Archives of Gynecology and Obstetrics

, Volume 275, Issue 4, pp 241–244

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

Authors

    • Department of Obstetrics & GynaecologyAhmadu Bello University Teaching Hospital
Original Article

DOI: 10.1007/s00404-006-0257-5

Cite this article as:
Adesiyun, A.G. Arch Gynecol Obstet (2007) 275: 241. doi:10.1007/s00404-006-0257-5

Abstract

Background

Female sterilization by tubal ligation is the most commonly used method of fertility regulation. However, in some lesser-developed country 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.

Keywords

Tubal ligationAcceptabilityPomeroy’s method

Introduction

In developing countries, particularly black African countries like Nigeria, female sterilization has not been practiced on a large scale as it is done in developed countries and some less developed countries in Asia and South America. This is largely due to persistent reluctance to accept family limitation as normal and deep-seated aversion for surgery [6]. Also, religion, ignorance and superstition based on ancient beliefs are contributory, even literates strongly hold on to superstitious belief in the community [8]. However, sterilization by tubal ligation is one of the most popular methods of contraception among women who have completed their family size [4]. The acceptability of sterilization, especially in developing countries, might be influenced by high cost of the procedure, scarcity of providers and surgical risk [1]. Cultural and religious re-orientation will also play a major role in improving the desirability and acceptability of sterilization as a mode of contraception.

Methods

We conducted a descriptive study of 102 patients that had sterilization by tubal ligation (TL) between January 1999 and December 2004 at a tertiary health institution. Information concerning the patients was obtained from their case files. The objective of the study is to assess factors that may influence decision to have sterilization. The 102 patients were divided into three main groups as follows:
  • Group A: Patients that had TL done at caesarean section.

  • Group b: Patients that had TL done at laparotomy for repair of ruptured uterus.

  • Group C: Clients that had TL alone on request.

The surgeries were performed under general anesthesia. All the clients in group C had TL through mini-laparotomy.

Result

Incidence

During the 6 years study period, there were 9,946 deliveries, giving a tubal ligation (TL) rate of 1.03%. Of the 102 patients/clients, 60 (58.8%) patients fell into group A, 28 (27.5%) patients were in group B and 14 (13.7%) clients were in group C.

In group C, 9 (64.3%) clients had interval TL and the remaining 5 (35.7%) had TL in the puerperium.

Age, parity, literacy level and TL

The rate of TL increased with age in the reproductive age group. The patient/client age varied between 19 and 44 years. The highest incidence of TL was in the age interval of 36–40 years. The highest incidence of TL in groups A, B and C was in the age groups 31–35, 36–40 and 41–45 years, respectively.

The parity distribution showed high rate of TL from parity 4 and above. In group A, the highest TL rate was recorded at parity 4 (65%). In groups B and C, the highest TL rate was from parity 6 and above (Table 1).
Table 1

Group distribution of age, parity, literacy level and type of union

 

Caesarean section and BTL (60)

Repair of uterine rupture and BTL (28)

BTL alone (14)

Total (102)

n

%

n

%

n

%

n

%

Age

 <20 years

2

3.3

0

0.0

0

0.0

2

2.0

 21–25 years

6

10.0

4

14.3

0

0.0

10

9.8

 26–30 years

8

13.3

6

21.4

1

7.1

15

14.7

 31–35 years

18

30.0

7

25.0

2

14.3

27

26.5

 36–40 years

16

26.7

9

32.1

5

37.7

30

29.4

 41–45 years

10

16.7

2

7.1

6

42.9

18

17.6

Parity

 1

0

0

0

0.0

0

0.0

0

0.0

 2

2

3.3

2

7.1

0

0.0

4

3.9

 3

5

8.3

2

7.1

1

7.1

8

7.8

 4

39

65.0

4

14.3

2

14.3

45

44.1

 5

8

13.3

7

25.0

3

21.4

18

17.6

 >6

6

10.0

13

46.3

8

57.1

27

26.5

Literacy level

 Illiterate

18

30.0

19

67.9

1

7.1

38

37.3

 Primary

12

20.0

5

17.9

2

14.3

19

18.6

 Secondary

16

26.7

2

7.1

3

21.4

21

20.6

 Post secondary

14

23.3

2

7.1

8

57.1

24

23.5

Type of union

 Monogamy

28

46.7

3

10.7

13

92.9

44

43.1

 Polygamy

32

53.3

25

89.3

1

7.1

58

56.9

BTL Bilateral tubal ligation

The literacy level distribution showed that the highest proportion of TL was amongst illiterates in group A (30%) and group B (67.9%). On the contrary, in group C, 57.1% of the clients had post secondary education.

