Female sterilization by tubal ligation: a re-appraisal of factors influencing decision making in a tropical setting

BACKGROUND

Female sterilization by tubal ligation is the most commonly used method of fertility regulation. However, in some lesser-developed countries like Nigeria, it has not been accepted as a popular method of contraception.

OBJECTIVE

To assess the pattern of female sterilization and determine factors that may influence its acceptability.

METHOD

A retrospective study of 102 cases of tubal ligation (TL) performed between January 1999 and December 2004.

RESULT

Of the 102 patients/clients, 60 (58.8%) had TL at caesarean section, 28 (27.5%) had TL with repair of ruptured uterus and 14 (13.7%) clients had TL alone on request. In the reproductive age group, the rate of TL increased with age. In the group that had TL at caesarean section, the highest incidence of TL (65%) was recorded against parity 4. However, in the groups that had TL with repair of ruptured uterus and TL alone, the highest proportion of TL was recorded against parity 6, with rates of 46.3 and 57.1%, respectively. The rates of TL increased with the level of literacy. In the group that had TL alone, 92.9% of the clients were in a monogamous union. On the contrary, 89.3% of patients that had TL with repair of uterine rupture were in a polygamous union. There was relative distribution of patients/clients amongst the two religions and five ethnic grouping. In 55 of the 102 patients/clients, the indication for TL was completion of family size, though 41 of the 55 patients had TL at caesarean section.

CONCLUSION

Demand for TL alone was low. A greater percentage of the patients had TL in conjunction with another surgical procedure.

Uso de métodos contraceptivos entre mulheres com vida sexual ativa em São Leopoldo, Rio Grande do Sul, Brasil

Foi realizado um estudo transversal de base populacional em São Leopoldo, Rio Grande do Sul, Brasil, com objetivo de analisar o uso de métodos contraceptivos. A amostra envolveu 867 mulheres de 20 a 60 anos com vida sexual ativa. Entre as mulheres que referiram atividade sexual, 627 (61,1%) referiram utilizar algum método contraceptivo. Entre as mulheres de 20 a 49 anos, 48,8% referiram utilizar anticoncepcionais orais; 18,7%, ligadura tubária; 17,3%, preservativos masculinos; e 7,3%, dispositivo intra-uterino. Entre as 186 mulheres de 50 a 60 anos que referiram vida sexual ativa, o método mais prevalente foi a ligadura tubária com 79,6%. Foi observada uma modificação de efeito em relação à prevalência de anticoncepcionais orais, idade e escolaridade, evidenciando uma menor prevalência nas mulheres de 20 a 29 anos e com baixa escolaridade. Assim, os achados da análise em São Leopoldo apontam para uma diversidade na prevalência do uso de métodos contraceptivos, inclusive não fazendo distinção na ocorrência de laqueadura tubária de acordo com variáveis sócio-econômicas, mas ainda revelam a necessidade de propiciar-se escolhas tecnicamente mais adequadas às mulheres mais jovens e com baixa escolaridade.

Regret following female sterilization at a young age: a systematic review

Women who undergo sterilization may later regret this decision. This systematic review examines whether age at sterilization is associated with poststerilization regret. Using MEDLINE and EMBASE, we identified 19 articles that examined associations between women's age at sterilization and later regret, requests for sterilization reversal and undergoing sterilization reversal or requesting in vitro fertilization (IVF) procedures. Study results showed that the younger women were at the time of sterilization, the more likely they were to report regretting that decision. Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret. They were also from 3.5 to 18 times as likely to request information about reversing the procedure and about 8 times as likely to actually undergo reversal or an evaluation for IVF. Results of studies that examined risk by continuous age showed a consistent inverse relationship between women's age at sterilization and their likelihood of regretting having had the procedure.

Barriers to obtaining a desired postpartum tubal sterilization

OBJECTIVE

To determine why women do not undergo postpartum sterilization despite expressing desire during antepartum care.

METHODS

In a retrospective chart review, we identified all women between March 2002 and November 2003 who requested postpartum sterilization during antepartum care but did not undergo the procedure. We report the reasons why sterilizations were not performed.

RESULTS

We reviewed 6,589 prenatal care and delivery records identifying 324 women meeting inclusion criteria. One hundred and four women changed their mind. Of women still desiring sterilization at discharge, the most common reasons for not undergoing the procedure were lack of valid Medicaid sterilization consent forms [n=121; 37.3%, 95% confidence interval (CI) 32.0-42.6%]; a medical condition precluding the procedure (n=47; 14.5%, 95% CI 10.7-18.3%); lack of availability of an operating room (n=2; 6.5%, 95% CI 3.8-9.2%).

