Sterilisation - Why it's the most common contraception in the world today

Over 250million women and men worldwide rely on a permanent contraceptive method – female sterilisation or vasectomy – to achieve their intention to limit childbearing; that’s according to a recent United Nations (UN) report. In 2014 the UN reported that for the world as a whole, female sterilisation is the most common method of contraception with more than 200 million women relying on it, representing 19% of women aged 15 to 49 who are married or in a union.

Trends of permanent contraceptive use across the world for women who are married or are in a union are; North America (33%), South America (26%), Asia (26%), Africa (2%); that’s according to United States Aid (USAID 2013).

Sterilisation has become so popular due to the need to limit or stop childbearing especially with couples who are certain they have completed their childbearing. According to the United States Census Bureau’s American Community Survey, 46% of women aged 15-44 were childless in June 2008 compared to 35% of childless women in 1976. The personal freedoms of a childless lifestyle and the ability to focus on their relationships were common motivations underlying the decision to be voluntarily childless. Such personal freedoms included increased autonomy and improved financial positions. The couples could engage in more spontaneous activities because they didn't need a babysitter or to consult with someone else. Women had more time to devote to their careers and hobbies.

Latin America, Asia and parts of North America and Western Europe have shown high and in many cases growing sterilisation prevalence with the largest increases recorded in the Democratic Republic and Brazil. The prevalence rate of female sterilisation is highest (47%) in the Democratic Republic. In Columbia, Costa Rica, El Salvador and Puerto Rico levels range between 30% and 40%, Brazil is over 25%, the Caribbean (26%) and a few countries in other regions, including China (29%) and India (36%) – according to UN 2013.

High resource countries/developed regions have a broad mix and high use of permanent methods as well as in the better resourced countries of developing regions. A 2014 USAID report showed that the United Kingdom (UK) has been one of the few countries where the incidence of sterilisation in men exceeds that in women. Female sterilisation prevalence in the UK is 8% while vasectomy is at 21%. The trend is the same in Canada where female sterilisation prevalence is 11% while vasectomy is at 22%. In the United States however, female sterilisation prevalence is higher – at 24% than vasectomy which is 13%. Vasectomy use alone accounts for almost one third of all modern method use in Canada and one quarter of such use in the UK.

Columbia and Thailand, both relatively wealthy countries but still classified by the UN as “less developed” have implemented longstanding successful programmes to make a broad range of contraceptive methods and services widely known, widely available and equitably accessible. Both countries including Brazil and Mexico have achieved a diversified method mix, with methods of contraceptive use comparable to or exceeding those in countries of Northern America and Western Europe. Permanent method use comprised 42% of all modern method use in Thailand in 1987 according to Chayovan, Kamnuansilpa & Knodel (1988) and 35% of such use in 2006 (UN 2012). In 2010 52% of all modern method use in Columbia consisted of permanent methods (Profamilia 2011). In both countries, female sterilisation is the predominant permanent method.

Sterilisation is however not very common in Africa representing only 2% use on a global perspective. In West Africa, 0% of women have been recorded to be using sterilisation as a family planning method, while in East Africa its 2% and 14% in Southern Africa. This low use of sterilisation is particularly common in low resource countries that in-turn have lower availability and access to permanent methods. USAID accredits this low use on socio-economic and political factors. It states that in the face of competing demands and countervailing factors, such as shift in program and donor focus to the HIV epidemic, political instability and decentralisation of health services, large successful family planning programmes aimed at increasing the knowledge of permanent methods of family planning mainly female sterilisation have fallen over the past 10-15 years. Knowledge of female sterilisation fell from 82% in 1988 to 67% in 2008 among Kenyan women and knowledge of vasectomy dropped from 48% to 38% (KNBS & ICF Macro 2010). Between 2008 and 2009 the female sterilisation prevalence in Kenya was 5% while vasectomy was 0%.

Nigeria and the Democratic Republic of Congo- DRC (which are the most populace countries in the West African region) are among the world’s lowest users of permanent family planning methods. Due to the countries dealing with armed conflict, ethnic strife and humanitarian crises; USAID suggests that a large family size remains ideal in these two countries at more than six children per woman. The prevalence of female sterilisation use in DRC is 0.8% and 0.3% in Nigeria. The prevalence of vasectomy use in both countries is 0%.  In Nigeria, knowledge of female sterilisation is only 44% among married women and 50% among married men. Knowledge of vasectomy is even lower, at 16% and 30% respectively. In Zimbabwe, the female sterilisation prevalence rate between 2010 and 2011 was 1.1% and vasectomy was 0%.

Available evidence indicates that a large subset of women and couples served by family planning programmes in low-resource countries would opt for a permanent method if it were available and accessible, just as women and couples do in higher resourced settings (WHO 2010). Hence a UN 2014 paper suggests that making permanent methods widely available and equitably accessible as a voluntarily chosen method in the family planning programs of low resource countries is not only feasible, cost effective and popular with clients – it is an ethical imperative. This follows the findings that; lower income countries have a high unmet need of their current use of long acting reversible contraceptive methods and short-acting resupply methods.

USAID reports that the demand to limit births now exceeds demand to space births in every region of the world except West and Central Africa, and the average age at which demand to limit exceeds demand to space is falling in many countries, to as low as age 23 or 24. (Van Lith, Yahner & Bakamjian, 2013). Clinical guidelines suggest additional care when counselling people under the age of 30 without children who request sterilisation, due to the possible increased incidence of regret.

In the UK from a legal perspective, only the patient who submits to operation needs to give consent and the operation can be performed without knowledge of the partner.  This has however not been the case in other parts of the world where the man gives consent even without the wife’s knowledge to carry out sterilisation. In some instances health care providers have tricked and coerced women in vulnerable situations into getting sterilised.  

Female sterilisation has not gone without controversy as in November last year, 13 women in India died and dozens more were hospitalised after undergoing sterilisation procedures in the central Indian state of Chhattisgarh. More than 80 women underwent surgery for laparoscopic tubectomies at a free government-run camp. Of these, about 60 fell ill shortly afterwards with officials saying blood poisoning or hemorrhagic shock might have been the cause.  

Some of the women receiving treatment after the mass sterilisation went horribly wrong. (Source: www.theguardian.com)

Despite being an effective method of contraception for those in stable relationships, sterilisation compared to many surgical procedures is still fraught with cultural, religious, psycho-social, psycho-sexual and psychological issues.