Infection prevention preparedness and practices for female sterilization services within primary care facilities in Northern India.

BACKGROUND: In 2014, 16 women died following female sterilization operations in Bilaspur, a district in central India. In addition to those 16 deaths, 70 women were hospitalized for critical conditions (Sharma, Lancet 384,2014). Although the government of India's guidelines for female sterilization mandate infection prevention practices, little is known about the extent of infection prevention preparedness and practice during sterilization procedures that are part of the country's primary health care services. This study assesses facility readiness for infection prevention and adherence to infection prevention practices during female sterilization procedures in rural northern India. METHOD: The data for this study were collected in 2016-2017 as part of a family planning quality of care survey in selected public health facilities in Bihar (n = 100), and public (n = 120) and private health facilities (n = 97) in Uttar Pradesh. Descriptive analysis examined the extent of facility readiness for infection prevention (availability of handwashing facilities, new or sterilized gloves, antiseptic lotion, and equipment for sterilization). Correlation and multivariate statistical methods were used to examine the role of facility readiness and provider behaviors on infection prevention practices during female sterilization. RESULT: Across the three health sectors, 62% of facilities featured all four infection prevention components. Sterilized equipment was lacking in all three health sectors. In facilities with all four components, provider adherence to infection prevention practices occurred in only 68% of female sterilization procedures. In Bihar, 76% of public health facilities evinced all four components of infection prevention, and in those facilities provider's adherence to infection prevention practices was almost universal. In Uttar Pradesh, where only 55% of public health facilities had all four components, provider adherence to infection prevention practices occurred in only 43% of female sterilization procedures. CONCLUSION: The findings suggest that facility preparedness for infection prevention does play an important role in provider adherence to infection prevention practices. This phenomenon is not universal, however. Not all doctors from facilities prepared for infection prevention adhere to the practices, highlighting the need to change provider attitudes. Unprepared facilities need to procure required equipment and supplies to ensure the universal practice of infection prevention.

Perioperative mortality in cats and dogs undergoing spay or castration at a high-volume clinic.

High volume spay-neuter (spay-castration) clinics have been established to improve population control of cats and dogs to reduce the number of animals admitted to and euthanazed in animal shelters. The rise in the number of spay-neuter clinics in the USA has been accompanied by concern about the quality of animal care provided in high volume facilities, which focus on minimally invasive, time saving techniques, high throughput and simultaneous management of multiple animals under various stages of anesthesia. The aim of this study was to determine perioperative mortality for cats and dogs in a high volume spay-neuter clinic in the USA. Electronic medical records and a written mortality log were used to collect data for 71,557 cats and 42,349 dogs undergoing spay-neuter surgery from 2010 to 2016 at a single high volume clinic in Florida. Perioperative mortality was defined as deaths occurring in the 24h period starting with the administration of the first sedation or anesthetic drugs. Perioperative mortality was reported for 34 cats and four dogs for an overall mortality of 3.3 animals/10,000 surgeries (0.03%). The risk of mortality was more than twice as high for females (0.05%) as for males (0.02%) (P=0.008) and five times as high for cats (0.05%) as for dogs (0.009%) (P=0.0007). High volume spay-neuter surgery was associated with a lower mortality rate than that previously reported in low volume clinics, approaching that achieved in human surgery. This is likely to be due to the young, healthy population of dogs and cats, and the continuous refinement of techniques based on experience and the skills and proficiency of teams that specialize in a limited spectrum of procedures.

100,000 quinacrine sterilizations.

100000 quinacrine nonsurgical female sterilizations have been completed over the past decade involving transcervical insertion of quinacrine (252 mg) as pellets by one, two or three monthly insertions. No deaths have been reported and serious complications are far fewer than for surgical sterilization. Side-effects are mild and transient. Efficacy has improved from 3 pregnancy failures per 100 women at one year to approximately 1 by improved insertion technique and use of adjuvants. Long-term follow-up of early cases in Chile shows no increased risk of cancer for this method. The main advantage of quinacrine sterilization is its ability to raise contraceptive prevalence and thereby reduce maternal mortality and morbidity, especially in rural and urban slum areas of developing countries. It should be made available as an option to well informed women everywhere as an economical and safe permanent family planning method.