CONCLUSION

We found that the Medicaid consent process, medical conditions and insufficient operating room space prevented women from having the desired surgery.

Do risk factors for epithelial ovarian cancer have an impact on prognosis? Focus on previous pelvic surgery and reproductive variables

OBJECTIVES

The prognostic impact of risk factors for ovarian cancer development is sparsely explored, but previous sterilisation has been shown to have a negative impact on survival.

METHODS

Ovarian cancer cases were from the Danish MALOVA study. Information on previous pelvic surgery as well as reproductive variables was obtained from a personal interview conducted closely after primary surgery. Cox regression models were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for ovarian cancer specific death in relation to previous pelvic surgery and reproductive variables including lifetime number of ovulation years.

RESULTS

A total of 295 women with Stage III ovarian carcinomas were identified and followed to death or for a median of 7.3 years (range 5.4-9.5 years). Previously sterilised or hysterectomised women seemed to have a slightly decreased risk of ovarian cancer death (HR = 0.62; 95% CI: 0.36-1.08 and HR = 0.82; 95% CI: 0.55-1.21), although none of these associations reached statistical significance. The prognostic impacts of the individual reproductive variables followed the same pattern as the impact of the variables on ovarian cancer development, although significance was only reached for age at menarche (HR = 0.91 per year; 95% CI: 0.84-0.99). By accumulation of the possible minor effects of the reproductive variables in calculation of the total lifetime number of ovulation years, we found that survival decreased significantly with increasing number of ovulations (HR = 1.53 per 10 years; 95% CI: 1.09-2.14).

CONCLUSION

Increasing lifetime number of ovulations was a negative prognostic factor for ovarian cancer specific survival. Previous sterilisation or hysterectomy seemed to be associated with improved survival.

Características dos candidatos à esterilização cirúrgica e os fatores associados ao tipo de procedimento

Em 1999, a Secretaria Municipal de Ribeirão Preto, São Paulo, Brasil, implantou a oferta de métodos de esterilização cirúrgicos, de acordo com a legislação vigente. Este estudo objetivou caracterizar os candidatos à esterilização cirúrgica e estudar as variáveis associadas ao tipo de procedimento. Foram pesquisados 95 prontuários de candidatos e realizada análise estatística por meio de regressão logística e do teste exato de Fisher, considerando-se o nível de significância de p = 0,05. A maioria dos candidatos são casais estáveis, de baixa escolaridade e baixa renda, satisfeitos com o número de filhos e que já haviam tentado limitar a prole com o uso de anticoncepcionais reversíveis. A média de idade era de 34,2 anos; 45,3% se submeteram à esterilização feminina; 35,8%, à vasectomia, e 18,9% não obtiveram o procedimento. A chance de o homem, com 35 anos ou mais, fazer vasectomia é 6,1 vezes a do homem mais jovem (OR = 6,1; IC95%: 2,4-16,4); submetem-se à vasectomia mais homens casados do que os que coabitam (OR = 4,0; IC95%: 1,5-12,4) e mulheres com quatro filhos ou mais fazem mais laqueadura do que aquelas com menos de quatro filhos (OR = 3,1; IC95%: 1,1-8,5).

Changes in family structure and regret following tubal sterilization

Tubal sterilization is one of the contraceptive methods whose use has increased the most in Brazil, but a growing number of women have expressed regret after the procedure. A case-control study was conducted at the Centro Integrado de Saúde Amaury de Medeiros (CISAM), Recife, Pernambuco, Brazil, in 1997 to investigate the association between changes in family structure and request for or submittal to surgical reversal of tubal sterilization, comparing 304 sterilized women who had requested or submitted to reversal of tubal sterilization and 304 women who were also sterilized but had not requested, had not submitted to, and who did not wish to submit to reversal. The simple and adjusted odds ratios were estimated using logistic regression. The results of the current study showed that death of children, partners without children prior to the current union, and partner change after tubal sterilization were associated with the request for or submittal to reversal of tubal sterilization. More strict criteria are suggested in the indication of tubal sterilization, including an in-depth profile of the woman requesting tubal sterilization and identification of risk factors for future regret.

