Risk factors for tubal sterilization regret, detectable before surgery.

Brazil has one of the highest prevalence rates of female surgical sterilization in the world. At the same time there is an increased demand for sterilization reversal. In order to understand which women tend to later request reversal of the procedure, a case-control study was carried out comparing 216 women who requested reversal with sterilized women who did not, paired by year of surgery. The relative risk of requesting reversal for women sterilized before age 25 was 18 times that of women sterilized after age 29. The elevated risk remained even after controlling for a number of variables present at the time of surgery. Multiple regression analysis showed that request for reversal was associated with younger age, less information about the procedure, and fewer contraceptive methods known before sterilization. These results support the recommendation that women should be fully informed about the tubal ligation procedure and have access to other contraceptive options before being sterilized.

An evaluation of Profamilia's female sterilization program in Colombia.

The findings of three surveys and three studies used by Profamilia to evaluate and improve their voluntary female sterilization program are presented. The surveys measured sociodemographic characteristics of users, factors behind the sterilization decision, and user satisfaction with the operation in the short run and over time. The studies explored methodologies for more accurate cost-effectiveness analysis. Results of the projects were used by Profamilia management to identify areas of program strengths and weaknesses and to implement operational changes.

PIP: Profamilia is a nonprofit, private family planning organization based in Bogota, Colombia. To improve program performance, the findings of 3 surveys and 3 studies were used by Profamilia to evaluate and improve their female sterilization (FS) program. The surveys measured socio- demographic characteristics of users, factors behind the sterilization decision, and user satisfaction with the operation in the short run and over time. The studies explored methodologies for more accurate cost- effectiveness analysis. Results of the projects were used by the Profamilia movement to identify areas of program strengths and weaknesses and to implement operational changes. In 1970, Profamilia offered vasectomy; FS was offered in 1972. The vasectomy program was ineffective; however, FS was very successful. Approximately 72% of all procedures performed in Colombia are done by Profamilia. In 1972, 2 Colombian gynecologists, (1 from Colombia) were trained in Colombia to do FSs by doctors from Johns Hopkins Hospital. At present, Profamilia uses about 40 doctors directly, and contracts with others. Program evaluation is done by using cost-effectiveness evaluation to measure financial efficiency, survey analysis to measure general program efficiency and client satisfaction, and collection of service statistics to measure program output. The 1st survey was done in 1976 and 1977 to learn about user characteristics. The 2nd project was a 2-phase (retrospective-prospective) survey carried out in 1978-83. In 1985, Profamilia decided to do a follow-up survey in conjunction with Association for Voluntary Surgical Conception (AVSC). It emphasized factors influencing the decision to be sterilized. Sterilization acceptors were interviewed in 8 clinics in a nonrandom sample. 3 cost- effectiveness studies have been done on Profamilia's FS program. A departmental study determined the cost per couple year of protection offered by the 5 service departments of Profamilia; an accounting study determined the full unit cost per sterilization; and an organization-wide cost study determined how to assign indirect and shared costs of support divisions to service departments like sterilization.

[Promotional campaign of temporary methods on the Atlantic Coast]. / Campana promocional de metodos temporales en la Costa Atlantica

PIP: In 1986 the Third National Survey on Contraceptive Prevalence took place in Colombia. The results of this article are based on the CPR of Colombia's Atlantic Coast. The information demonstrated the high prevalence of female sterilization in the area, but also the lowest CPR among temporary methods. As a result of these outcomes PROFAMILIA, along with The Futures Group/SOMARC and Johns Hopkins University launched a promotional campaign in the Atlantic Region to increase the CPR. However, prior to the campaign, PROFAMILIA instituted 2 surveys to collect baseline data for the promotional campaign. The initial KAP survey was the 1st of its kind in the Atlantic Coast directed at men (15-59) and women (15-49) in fertile ages; while the 2nd KAP survey was directed at the pharmacists in the region. Focus groups were organized to determine attitudes and practices of individual men and women in the area. The social marketing of condoms and orals took place because of the attitudes of men and women towards childbearing. Most women wanted to have their children quickly followed by getting "disconnected" from childbearing through sterilization. While they are having children, they need the pill to properly space each birth. The outcomes of marketing these 2 methods demonstrated that condoms were easier to market than the pill.^ieng

Survey report: Puerto Rico.

