active unmarried women who are not using contraception. III. Findings: Issues of Concern Focus group discussions with 57 women in three villages highlighted the following major issues of concern: 1. Women cannot exercise their right to make autonomous decisions about reproduction and bodily integrity. Women are unaware of their contraceptive options. The women overwhelmingly rely on the public health system for contraceptive information and services. The National Rural Health Mission (NRHM) guarantees a basket of contraceptive choices to women. However, the focus group discussions revealed that very few women use non-permanent forms of contraception. While many women know about and use female sterilization or the Copper-T to prevent pregnancy, very few women knew 6

7 about alternate forms of contraception. Even fewer women had actually ever used an alternate contraceptive method. The visit to the Nuh Community Health Centre underscored women s limited options. In violation of government guarantees, the facility only provides two forms of contraception: sterilization surgeries and Copper-Ts. Many of the women specifically link inadequate, inaccessible, poor quality, and unacceptable contraceptive information and services with unwanted and forced pregnancies clear violations of a woman s right to bodily integrity. The state has not taken steps to ensure that women have the information and services to make decisions regarding contraceptives. Myths and rumors about various forms of contraception persist. Many women told the fact-finding team that they wanted a contraceptive injection in the uterus and that the injectable would last five years. These commonly held misconceptions illustrate the wide gulf between government schemes regarding contraceptive information and services and the reality on the ground in Mewat. The women have not had individual (with an Accredited Social Health Activist, ASHA) or group (through awareness activities) counseling on contraception. Without access to accurate information, women cannot make decisions about their own bodies. Likewise, men in the villages have not had counseling. Women widely reported that their husbands refused to wear condoms or to participate in conversations about family planning. 7

8 2. Women do not have access to adequate, acceptable, quality reproductive health care or to trained medical professionals and equipped facilities. When women do use contraception, they do not have adequate support, aftercare, and counseling from medical professionals. For instance, many women discussed quality of care issues with Copper-Ts. They told the team that their husbands complain that they feel the IUCD during intercourse. Where women do not have access to medical professionals and facilities, this type of negative experience with a particular form of contraception discourages use and fuels myths and misconceptions about contraception. Women expressed similar concerns regarding the birth control pill (Mala- D). In some cases, use of Mala-D can lead to side effects like nausea, headache, and weakness. Women who experienced these side effects did not have access to a doctor or medical professional. Accordingly, these women discontinued use and discouraged their friends from taking Mala-D to prevent pregnancy. The government does not provide awareness programs or follow up trainings for ASHAs and Auxiliary Nurse Midwives (ANMs). Under government schemes, these ground level health workers are responsible for contraceptive counseling and for distributing contraception in rural villages. Most women had never discussed contraception with a government health worker. In clear violation of government mandates, 8

9 ground level health workers in Mewat do not provide adequate counseling or contraceptive services. Sub-centres in Mewat are non-functional. Under government schemes, women should have access to contraceptive information and services through an ASHA worker and their village level sub-centre. In Mewat, the sub-centres have limited hours and are largely understaffed and poorly equipped. Women in Mewat prefer to go to private facilities even though the district has three large government hospitals. Many women are unaware of their right to access services and financial support under government maternal health schemes. Women reported that they do not receive their government-mandated cash incentive for institutional delivery. The staff nurse at the CHC incorrectly told the factfinding team that the incentive scheme for institutional deliveries did not apply at that facility. 3. Inadequate access to quality contraceptive information and services generates high out of pocket expenditure and strains economically marginalized families. Discussions revealed that most women in Mewat do not spend money directly on contraception, as they receive services from the government or do not use contraception at all. However, women told the team that inadequate access to contraception results in unplanned and unwanted pregnancies. Public facilities do not provide adequate care or a full range of mandatory services. As a result, women and their families have no 9