Contraceptive use--United States and territories, Behavioral Risk Factor Surveillance System, 2002

PROBLEM

Contraceptive use is an important determinant of unintended pregnancy. In the United States, approximately half of all pregnancies are unintended. Population-based information about contraceptive use patterns is limited at the state level. Information about contraceptive use for states can be used to guide the development of state programs and policies to decrease unintended pregnancy and the spread of sexually transmitted infections. Information about contraceptive use for specific subpopulations can be used to further refine state efforts to improve contraceptive use and subsequently decrease the occurrence of unintended pregnancy.

REPORTING PERIOD

Data were collected in 2002 for men and women.

DESCRIPTION OF SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is a random-digit--dialed, telephone survey of the noninstitutionalized U.S. population aged > or =18 years. All 50 states, the District of Columbia, Guam, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands participated in BRFSS in 2002. These data can be used to track state progress towards the national health objectives for 2010 for responsible sexual behavior. The 2002 BRFSS data represent the first time state data on contraceptive use in all 50 states will be presented and examined by selected sociodemographic characteristics. The 2002 BRFSS also, for the first time, provided an opportunity to examine state-level contraceptive use patterns among men.

RESULTS

Variation across states and territories was observed for the majority of contraceptive methods among the different demographics analyzed and among men and women. The percentage of men and women at risk for pregnancy who said they or their partner was using birth control was high overall and ranged from 67% (Guam) to 88% (Idaho). Oral contraceptives (i.e., the pill), vasectomy, tubal ligation, and condoms were the methods most frequently reported by both male and female respondents who said they or their partner was using birth control. Among female respondents using birth control, the pill was the most common method reported. Among men, vasectomy was the most commonly reported method. The prevalence of use for the four most commonly reported methods (pills, vasectomy, tubal ligation, condoms) varied as much as six-fold among states for vasectomy and three- to four-fold for condoms, pills, and tubal ligation.

INTERPRETATION

The findings in this report document substantial differences among states and sociodemographic groups within states in contraceptive method use.

PUBLIC HEALTH ACTION

These data can help states identify populations with an unmet need for birth control, barriers to birth control use, and gaps in the range of birth control methods offered by health-care providers. An analysis of the prevalence of birth control use by state and selected population characteristics can help states target contraceptive programs to best meet the needs of their population.

The impact of franchised family planning clinics in poor urban areas of Pakistan

This study uses a quasi-experimental design to determine the impact of new family planning clinics on knowledge, contraceptive use, and unmet need for family planning among married women in poor urban areas of six secondary cities of Pakistan. Baseline (n = 5,338) and endline (n = 5,502) population surveys were conducted during 1999-2000 and 2001-02 in four study sites and two control sites. Exit interviews with clients identified the sociodemographic and geographic characteristics of clinic users. The results show that the clinics contributed to a 5 percent increase in overall knowledge of family planning methods and an increase in knowledge of female sterilization and the IUD of 15 percent and 7 percent, respectively. Distinct effects were found on contraceptive uptake, including an 8 percent increase in female sterilization and a 7 percent decline in condom use. Unmet need for family planning declined in two sites, whereas impacts on the other sites were variable. Although the new clinics are located within poor urban communities, users of the services were not the urban poor, but rather were select subgroups of the local population.

Failure to obtain desired postpartum sterilization: risk and predictors

OBJECTIVE

The aim of this study was to assess the rate of and risk factors for not obtaining postpartum sterilization among women who expressed a desire for sterilization during antepartum care.

METHODS

In this retrospective study, we identified a cohort of women who expressed desire for postpartum sterilization at our center between March 2002 and November 2003. We compared women who did and those who did not undergo the procedure, based on demographic, antenatal, and intrapartum factors.

RESULTS

Of the 712 women who expressed desire for postpartum sterilization during antepartum care, 327 (46%) did not undergo the procedure. In multivariable analysis, women who were between the ages of 21 and 25 years (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.35-0.89), were African American (OR 0.68, 95% CI 0.47-1.00), requested sterilization in the second trimester (OR 0.50, 95% CI 0.29-0.86)), and had a vaginal delivery (OR 0.21, 95% CI 0.14-0.32) rather than cesarean delivery were least likely to undergo postpartum sterilization.

CONCLUSION

Despite their initial request, only 54% of women in our sample underwent sterilization. Young age, African-American race, request in the second trimester, and vaginal delivery were significantly associated with not undergoing sterilization. Our data suggest that providers should counsel all women who desire postpartum sterilization about the wide array of contraceptive methods available, with the understanding that approximately half of all women may not undergo the sterilization procedure.