PIP: Findings of the 1982 Fertility and Family Planning Assessment suggest that Puerto Rico may have the highest rate of sterilization acceptance in the world. The survey found that 41% of married women in Puerto Rico have been sterilized to prevent further pregnancies and another 4.6% had husbands who had been sterilized. Moreover, 39% of young married women (25-29 years of age) opted for this method of permanent fertility control. Overall, 69% of married women were using some form of birth control at the time of the 1982 survey. Female sterilization accounted for 58% of total birth control use, compared with only 26% in the US. Oral contraceptives (8.3%), rhythm (5.2%), and the condom (4.4%) were the next most popular methods of family planning among the Puerto Rican contraceptive acceptors. Female sterilization was twice as prevalent among non-college educated Puerto Rican women than college-educated women, while reliance on male sterilization was greater among couples where the wife had at least a high school education. An estimated 33% of the decline in marital fertility in Puerto Rico in 1977-82 has been attributed to the level of sterilization. 27% of the sterilized women in Puerto Rico never used any other method of family planning, indicating a need for improved access to information about reversible methods for young women.^ieng

Sterilization approval and follow-through in Brazil.

The purpose of this study was to examine the factors that affect approval for and completion of sterilization in Rio de Janeiro. Of 2,186 new female family planning clients, 1,256 requested sterilization and 925 were approved for surgery. Among the approved women, 639 scheduled surgery and, of these, 595 were sterilized within three months of approval. While approval is dependent mainly on demographic variables, especially age and parity, follow-through by a woman is related to her education and income. The steps that a woman must complete to obtain a sterilization also affect whether she ultimately undergoes surgery. Almost no women were scheduled for sterilization during their initial clinic visit. Women who were not scheduled because they lacked certain documentation were more likely to follow through than women who, in addition to lacking documentation, were asked to switch from an inefficient contraceptive method (or no method) to a more modern one. The lessons to be learned from this study provide useful information to programs in other countries that are concerned about maintaining high standards but do not want to discourage women in their efforts to be sterilized.

PIP: The purpose of this study was to examine the factors that affect approval for and completion of sterilization in Rio de Janeiro. Of 2186 new female family planning clients, 1256 requested sterilization and 925 were approved for surgery. Among the approved women, 639 scheduled surgery and, of these, 595 were sterilized within 3 months of approval. While approval is dependent mainly on demographic variables, especially age and parity, follow-through by a woman is related to her education and income. The steps that a woman must complete to obtain a sterilizaion also affect whether she ultimately undergoes surgery. Almost no women were scheduled for sterilization during their initial clinic visit. Women who were not scheduled because they lacked certain documentation were more likely to follow through than women who, in addition to lacking documentation, were asked to switch from an inefficient contraceptive method (or no method) to a more modern one. The lessons to be learned from this study provide useful information to programs in other countries that are concerned about maintaining high standards but do not want to discourage women in their efforts to be sterilized. Approval rates increased with age of the youngest child. Women whose last pregnancy ended in an abortion were more likely to be approved than were women whose last pregnancy ended in a delivery. The woman's motivation--as assessed by the timing of her decision to have a tubal ligation and whether she made previous attempts to have surgery--was not important in determining approval. The number of steps a woman had to complete to undergo sterilization was important in determing whether she, in fact, obtained the sterilization. More than 1/5 of the women said that they did not obtain the signature of their partners to indicate that they approved of the sterilization. In the follow-up interview, 8.2% of the women gave this as a reason for not having had the surgery. Sterilization programs in other countries should be reviewed to make sure that sterilization is not being limited to only the most perservering women.

[Is female sterilization voluntary in El Salvador]?]. / Es voluntaria la esterilizacion de la mujer en El Salvador?

PIP: Sexual sterilization has become an increasingly important family planning method in developing countries, and notably so in Latin America, but some controversy has surrounded the practice because of the suggestion that individuals are coerced into undergoing sterilization. With the goal of examining allegations that low-income women in El Salvador are sterilized without their full knowledge or consent in family planning programs financed by the US, researchers interviewed 648 women who had received the operation in one of 7 facilities in El Salvador. In general, women were interviewed 1 month after their operation, by 6 trained female interviewers, with the assurance that the follow-up effort was not in any way connected with the facility performing the operation. An effort to sample approximately the same number of women from each facility was not entirely successful because of access difficulties. Most interviewees had been sterilized at below 30 years of age (average age at sterilization was 28 years), had begun having children in adolescence, and had not received more than a primary education. They had an average of 3.4 children and 1/3 had experienced the death of at least 1 child. The response to the survey indicated that female sterilization in El Salvador is voluntary. Women were shown to be aware of other contraception options. They had found out about sterilization and had become further informed about the method through providers and through communications with other women who had known about the operation at least 3 years before making a decision to submit to it, and many had waited between 1 month and 1 year before/between the decision and the actual operation. Only 1 women claimed to have felt pressured to be sterilized, identifying her mother as the source of the pressure.^ieng

[Surgical sterilization: 10 years' experience]. / Esterilización quirúrgica: experiencia en 10 años.