Female sterilisation.

Adverse effects of female sterilisation are a popular subject for media focus; however, in reality modern techniques mean that the benefits outweigh the risks.

PIP: The author updates a 1986 review conducted by Paterson of the long-term sequelae of female sterilization. This review encompasses all English-language papers on the sequelae of tubal sterilization as listed in Index medicus over the period 1984-94. The adverse effects of female sterilization have been sporadically reported including increased frequency of menorrhagia, dysmenorrhea, oligomenorrhea, polymenorrhea, and a higher incidence of subsequent gynecological surgery or hysterectomy. No consistent pattern exists, however, to the events and some studies do not reflect any adverse changes. It may be held that female sterilization is unlikely to have a significant association with any consistent pathological change. Moreover, the review found several methods of sterilization to be lumped together, eliminating the possibility of drawing any conclusions about the newer, less invasive method of tubal clipping, which should be the method of choice for the 1990s. There may be some adverse effects of sterilization in some women, but one must consider the incidence of such effects in the context of the risk-benefit ratio. The author argues that for women who understand the procedure, the benefits of laparoscopic sterilization far outweigh the risks.

Declining mortality in international sterilization services.

Between 1973 and 1988, AVSC supported 1,516,478 female sterilizations and 401,856 vasectomies in 50 countries. Overall, 73 deaths were attributable to voluntary sterilization procedures (yielding mortality rates of 4.7 deaths per 100,000 female sterilizations and 0.5 per 100,000 vasectomies). Causes of death, in order of frequency, were anesthesia (22), intestinal injury (20), infection (19), intra-abdominal hemorrhage (6) and other (6). The female sterilization mortality rate declined from 7.1 per 100,000 procedures in 1973-1981 to 3.7 per 100,000 in 1982-1988. Safer anesthesia practices and improved infection control contributed most to this decline. The mortality rate related to surgical errors declined proportionately less than the rates related to anesthesia and infection. Contraceptive sterilization has become a very safe procedure in these 50 countries, where anesthesia (local and general), surgical technique (minilaparotomy and laparoscopy) and timing of the procedure (interval and postpartum) vary substantially. Future deaths will probably be rare. However, expert surgeons should review each case because identifying the most likely cause of death is always complex and these analyses help shape surgical contraception practices.

Sterilization.

Male and female sterilization is a safe and effective form of permanent contraception. The number of patients accepting this method has rapidly increased over the last ten years and is likely to continue. In some countries the rate has plateaued out: in the USA it has been 31 per cent of all married women for the last eight years. Before sterilization it is important that adequate counselling is given to both partners and that the decision is not hurried. This is emphasized by the number of women and men requesting reversal of sterilization (thought to be between 0.1 and 10 per cent of all sterilizations). These requests for reversal usually come from couples who have remarried, tend to be younger, have fewer live children, have had more abortions, less schooling and are poor users of contraception. In these high-risk patients counselling and time to make the decision is essential. Other studies indicate that regret after puerperal sterilization may be commoner, but the risks of further pregnancies have to be weighed against sterilization regret. The methodology of male sterilization has changed little in the last ten years; it is simple and usually done under local anaesthesia. In contrast, female sterilization methods are constantly being refined, from laparotomy to laparoscopy and from extensive tubal destruction or excision to minimal tubal damage. The common methods now are mini-laparotomy and laparoscopy under local or general anaesthesia, with tubal occlusion by clips, rings or bipolar or thermal coagulation. There is no place now for unipolar diathermy, because of the higher complication rate, especially for major complications such as bowel burns. Recent multicentre studies comparing different methods give low rates for immediate morbidity and surgical complications (0.8 to 2.5 per cent of cases). Technical failure is rare but often due to a pre-existing condition, for example obesity or previous pelvic disease. Some failures are due, however, to difficulties with the instruments, especially at laparoscopy; here further developments and the use of teaching aids for those in training will help to reduce problems. Mortality from female sterilization is low, at 2 to 10 per 100 000 procedures; however, half is due in part to anaesthetic complications (hypoventilation), which can be avoided by intubation, and others are due to pre-existing medical conditions. Long-term follow-up has now shown that sterilization does not cause an increase in menstrual blood loss.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: An estimated 1/3 of couples using contraception in the world have selected sterilization. The increased acceptability of this method has produced a need for reliable methods of male and female sterilization with low morbidity and mortality rates as well as for proper counseling regarding the permanency of the method. Current methods of female sterilization include choice of general or local anesthesia, a reduction in the size of the incision (mini-laparotomy), and the use of new occlusive methods such as clips or rings via laparoscopy or mini-laparotomy. In terms of timing, there has been a trend toward sterilization more than 6 weeks after a pregnancy rather than in the immediate postpregnancy state. Pregnancy rates after sterilization differ with the method used, surgical approach, operator skill, and type of patient. Acceptable failure rates are seen with the modified Pomeroy tubal ligation method, the tubal ring, and some clips. Menstrual patterns after sterilization are affected by the type of contraception used before the procedure and the presence of abnormal or irregular cycles. Remarriage is the most common reason for requests for reversal. Since reversal is more often sought by young women with low levels of education and fewer children and more abortions, these women should be sterilized by a method that destroys the least tube. Cutting followed by ligation remains the most frequently used method of male sterilization. Vasectomy has a low morbidity, can be reversed, and does not appear to be associated with endocrine or morphologic changes. There is a growing demand for sterilization by couples with no children; in general, couples are now presenting for sterilization at an earlier age and at lower parity.

