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.
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