10 choice but to pay for abortions out of pocket at private facilities. Women who cannot afford or access abortion told the team that additional children placed great economic strains on their families and made it difficult to provide adequate food and basic necessities to all their children. 4. The state has failed to address social and religious norms regarding contraception. Religious and social norms limit contraceptive use. In Mewat, health service providers and ASHAs believe that Muslim women will not accept modern contraceptive methods. This mindset has permeated through the public health system and many ASHA workers have ceased counseling in Muslim areas. While women in Mewat expressed concerns related to their religion, they also expressed a strong desire to control and plan for pregnancy. Social norms also prevent women from making autonomous decisions regarding pregnancy. Many women told the team that they did not want more children, but that their husbands and mothers-in-law demanded additional children or male children. Women do not have the power to make decisions regarding reproduction. Under international law, the state has an obligation to address cultural norms that perpetuate discrimination and inequality. Current state policy does not address existing social and religious norms. Government contraceptive policies must address these norms and ensure that all 10

11 women have access the information they need to make decisions regarding their bodies. 5. State focus on female sterilization limits women s access to nonpermanent forms of contraception. The focus groups and District Level Household Survey-3 (DLHS-3) data clearly show that the state s family planning schemes center on female sterilization. The state targets women for sterilization camps and offers incentives to women who undergo tubectomies. The fact-finding team found that the vast majority of women who use contraception in Mewat have been sterilized at a government camp. Many of these women had no knowledge of non-permanent forms of contraception at the time of sterilization or at the time of the fact-finding. They did not receive counseling before their surgeries. Many women told the team that they would not have opted for sterilization if they knew about non-permanent contraceptives. The focus on sterilization violates the National Population Policy and the inadequate pre-surgery counseling violates Union of India Sterilization Guidelines and fundamental rights enshrined in the Constitution of India and international human rights law. IV. Findings: Focus Group Discussions Date: 8 th February to 9 th February 11

12 1 st Focus Group Discussion: Akheda Village, Nuh, Mewat District, Haryana Date: 8 Feb, 2014 The meeting started with a round of introductions. The team shared the purpose of the meeting and took verbal consent for conducting the meeting, recording the discussion, and taking photographs. The team requested that all men leave the room as the women did not feel comfortable discussing private issues in front of them. The fact-finding team conducted a focus group discussion with 20 women. Most women belonged to the Muslim community. Focus Group Discussion, Akheda Village, Mewat 12

13 Background information of FGD participants: S.No. Name Age Number of children 1. Jamila Mobina Kiran Kailash Anita Veermati Sunita Hema Majita Saliman Rubina Bismillah Busrah Jamshida Abriya Kashmiri Rahiman Farida Samina Rabina 25 2 Average age: 30.3 Average number of children:

14 Findings: 1. The ASHA workers and health service providers do not play an active role in providing comprehensive contraceptive information and services especially regarding alternatives to tubectomy and Copper-T. 2. Many women, due to the strict religious beliefs, do not go to government tubectomy camps. A few of the Muslim women who use Copper-Ts are afraid that if they die before removing Copper-T, god will punish them. 3. Aside from sterilization and Copper-Ts, the women are only aware of the birth control pill (Mala-D) as a third way to prevent pregnancy. Most of the women complained about these pills being ineffective and causing negative side effects including nausea, excessive bleeding, and weakness. Despite the negative side effects, many Muslim women in the focus groups who do use contraceptives use the birth control pill. 4. Men in the villages refuse to use condoms as a form of contraception. Women shared that it is difficult for them to talk to their husbands about condom use. There is a need a male outreach worker to counsel men in the village about condom use and vasectomy. 5. Most of the women in this village prefer to go to private hospitals for their treatment even though there are three large public hospitals near the village (1) Medical College, (2) Nalhad CHC, and (3) District Hospital, Nuh. 14

15 6. There is a sub-centre in the village, which remains closed most of the time. It is written near the gate of sub-centre, at every first and fourth Wednesday of each month, pregnant women and children would be vaccinated and immunized and death and birth certificates will be provided from here. According to the people in the village, this subcentre opens only once a month. Sub-centre 7. Women have not been provided with antenatal cards, which should be provided to all pregnant women according to government schemes. 15

16 8. Women are not aware of existing government schemes for pregnant women and lactating mothers. As per their knowledge, no scheme is available to them. Women in Akheda Village Individual Cases: Noor Begum- In order to prevent pregnancy, Noor Begum took an expensive contraceptive injection from a private clinic in July For three months after her injection she experienced heavy bleeding, and she spent Rs. 14,000 for treatment. She did not have access to an alternative form of contraceptive during this time. As of 8 th February 2014 Noor Begum is 4 months pregnant with an unwanted pregnancy. 16