Type of marital union, religion, ethnicity and TL

Except for a patient in group B that was a widow, all patients/clients were married. The rate of TL fairly cuts across the two religions and the five ethnic groupings in Nigeria. Of the 102 patients/clients, 58 (56.9%) were in a polygamous union and 44 (43.1%) in a monogamous union (Table 2).
Table 2

Religion, ethnicity and bilateral tubal ligation

  

Group A

Group B

Group C

Religion

 Christianity

48

26

13

9

 Islam

54

34

15

4

Ethnicity

 Hausa

28

18

7

3

 Yoruba

22

12

6

4

 Igbo

18

10

5

3

 Northern minority

20

14

5

1

 Southern minority

14

6

5

3

In group A, 46.7% were in a monogamous union and 53.3% in a polygamous union. In group B, 10.7% were in a monogamous union and 89.3% in a polygamous union. In group C, 92.9% were in a monogamous union and 7.1% in a polygamous union.

Indication for TL

On the whole, indication for TL was completion of family size in 55 (53.9%) patients/clients, repeated caesarean births to avoid future obstetric complication in 19 (18.6%) patients and prevention of obstetric complication in patients that had uterine rupture in 28 (27.5%) patients (Table 3).
Table 3

Indications for bilateral tubal ligation

Indications

Group A

n = 60

Group B

n = 28

Group C

n = 14

Total

n = 102

n

%

n

%

n

%

n

%

Completion of family size

41

68.3

0

0.0

14

100.0

55

53.9

Repeated caesarean birth

19

31.7

0

0.0

0

0.0

19

18.6

Prevention of future obstetric complication

0

0.0

28

100.0

0

0.0

28

27.5

In group A, 41 (68.3%) of the 60 patients had TL due to completion of family size while 19 (31.7%) had it due to repeated caesarean births.

Methods of TL and its complications

Pomeroy’s method was used to achieve TL in 91.2% of the patients/clients. The only complication encountered was intra-abdominal bleeding secondary to slipped ligature from the tube. It occurred in one of the clients that had interval sterilization in group C.

Discussion

Female sterilization is a permanent method of contraception. It is effective and the most widely used and accepted method of family planning, with over 100 million women of reproductive age group using it world wide [3, 9]. However, in some lesser developed countries, the acceptability of this method is limited by some factors [1]. This low rate of tubal ligation recorded in this review is similar to 2.7% reported in the southeast region of Nigeria [5].

The group distribution of patients in our study showed that a significant percentage (86.3%) of the patients had TL done concurrently with an operative procedure. More importantly about 59% of patients had TL done at caesarean section. However, Ezegwui [5] in his series reported that about 48% had TL done concurrently with another operative procedure, of which about 30% had TL done at caesarean section. This shows that female sterilization is still not widely acceptable in our environment. This is similar to reports from another developing country [7]. Perhaps the most intriguing finding is that two-thirds of the patients that had TL at caesarean section had it on account of completion of their family size. The possible interpretation of this findings when compared to the very small percentage (13.7%) of clients that had TL alone on request is that aversion to surgery and the cost of sterilization still plays an important role in the acceptability of TL as a form of contraception in our setting. Low cost of sterilization is one of the components of an ideal female sterilization procedure as recommended by the World Health Organization Task Force on female sterilization [10]. However, the cost of female sterilization in our environment is a far cry from the ideal WHO recommendation. Contributing to the high cost is anesthesia and the surgical nature of the procedure used.

Age, parity and literacy level influenced the acceptability of sterilization in our series. Similarly, emerging reports from Zimbabwe found TL to be the choice of older women that are gravidae five and above with less education [7]. The percentage of TL peaked at parity 4 in our series; this may be a reflection of TL offered to most of our patients at their fourth caesarean section. The highest proportion (37.3%) of TL was recorded amongst the non-literates in this series. This is attributed to the high percentage (50%) of non-literates in the group that had TL in conjunction with repair of ruptured uterus.

There was no preponderance of TL in one type of marital union over the other. However, more pertinent is the dominance (92.9%) of monogamous union in the group (group C) that had TL alone on request. This may be a reflection of the level of instability in a polygamous union and the fear of the unknown in the future. The preponderance (89.3%) of polygamous union in the group that had TL with repair of ruptured uterus (group B) is more worrisome. This is best explained mainly by their non-literate status and probably rivalry between mates with references to the number of children they have.

Religious belief and cultural background still has much influence on the acceptance of female sterilization in our society. The fair distribution of patients/clients across the two religious belief and ethnic groupings supports this fact.

Pomeroy’s method of TL via laparotomy or mini-laparotomy route was the most employed method of TL in this series. Though Pomeroy’s method has been described to be elegant in its simplicity with the added virtue of ensuring that hemorrhage from the mesosalpinx is prevented [2], the only immediate post-operative complication attributed to sterilization in this study was intra-abdominal bleeding. It occurred in a client that had interval sterilization. The low incidence of complication recorded in this study is similar to reports by Ezegwu and Nwogu-Ikogo [5].

We recommend a re-appraisal in the modality and channel of public enlightenment, with involvement of traditional and religious institution. The development of non-surgical methods of sterilization that is cheap will improve the accessibility and acceptability of sterilization in our setting.

Copyright information

© Springer-Verlag 2006