LEVEL OF EVIDENCE

II-2.

Multiple repeat caesarean section: is it safe?

OBJECTIVE

We aimed to evaluate the obstetric outcome of patients without obstetric risks, who had two or more previous caesarean sections (C/S) prior to the current pregnancy, which was managed by caesarean section in our obstetric department.

METHODS

We studied the case notes of 602 women who had a repeat caesarean section in our unit between May 2002-June 2003. We then compared the two groups: (1) those who had two or more previous caesarean sections and (2) those who had only one previous caesarean section.

RESULTS

In the study group, while dense intraperitoneal adhesions were present in 3.6% of the patients, they were not found in control group. This difference was statistically significant (P < 0.05). Uterine wound separation rate was 1.9% in the study group and none of the patients in control group had uterine wound separation, which was statistically significant also (P < 0.05). There was no statistically significant association between Apgar scores and number of previous caesarean sections. Postoperative complication rates did not differ between the two groups (P > 0.05).

CONCLUSION

Patients without any obstetric risks, with two or more previous caesarean sections had significantly more dense adhesions and uterine wound separations in the current caesarean section compared to patients with one previous caesarean section. But, maternal and fetal mortality and morbidity in women who have two or more previous caesarean sections did not differ from the patients with one previous caesarean section.

Provision of female sterilization in Ribeirão Preto, São Paulo, Brazil

Forty percent of Brazilian married women from 15 to 49 years of age have undergone surgical sterilization. The 1988 Brazilian Constitution states that all scientifically proven contraceptive methods should be available to all citizens, but it was only in 1997 that specific family planning legislation was approved. This study examines physicians' perceptions and attitudes towards the current provision of female sterilization and its legal implications, as well as women's experience with obtaining and undergoing sterilization. The study design included: (1) an investigation of the hospitals and health professionals and (2) a survey of women sterilized in combination with cesarean delivery in 1998. The survey showed they had a median of 3 living children, 60.0% had been sterilized between 30 and 39 years of age, and 61.0% had paid for the procedure. Many women reported previous method failure and adverse effects with hormonal contraceptives. Women with less schooling and lower socioeconomic status had more children and had begun childbearing and had been sterilized at younger ages than women with more schooling and higher socioeconomic status. Inequalities related to reproduction were strongly associated with teenage pregnancy and inadequate knowledge about contraceptives.

Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24 046 patients

BACKGROUND

Gynaecological laparotomies are associated with considerable adhesion-related burdens; however, few data are available concerning laparoscopic surgery. This study evaluated the epidemiology of adhesion-related readmissions following open and laparoscopic procedures.

METHODS

Records from 24,046 patients undergoing gynaecological surgery in Scottish National Health Service hospitals during 1996 were assessed retrospectively. Cohorts comprised 15,197 patients undergoing laparoscopic surgery and 8849 patients undergoing laparotomies. Adhesion-related readmission episodes (directly and possibly related) were assessed over 4 years following initial surgery and were expressed as percentages of the number of initial procedures.

RESULTS

Directly adhesion-related readmissions 1 year after initial laparoscopic surgery were: in the high-risk group (adhesiolysis and cyst drainage) 1.3%; medium-risk (therapeutic and diagnostic procedures not categorized as high- or low-risk) 1.5%; and low-risk (Fallopian tube sterilizations) 0.2%. Readmissions for laparotomy following surgery on the Fallopian tubes were 0.9%, ovaries 2.1%, uterus 0.6% and vagina 0%. Readmissions occurred at reduced rates in the second, third and fourth years after surgery. Exclusion of patients who underwent surgery within the previous 5 years resulted in reduced readmission rates following laparotomy and high-risk laparoscopy.

CONCLUSIONS

With the exception of laparoscopic sterilizations, open and laparoscopic gynaecological surgery are associated with comparable risks of adhesion-related readmissions.

Female voluntary surgical contraception via minilaparotomy under local anesthesia

OBJECTIVE

To examine changes in prevalence and acceptance of sterilization methods in a developing country from 1986 to 1990.

METHOD

Data from 5182 voluntary female sterilizations performed at 52 service sites in Nigeria were retrospectively reviewed for sterilization method, anesthesia technique, demographic factors, and patient acceptance.