17 Rubina- Rubina has two children and has had one miscarriage. Rubina went to a hospital during her miscarriage, but she still suffers from pain. She is unable to sit or sleep properly. She never wanted to have more than one child but she did not have access to contraceptives. She never used any method of contraception and is now again nine months pregnant. She works as a member of the midday meal cooking team at the school. Rubina has to take her two small children to work with her and will have to bring her third child along immediately after delivery. Rubina told the team that it is impossible to adequately care for her children while she is working. Her family relies on her income to survive. 2 nd Focus Group Discussion: Khelra Village, Nuh, Mewat District, Haryana The fact-finding team had a focus group discussion with 17 married women and 3 unmarried women. The group included both Muslim and non-muslim women. The team introduced itself and explained the purpose of the meeting and took verbal consent for conducting the discussion. 17

18 Focus Group Discussion in Kheira Village Background information of Villagers: S.No. Name of the women Age No. of children 1. Jyoti Rajesh Manju Minakshi Zenab Kashmiri Majla Devi Arifa Hafizan Zakhiya Dayawati

19 12. Khurshida Harman Kunja Geeta Samantra Mukesh Bilkis Yogita Roopwati 25 0 Average age (married women): 33 Average number of children (married women): 3.6 Findings: 1. Out of the 18 married women present during the focus group discussion, 7 women had undergone tubectomies. Most of the women who had tubectomies were not aware of any other form of contraception. They reported that at the time of sterilization, they did not have counseling about other temporary methods. The fact-finding team asked these women if they would still have had the operation if they knew about non-permanent, non-surgical forms of contraception. The seven women unanimously said that they would not have had a tubectomy if they had known about other contraceptives. 2. The women reported incorrect information to the team regarding injectable contraceptives. Women told the team there are injectables that last for three or 19

20 five years. These drugs do not exist in India. They also told the team that the doctor injects the contraceptive drug directly into the uterus. 3. During the discussion women told the team that they want their husbands to use condoms as provided at government health facilities or by ASHA workers, but the men refuse to use them. 4. Some women have received Copper-Ts at the sub-centre but women report that the Copper-Ts fall out with menstrual bleeding. The team could not determine whether this was a rumor, whether this is from poor placement at government facilities or whether this refers to husbands being able to feel the Copper-T during intercourse. 5. None of the women received JSY money in spite of having institutional delivery. Women in Kheira Village Individual Cases: 20

21 Name: Arifa Arifa, a 35-year-old woman, has four children and has had two miscarriages. Two years ago, during her 6 th delivery, her uterus ruptured and she was immediately rushed to the District Hospital at Nuh. From there she was taken to a hospital in Gurgaon and from there she was referred to Safdarjung Hospital, Delhi where she was treated. She shared that after having four children she was not prepared mentally, physically, and financially to have more children. In the absence of contraceptive information and services, combined with religious and cultural beliefs that discourage contraceptive use, she conceived twice and faced complications and morbidity. Villagers raised funds for her treatment and helped her financially. Her family requested doctors at Safdarjung Hospital to sterilize her with her consent before discharging her but because she is anemic the hospital could not perform the tubectomy. Arifa also took Mala-D but she suffered from severe bleeding. Now she is using Saheli a contraceptive pill she purchased out of pocket from the medical store. The ASHA worker told her about this alternative pill. Geeta Geeta is 30 years old and has three children. Her husband wants another male child. Geeta does not want any more children. Her husband and mother-in-law treat her poorly and she suffers from regular domestic violence. Women participating in the meeting sympathized with Geeta but considered domestic violence a private matter and a normal part of married life. 21

