Contraceptive Sterilization

Why a Book on Contraceptive Sterilization?
Contraceptive sterilization is one of the oldest modern methods of fertility control, datingto the 19th century. Yet, as we advance into the 21st century, contraceptive sterilization(hereafter referred to as sterilization) continues to warrant considerable attentionand study by those involved in the field of family planning and reproductive health care.Why? The answer is simple: Despite the development and introduction of many newcontraceptive methods over the last 15 years, sterilization is the most widely usedmethod in the world, in developing and developed countries alike.Couples and individuals around the world choose sterilization because they want tolimit or end childbearing, rather than space future births. For some women, reversiblemethods are unavailable or inconvenient; for others, contraceptive use may begin onlyafter they have achieved or surpassed their desired fertility. For many, then, sterilizationis their first method. The method requires no action on the part of the user beyond electionof the initial surgical procedure. It produces a minimum of side effects, while generallyoffering a lifetime of contraceptive protection. Moreover, female sterilization requiresno ongoing cooperation by the sexual partner or spouse, thereby representing acontraceptive option for women who may be powerless to ensure such cooperation.Thus, quality sterilization services will always be a crucial component of any comprehensivefamily planning service.

As we move into the 21st century, however, two key challenges have emerged forthose working to ensure access to quality family planning services. First, over the past10 years it has become clear that family planning does not stand in a vacuum. Near theclose of the 20th century, the international community reached consensus on a broaderapproach for supporting sustainable development, health, and equity, one that was fullyarticulated in the Programme of Action of the International Conference on Populationand Development, held in Cairo in 1994. The Programme of Action reflected a shiftfrom a focus on population stabilization to a focus on the rights and needs of people, especiallywomen. Realization of this broader approach requires that family planning befully integrated with comprehensive sexual and reproductive health services. However,adaptation to this new paradigm requires resources, skills, and a policy mandate, all ofwhich remain insufficient in many national contexts. The result is that the paradigm shiftcalled for in Cairo has yet to be fully achieved.

The second challenge is that the world confronts a public health threat like none before,with AIDS having already devastated Africa and now on the threshold of wreakingsimilar havoc in China, India, Russia, and many other countries. Other sexuallytransmitted infections (STIs) long neglected in service-delivery settings now appear toincrease the likelihood of HIV transmission. Yet sterilization, like all other modernmethods of contraception other than the condom, affords users no protection from HIVor other STIs. Thus, programs must intensify efforts to promote barrier methods becauseof the dual protection they afford and must determine how best to meet the noncontraceptivereproductive health needs of sterilization users.

Regardless of how these challenges are met, safe and effective means of limitingfamily size will always be needed. For couples who do not want more children, sterilizationwill continue to be a vital and relevant option. Furthermore, the contraceptive decisionmaking and the social realities that underlie the fact of sterilization's high prevalenceare likely to remain largely unaltered for years to come. Thus, it is imperative thatwe continue to closely study developments in sterilization technology, policy, servicedelivery, and usage. This is the knowledge base upon which the consensus for change isbuilt and upon which assurances of access, safety, and protection of individual rights inexisting services lie.

Voluntary Sterilization: A Snapshotof Developments
In 1985, EngenderHealth (then the Association for Voluntary Sterilization) publishedVoluntary Sterilization: An International Fact Book, written by John Ross, SawonHong, and Douglas Huber. That was the first source book on sterilization ever to havebeen published, bringing together the results of clinical studies and social science researchto provide a comprehensive overview of the practice of contraceptive sterilizationworldwide. This book, the successor to the 1985 volume, is intended to serve as analbum depicting the state of contraceptive sterilization as the 21st century began. Thefollowing are some of the highlights from this effort.

Delivering quality services
Among the many factors that affect the quality with which contraceptive sterilizationservices are delivered, three require special attention: actual service-delivery modalities,fees and compensation programs, and the cost of service provision. For instance, whilesterilization services are provided in an inherently medical context, men's and women'saccess can be broadened if services are offered during the postpartum period, throughmobile outreach, or in male-only clinics (for vasectomy). Likewise, while fees and compensationfor providers have led to concern over the potential for coercing clients intoaccepting sterilization, there is little evidence that such approaches have promoted relianceon this method (see Chapter 1).

