•
R ic a rd o B a rin i, A a ra o M e n d e s P in to -N e to , L u c ia H e le n a S im o e s C o s ta , A rle te d e S o u z a B a rro s , N a d ia M a ria M a rc h i, L u c ia d e L o u rd e s F e rre ira , E rm e lin d a M a ria B u e n o , A k e m i M u ra y a m a , C la u d ia S a m p a io d o N a s c im e n to , L a fs e P o te rio d o s S a n to s H in z , O lfv ia J o s a n e B a rre to d e A lm e id a
M ultidisciplinary experience in the selection
of patients for tubal sterilization
W o m e n 's In te g r a l H e a lth A tte n tio n C e n te r , D e p a r tm e n t o f T o c o g y n e c o lo g y , F a c u ld a d e d e C ie n c ia s M e d ic a s , U n iv e r s id a d e E s ta d u a l d e C a ln p in a s - S ilo P a u lo , B r a z il
R esults of the use of a special protocol for evaluation of patients requiring tubal ligation is presented after applied by a m ultidisciplinary group. T he authors conclude that the use of defined param eters of age, parity, m arital union duration,
num ber of children alive and the presence of m aternal clinical pathology are useful to identify patients w ith sm aller chances of regret after surgery.
U N IT E R M S : T ubal ligation. E valuation protocol. C riteria for indication of surgery.
IN T R O D U C T IO N
B
ra z ilia n sta tistic s a re e x tre m e ly sh o c k in g in w h a t re fe rs to th e u se o f c o n tra c e p ti v e m e th o d s.A p p ro x im a te ly 5 3 % o f th e w o m e n th a t h a v e
d e c id e d in fa v o r o f c o n tra c e p tio n , h a v e b e e n tu b a lly
ste riliz e d o r m a k e u se o f c o n tra c e p tiv e p ills (B e m fa m /
P N A D ). 2 7 % o f w o m e n b e tw e e n 1 4 a n d 4 4 y e a rs h a v e
A d d re s s fo r c o rre s p o n d e n c e :
R ic a rd o B a rin i
C e n tro d e A te n 9 8 0 In te g ra l
a
S a u d e d a M u lh e r C a ix a P o s ta l 6 0 8 1C a m p in a s - S P - B ra s il- C E P 1 3 0 8 1 -9 7 0
c h o se n su rg e ry a s c o n tra c e p tiv e m e th o d . T h is re p re se n ts.
4 0 % o f th e to ta l o f w o m e n a c tu a lly u sin g a n y k in d o f
c o n tra c e p tio n d e v ic e s, a c c o rd in g d a ta fu rn ish e d b y th e
N a tio n a l S u rv e y o n M a te rn a l a n d C h ild h o o d H e a lth a n d
F a m ily C o n tro l P la n (B e m fa m , 1 9 8 6 ).
M o st o f th e w o m e n w e re su b m itte d to tu b a l
ste riliz a tio n ta k in g a d v a n ta g e o f a c e sa re a n su rg e ry , w h ic h
p ro c e d u re re su lts in se v e ra l in c o n v e n ie n c e s. T h e first
a sp e c t is th e ju stific a tio n th a t th e h e a lth a ssista n c e
fin a n c in g c o m p a n ie s d o n o t p a y fo r ste riliz a tio n su rg e rie s
so le ly , b u t th e y re im b u rse c e sa re a n c o sts, in d e p e n d e n tly
fro m in d ic a tio n , p re v a le n c e o r c o m p lic a tio n s. T h is p ra c tic ~
re su lts in a p ro p o rtio n a l in c re a se o f c e sa re a n su rg e ry
p ro c e d u re ~ in a d e q u a te ly in d ic a te d if c o n sid e rin g m e d ic a l
p o in t o f v ie w , b e in g b o th , m a te rn a l a n d fe tu s d ise a se s a n d
m o rta lity ta b le s h ig h e r w h e n a b d o m in a l b irth s a re c h o se n .