22 Geeta s husband does not allow her to use contraception to prevent pregnancy. Her youngest child is almost 4 years old. When asked about the reason for the gap between her children and any contraception used, she shared that she went to her parents house when the beatings and fights became unbearable. Now she is back to her in-laws house and she fears conceiving again. She can use some contraceptives without her family s knowledge, but she is unable to access contraceptive information or services. Sushma: Sushma is a 20-year-old woman who got married on 25 th February, She became pregnant within two months of marriage. After marriage, she wanted to delay the first pregnancy and practice spacing between subsequent pregnancies. She was not able to talk to her husband about this plan and no ASHA or Anganwadi Worker contacted her regarding contraceptives. Just one year after her marriage, Sushma has a nine-month-old baby and is currently six months pregnant. After her first delivery, her doctor husband purchased a once-amonth contraceptive pill. Sushma took the pills for six months, but she still conceived. The team tried to ascertain what this once-a-month pill contraceptive pill actually was, but Sushma did not have additional information. Her husband is not a doctor; he works in the pharmacy and has no medical training. Sushma appears very weak and is not receiving proper nutrition due to lack of finances as her husband earns only Rs. 6,000 per month. She did not want an early pregnancy. She was not able to breastfeed her first child more than six months, due to her immediate second pregnancy. She has not received her 22

23 government mandated antenatal checkups, medicine or visits from an ASHA worker. Sushma told the team that she is struggling to provide care for her nine-monthold baby while maintaining her health during her pregnancy. Sushma Day Two, Date: 9th Feb rd Focus Group Meeting: Ghasera Village, Nuh, Mewat District, Haryana The fact finding team had a focus group discussion with 17 women in Ghasera Village, Nuh area. It was a group of religiously mixed women with a majority of women from the Muslim community. 23

24 Background information of Focus Group Participants: S.No. Name of the women Age No. of children 1. Premla Amina Rukaiya Rahila Sadiyan Salma Basiya Akbari Sakila 22 1(5 miscarriage) 10. Jagni Emna 45 6(1 miscarriage) 12. Zubeda Rukaiya NurNisha Ruksana Raukaiya Parmina 26 7 Average age: 32.5 Average number of children: 5.4 Findings: 24

25 The fact-finding team members introduced themselves, shared the purpose of the meeting, and asked for consent /permission to conduct the meeting, to make an audio recording, and to take photographs. All women consented willingly and unanimously. Women in Ghasera Village 1. Initially, just one woman expressed any knowledge of contraceptives. The fact-finding team discovered that she was actually the village ASHA worker. Once she started sharing, other women also opened up about their experiences with contraception. 2. Out of the 17 women, 6 women had undergone a tubectomy surgery. 3. Most of the women reported that they refrain from using contraception due to their interpretation of Islamic law. As discussion progressed, fear of side effects also emerged as a major deterrent to contraceptive use. 25

26 Women speak with the fact-finding team in Ghasera Village 4. Many women used contraceptive pills but experienced side effects and discontinued use. One woman told the fact-finding team that she used Mala-D for two and a half months. During this time she experienced side effects like nausea, headache, and weakness. As a result, this woman grew skeptical about the effectiveness of the pill and discontinued use. She did not have access to a public health worker with whom she could discuss the side effects. She is not currently using contraceptives even though she does not want to have additional children. 5. Most of the women participating in the meeting were against using Copper-Ts. They explained that as per their religious beliefs, any cut or surgery or foreign object inside the body would disqualify them from offering prayer and that god would not accept them after death. 26

27 6. The ASHA worker reported that she makes home visits to counsel women on pre-natal care, cleanliness, and contraceptive pills. There is one delivery point in the village with one worker, one ASHA, and one helper. The ASHA takes care of the T.T injections that need to be given to the mother during pregnancy along with child immunization. 7. The ASHA worker shared that she tells women to have pills after their monthly cycles. They refer to the birth control pill as Mala-D and condoms as Nirodh. There is no generalized or local terminology for these contraceptives. The ASHA worker told the team that she has never held a meeting to impart detailed information related to contraceptives, available options, and advantages and disadvantages of particular methods. 8. ASHAs need comprehensive follow up training on contraception and counseling. Their knowledge about contraceptive methods did not meet the requirements established in the NRHM. Although the ASHA worker shared that they recently participated in training and will hold group meetings in the villages to share information on contraception and the options available to the women, she did not share a specific time or date for these meetings. 9. The women reported that the ASHA worker does not provide counseling on available contraceptive methods. 10. Women expressed that due to limited financial resources and paucity of time to take proper care of children, they want to space as well as limit the number of children they have. Women work at home and in agricultural 27

