Intention-to-treat studies crucial for contraception research

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it

BACKGROUND

Despite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies - nearly a hundred million annually - cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an "intention-never-to-become-pregnant-again" analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an - anyway performed - CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour.

PARTIAL SOLUTION

Millions of women are within reach of attaining freedom from the "tyranny of excessive fertility" when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have "what if you have a CS" counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would.

CONCLUSION

Withholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient's best interest.

FIGO's ethical recommendations on female sterilisation will do more harm than good: a commentary

The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women's Health advises against tubal occlusion (TO) performed at the time of caesarean section (CS/TO) or following a vaginal delivery (VD/TO) if this sterilisation has not been discussed with the woman in an earlier phase of her pregnancy. This advice is neither in accordance with existing medical custom nor evidence based. Particularly in less-resourced locations, adherence to it would deny much wanted one-off sterilisation opportunities to hundreds of thousands of women, many of whom have no reliable contraceptive alternative. To be sure, a well-timed discussion in pregnancy about a potential peripartum TO is preferable and, if conducted as a matter of course (as the Committee appears to promote), would represent an enormous improvement on current practice. Earlier counselling has the advantage that it results in fewer women who regret having rejected the CS/TO or VD/TO option. However, there is no evidence that earlier counselling leads to a smaller proportion of regretted sterilisations. Consequently, where early TO counselling has been impossible, forgotten or deliberately omitted on pronatalist, traditional, financial, cultural or religious grounds, offering a perinatal sterilisation belatedly and in an unbiased, culturally sensitive manner is often verifiably better than not presenting that option at all, notably where high parity and uterine scars are particularly dangerous. Belated counselling, as will be demonstrated in this paper, saves many lives. The Committee's blanket rejection of belated counselling on perinatal sterilisation is therefore unjustified.

The right to informed choice. A study and opinion poll of women who were or were not given the option of a sterilisation with their caesarean section

BACKGROUND

In The Netherlands, caesarean sections (CSs) are rarely combined with tubal occlusion (TO), partly because discussing CS/TO near delivery is considered unethical and earlier hypothetical counselling--i.e. suppose you happen to need a CS--is rare. This results in more unintended pregnancies and is inconsistent with informed choice. We explored whether TO should indeed not be made routinely available to eligible women.

METHODS AND FINDINGS

A questionnaire was mailed to 515 Para ≥2 who underwent in the past ≥1 CS. 498 (96.7%) responded. They were on average 35.3 years old, had 2.5 children, had undergone 1.6 CSs, and 3.3 years had passed since their index delivery, either a CS (393) or vaginal birth (105) after a previous CS. 87% of the 498 believed that pregnant mothers with ≥1 children should be routinely counselled about CS/TO. Indeed, 58% and 85% respectively, thought women/couples expecting their second or third child should still be given the TO option days before delivery, if omitted earlier. Counselled women, 138/498 (27.8%), were far more often satisfied than those without CS/TO option. 33/393 had a CS/TO. None indicated regret in the questionnaire. Another 119 also would have elected a CS/TO if given that option. Therefore, 152 (38.7%) of 393 Para ≥2 had or would have liked a concurrent TO. 118/119 wrote they still regretted missing this opportunity. The exception's husband had had a vasectomy. 100/119 were good TO candidates: they were ≥28 years when they delivered an apparently healthy baby of ≥37 weeks. The current contraceptive use of these 100 suggests that this group will have at least 8 unintended pregnancies before age 50.

CONCLUSION

The experiences and opinions of previous potential candidates for a CS/TO do not support the reluctance of Dutch obstetricians to counsel pregnant Para ≥1 about the TO option for a (potential) CS.