PIP: A sample of 1003 records of surgical sterilizations was studied from among the 9400 performed between July 1972-June 1982 at a university hospital in Nuevo Leon, Mexico. 12 patients were aged 15-19, 104 were 20-24, 244 were 25-29, 291 were 30-34, 267 were 35-39, and 85 were 40-45. Not all patients met the recommended conditions of being at least 25 years old and/or having at least 3 pregnancies. 11.6% of the patients were sterilized because of psychiatric problems, multiparity, 2 previous cesarean sections or on request of the spouse. 95.5% of the women were married, 2.1% were single, 1.6% lived in free union and .8% were widowed. 14.0% were illiterate, 57.7% had incomplete primary educations, 19.3% had completed primary school, 2.5% had incomplete secondary or technical schooling, and .3% had professional studies. 27 women had had 0-2 pregnancies, 336 had 3-5, 336 had 6-8, 198 had 9-11, and 106 had 12 or more. The maximum number of pregnancies was 20 and the average was 7.1/woman. 6 women had preoperative hemoglobin levels of 6.0 g or less, 12 had 7.0 g, 44 had 8.0, 119 had 9.0 g, 756 had 10.0, and 566 had 11.0 g or higher. Transfusions were given to all women with less than the minimum level of 10.0 g. 460 of the operations were postpartum, 334 were transcesarean, and 209 were interval procedures. 696 operations were done by the Pomeroy method, 52 by modified Pomeroy, 27 by fimbriectomy, 16 by salpingectomy, and 2 by the Uchida method. Among laparoscopic methods, 82 were done by cauterization and 128 with Yoon rings. 392 postpartum and 286 transcesarean operations were performed using the Pomeroy technique, while 82 interval sterilizations were done using cauterization and 107 using Yoon rings. Epidural anesthesia was used in 457 postpartum and 325 transcesarean procedures, while general anesthesia was used in 175 interval sterilization. There were few transoperative complications. There were 2 cases of failure to achieve salpingoclasy, 4 cases of hemorrhage, 1 case of burning of the visceral wall, 1 case of anesthetic accident, and 12 cases of other complications. Among postoperative complications there were 15 cases of abdominal pain, 1 each of fever and infection, and 1 of other complication. There was 1 pregnancy among the 1003 cases. All the procedures were performed by physicians in training.^ieng

Why women don't get sterilized: a follow-up of women in Honduras.

In 1980, a study to determine interest in and access to sterilization for females was initiated at two Ministry of Health hospitals in Honduras. Results of the baseline study showed that 42 percent of women desiring sterilization from the Tegucigalpa hospital and 21 percent from the San Pedro Sula hospital had had a tubal ligation. A second study was conducted two years later, following up the interested but unsterilized women from the baseline study. Results show that 33 percent of women in the Tegucigalpa group, compared to 15 percent in the San Pedro Sula group, had been sterilized. Part of this difference can be attributed to an increase in sterilization facilities in Tegucigalpa over the two years after the baseline study was conducted. Among the major reasons women gave for not having been sterilized were financial and time constraints. Over the two-year period, the authors estimate that, of women interested in sterilization at delivery, 52 percent in total were sterilized in Tegucigalpa and 29 percent in San Pedro Sula.