RESULTS

The annual number of sterilization procedures increased dramatically over this period from 688 in 1986 to 1911 in 1989. Overall, 74.3% of the procedures were performed by minilaparotomy under local anesthesia (ML/LA), 6% by laparoscopy/general anesthesia, and 19.7% by laparatomy/general anesthesia. ML/LA was found to be a very safe method, with a complication rate of 1.4%. 98.6% of ML/LA patients expressed complete satisfaction with the procedure.

CONCLUSION

Female sterilization increased in acceptance in Nigeria over the period 1986-1990 concomitant with the increased use of ML/LA. This approach is safe, cost-effective, and appropriate for the developing world.

Female surgical sterilization at a tertiary care hospital in Karachi

BACKGROUND

Tubal ligation for sterilization is one of the common methods of contraception practiced by women in developing countries like Pakistan. This study was undertaken to study characteristics of couples undergoing surgical sterilization, and to identify ways of improving utililization of contraceptive services.

MATERIAL AND METHODS

Details of 1148 women who underwent tubal ligation at the reproductive health center Jinnah Postgraduate Medical Center Karachi from January to December 2002 were recorded on a special proforma. The woman's age, duration of marriage, number of living children and the couple's educational status were recorded. Contraceptive use and duration, and associated medical conditions were documented. Data was entered in SPSS, frequency tables, means and standard deviations were obtained and comparative evaluation undertaken using non parametric methods, as indicated.

RESULTS

Out of the 4210 initial clients, 1163 (27.62%) underwent surgical sterilization. This included 1148 (98.69%) tubal ligations and 15 (1.31%) vasectomies. Of these, 608 (52.96%) were carried out in the immediate puerperium. The mean age of women was 33.1+/-3.55 years, they had been married for 14.84+/-4.22 years and 44.34% had already had 6 or more children.

CONCLUSION

Tubal ligation performed after careful selection and counseling, by experienced personnel under local anaesthesia is a safe procedure with very few complications. However older women with no history of contraception, who have already had 6 or more children, seem to avail it. Promotion of temporary contraceptives for birth spacing among younger couples is more likely to improve maternal and newborn health in addition to limiting the family size.

Fertility and reproductive history of sterilized and non-sterilized women in Campinas, São Paulo, Brazil

This article compares sterilized and non-sterilized women in relation to socio-demographic characteristics, reproductive history, and cohabitation status. Women from 30 to 49 years of age and residing in Campinas, São Paulo State, Brazil, were interviewed with a pre-tested and structured questionnaire: 236 women sterilized at least five years before the interview and 236 non-sterilized women. The sterilized women were significantly more likely to be married or cohabiting, to be younger when they began cohabiting, and to have been in the union longer than the non-sterilized women. They also began childbearing at an earlier age and had a history of more pregnancies and more live births than non-sterilized women. Factors associated with a history of 3 or more live births at the time of the interview were surgical sterilization, younger age at first childbirth, older age at the interview, recognition of fewer contraceptive methods, and lower per capita income. The article concludes that sterilization generally appears to be the consequence of higher fertility in a group of women who initiate childbearing early in life, although its role in preventing these women from having even larger families may also have a demographic impact.

The incidence of sterilisation in the UK

OBJECTIVE

To estimate incidence rates for tubal occlusion and vasectomy, and to examine how these vary with age, geographical area and time.

DESIGN

Search of patient files for operation codes in the years 1992-1999 and calculation of person time.

POPULATION AND SETTING

General Practice Research Database.

METHODS

Patient files of women aged 20-54 years and men aged 20-64 years were searched for sterilisation operation codes. Annual incidence rates in five year aged bands were calculated for sterilisation operations for both sexes. Figures were examined according to National Health Service Region and population density category of the general practices. The relationship between year of operation and mean age at operation was also examined.

MAIN OUTCOME MEASURES

Incidence rates by year, age group and geographical area.

RESULTS

The average annual incidence of sterilisation in the eight year period was 4.75 per 1000 person years at risk for women aged 20-54 and 4.48 per 1000 person years at risk for men aged 20-64. For women, there was a statistically significant 30% decrease in incidence of tubal occlusion over the study period. There was no change in vasectomy rates over time. About one-third of all vasectomies in the UK are estimated to be performed outside hospital and community clinic settings. The rates of sterilisation in both sexes were much lower in Greater London than elsewhere in the UK.

CONCLUSIONS

The popularity of tubal occlusion appears to be on the decline. Since 1996, the UK has been one of very few countries in which sterilisation incidence in men is greater than that in women.

