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

Patients' need for information on permanent contraception during a cesarean section: A cross-sectional questionnaire survey

AIM

The present study aimed to explore the need for information about permanent contraception in Japanese women with repeated cesarean sections (CS).

METHODS

The present, cross-sectional survey used a self-administered questionnaire mailed to women with a second or later CS at Tokyo Metropolitan Tama Medical Center between March 2010 and December 2017. Those who were pregnant, had given birth less than 1 year before the survey or had an hysterectomy were excluded.

RESULTS

The present study analyzed 284 patients (60 with permanent contraception, 224 without permanent contraception). Forty-eight (80%) of women with permanent contraception, and 135 (60%) of women without permanent contraception believed that information on permanent contraception was needed before CS. Among women without permanent contraception, significantly fewer women obtained adequate information of permanent contraception from their healthcare workers before a CS compared with women with permanent contraception (8% vs. 71%, p < 0.001). A higher rate of unreliable contraceptive use (41%) and unintended pregnancies (4%) after the latest CS were found among the women without permanent contraception.

CONCLUSIONS

A large portion of the study cohort wished they had received information on permanent contraception before CS; however, the patients without permanent contraception had limited access to this information. Adequate information about permanent contraception should be provided to women planning a CS to enable them to make an informed decision with respect to the treatment.

Sterilisations at delivery or after childbirth: Addressing continuing abuses in the consent process

Non-consensual sterilisation is not only a historic abuse. Cases of unethical treatment of women around the time of a pregnancy continue in the Twenty-First Century in five continents. Sterilisation is being carried out by some healthcare professionals at the time of delivery, or soon afterwards, without valid consent. A range of contemporary examples of such practices is given. Respecting women's autonomy should be the touchstone of the consent process. Avoidance of force, duress, deception and manipulation should go without saying. Ethnic minority communities and women living with HIV, in particular, are being targeted for this kind of abuse. Attempts have been made in various countries and by international professional organisations to introduce clinical guidelines to steer health professionals away from this malpractice. Survivors have sought justice in domestic and international courts. This paper critically assesses the evidence on the practical, ethical and legal issues around the handling of consent for these procedures. Suggestions are made about possible regulatory responses that address abuse, whilst maintaining access for those individuals who freely elect to undergo these procedures.

Tubal Sterilization in Women Under 30: Case Series and Ethical Implications

OBJECTIVE

According to the SOGC Contraception Consensus, it is recommended that permanent contraception be offered to women regardless of age or parity. Many women who desire sterilization at a young age experience barriers from physicians who decline to facilitate the request.

METHODS

As part of a quality assurance project, we performed a review of cases where tubal sterilization was performed in women under 30 over a 42-month period (September 2013-March 2017). We also performed a literature review on the ethical and clinical considerations with respect to young women requesting permanent contraception.

RESULTS

We identified 29 women under 30 who had consented for tubal sterilization; 27.5% of women were nulliparous, and 27.5% had a medical condition for which unintended pregnancy is associated with an increased risk of adverse event. As documented in the patients' records, many women expressed prior difficulty in obtaining the procedure. Despite being informed of the risk of regret, most women proceed with the surgical procedure. Three additional women had consented and subsequently cancelled their surgical procedure.

CONCLUSION

Women who are well-informed and desire permanent contraception should be offered the procedure, regardless of age or parity. Declining such requests is a form of conscientious refusal and is not a clinical decision.

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.