PIP: In 1980, a study to determine interest in and access to sterilization for females was initiated at 2 Ministry of Health hospitals in Honduras. Results of the baseline study showed that 42% of women desiring sterilization from the Tegucigalpa hospital and 21% from San Pedro Sula hospital had had a tubal ligation. A 2nd study was conducted 2 years later, following up the interested but unsterilized women from the baseline study. Results show that 33% of women in the Tegucigalpa group, compared to 15% in the San Pedro Sula group, had been sterilized. Part of this difference can be attributed to an increase in sterilization facilities in Tegucigalpa over the 2 years after the baseline study was conducted. Among the reasons women gave for not having been sterilized were financial and time constraints. Over the 2-year period, the authors estimate that, of women interested in sterilization at delivery, 52% in total were sterilized in Tegucigalpa and 29% in San Pedro Sula. Results show that in Honduras as elsewhere in Latin America, obstacles to sterilization exist in the form of cost, travel time and family-related constraints. Institutional requirements and availability of facilities also creat barriers for clients. Fear of surgery was not a very important reason for not getting sterilized among women in the baseline study, only those who said they still wanted to be sterilized were interviewed for the 1982 study. The fees for sterilization are US$17.15 at Materno Infantil (or blood can be given instead) and US$10.0 at Leonardo Martinez and Centro Medico Quirurgico, but financial help is available for women who cannot pay. A new study will be carried out in Tegucigalpa to determine the impact of the various changes aimed at improving access to sterilization there. Programs to be studied include the availability of new facilities to provide postpartum sterilization at Materno Infantil and the provision of travel money and additional facilities that make it easier for a women to complete sterilization requirements at Centro Medico Quirurgico.

Sterilization in Honduras: assessing the unmet demand.

The purpose of this study was to evaluate and compare the availability of sterilization services at two hospitals in Honduras. Approximately 7,000 women who had given birth at the Hospital Materno Infantil in Tegucigalpa and the Hospital Leonardo Martinez in San Pedro Sula were asked about their desire for sterilization. Of the women who wanted to be sterilized, a considerable percentage had not been sterilized four months after they had given birth--58 percent of those who had delivered at Materno Infantil and 79 percent of those who had delivered at Leonardo Martinez. Twenty-three percent of the women who delivered at Materno Infantil and 4 percent of the women who delivered at Leonardo Martinez were sterilized before they were discharged. The difference may be attributed to the poor quality of the facilities at Leonardo Martinez.

PIP: The percentages of women sterilized postpartum or within 4 months of delivery hwere much higher for women delivering at Materno Infantil than at Leonardo Martinez, both being hospitals in Honduras. Of the 829 women from the former who said they were interested in a tubal ligation, 42% were sterilized either before being discharged from the hospital or within 4 months of delivery. In contrast, only 21% of the women from the latter hospital had sterilizations. The differences between the 2 hospitals in the percentage of women sterilized may be attributed to availability of facilities. The poor quality of the facilities at Leonardo Martinez (LM) results in women having access to health care, including postpartum sterilization. And while Materno Infantile (MI) has done better in making postpartum sterilization available, it was difficult for a woman to obtain a postpartum sterilization on other than medical grounds in both hospitals. A higher percentage of women who delivered at MI than at LM obtained interval sterilizations within 4 months of delivery. Even though the women from LM had to travel farther to be sterilized than the women from MI, neither this nor any differences in the characteristics of the women accounted for this percentage difference. Since it is unknown if any women tried to get sterilized and failed, it is not possible to determine if the difficulty of scheduling sterilizations or in meeting the requirements at each hospital could have accounted for the difference. Neither is it known what percentage not sterilized within 4 months of delivery were sterilized later, though this information will be forthcoming as the result of a follow-up. In both study populations, a large percentage of those not sterilized were still interested in having a tubal ligation. On 1 August 1982, new operating rooms were put into use at MI and data indicate that 362 procedures were performed from that time to the end of the year.

Motivation of sterilization patients: implications for family planning education programmes.

PIP: A study among almost 2000 female sterilization patients in England, El Salvador, and the Philippines showed that their reasons for electing sterilization were similar; the people involved in the decision varied with the position of the women on the education/development continuum. Sociodemographic information and information regarding the decision for sterilization was gathered and graphed. The majority of women in all 3 countries chose sterilization over other, nonpermanent methods of birth control out of fear of side effects with the other methods. This concern increased with duration of marriage and increasing age of the youngest child. The concern was greatest among users of IUDs or oral contraceptives. Unreliability and inconvenience of other methods were secondary concerns. Women at the lower end of the education/development continuum relied on peers for information and support concerning family planning; those at the upper end of this continuum relied on themselves and the medical establishment.^ieng

Male sterilization is Guatemala.

PIP: During 1973-1975, 968 Guatemalan men underwent vasectomies. The majority of these were skilled and unskilled workers, the sectors of Guatemalan society believed to be most conservative. A survey of the men indicated that, until the time of the vasectomy, the females in these relationships had taken major responsibility for contraception. It seems that the role of the male in family planning is changing in Guatemala. Men seem to be genuinely concerned for the well being of the family. It is predicted that, once the vasectomy program is well established, information regarding it will spread through word-of-mouth contacts.^ieng