Female sterilisation: is it what women really want?

OBJECTIVE

To audit the effectiveness of a female sterilisation counselling clinic.

DESIGN

A prospective, observational study of a female sterilisation counselling clinic over a 6-month period to determine the proportions of attenders keeping their appointment, proceeding to sterilisation, and attending for surgery.

SETTING

A hospital-based, city centre family planning clinic run by permanent, family planning-trained staff.

RESULTS

A total of 226 women had appointments for female sterilisation counselling and most confirmed attendance. Only 153 (68%) women attended; of those 101 (66%) chose to be sterilised, the remainder choosing reversible contraception. Ninety-three (92%) women went ahead with the sterilisation procedure. Thus only 61% of the original attenders were sterilised; this was only 41% of those referred.

CONCLUSIONS

The study suggests that many women referred for sterilisation counselling fail to attend. This finding needs to be further explored. For those women who do attend, accurate information and informed counselling is important. Many women are still unaware of highly effective long-term reversible contraception, and following discussion decide against female sterilisation. Services offering counselling for female sterilisation should also be able to provide easy access to a full range of contraceptive methods.

Voluntary surgical contraception: a study on level of satisfaction

Voluntary surgical contraception (VSC) is said to be one of the most popular, safe, effective and long term methods of birth control not only in Nepal but also in the world One of the very frequently suspected complication or effect of voluntary sterilization (female) is "post tubal sterilization syndrome". The term post tubal sterilization syndrome has been used variously to include abnormal menstrual bleeding, dysmenorrahoea, premenstrual distress, hysterectomy and miscellaneous other conditions like need for recanalisation, feeling of regret and menopausal syndrome. Abnormal vaginal bleeding due to ovarian dysfunction has been a regular and common complaint of the female clients after their TS. This study was carried out in a clinic setting to find out the level of satisfaction among the cases of VS. Level of satisfaction was measured by whether the client regretted the procedure, whether their menstrual pattern was changed after the procedure, performed either by themselves or VSC by the husband and also by finding out how many of them needed hysterectomy and recanalisation procedure. Women who had undergone TS were taken as the cases (group A) and those women whose husband has VSC were taken as control group (group B). The result showed that there is almost no difference in the age group of both case and control at the time of their consultation. At the time of VS almost 60% (56.53%) of cases were <29 years of age and >70% (71.23%) of the women were <29 years of age when their husbands were vasectomised. 26.15% of the women in group A were in the age group of 30-40 whereas this age group comprised of only 15.38% in group B. Average age at menarche was 14 years and average age at marriage 17 years. The menstrual pattern was not found to have changed in both groups excepts for those who had organic condition. Hysterectomy had been performed in only 5 cases at the age of 30, 34, 40, 42 and 43 years in group-A and in two case in group-B. Indications of hysterectomy n these cases were (DUB) and fibroids. Two patients in group-A had to undergo recanalisation but the indication in both the cases were loss of previous children.

Child disability and mothers' tubal sterilization

CONTEXT

The needs of children with disability can be substantial, leading some parents to consider contraceptive sterilization to prevent additional births.

METHODS

Matched records from the 1993 National Health Interview Survey and the 1995 National Survey of Family Growth were used to investigate the relationship between child disability and mothers' sterilization. Data included the birth records of 8,711 children, information on older children in the household, and the mothers' background and reproductive characteristics. Logistic and Cox regression models were used to estimate the effect of the birth of a child with a disability on the risk of mothers' sterilization.

RESULTS

The birth of a child with disability has no effect on the likelihood that a mother will undergo sterilization within the next month; however, women who have an older child with severe disability are more likely than those whose older children are nondisabled to undergo sterilization within a month after the birth of another child (odds ratio, 2.6). Severe disability in a newborn significantly increases the risk of sterilization 1-36 months after birth (risk ratio, 1.7); severe disability among older children also appears to increase the risk of sterilization 1-36 months after birth (1.5), although this result was only marginally significant.

CONCLUSIONS

Women often respond to the birth of children with disabilities by changing their fertility plans, although usually not immediately unless they have older children with severe disability. These findings are consistent with parents'desire to have a nondisabled child and with their need to care for an exceptional child by forgoing additional births.

