NEW DELHI — The women were poor, from villages in central India where the promise of a few dollars is all but impossible to resist. Many had babies so young they were still nursing at their mothers' breasts.
The deaths of 12 women after they underwent sterilization procedures this week have raised serious ethical questions about India's drive to curb a booming population by paying women who get sterilized. The deaths also exposed the dangerous lack of oversight in India's $74 billion health care industry.
"We really are not paying enough attention to the quality of care in the public health system," said Jay Satia, an adviser to the Public Health Foundation of India.
The surgeon who performed the operations at the government-run "health camp" in Chhattisgarh state plowed through more than 80 surgeries in six hours — a clear breach of government protocol, which prohibits surgeons from performing more than 30 sterilizations in a day, a top medical official said Wednesday.
The surgeon, Dr. R.K. Gupta, was honored by the state government in January for performing over 50,000 laparoscopic tubectomies, said Dr. S.K. Mandal, the chief medical officer in Chhattisgarh.
"He's a very senior and respected surgeon," he said.
Mandal said he believed Gupta was under pressure to meet government-set targets for sterilizations.
"The people from the health department set up some targets and we have to achieve them by 31st March," Mandal said.
A spokeswoman for the federal health ministry said she was not aware of sterilization targets for states. India's government had said it stopped setting targets for sterilizing women in the 1990s.
But doctors and human rights workers have alleged for years that targets exist — which would lead to inevitable coercion in villages where most people have very limited access to both education and health care.
"The government of India denies that there are targets but they're clearly set and when it goes down to the district or village level that's a real problem. Extreme pressure is the crux of the problem," says Sona Sharma, joint director for advocacy at the New Delhi-based Population Foundation of India.
Mandal said that his state had a target of 220,000 sterilizations this year and Bilaspur, the district where the botched surgeries took place, had a target of about 15,000 surgeries.
Sterilization targets have a troubled history in India. In the 1970s, Prime Minister Indira Gandhi imposed a policy of forcibly sterilizing men who had already fathered two children. Opponents at the time said the program targeted unmarried and poor men, with doctors given bonuses for operating on low-income patients.
Still, many experts caution that the sterilization surgeries can be a lifeline for poor women who are tired of multiple pregnancies or who want to take control of their fertility.
"It is convenient for many women. It's not ideal, but it's a one-time surgery and then you're done," says Sharma.
But she said incentive payments and government quotas make doctors pressure patients into surgery rather than advising them on contraception.
"Women are not informed about the choices in contraception they have. It's their right to know that other methods exist," she added.
Women in most Indian states are promised 1,400 rupees ($23) when they chose to have laparoscopic, or "keyhole," sterilization surgeries like those conducted in Bilaspur. The procedure is one of the most commonly performed minimally invasive surgeries, and is usually done under a local anesthetic.
India has one of the world's highest rates of sterilization among women, with about 37 percent undergoing such operations compared with 29 percent in China, according to 2006 statistics reported by the United Nations. About 4.6 million Indian women were sterilized in 2011 and 2012, according to the government.
In comparison, less than 1 percent of men choose to undergo vasectomies even though the cash incentive is higher at about 2,000 rupees ($33), says Sharma.
"They're worried about losing their virility. No amount of compensation will draw them to vasectomies."
A total of 83 women had the operations Saturday as part of the free sterilization campaign and were sent home that evening. But dozens later became ill and were rushed in ambulances to private hospitals in Bilaspur city. By Wednesday at least 12 women were dead. Dozens more are hospitalized, and at least 13 are fighting for their lives.
Outside the hospital, the relatives and young children of the dead women wailed or looked frozen in shock.
"The families of at least 10 women said that they had young babies, most of them under 6 months old, and were still being breastfed. Now the mothers are dead," said Kamlesh Pandey, a local journalist based in Bilaspur.
One man told The Indian Express newspaper that his sister-in-law had just given birth and did not want to sterilization surgery but was bullied into it by local officials.
"They said nothing would happen. It was a minor surgery," Mahesh Suryavanshi said.
Yet Gupta, the surgeon, was performing operations in a private clinic that wasn't even registered with the government and in an operating theater that Mandal says should never have been used.
The apparent cause of death was either blood poisoning or hemorrhagic shock, which occurs when a person has lost too much blood, state deputy health director Amar Singh said.
The Chhattisgarh state government sent a plane to New Delhi to pick up seven doctors to help treat the patients.
"Whatever treatment is being provided to the victims is good," said Dr. Anjan Trikha of the Delhi-based All India Institute of Medical Science, speaking with reporters at one of the hospitals in Bilaspur.
He declined to say anything more until the results of autopsies are released.
The government has also started a criminal investigation into Gupta's conduct and said that the victims' families would each receive about $6,600 in compensation. Four government doctors, including Gupta and the district's chief medical officer, have been suspended.
Associated Press writers Katy Daigle in New Delhi and Indrajit Singh in Patna, India, contributed to this report.