For many years, Population Research Institute has received persistent reports that the Instituto Mexicano del Seguro Social (IMSS) practices coercive family planning, using force and deception to get women to agree to limit the size of their families. We have found similar patterns of coercion and deception in other countries, all in the name of reducing population growth on the premise that too many people undermine prosperity. In an effort to determine how accurate these reports are, we interviewed knowledgeable doctors, lawyers, and women who are potential victims, to discover what abuses occur, and how recent and widespread these offenses were.
The planificacion familiar (family planning) system of IMSS dates back to 1974, although IMSS’ mission statement contains no reference to family planning. The National Population Council (CONAPO) was formed at that time with the function of “demographic planning in the land.” the goal being to “establish a demographic culture in harmony with growth and sustainability of development.” CONAPO, which is part of the federal government, tracks the loss of Mexican population through immigration, disease, and national disaster. It then determines what Mexico needs in terms of workers, and uses this information to assign quotas for population control. CONAPO was put in place with practically no public debate and is now little discussed officially. A number of secretaries and directors in the federal government report regarding family planning matters to CONAPO. This system has the purpose of reducing the national fertility of Mexican women. The family planning ideal is two children per family.
Family Planning Subspecialty
In medical terms, family planning is a subspecialty of obstetrics and gynecology, surgery, or internal medicine. IMSS doctors opt into the subspecialty and receive training with IMSS for one year. The training consists of medical indications and contraindications of the various population control measures available to family planners. Despite the fact that it would be acceptable to the majority Catholic population in Mexico, Natural Family Planning (NFP) is not officially recognized by IMSS. According to two IMSS doctors, it is considered unreliable and unteachable to the illiterate. The recognized measures in which doctors, nurses, and social workers arc trained are the pill, implants, IUD (copper T and spiral), tubal ligation, and abortion. Upon completion of their training, the doctor is recognized as a family planning physician and heads a team that is assigned women from the stream of women coming into the clinic or hospital for any kind of treatment.
Subspecialty physicians are expected to prescribe artificial contraceptives and abortifacients, and to recommend or perform ligations or abortions. A trained physician who declines further participation in family planning yet still wants to work at IMSS may be penalized. For example, a physician on a day shift who declines on the basis of conscience may be assigned to the night shift where they are not required to prescribe anti-natal drugs. Reproductive health quotas for contraceptive drugs, inserts, or ligation are assigned from CONAPO in Mexico City, then broken down for each hospital or clinic, then further broken down for assignment to teams. Quota-based performance by doctors is the primary family planning management tool available to IMSS. Physicians can actually lose pay for failing to meet quotas. The stage is thus set for coercion and for surreptitious placement of IUDs.
Abortion is not officially discussed in IMSS. The IMSS consent form does not mention abortion as an option. However the term “normalization of menstruation,” another euphemism used in IMSS family planning circles, has become a widely-used codeword for abortion. Another method available to physicians to meet quotas is for two to certify and sign records indicating the advisability of an abortion to preserve the mother’s health. What constitutes a threat is commonly given liberal, that is to say, inclusive interpretation.
Constitutional Guarantees to Life and Freedom
The Mexican Constitution is very precise in its guarantees of life to the unborn. It states, “… issuing from a fundamental norm it is established, firstly, the protection of the child’s life before and after birth, and secondly, that this right to life inheres in the human person … resides juridically throughout the fullness of gestation, and considering the unborn child as a person with life … and whomever causes his/her death is subject to sanctions, in such a manner that the child is protected … this right to life derives as much from the Constitution of the United States of Mexico as well as from international treaties.”
The candidate for chemical or surgical family planning is selected from among those who come to IMSS on the basis of age, general health, existing medical conditions or number of children, but not necessarily desire to participate in the program. There is reason to believe that IMSS reacted to a public image of arbitrary, clandestine placement of intrauterine devices and sterilizations by creating an informed consent form, among other measures. The manner and circumstances of obtaining consent from the mother are important because the consent form, duly signed and authenticated, becomes proof that the mother agreed to the family planning procedure. This, of course, helps the doctor meet his quota.
Signing the form constitutes formal entry into the family planning program and allows IMSS to deal with claims, which had by the late ’90s become numerous, that sterilizations and placement of intrauterine devices were commonly done either forcibly, without consent, or clandestinely. These practices were not confined to IMSS hospitals and clinics, although the majority of cases took place there, The social workers often visited the family for the purpose of obtaining the mother’s signature. Some women characterized these visits as harassment because of their regularity and because their purpose seemed to be to obtain a signature on the consent form. Social worker home visits are scheduled during the day so that the husband is absent. One woman signed because only by her consent would the IMSS physician agree to certify her for maternity leave from work. The infringements are not only upon basic rights of life of the unborn but upon the basic freedoms of the mother. The General Law of Population states, “family planning programs will be completed with absolute respect for fundamental rights of the people and families all in accordance with the rational regulation and stabilization of the population and its growth as well as deriving maximum benefit from natural resources.”