Frustrated demand for postpartum female sterilization in Brazil

During the last three decades, Brazilians have relied almost exclusively on two contraceptive methods, the pill and female sterilization, with sterilization use increasing over time. Until a new law was passed in 1997, sterilization was virtually illegal and not covered by either public or private health insurance. It was, however, frequently provided in public and private hospitals in conjunction with a cesarean section. The new law regulating sterilization provided for reimbursement for interval sterilizations by public health insurance, but placed restrictions on availability intended to reduce the use of cesareans. These restrictions included the prohibition of postpartum sterilizations. This paper focuses on women's sterilization intentions during pregnancy and their experiences postpartum. In a prospective study of 1612 pregnant women carried out in four Brazilian cities, there was substantial demand for postpartum sterilization in both the private and public sectors among women who wanted no more children. However, public patients were much less likely to be sterilized than private patients. Thus, the new law may not have reduced inequities in access or, paradoxically, the incentive for unnecessary cesarean sections.

Sterilization failure, sterilization reversal, and pregnancy after sterilization reversal in Quebec

OBJECTIVE

1). To determine the likelihood of sterilization reversal and of subsequent sterilization after sterilization reversal among men and women and 2). to examine the likelihood of pregnancy after sterilization (contraceptive failure) and of pregnancy after sterilization reversal.

METHODS

Payment data from the Quebec provincial health insurance system were obtained for each person undergoing vasectomy or female sterilization from January 1, 1980 to December 31, 1999 and linked through a unique identifying number for each person. Using standard techniques of survival analysis, we computed the cumulative probability of experiencing each of six events.

RESULTS

Among women, 0.9% (of 311960) experienced a pregnancy after sterilization, 1.8% (of 321929) obtained a reversal after sterilization, 61% (of 4369) achieved a pregnancy after sterilization reversal and 48% achieved a delivery; 23% (of 4677) obtained a subsequent sterilization after reversal. Among men, 2.4% (of 310827) obtained a reversal after vasectomy and 18% (of 6694) obtained a subsequent vasectomy after reversal. All of these risks were much higher among those in the youngest age groups.

CONCLUSION

Sterilization reversal and pregnancy after sterilization are not rare. Relatively high rates of reversal among the youngest age groups suggest a need for better counseling about alternative contraceptive strategies.

Esterilização feminina, AIDS e cultura médica: os casos de São Paulo e Porto Alegre, Brasil

Este artigo busca identificar os fatores que interferem nas escolhas reprodutivas de gestantes HIV positivo focalizando, em particular, o papel desempenhado pelos serviços de saúde e pela cultura médica nessas escolhas. O desejo e a realização de laqueadura tubária pós-parto constituem os eventos reprodutivos tomados como questões de análise. Os dados apresentados resultam de uma pesquisa desenvolvida em serviços de pré-natal nas cidades de São Paulo e Porto Alegre, que utilizou um desenho que combinou duas estratégias metodológicas: quantitativa, a partir de dados coletados em 427 prontuários clínicos, e qualitativa, por meio da observação etnográfica e realização de sessenta entrevistas em profundidade. A grande maioria de mulheres nas duas cidades manifestou o desejo de realizar a esterilização depois do parto. Entretanto, uma proporção muito maior de mulheres em São Paulo atingiu sua meta comparada a uma pequena proporção em Porto Alegre. A cultura médica local com relação à laqueadura, aliada à organização da prática de assistência ao pré-natal e parto, mostrou-se fator fundamental para compreender as diferenças encontrada nas duas cidades.

Direitos reprodutivos de mulheres e homens face à nova legislação brasileira sobre esterilização voluntária

O objetivo deste trabalho é analisar os impactos e as possíveis mudanças que a implementação da nova legislação sobre planejamento familiar teve nas práticas reprodutivas, especialmente na esterilização voluntária, e observar se os diretos reprodutivos de mulheres e homens têm sido satisfeitos. A abordagem metodológica é baseada em uma pesquisa follow-up, aplicada a uma amostra de 159 indivíduos durante seis meses e em seis diferentes capitais de estado. Além de verificar se os critérios estabelecidos na lei estavam sendo seguidos pelo setor público de saúde, nós analisamos o tempo de espera entre a solicitação pela esterilização e a realização da cirurgia, utilizando análise de sobrevivência. Adicionalmente, foram realizadas entrevistas com profissionais de saúde, as quais são muito elucidativas dos procedimentos adotados na prática da esterilização. Os resultados mostram que, por diferentes motivos, a lei mudou pouco a prática usual da esterilização e ainda não satisfaz os direitos reprodutivos de mulheres e homens no Brasil.