A nother consequence is that patients aIm Ing for
sterilization, becom e pregnant expecting to be subm itted
to sterilization under cesarean surgery conditions.
Fundam ental as w ell is consideration outlined already
in several revisions, saying that "w om en subm itted. to
surgery during their pregnant period, have proportionally
m ore chances to regret". T hese figures generated a practice
betw een phisicians and patients according w hich a
w om an,if she w ants to be sterilized, she m ust be pregnant.
Pregnancy, on its turn, represents a period of great
psychosocial changes and is the w orse m om ent of a
w om an's life to deci de on a defini ti ve sterilization
procedure.
L iterature inform ations and. personal experience at
the D T G IFC M lU N IC A M P com pelled us to consider social
profile of patients that regret after surgery.
B oring, R ochat & B ecerra (1988) studied reasons
for regretting, am ong 846 patients that have been tubally
sterilized in Puerto R ico. T hey observed that 21.6% of
them declared to be unsatisfied w ith surgery. From this
total, 75% expressed their w ish in having m ore children.
T hese authors reported that there w as a very tight statistical
association betw een the age of the patient w hen sterilized
and the risk of regretting. E ach year difference in age
represented a 1.10 ("odds ratio") risk of regretting. For
exam ple: for surgeries perform ed in 24 years old w om en,
regretting w as 1.10 tim es m ore than expressed by w om en
25 years old, etc. T hey reported also that possibility of
regretting w as higher w hen surgeries w ere decided upon
by others, such as resulting from m edical indications.
L eader et al. (1983) studied the profile of 159 patients
that requested reversal of sterilization. T hey observed that
such desire w as due, in rpost of the cases, to a new m arital
union, as these patients m arried very young, form ed
fam ilies sooner than the usual and w ere sterilized. very
young as w ell.
Pinotti et al. betw een July, 1985 and January, 1986,
held interview s w ith 231 w om en at least three years after
tubal sterilization w as perform ed and under m edical
assistance at the H ospital das C linicas at U N IC A M P for
the m ost different reasons, trying to evaluate satisfaction
rates w ith surgery. T hey found 11.6% of w om en unsatisfied
w ith sterilization. In this group of w om en, 50% w ere
sterilized less than 25 years old.. .
Faundes et al. (1991), studying at the Sterility
A m bulatory of the D T G /FC M /U N IC A M P, com pared
prevail of the tubal sterilization and the num ber of patients
that requested for its reversal, during tw o 30 m onths
periods and a 10 years interval (1978 till 1980 and 1988
till 1990). In the first period, 28% of the patients presented
tubal factor and 2.4% of the total w as represented by
patients asking for reversal. In the second period, 34.5%
of patients presented tubal factor and 12.4% regret from
surgery. A ll patients of the first period and 87.3% of the
second one w ere subm itted to sterilization less than 31
years old. In the second group 45.8% of the regretting
patients had one or tw o children at the tim e surgery w as
perform ed.
R esults above, pointed out by other sources as w ell
(G rub et aI., 1985; D ivers, 1984), have conducted to the
developm ent of a system atic evaluation of the cases
involving w om en, pregnant or not, w ho apply for
sterilization surgery at the D T G /FC M IU N IC A M P.
T his report sum m arizes the experience of a
m ultidisciplinary group in this evaluating process,
presenting their activity in its entirety, since program
started, in July, 1988 till D ecem ber, 1989 and, afterw ards,
a detailed description of the m edical and social
characteristics of the cases analyzed betw een June, 1988
and July, 1989.
M A T E R IA L A N D M E T H O D S
I • Phases of the evaluation program of patients requesting
sterilization
surgery
Starting June, 1988, D T G /FC M IU N IC A M P created
a graphic of attendance for all patients w ishing sterilization,
for both, patients of the Institute or sent to Institute by
m eans of the prim ary assistance netw ork in C am pinas and
neighborhood. Patients are divided into tw o groups
follow ing the sam e procedures: pregnant and not pregnant.
