Sterilization most widely used contraceptive method in world.

Contraceptive sterilization is one of the oldest modern methods of fertility control, dating to the nineteenth century. Yet, as we advance into the twenty-first century, contraceptive sterilization (hereafter referred to as sterilization) continues to warrant considerable attention and study by those involved in the field of family planning and reproductive health care.

Why? The answer is simple: Despite the development and introduction of many new contraceptive methods over the last 15 years, sterilization is the most widely used method in the world, in developing and developed countries alike.

Couples and individuals around the world choose sterilization because they want to limit or end childbearing, rather than space future births. For some women, reversible methods are unavailable or inconvenient; for others, contraceptive use may begin only after they have achieved or surpassed their desired fertility.

For many, then, sterilization is their first method. The method requires no action on the part of the user beyond election of the initial surgical procedure. It produces a minimum of side effects, while generally offering a lifetime of contraceptive protection.

Moreover, female sterilization requires no ongoing cooperation by the sexual partner or spouse, thereby representing a contraceptive option for women who may be powerless to ensure such cooperation. Thus, quality sterilization services will always be a crucial component of any comprehensive family planning service.

STERILIZATION SERVICES

Among the many factors that affect the quality with which contraceptive sterilization services are delivered, three require special attention: actual service-delivery modalities, fees and compensation programs, and the cost of service provision.

While sterilization services are provided in an inherently medical context, men's and women's access can be broadened if services are offered during the postpartum period, through mobile outreach, or in male-only clinics (for vasectomy). Likewise, while fees and compensation for providers have led to concern over the potential for coercing clients into accepting sterilization, there is little evidence that such approaches have promoted reliance on this method.

The provision of quality sterilization services hinges on the client's ability to make a well-informed, voluntary decision (informed choice), his or her authorization to proceed with the surgical procedure (informed consent), and the client's participation in true two-way communication with a health care worker about the risks and benefits of the procedure (counseling).

In helping a client make an informed decision, providers need to assess the client's needs, offer appropriate method options, fill in knowledge gaps, help the client make his or her own choice, and encourage utilization of other appropriate reproductive health services.

The spread of HIV and other STIs across the globe since 1985 has important implications for women and men considering or already using sterilization. Like most contraceptive methods, sterilization fails to offer any protection against STIs, including HIV. Thus, it is imperative for family planning providers to ensure that men and women seeking to use sterilization understand safer-sex practices and how to protect themselves and their partners from these diseases.

Incidence and prevalence. Reliance on both male and female sterilization has grown substantially since 1980, when 99 million couples were estimated to be using sterilization; by 1995, this number had climbed to about 223 million couples--180 million women using female sterilization and 43 million men using vasectomy. The number of female sterilization users in 1995 was 42 million higher than 1990 estimates; in contrast, in 1995, the number of vasectomy users was only 1 million more than 1991 levels.

Use of female sterilization services seems to have increased in regions where it had been low, particularly in Sub-Saharan Africa. Thus, in nations such as Botswana, Cape Verde, Kenya, Mauritius, Namibia, South Africa, and Swaziland, sterilization prevalence rates are now five percent or higher. The introduction of minilaparotomy services (sterilization under local anesthesia provided by nonspecialized doctors or by appropriately trained and supervised nurse-midwives) into family planning programs in Sub-Saharan Africa may account for some of this increase in use.

Who uses female sterilization? Since only individuals and couples who want no more children elect to be sterilized, it is not surprising that sterilization is more common among older women.

Nevertheless, the prevalence of female sterilization and the age at which women obtain a sterilization are inversely related: In countries where prevalence is high, the median Age is generally low, while in low-prevalence countries, women often are not sterilized until older ages.

In high-prevalence regions such as Asia and Latin America and the Caribbean, half of sterilized women have three to four children. Yet overall, the number of births among sterilized women ranges from a median of two or fewer in China and the United States to five or more in Africa. In Asia and Sub-Saharan Africa, most sterilization users reside in rural areas, while in North America, North Africa, and Latin America and the Caribbean, the majority of users live in urban locales.

Sterilization procedures performed at some time unrelated to a pregnancy (known as interval sterilizations) are more common than postpartum sterilizations in many countries located in North Africa, Sub-Saharan Africa, and South Asia. In contrast, postpartum sterilizations are more common in some countries in Latin America and the Caribbean.

Regardless of when a sterilization is performed, though, for many women it is their first experience with modern contraception: It is often the case that more than 50 percent of women using female sterilization have never used a modern contraceptive method.

FEMALE STERILIZATION

Even though tubal sterilization usually involves abdominal surgery, it is one of the safest operative procedures: Complications are rare and occur in fewer than one percent of all female sterilization procedures. Moreover, the likelihood of failure is very low, at less than two percent even 10 years after surgery.

There are two broad elements in the performance of female sterilization: the means of reaching the fallopian tubes, and the methods used to occlude the tubes. The selection of a procedure is determined by such factors as the timing of sterilization in relationship to pregnancy; the need for other gynecological procedures; the women's health; the provider's training, expertise, and experience; the cost of and logistics of maintaining equipment, and the availability of back-up services.