Sterilization-associated deaths: a global survey.

Except for data from several geographically limited studies, little is known globally about the number and causes of death associated with surgical sterilization. To identify clinical characteristics and problems leading to deaths related to the procedures, the International Planned Parenthood Federation ( IPPF ) and the Centers for Disease Control (CDC) in the United States collaborated in a global mail survey of 4642 physicians. Usable responses were received from 1298 physicians (28%) in 80 countries. Fifty-five sterilization-associated deaths which occurred from January 1, 1980 to June 30, 1982 were reported. The most frequently reported causes of death were infection, anesthetic complications, and hemorrhage. There were some regional differences in the relative frequencies of these causes. Most cases did not involve surgical accident. The characteristics most frequently associated with the reported fatal procedures were: interval sterilizations, minilaparotomy incision, tubal ligation and general anesthesia. Most deaths were attributable to the surgical sterilization procedure.

PIP: To obtain information on the number and causes of deaths associated with surgical sterilization, the Centers for Disease Control (CDC) and the International Planned Parenthood Federation (IPPF) collaborated in a global mail survey of 4642 IPPF-affiliated physicians. Usable responses were received from 1298 physicians (28%) in 80 countries. A total of 55 deaths (54 associated with tubal sterilization and 1 with vasectomy) were reported for the period January 1, 1980-June 30, 1982. The largest number of fatalities occurred in Asia (33) and Latin America (15). The median age at death was 32 years. Characteristics most frequently associated with the reported fatal procedures were interval sterilization (25 cases), minilaparotomy incision (19), tubal ligation (34), and general anesthesia (28). 38 of the tubal sterilization-associated deaths and the 1 vasectomy-related death were directly attributable to the sterilization procedure. The most frequently reported causes of death were infection (20 cases), anesthetic complications (12), and hemorrhage (8). Surgical accidents were reported for 17 of the tubal sterilization-associated fatalities. Some regional variation was noted in the relative frequencies of these causes. These data are known to reflect a substantial underreporting of sterilization-related mortality. In addition, the nonavailability of denominator data precluded estimation of the risk of death associated with surgical approach, method of tubal occlusion, timing of the sterilization procedure in relation to last pregnancy, or anesthesia. However, it can be stated that many of the deaths reported in this series could have been prevented by more adequate staff training, use of sterile equipment, and improved follow-up procedures. It is recommended that data on sterilization-related fatalities be reported to a central location to facilitate their aggregation and analysis.

[Postpartum sterilization and maternal mortality in Paarl Hospital]. / Postpartum sterilisasie en moederlike mortaliteit in die Paarl-Hospitaal.