First step of the process consists in interview s held
by a social assistant for social level evaluation of the
couple, patient's surgery expectation and relationship
conditions of the couple.
In the second phase, patients are scheduled for group
activities, usually participating 8 w om en under the
coordination of one nurse and one social assistant. T his
activity covers, basically, educational aspects of the
reproductive physiology, sexuality, genitals anatom y and,
m ainly, diffusion of the general contracepti ve devices
(D IU , C ondom , D iaphragm , etc.). E m phasizes critical
considerations on definitive m ethods (tubal sterilization
and vasectom y) w ith the purpose of enlarging patients
acquaintance w ith this process.
T hird step consists in an interview of the couple w ith
the social assistant, trying to involve the partner in the
process of the surgery, once both of them are responsible
•
F in a l re s u lts o f th e
s p e c ia l e v a lu a tio n
fo r fa m ily sc h e d u le . A t th is m o m e n t, d isc u ssio n is h e ld ,
a g a in , o n e x p e c ta tiv e s re g a rd in g su rg e ry , k n o w le d g e a b o u t
c o n tra c e p tiv e m e th o d s a n d , fin a lly , if th e su rg ic a l
p ro c e d u re is c h o se n , sh o u ld b e ste a d ily a g re e d u p o n b y
th e p a rtn e r a n d th is a g re e m e n t m u st b e a tta c h e d to th e
o th e r d o c u m e n ts p e rta in in g to th e e v a lu a tin g p ro c e ss.
W h e n e v e r n e c e ssa ry , p a tie n ts a re d ire c te d fo r
p sy c h o lo g ic a l a tte n d a n c e a n d e v a lu a tio n , sp e c ia lly w h e n
o b se rv e d th a t e m o tio n a l fa c to rs in flu e n c e e x c e ssiv e ly th e
re q u e st fo r su rg e ry .
F in a lly , a n e v a lu a tin g c o m m issio n , c o o rd in a te d b y a
p h y sic ia n a n d a so c ia l a ssista n t, a n u rse a n d a p sy c h o lo g ist
(in v o lv e d in th e p ro g ra m ), d isc u ss e a c h c a se se p a ra te ly
a n d d e c id e if su rg e ry sh o u ld b e a u th o riz e d o r n o t.
F o llo w in g situ a tio n s a re a u th o riz e d :
1 . W o m e n m o re th a n 3 0 y e a rs o ld ;
2 . H a v in g , a t le a st, 3 c h ild re n a liv e (p re fe ra b ly b o th
se x e s);
3 . H a v in g , a t le a st, 5 y e a rs m a rita l u n io n
re la tio n sh ip ;
4 . A firm a g re e m e n t o n su rg e ry is su p p lie d b y th e
p a rtn e r;
5 . M e d ic a l in d ic a tio n s a re c o n sid e re d fo r th e re q u e st
(w h e n a n y o n e o f th e h e a lth g ro u p , p e rta in in g o r n o t to th e
In stitu tio n , in d ic a te s su rg e ry a s b e in g a p a tie n t's h e a lth
p re v e n tin g m e a su re ).
II
- Casuistic
1 ,6 3 0 p a tie n ts w e re e v a lu a te d b e tw e e n Ju n e , 1 9 8 8
a n d D e c e m b e r, 1 9 8 9 . F ro m th e se , 8 1 2 w e re fo u n d p re g n a n t
d u rin g th e p ro c e ss. F irst 4 1 8 c a se s e v a lu a te d b y th e
p ro g ra m w e re se p a ra te d fo r a n a c c u ra te a n a ly sis o f th e
m e d ic a l a n d so c ia l c h a ra c te ristic s.