The candidate selects a method of family planning based on information concerning each option supplied by the doctor, in the presence of a witness, who signs the consent form along with the woman and the doctor. Two women complained that although they used N FP, this was insufficient to persuade the physician to sign maternity leave certifications. The candidate is supposed to understand fully all ramifications of her choice as well as her medical condition and family situation, along with the other choices proposed by the doctor or nurse. Both sign in the presence of a witness who also signs after the candidate has entered the measure she selects. The candidate agrees to return for treatment of complications. The form remains on file in the reproductive health office. Neither the doctor nor a witness signed the consent form shown on the next page.
These ideal conditions are rarely met. The consent form allows a thumbprint in place of signature for the illiterate. Illiteracy is sufficiently common in Mexico that thumbprints are often used. One doctor intimately acquainted with the IMSS family planning system described the deceptive practice of attending physicians obtaining consent on the operating table for tubal ligation during a Cesarean birth. Cesarean delivery is chosen by the physician, and with the knowledge that the fallopian tubes will be exposed, requests consent to perform a tubal ligation as the mother lies on the operating table, in too much pain to make an informed decision. One doctor alleged the daily occurrence of this practice in larger IMSS hospitals.
Cases of Abuse
PRI has case files on 40 women who complained unofficially of abuse by IMSS and other government hospitals and clinics. These cases prove that abuses do occur, tell us of the nature of these abuses and suggests what a systematic survey might yield in terms of nature, type, and frequency of violations of mother’s rights. One woman agreed to a Cesarean delivery, but sterilization was performed at the same time, without her consent. Another had two intrauterine devices inserted by the doctor. Double insertion allows the physician to remove one at a later date yet leave the woman unable to conceive. There is a seemingly high correlation of intrauterine device insertion without consent accompanied by subsequent inflammation, giving rise to the possibility of poor technique on the part of the medical staff. There are several cases where the woman learned of surreptitious intrauterine insertion several years later when they had been unable to conceive.
It is difficult to escape the conclusion that a structure exists in IMSS hospitals and clinics, which encourages violations of mother’s rights in the name of family planning. Proof comes from the numerous cases of coercive or surreptitious action, or both, by physicians and their teammates. From PRI files, a strong case can be made that the favored option by family planning teams is the IUD, emplaced surreptitiously. Management rewards those who reach their assigned quota and penalizes those who do not. While to outward appearances women are constitutionally protected from family planning abuses, there exists considerable latitude to doctors, nurses and social workers in obtaining so-called informed consent or proceeding without the knowledge of the patient.
Violations of informed consent result in a pattern of abuse. The consent form is in all probability not designed to protect women’s rights but to give IMSS staff a ready response to accusations of abuse, while they continue to meet their quotas. It is noted that the consent form shown above, dated June 2002, was signed by the complainant in order to obtain maternity leave. The physician, who did not sign, refused to certify pregnancy and therefore eligibility for maternity leave if she did not agree to insertion of a device. This is coercion. The form clearly states that signing is a free act in the presence of a witness and without pressure or coercion, but this was not the case. Coercion or deception would seem to be the order of the day for IMSS doctors obtaining signatures on the consent form.
The consent form does not mention abortion. However, doctors get around this by performing abortions under the guise of “normalization of menstruation” or by obtaining the signature of two physicians, who state that abortion is necessary. It seems fair to conclude that the consent form has not undergone legal review by attorneys outside IMSS who bring objective legal standards to bear on the policy reflected in the wording. Given the constitutional protections of mother and child in Mexico it is probable that the form would not stand up under such review.
Does family planning in Mexico compare to that in Peru? The sterilization policies during the period 1990–2000 in Peru had a scorched-earth quality, which is not present in Mexico. In Peru, massive human rights violations against women, particularly poor women living in remote areas, occurred in the name of family planning. The Peruvian program called for sterilization because it was cheap and permanent. These sterilizations were not isolated incidents of medical or bureaucratic incompetence, nor were they consensual. The result was over 300,000 women coercively sterilized. [See PRI Review, July-August 2002.] Unlike the Peruvian program, IMSS allows the choice of a method, but does not allow women the option to choose no method, or to choose NFP.