A single maternal death associated with postpartum sterilization has been encountered at Paarl Hospital among the 3 742 such procedures performed between January 1972 and December 1982 (19,75% of all the mothers delivered were sterilized). The safety of postpartum sterilization is confirmed. A strong plea is voiced for the expansion of this procedure on a massive national scale because of its simplicity and effectiveness.

Sterilization in Bangladesh: mortality, morbidity, and risk factors.

Although surgical sterilization in Bangladesh is common and has been designated as the primary means of helping the country slow its population growth, no reliable information exists regarding the procedure's safety. To define the types and rates of medical complications associated with sterilization, we followed 5042 women and 264 men undergoing sterilization. The problems that increased most markedly after the procedure compared with before included painful urination, shaking chills, fever for at least 2 days, and frequent urination. Most of the postoperative problems could be predicted by the presence of the same problem before the operation. Factor analysis of complaints in those persons who did not have a specific preoperative complaint showed that complaints clustered into three groups: urinary tract symptoms (urinary urgency and frequency), skin problems (bleeding from the incision, sore with pus, and stitches or skin breaking open), and general complaints (weakness and dizziness). The patient's sex, the sponsor and patient load of the sterilization center, and the dose of sedatives administered to women were significantly associated with specific postoperative complaints. Five women died during the study, resulting in a death-to-case rate of 9.9/10,000 procedures tubectomies; four deaths were due to respiratory arrest caused by oversedation.

PIP: Data were collected from February-June 1980 on 5042 women and 264 men undergoing surgical sterilization in Bangladesh to define the types and rates of medical complications associated with sterilization. The major findings of this study are that: 1) one of every 1000 women undergoing sterilization in Bangladesh dies as a result of the procedure; 2) overuse of systemic sedatives is common and was the principle contributor to 5 deaths that occurred; and 3) chief health complaints are urinary tract symptoms, skin problems, and systemic complaints. The death-to-case rate of 9.9/10,000 procedures in this study is similar to the 10.0 deaths/10,000 cases estimated on the basis of a 1979 follow-up study in an Indian female sterilization camp. The presence of a complaint before the operation was generally a good predictor of postoperative complaints. Centers performing fewer than 200 procedures were associated with more complaints.

Reproductive mortality in the United States.

Maternal mortality in the United States has declined by 50% during the last decade. This decline took place at the same time as changes in the availability and use of contraceptive measures, including temporary contraceptives and sterilization. To examine the impact of these changes on mortality we estimated the reproductive mortality rate, which includes pregnancy-related deaths as well as deaths from the side effects of contraceptive methods. The estimated reproductive mortality rate fell by 73% from 1955 to 1975. The decrease was greater for women younger than 35 years. The slower decline for women aged 35 years and older was due to oral-contraception-related deaths. By 1975, pregnancy prevention was responsible for nearly as many deaths as pregnancy itself. The reproductive mortality rate is more appropriate than the maternal mortality rate for evaluating the health risks of reproduction and contraception. We urge that national surveillance of maternal mortality should be expanded to include deaths associated with contraceptive methods.

Sterilization-attributable deaths in bangladesh.

From January 1, 1979, to March 31, 1980, 20 sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. The leading cause of death from tubectomy was anesthesia overdose and from vasectomy, scrotal infection. Overall. The sterilization-attributable death-to-case rate was 21.3 deaths/100,000 procedures. The health impact of contraceptive sterilization is highly favorable: for each 100,000 tubectomies performed, the cost in lives (19) is offset by approximately 1015 maternal deaths averted.

