[New opportunities for preventing ovarian carcinoma]

A large majority of patients with ovarian carcinoma does not carry a BRCA1/2 mutation, nor another known mutation that increases the risk of ovarian carcinoma. Screening for early ovarian carcinoma in this low-risk group is not efficient. It is, however, a known fact the risk for ovarian carcinoma decreases slightly, but to a statistically significant extent, following sterilisation via tubal occlusion. It has recently become apparent that this risk declines further after complete removal of both fallopian tubes, because many cases of ovarian carcinoma start in or on the tubes. In many countries this knowledge has led to the recommendation to give preference to bilateral total salpingectomy in routine female sterilisation. Additionally, it is often thought advisable that women with completed families who will be undergoing an abdominal intervention should be given timely counselling about an opportunistic bilateral total salpingectomy, even if they are postmenopausal, so that they can make an informed choice. This intervention will probably reduce the risk of ovarian carcinoma by approximately 50%.

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.

Symphysiotomy in Zimbabwe; postoperative outcome, width of the symphysis joint, and knowledge, attitudes and practice among doctors and midwives

BACKGROUND

Obstructed labour remains one of the leading causes of maternal and foetal death and morbidity in poorly resourced areas of the world, where the 24 hours availability of a caesarean section (CS) cannot be guaranteed, and the CS related mortality rate is still high. In these settings, reinstatement of symphysiotomy has been advocated. The objectives were, in1994; to study perioperative and long-term complications of symphysiotomy and compare them to those related to CS for similar indications, in 1996; to measure the symphyseal width after symphysiotomy and compare it to that after normal vaginal delivery, and, in 1998; to assess knowledge, attitudes and practice related to symphysiotomy among doctors and midwives in Zimbabwe.

METHODS AND FINDINGS

Thirty-four women who had undergone symphysiotomy and 29 women who had undergone a CS for obstructed labour were interviewed. The symphyseal widths of 19 women with a previous symphysiotomy were compared to that of 92 women with previous normal vaginal deliveries, using ultrasound technique. Forty-one doctors and 39 midwives, in three central hospitals and seven district hospitals in Zimbabwe, were interviewed about symphysiotomy. None of the 34 women reported serious soft tissue injuries or infections post symphysiotomy. Long-term complications after symphysiotomy do not differ notably from those after CS for similar indications. The intra-articular width of the symphysis pubis is increased after a symphysiotomy. Seventy-nine of the 80 interviewed health care workers knew about symphysiotomy. One obstetrician had performed symphysiotomies. Two-thirds of the participants considered symphysiotomy an obsolete and second-class operation, but lifesaving and appropriate in remote areas of Zimbabwe. Ten of 13 midwives in remote areas wanted to carry out symphysiotomies themselves.

CONCLUSIONS

No severe complications due to symphysiotomy were revealed in this study. The results suggest that a modest permanent enlargement of the pelvis post symphysiotomy (together with the absence of a scarred uterus) may facilitate subsequent vaginal delivery. Doctors and midwives working in district hospitals have a more positive attitude to symphysiotomies than the colleagues in central hospitals. Obstetricians (who would have to do the teaching), working in the large urban hospitals almost exclude symphysiotomy as an alternative management in Zimbabwe.

Retrospective study from Harare Central Maternity Hospital comparing symphysiotomies with Caesarean Sections for similar indications

OBJECTIVE

To explore the possibility that in obstructed labour with a live baby, a delivery by symphysiotomy is an ethical option.

DESIGN

Retrospective cohort study.

SETTING

Teaching hospital with busy maternity wards.

SUBJECTS

Women in (nearly) second stage obstructed labour who were either delivered by Caesarean Section (79), or symphysiotomy, (172).

MAIN OUTCOME MEASURES

Comparing perinatal mortality and morbidity and maternal complications, pain, long term morbidity and subsequent reproductive behaviour.

RESULTS

There is no evidence of more foetal mortality or morbidity after a symphysiotomy. Short term maternal morbidity is more serious after Caesarean Section. Long term maternal morbidity might be increased after symphysiotomies, compared with Caesarean Section. Because there are more repeat operative deliveries and trials of scar after a Caesarean Section, future maternal, foetal and infant mortality is higher.

CONCLUSION

Rejection of symphysiotomies as an option for delivery in cases of obstructed labour is not evidence based. It is very likely that lives could be saved if symphysiotomies were taught in the sub-Saharan teaching hospitals and practiced in the district hospitals. Those who oppose symphysiotomies should provide the relevant data.

Sterilisation during unplanned caesarean sections for women likely to have a completed family--should they be offered? Experience in a country with limited health resources

OBJECTIVE

To determine if it is proper to give a woman of higher parity who needs at short notice a caesarean section the option of a tubal ligation.

DESIGN

Retrospective study.

SETTING

Maternity unit of a tertiary hospital in Bulawayo, Zimbabwe.

POPULATION

Women of higher parity who were delivered by an emergency caesarean section, by an elective caesarean section or vaginally and who had been asked or not asked whether they wanted a tubal ligation.

METHODS

A postal questionnaire and visits to the participants.

MAIN OUTCOME MEASURES

Satisfaction with (in)fertility after having had, or not had, the option of a tubal ligation with the last delivery.

RESULTS

In women who had an emergency caesarean section and who were successfully followed up, 301/418 (72.0%) had been offered a tubal ligation and 241/301 (80.1%) accepted. Of the 301 women, 269 (89.4%) were happy with the outcome. Thirty-two women were unhappy (of whom 6 had tubal ligation, 24 had declined a sterilisation and in 2 cases the doctor forgot to do the sterilisation). Of the 117/418 women not offered a tubal ligation, 75/117 (64.1%) regretted not having had one. The relative risk of being unhappy with the consequences of not being offered tubal ligation compared with being given this option was 6.0 (95% CI 4.2-8.6, P < 0.001). Tubal ligations performed during emergency caesarean sections had no higher regret rate (2.5%) in this setting than those performed during elective caesarean sections (3.2%) and not much higher than postpartum sterilizations (0.5%). Women who did not have a tubal ligation during an emergency caesarean section regretted this (56.4%) significantly more often than women who did not have a tubal ligation with an elective caesarean section (34.6%) or after vaginal delivery (45.0%) (P < 0.01 and P < 0.02, respectively).

CONCLUSIONS

We found no evidence that the need to take an urgent decision resulted in more regret following tubal ligation. Women were far more likely to regret declining a tubal ligation (40%) than regret accepting one (2.5%). In this setting, some women are more likely to die of the next pregnancy than to regret an emergency tubal ligation.