A g e , p a rity , n u m b e r o f c h ild re n a liv e , se x o f c h ild re n ,
m a rita l u n io n d u ra tio n a n d m e d ic a l re a so n s in d ic a tin g
su rg e ry w e re th e c h a ra c te ristic s a n a ly z e d . G ro u p s o f
p re g n a n t a n d n o t p re g n a n t w o m e n w e re se p a ra te d a n d
g ro u p s a p p ro v e d a n d n o t a p p ro v e d w e re c o m p a re d ,
c o n sid e rin g th e a b o v e m e n tio n e d c h a ra c te ristic s.
III - Data collections
D a ta re fe re n t to p a tie n t's m e d ic a l a n d so c ia l v a ria b le s
w e re c o lle c te d th ro u g h in fo rm a tio n s sta tin g o n th e
in te rv ie w in d e x c a rd s a n d c lin ic a l a ssista n c e file o f th e
p a tie n ts b e in g o b se rv e d a t th e D T G /F C M IU N IC A M P .
A d a ta b a se p ro g ra m w a s c re a te d , c o m p ile d fo r
c o m p u te riz e d d B a se III p lu s la n g u a g e , u sin g a 1 6 b its P C
m ic ro sy ste m .
IV - Data analysis
D a ta w e re a n a ly z e d w ith th e su p p o rt o f a sta tistic a l
p a c k a g e n a m e d E p iin fo 5 .0 (E p id e m io lo g ic a l
In fo rm a tio n ), d istrib u te d b y th e C e n te r o f D ise a se C o n tro l,
A tla n ta , U S A .
D iffe re n c e s in th e c o n tin u o u s v a ria b le a v e ra g e s w e re
stu d ie d th ro u g h o u t th e " T " te st o f S tu d e n t. C o m p a riso n
b e tw e e n th e re su lts o f th e g ro u p s a p p ro v e d a n d n o t
a p p ro v e d fo r su rg e ry p u rp o se s w e re d o n e u sin g th e Q u
i-sq u a re te st. In b o th te sts, sta tistic a l d iffe re n c e s ra n g in g
5% w e re c o n sid e re d a s b e in g sig n ific a n t.
R E S U L T S
1 ,6 3 0 re q u e sts fo r fe m a le ste riliz a tio n w e re e v a lu a te d
d u rin g th e p e rio d o f Ju n e , 1 9 8 8 till D e c e m b e r, 1 9 8 9 .
D u rin g th is sa m e p e rio d , 1 ,8 9 2 re q u e sts h a v e b e e n
su b m itte d b u t, a t th e tim e th e se d a ta w e re c o lle c te d , 2 6 2
c a se s w e re a lre a d y in c o u rse .
C o n sid e rin g th e p ro c e sse s c o n c lu d e d , 1 ,0 1 8 w e re
a p p ro v e d , 1 9 7 c a se s w e re d e n ie d a n d 4 1 5 p a tie n ts
d isc o n tin u e d p ro c e ss.
T a b le 1 sh o w s d istrib u tio n o f c a se s a c c o rd in g to th e
o rig in o f th e p e titio n a n d re su lts.
T h e first 4 1 8 c a se s e v a lu a te d b e tw e e n Ju n e , 1 9 8 8
a n d D e c e m b e r, 1 9 8 9 w e re stu d ie d a c c o rd in g to
c h a ra c te rstic s su c h a s a g e , p a rity , n u m b e r o f c h ild re n a liv e ,
se x o f c h ild re n , m a rita l u n io n d u ra tio n a n d m e d ic a l
in d ic a tio n .
T a b le 2 re fle c ts d istrib u tio n o f g ro u p s c o n sid e rin g
a g e a n d e v a lu a tio n re su lts. G ro u p o f w o m e n 3 0 y e a rs o ld
o r m o re w a s a p p ro v e d fo r su rg e ry in a p ro p o rtio n a lly
h ig h e r d e g re e th a n th e o th e rs (p < 0 ,0 0 0 1 ).