The provision of quality sterilization services hinges on the client's ability to makea well-informed, voluntary decision (informed choice), his or her authorization to proceedwith the surgical procedure (informed consent), and the client's participation intrue two-way communication with a health care worker about the risks and benefits ofthe procedure (counseling). In helping a client make an informed decision, providersneed to assess the client's needs, offer appropriate method options, fill in knowledgegaps, help the client make his or her own choice, and encourage utilization of other appropriatereproductive health services.

The spread of HIV and other STIs across the globe since 1985 has important implicationsfor women and men considering or already using sterilization. Like most contraceptivemethods, sterilization fails to offer any protection against STIs, includingHIV. Thus, it is imperative for family planning providers to ensure that men and womenseeking to use sterilization understand safer-sex practices and how to protect themselvesand their partners from these diseases (see Chapter 1).

Incidence and prevalence
Reliance on both male and female sterilization has grown substantially since 1980, when99 million couples were estimated to be using sterilization; by 1995, this number hadclimbed to about 223 million couples-180 million women using female sterilizationand 43 million men using vasectomy. The number of female sterilization users in 1995was 42 million higher than 1990 estimates; in contrast, in 1995, the number of vasectomyusers was only 1 million more than 1991 levels (see Chapter 2).

Use of female sterilization services seems to have increased in regions where ithad been low, particularly in Sub-Saharan Africa. Thus, in nations such as Botswana,Cape Verde, Kenya, Mauritius, Namibia, South Africa, and Swaziland, sterilizationprevalence rates are now 5% or higher. The introduction of minilaparotomy servicesinto family planning programs in Sub-Saharan Africa may account for some of this increasein use.

Who uses female sterilization?
Since only individuals and couples who want no more children elect to be sterilized, itis not surprising that sterilization is more common among older women. Nevertheless,the prevalence of female sterilization and the age at which women obtain a sterilizationare inversely related: In countries where prevalence is high, the median age is generallylow, while in low-prevalence countries, women often are not sterilized until older ages(Chapter 3).

In high-prevalence regions such as Asia and Latin America and the Caribbean, halfof sterilized women have 3-4 children. Yet overall, the number of births among sterilizedwomen ranges from a median of two or fewer in China and the United States to fiveor more in Africa. In Asia and Sub-Saharan Africa, most sterilization users reside inrural areas, while in North America, North Africa, and Latin America and theCaribbean, the majority of users live in urban locales.

Sterilization procedures performed at some time unrelated to a pregnancy (knownas interval sterilizations) are more common than postpartum sterilizations in many countrieslocated in North Africa, Sub-Saharan Africa, and South Asia. In contrast, postpartumsterilizations are more common in some countries in Latin America and theCaribbean. Regardless of when a sterilization is performed, though, for many women itis their first experience with modern contraception: It is often the case that more than50% of women using female sterilization have never used a modern contraceptivemethod before having the sterilization procedure done.

Legal and policy issues
National laws and policies governing sterilization provision have been liberalized ormade clearer in a number of nations. As of 2001, 74 countries had laws explicitly permittingvoluntary sterilization for contraceptive purposes, while in 55 the legal situationwas unclear. In just eight countries, access to sterilization was restricted by law (eitherexplicitly or by interpretation) except for therapeutic, medical, or eugenic reasons in2001, far fewer than the 28 countries with such restrictions in 1985 (see Chapter 4).Yet a number of nations qualify the ability of some groups (most often women) tochoose sterilization. Twenty-five countries require a spouse, parent or guardian, physician,or medical committee to grant their consent before at least some sterilization proceduresare performed. Moreover, 24 countries have age or parity requirements thatmust be met prior to sterilization.

What makes people choose sterilization?
The prevalence of contraceptive sterilization varies among different social groups, yetsocioeconomic status generally does not appear to be associated with the decision tochoose sterilization. Nevertheless, the likelihood of sterilization is greater among couplesof lower socioeconomic status in countries such as Bangladesh and India, whilehigher socioeconomic status is associated with a greater likelihood of sterilization use inLatin America and the Caribbean (Chapter 5).