PIP: Over the January 1, 1979 to March 31, 1980 period sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. These deaths were identified primarily through government records of compensation to families of deceased sterilization patients. This list was augmented by deaths reported from clinics of the Bangladesh Association for Voluntary Sterilization, detected through a prospective study of sterilization in Bangladesh, and identified by interviews with government family planning officials. A sterilization-associated death was defined as the death of a patient from any cause occurring within 42 days of tubal ligation or vasectomy. Death-to-case rates for vasectomy and tubal ligation were calculated for each month with 95% confidence intervals based on the Poisson distribution. 31 sterilization-associated deaths were identified over the study period. 28 of these were sterilization attributable and 3 were not. The mean age of the 21 women was 30.6 years, and their mean parity was 4.8. The mean age of the 7 vasectomy patients was 37.0 years. Abdominal Pomeroy method of tubal ligation was the only female sterilization technique used. 2 temporal clusters of sterilization attributable deaths occurred during the study. The 1st was a cluster of 5 deaths from tubal ligation performed in June 1979. 3 of these operations took place on June 5, 1979 but in different facilities. 1 factor common to each of these operations was the unseasonably hot weather. The 2nd temporal cluster consisted of 3 deaths after vasectomy in July 1979. 2 men from the same village died from scrotal infections after vasectomy on July 19, 1979 by the same surgeon at a single clinic. A similar death occurred earlier the same month. Another patient of the same surgeon and clinic associated with the deaths after operation on July 19 died from scrotal infection in January 1980. 3 vasectomy deaths related to 1 surgeon in a single remote facility suggests a breach of sterile technique. This could not be confirmed as this clinic physician could not be interviewed. The death-to-case rate for all procedures combined was 21.3 deaths/100,000 procedures, with the rate for vasectomy 1.6 times higher than that for tubal ligation. Anesthesia overdosage was the leading cause of death attributed to tubal ligation with tetanus (24%), intraperitoneal hemorrhage (14%), and infection other than tetanus (5%) as other leading causes. 2 patients (10%) died from pulmonary embolism after tubal ligation; 1 (5%) died from each of the following: anaphylaxis from anti-tetanus serum, heat stroke, small bowel obstruction, and aspiration of vomitus. All 7 men died from scrotal infections after vasectomy. Improvement in anesthesia management and sterile technique can lower the death-to-case rate for contraceptive sterilization in 2 Divisions of Bangladesh.

The risk of death from combined abortion-sterilization procedures: can hysterotomy or hysterectomy be justified?

Clinicians have debated whether women who request permanent sterilization when they undergo elective abortion should have the two operations done concurrently. Moreover, if the procedures are performed concurrently, the appropriate surgical approach is unknown. To evaluate the latter issue, we identified all concurrent abortion-sterilization deaths in the United States in the period 1972 to 1978 from the Centers for Disease Control's nationwide surveillance of abortion mortality and divided them into two groups: those who had hysterotomy with tubal ligation or hysterectomy (H/H) and those who had curettage or instillation procedures, with tubal ligation by laparoscopy or laparotomy (other procedures). We then used data from the Joint Program for the Study of Abortion (JPSA/CDC) to estimate the number of procedures done in the United States in the period 1972 to 1978 and calculated death-to-case rates for each group. We found that the risk of dying from a concurrent abortion-sterilization procedure was 3.3 times higher if done by H/H. The relative risk for this group was highest during the first 12 weeks of gestation (4.6) and lowest at 13 weeks or later (1.3), regardless of the presence or absence of preexisting medical conditions. Except in the rare instances where the woman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterectomy for concurrent abortion-sterilization, particularly at less than 13 weeks' gestation, does not appear justified.

Comparative risk of death from induced abortion at less than or equal to 12 weeks' gestation performed with local versus general anesthesia.

Although complications of anesthesia are now the leading cause of death from abortion at less than or equal to 12 weeks' gestation, the comparative risk of death from abortions performed with local versus general anesthesia is unknown. To estimate this risk for both anesthesia-related and nonanesthesia-related legal abortion deaths at less than or equal to 12 weeks' gestation, we used 1972-1977 data from the Center for Disease Control and the Alan Guttmacher Institute. When adjusted for preexisting disease and concurrent sterilization, the death-to-case rate for abortions at less than or equal to 12 weeks' gestation associated with general anesthesia was 0.37/100,000 abortions, and the rate with local anesthesia was 0.15/100,000. For nonanesthesia-related deaths, the comparable adjusted rates were 0.49 and 0.28, respectively. Use of general anesthesia is associated with a twofold to fourfold increased risk of death from abortion at less than or equal to 12 weeks' gestation.