Much has changed in the nearly 20 years since Dr. Mila Marantan first learned how to perform tubal ligation-for example, the procedure has become faster, safer, and more accessible. But perhaps the biggest recent change has been in the local demand for the procedure.

In the three years since AVSC began providing technical and financial assistance at Alfonso Ponce Enrile Memorial District Hospital-one of 156 government hospitals in the Philippines that receive AVSC assistance-the facility has seen enormous growth in the number of women served.

"Before, we used to average four to five cases a month," says Marantan, one of only two surgeons at the hospital able to perform female sterilization. "Recently, we actually recorded a total of 65 cases in a single month!"

Marantan's success is even more remarkable considering what statistics reveal about national contraceptive use. In 1998, only 28% of the Philippine population regularly used modern contraceptive methods like condoms, IUDs, or voluntary sterilization.

Marantan attributes the increase of voluntary sterilization in her district to improved referral systems and more widespread communication about the procedure. "Actually, a lot of women are interested in tubal ligation," she explains. "They just don't know where and how to avail themselves of it."

For example, in the spring of 1999, the facility began sending barangay (village) health workers around the district's four municipalities to speak to potential clients on anything and everything they need to know about voluntary sterilization. This approach has particularly affected rural women, many of whom are now beginning to use the services.

In addition, the facility has begun to improve internal referral systems. "We provide family planning counseling during the prenatal visit," says Marantan. "That way, the woman can consult her husband on the matter and they can make informed choices together."

Counseling is key in both of these activities. "We explain to the clients the elements of informed consent," says Marantan. "They're completely aware of what's involved in the procedure."

Having doubled as a counselor at the hospital, Marantan is very much in touch with what her clients want. She says that many mothers prefer sterilization to temporary forms of contraception because they feel that their families are complete. Many of these women already have three or four children by the time they are in their late 20s, says Marantan. "They don't want to add to the number of their children."

The speed, safety, and cost of the procedure also make tubal ligation an attractive alternative to the pill, IUD, or injectables for some of these women. Clients report few complications during follow-up visits.

"Based on my interviews, women who have undergone sterilization tell me that they're very content with the service," remarks Marantan. "They also say that they no longer worry about another pregnancy and that they're now able to provide a better quality of attention and love to their kids."

Maritel Costales manages AVSC's Philippines program.