Users of sterilization frequently say that they chose the method for economic reasonsor because they had all of the children they wanted. But other factors also clearlyplay a role. In particular, friends, relatives, other sterilization users, and health careworkers can be important influences on the decision. Misconceptions and misinformationmay either encourage or discourage individuals from choosing sterilization. Likewise,gender issues, cultural issues, and degree of empowerment affect the decisionmaking of women and men. Power dynamics within couples appear to play an especiallystrong role in the choice of sterilization and the type of permanent method selected.Informed choice and lack of coercion are key factors in ensuring that sterilizationclients are satisfied with the method. Regret over being sterilized is generally low amongusers, but rates vary by region, from around 7% in Colombia and the United States toabout 17% in Bangladesh and the Dominican Republic. Risk factors for regret can generallybe divided into three categories: client characteristics (such as age at sterilizationand marital stability), circumstances at the time of sterilization, and changes in clients'characteristics or circumstances after the procedure is done.

Female sterilization
Even though tubal sterilization usually involves abdominal surgery, it is one of the safestoperative procedures: Complications are rare and occur in fewer than 1% of all femalesterilization procedures. Moreover, the likelihood of failure is very low, at less than 2%even 10 years after surgery (see Chapter 6).

There are two broad elements in the performance of female sterilization: the meansof reaching the fallopian tubes, and the methods used to occlude the tubes. The selectionof a procedure is determined by such factors as the timing of sterilization in relationshipto pregnancy; the need for other gynecological procedures; the woman's health; theprovider's training, expertise, and experience; the cost and logistics of maintainingequipment; and the availability of back-up services.

Female sterilization results in few long-term side effects. The overall risk of ectopicpregnancy is low (although if a pregnancy occurs, the probability that it will be ectopicis high). Perceived alterations in women's menstrual flow, length, or pain followingtubal sterilization (referred to as poststerilization syndrome) have been debated andstudied, but research carried out in the United States has shown no strong evidence forthe existence of such a syndrome (see Chapter 6).

Male sterilization
The situation with male sterilization is similar to that of female sterilization: Vasectomyis one of the safest and most effective contraceptive methods, with very low complicationrates (especially with no-scalpel vasectomy) and failure rates generally thought tobe in the range of 2-4 per 1,000 (see Chapter 7).

While potential physiological effects and long-term sequelae of vasectomy havebeen studied extensively over the past few decades, research has offered reassurancethat this method has no serious long-term negative effects on men's physical or mentalhealth. There is little evidence for a causal association between prostate cancer and vasectomy,and a panel of experts convened by the U.S. National Institute of Health in1993 concluded that no change was necessary in the practice of vasectomy.No-scalpel vasectomy, which requires local anesthesia and only a small incision,has helped to revitalize vasectomy provision in many countries (Colombia, Mexico,Thailand, and the United States among them), and was the impetus for introducing vasectomyservices in others (such as Kenya and Turkey). However, experimental nonsurgicalmethods of occluding the vas are unlikely to become available in the near future,as a result of questions not only about their efficacy, but also about their ability tobe offered in low-resource settings.

Future trends in sterilization usage
Projections suggest that sterilization reliance will increase substantially through 2015,especially in areas of Latin America and the Caribbean and in Sub-Saharan Africa (seeChapter 8). In Asia, by contrast, the prevalence of sterilization is likely to decline as reversiblemethods become more widely available, particularly in countries (such asChina, India, and South Korea) where sterilization usage is currently greatest.Countries where sterilization prevalence is moderate, such as Bangladesh and Pakistan,will see more modest declines to 2015. Method prevalence is also expected to risemodestly in Vietnam and more dramatically in the Philippines between 2000 and 2015,however, and Indonesia can anticipate a slight rise in prevalence as well.

Potential users of sterilization (defined as fecund women who are in union, want nomore children, are not using a contraceptive method, and report that they are consideringsterilization as their preferred method) have characteristics similar to women alreadyusing sterilization: About half are age 30 or older, their mean number of children andeducational level vary widely by country, and they are more often rural residents.Overall, sterilization prevalence over the next 15-20 years is not likely to differ dramaticallyfrom levels seen at the beginning of the century, although the numbers of sterilizationusers may increase simply as a factor of population growth. Future levels of relianceon contraceptive sterilization in any particular country may vary as a result ofunpredictable factors, however, such as changes in sterilization's legal status, the developmentof new contraceptive methods, or shifts in economic circumstances affectingfamily planning programs. Continued monitoring of these factors, as well as of societalattitudes toward sterilization and fertility regulation, will be crucial to understanding andanticipating demand for contraceptive sterilization services in both developed and developingcountries.