28 work. Most of the women are not allowed to rest for the 40 days after delivery (as is mandated culturally) and resting after delivery is considered a burden to the family. Women have to leave newborn babies at home in the care of an old woman or mother in law, to do agricultural work. This means women cannot breastfeed their children. Babies receive breast milk once a day, in the evenings when women return from the field. At home women do the household cooking, washing, and cleaning leaving no time to take care of children. The women feel that they have no control over the number of children they have or over spacing between births. There is a huge unmet need both for correct information on contraception as well as availability of methods. 11. Women participants in Ghasera village shared that there is a woman who reads a holy book to them in large groups every Friday. The writings of the book reflect the religious proscription against contraceptives. Women and their children in Mewat 28

29 Individual Cases: Sakila Sakila is 22 years old with one surviving child. She has had 5 miscarriages. She does not know the medical reason for any of her miscarraiges. She wants to have additional children, but she does not have access to medical professionals who can provide her with the specialized antenatal care she requires. Parmina Parmina shared her daughter-in-law s experience. Her daughter-in-law has seven children and she was using contraceptive pills but she experienced side effects. She became weak and pale. She continued to use the birth control pill on and off for two years depending on when her husband was in town. While on the pill, she conceived and had a medical abortion. She purchased a pill from a pharmacy for Rs. 250/-. She had severe bleeding. Six weeks after the medical abortion, she went to the hospital for a tubectomy. Facility Visit: Place: Community Healthcare Centre (CHC), Nuh, Mewat District, Haryana The team visited CHC, Nuh to observe the conditions and available services. The Community Health Center covers 32 villages over a range of 35 km. Findings: 29

30 1. The Staff Nurse explained there are 3 doctors available at the CHC. In violation of government guidelines, none of the doctors are specialists. The CHC does not have a gynecologist or pediatrician. The staff nurse conducts all deliveries. The facility refers complicated cases to the District Hospital, Nuh or to a Hospital in Gurgaon. 2. This facility is very neat, clean and well equipped. The Staff Nurse shared that the delivery room of this CHC was declared the best by RAPID team. (Rapid Appraisal of Programme) assessments of all health facilities were conducted in February 2012). 3. Approximately 200 deliveries take place per month. However, the facility does not have a procedure to ensure Janani Suraksha Yojana (JSY) payments to the women delivering at CHC. The Staff Nurse said that Below Poverty Line (BPL) women with two or fewer children receive JSY payments. This information is incorrect. A 2013 directive issued by the Ministry of Health and Family Welfare clearly states that all women are entitled to JSY payment regardless of number of children they have. The Staff Nurse told the team, This scheme (JSY) is not being implemented in Mewat. As you have talked with village women about JSY money from CHC, they will blame us for keeping the JSY money. 30

31 Delivery room 4. To date, no maternal death cases have happened in the CHC, as they refer complicated cases to Nalhad hospital. 5. In clear violation of government schemes, the Staff Nurse told the team, The CHC only provides Copper-T and sterilization services and no other form of contraception is available here. Also, the Staff Nurse incorrectly told the team that ASHAs and PHCs are responsible for distributing contraceptive methods Ssuch as pills and condoms to women. As per a circular from Ministry of Health and Family Welfare, dated 4 th August 2011, the Government of India decided to utilize the services of ASHAs to deliver contraceptives directly to the doorstep of couples. The circular mandated withdrawal of free contraceptives at the Primary Health Centre (PHC) and sub-centre levels. However, the circular states that free supplies of contraceptives will continue at CHCs and sub divisional and district level hospitals as before. The team s interaction with the CHC Staff Nurse illustrates a fundamental communication gap between the Ministry of Health and Family Welfare and service providers. 31

32 6. Every Tuesday the CHC organizes a sterilization camp, where an average of five to six women come for surgery. Sometimes there are women. Although the CHC offers vasectomies, men do not request the procedure. For general category women the incentive payment for tubectomy is Rs. 250/- and for BPL women the incentive is Rs. 600/-. Each tubectomy takes the doctor ten minutes and patients are able to recover at the facility for two to three hours after their surgeries. VI. Conclusion and Acknowledgments To ensure fundamental rights enshrined in the Constitution of India and international law, women in Mewat urgently require adequate, accessible, acceptable, quality contraceptive information and services as per Union of India guidelines and guarantees. HRLN would like to thank the Center for Reproductive Rights for its generous support for this fact-finding mission. 32