Around 39 percent of married women report being sterilised, against just 0.3 percent of married men. This translates into roughly 130 women undergoing sterilisation in India for every man. The ratio has remained virtually unchanged for nearly 15 years, making it one of the most enduring imbalances in the country's family planning programme. The disparity reflects more than individual contraceptive choices. It reveals how responsibility for permanent contraception continues to fall overwhelmingly on women.
An Imbalance by Design
The persistence of this imbalance is striking because vasectomy is cheaper, safer and less invasive, yet India's family planning programme gradually came to rely on female sterilisation. India introduced family planning under the National Family Planning Programme in 1954, and for decades vasectomy accounted for a substantial share of sterilisation procedures. Over time, however, the expansion of laparoscopic tubectomy, together with programme priorities, provider familiarity and service delivery practices, steadily shifted the focus towards female sterilisation, making it the default method of permanent contraception.
The consequences extend beyond how permanent contraception is delivered. Compared with vasectomy, female sterilisation carries higher complication and failure rates and, although uncommon, a higher risk of procedure-related mortality. Some recent studies have also reported associations with longer-term reproductive health concerns, including abnormal discharge, menstrual problems and pain during intercourse. A recent study from Bihar further reported an association between female sterilisation and premature menopause, even after accounting for hysterectomy and other contributing factors.
Although serious complications remain uncommon, failures in programme quality continue to occur. Bihar reported nine sterilisation-related deaths in 2020–21, the highest among Indian States that year. Earlier this year, a woman in Chennai died after failing to regain consciousness following a sterilisation procedure at a government hospital. The risks associated with female sterilisation therefore cannot be considered solely in terms of the procedure itself, but also in terms of how safely and consistently it is delivered in practice.
When Responsibility Becomes Gendered
The persistence of this imbalance is not simply a matter of programme design; it is also reinforced by social norms. As of 2019, India is among the small group of countries where more than 30 percent of women of reproductive age are estimated to have undergone sterilisation. This reflects entrenched gender norms that continue to cast contraception as a woman's responsibility. When men can distance themselves from both the practical and bodily work of family planning, women absorb its recurring costs: negotiating contraception within the household, depending on a partner's cooperation, and bearing the consequences of contraceptive failure. Sterilisation then becomes the default long-term solution, placing the physical burden of permanent contraception almost entirely on women's bodies.
High rates of female sterilisation should not automatically be interpreted as evidence of unconstrained choice. Decisions about contraception are shaped by the methods that are readily available, the counselling couples receive, prevailing gender norms and the options that family planning programmes actively promote.
National Family Health Survey (NFHS) data point to the same conclusion. Across the last three survey rounds, three patterns consistently emerge.
First, wives of men who believe contraception is "women's business" are consistently more likely to be sterilised. The difference is most significant in NFHS-3, when 43.7 percent of these women were sterilised, compared with 36 percent of women whose husbands did not share this belief. Although the gap narrowed to 2.3 percentage points in NFHS-4 and 1.3 percentage points in NFHS-5, the pattern persisted.
Second, these same men are substantially more likely to report that the couple uses no contraception at all. The gap is modest in NFHS-3 – 50.8 percent compared with 47.5 percent – but widens to about nine percentage points in each of the two most recent survey rounds.
Third, husbands' and wives' accounts differ significantly. In NFHS-5, among couples where the husband describes contraception as "women's business", he reports no contraceptive method about 70 percent of the time, while his wife does so only about 30 percent of the time. He reports female sterilisation in about 10 percent of cases; she reports it in 37 percent of cases. Some of this mismatch may reflect differences in survey responses or recall. Even so, its direction is revealing: contraception is still not understood or practised as a shared responsibility, even within the same household.
Rebalancing the Burden
If vasectomy is safer and less invasive, why does it remain so rare in India? Family planning programmes continue to focus overwhelmingly on women, with comparatively little sustained effort to promote male sterilisation. The legacy of the coercive nasbandi campaigns during the Emergency continues to shape public perceptions, while misconceptions remain widespread. Surveys consistently show that many men believe vasectomy causes physical weakness or sexual dysfunction, alongside fears of social ridicule. Some even believe tubectomy is the simpler procedure.
Three changes could help rebalance responsibility within India's family planning programme. First, the contraceptive method mix should be monitored routinely at the district and block levels. Wherever female sterilisation overwhelmingly dominates and vasectomy uptake remains negligible, it should be recognised as a programme imbalance rather than assumed to reflect women's preferences.
Second, behavioural change campaigns should directly address persistent myths surrounding vasectomy. Delivered through trusted local voices – including male health workers, community leaders and men who have undergone the procedure – such campaigns should present vasectomy as an act of responsible parenthood rather than an instrument of state control.
Finally, joint counselling of couples should become routine during antenatal, postnatal and immunisation visits, alongside immediate access to reversible contraceptive methods, so that sterilisation is never perceived as the only practical long-term option.
Towards More Equitable Family Planning
Millions of Indian women continue to face an unequal reproductive burden. While expanding contraceptive access remains essential, a family planning programme cannot be considered equitable when women continue to shoulder almost the entire responsibility for permanent contraception. Rebalancing that responsibility requires more than increasing contraceptive availability. It requires correcting a longstanding structural imbalance in how family planning is understood, promoted and delivered, so that responsibility for fertility regulation is shared more equally between women and men.