Female sterilization results in few long-term side effects. The overall risk of ectopic pregnancy is low (although if a pregnancy occurs, the probability that it will be ectopic is high). Perceived alterations in women's menstural flow, length, or pain following tubal sterilization (referred to as poststerilization syndrome) have been debated and studied, but research carried out in the United States has shown no strong evidence for the existence of such a syndrome.

MALE STERILIZATION

The situation with male sterilization is similar to that of female sterilization: Vasectomy is one of the safest and most effective contraceptive methods, with very low complication rates (especially with no-scalpel vasectomy) and failure rates generally thought to be in the range of two to four per 1,000.

While potential physiological effects and long-term sequelae of vasectomy have been studied extensively over the past few decades, research has offered reassurance that this method has no serious long-term negative effects on men's physical or mental health.

There is little evidence for a casual association between prostate cancer and vasectomy, and a panel of experts convened by the U.S. National Institutes of Health in 1993 concluded that no change was necessary in the practice of vasectomy.

No-scalpel vasectomy, which requires local anesthesia and only a small incision, has helped to revitalize vasectomy provision in many countries (Colombia, Mexico, Thailand, and the United States among them), and was the impetus for introducting vasectomy services in others (such as Kenya and Turkey).

However, experimental nonsurgical methods of occluding the vas are unlikely to become available in the near future, as a result of questions not only about their efficacy, but also about their ability to be offered in low-resource settings.

FUTURE TRENDS

Projections suggest that sterilization reliance will increase substantially through 2015, especially in areas in Latin America and the Caribbean and in Sub-Saharan Africa. In Asia, by contrast, the prevalence of sterilization is likely to decline as reversible methods become more widely available, particularly in countries (such as China, India, and South Korea) where sterilization usage is currently greatest.

Countries where sterilization prevalence is moderate, such as Bangladesh and Pakistan, will see more modest declines to 2015. Method prevalence is also expected to rise modestly in Vietnam and more dramatically in the Philippines between 2000 and 2015, however, and Indonesia can anticipate a slight rise in prevalence as well.

Potential users of sterilization (defined as fecund women who are in union, want no more children, are not using a contraceptive method, and report that they are considering sterilization as their preferred method) have characteristics similar to women already using sterilization: About half are age 30 or older, their mean number of children and educational level vary widely by country, and they are more often rural residents.

Overall, sterilization prevalence over the next 15 to 20 years is not likely to differ dramatically from levels seen at the beginning of the century, although the numbers of sterilization users may increase simply as a factor of population growth.

Future levels of reliance on contraceptive sterilization in any particular country may vary as a result of unpredictable factors, however, such as changes in sterilization's legal status, the development of new contraceptive methods, or shifts in economic circumstances affecting family planning programs.

Continued monitoring of these factors, as well as of societal attitudes toward sterilization and fertility regulation, will be crucial to understanding and anticipating demand for contraceptive sterilization services in both developed and developing countries.

This article is excerpted from Contraceptive Sterilization: Global Issues and Trends, which was edited by Evelyn Landry and just published by EngerderHealth, 440 Ninth Avenue, New York, NY 10001. Phone: [phone]. Fax: [phone]. E-mail: [e-mail] Web site: www.engenderhealth.org

RELATED ARTICLE: EMERGENCY CONTRACEPTION (EC) LIKELY PLAYED ROLE IN ABORTION RATE DECLINES

More than 1.3 million abortions were performed in the United States in 2000-110,000 fewer than in 1994. The Alan Guttmacher Institute (AGI) has just published an analysis showing that 46 percent of the reduction was likely due to the use of emergency contraception (EC).

EC is a specific dose of birth control pills taken within 72 hours of unprotected intercourse or insertion of an IUD within seven days. Such intervention stops ovulation, fertilization, or implantation.

The study, published in AGI's Perspectives on Sexual and Reproductive Health, surveyed 10,683 women in the United States who had abortions in 2000-2001.

The analysis pointed to previous research indicating that seven percent of all women 15 to 44 years of age do not use contraceptives and that these women account for about half of all abortions.

Specifically, the data indicated that of women who did not use contraceptives:

* 33 percent said they did not think they would become pregnant

* 32 percent said they had concerns about methods, including side effects and problems with methods in the past

* 26 percent said they did not expect to have sexual intercourse 

* 22 percent said they had not thought about contraception or had not yet begun using a method

* 12 percent said they had problems accessing contraceptives

* 5 percent said they were ambivalent about pregnancy

* 2 percent said they did not want their parents to know they were sexually active

* 1 percent said they were forced to have sexual intercourse

Of those women who used contraceptives:

* 76 percent said they had used contraceptive pills inconsistently

* 49 percent said they used condoms inconsistently

* 42 percent said they used condoms that had broken or slipped out of place

"Our findings indicate that women and their partners continue to need better information and resources to help them use contraceptive methods consistently and correctly," said Dr. Jacqueline B. Darroch, AGI senior vice president and vice president for science and an author of the study published in the current issue of Perspectives on Sexual and Reproductive Health.

"EC is a particularly promising solution, especially for those women who have had sex without a contraceptive because they did not expect to have sex, or for those who realize that they used their method incorrectly," she continued.

The analysis was based on the commonly held estimate that BC will prevent three out of four unwanted pregnancies.

EC was estimated to have averted 4,000 abortions in 1994, the last time AGI conducted a similar survey.

For more information, go to the AGI web site at www.guttmacher.org