T a b le 1
D is tr ib u tio n o f s te r iliz a tio n r e q u e s ts a c c o r d in g to
o r ig in a n d e v a lu a tio n r e s u lts
E v a lu a tio n p re m is e s
F a m ily N o rm a l P re n a ta l
(n ) s c h e d u le P re n a ta l
(% ) (% ) (0/0 )
A p p ro v e d 1 ,0 1 8 5 4 .3 6 8 .7 6 8 .5
N o t a p p ro v e d 1 9 7 ,0 0 0 5 .9 1 9 .4 1 2 .2
R e tire 4 1 5 ,0 0 0 3 9 .8 1 1 .8 5 .5
T o ta l 1 ,6 3 0 8 1 8 6 5 6 1 5 6
A g e
T a b le 2
D is trib u tio n o f g ro u p s b y a g e a n d
s u rg e ry e v a lu a tio n re s u lts
E v a lu a tio n re s u lts
A p p ro v e d N o t a p p ro v e d T o ta l
T a b le 4
D is trib u tio n o f c h ild re n b y s e x a n d re s u lts o f s te riliz a tio n e v a lu a tio n
E v a lu a tio n re s u lts
S e x o f c h ild re n A p p ro v e d N o t a p p ro v e d T o ta l
>
=
3 0 y e a rs< 3 0 y e a rs
T o ta l
2 7 5
4 3
3 1 8
5 6
3 4
90
3 3 1
77
4 0 8
D iffe re n t
S a m e
T o ta l
2 4 2 7 6
3 1 8
4 8
4 2
90
290
1 1 8
4 0 8
(p < 0 ,0 0 0 1 ) (p < 0 ,0 0 1 )
E v a lu a tio n re s u lts
D u ra tio n o f m a rita l
u n io n (y e a rs ) A p p ro v e d N o t a p p ro v e d T o ta l T a b le 5
D is trib u tio n o f th e m a rita l u n io n d u ra tio n a n d re s u lts o f s te riliz a tio n e v a lu a tio n (
A n y p a th o lo g y p r e s e n c e h a d s h o w n m o r e s ig n if ic a n t in f lu e n c e w h e n p a tie n ts , le s s ' th a n 3 0 y e a r s o ld , w e r e e v a lu a te d s e p a r a te ly , a s it m a y b e s e e n o n T a b le 7 -d is tr ib u tio n o f p a to lo g ie s a n d e v a lu a tin g r e s u lts f o r s u r g e r y in d ic a tio n . I n th is g r o u p , p r e s e n c e o f a t le a s t o n e p a th o lo g y r e in f o r c e d th e s u r g e r y in d ic a tio n in a v e r y s ig n if ic a n t d e g r e e f r o m th e s ta tis tic a l p o in t o f v ie w ( p
<
0 ,0 0 5 ) .3 5 0
5 8
4 0 8
67
23
90
2 8 33 5
3 1 8
(p < 0 ,0 0 0 1 ) > = 5
< 5
T o ta l
T a b le 3 s h o w s d is tr ib u tio n o f th e c h ild r e n a liv e a n d r e s u lts o f s u r g e r y e v a lu a tio n . I t m a y b e o b s e r v e d th a t w o m e n w ith 3 c h ild r e n o r m o r e g e t s u r g e r y a p p r o v a l in a s ig n if ic a n tly h ig h e r p e r c e n ta g e th a n th e o th e r s ( p
<
0 ,0 0 0 1 ) .
T a b le 4 s h o w s d is tr ib u tio n o f c h ild r e n p e r s e x a n d a p p r o v e d s u r g e r ie s . I t c a n b e o b s e r v e d th a t th is c r ite r ia in f lu e n c e d th e e v a lu a tio n p r o c e s s in th e s a m e w a y a s th e o th e r s , i.e ., c h ild r e n b e in g th e s a m e s e x , s u r g e r y w a s n o t in d ic a te d in m o s t o f th e c a s e s .
D is tr ib u tio n c o n s id e r in g m a r ita l u n io n d u r a tio n a n d s u r g e r y in d ic a tio n r e s u lts m a y b e o b s e r v e d o n T a b le 5 , w h ic h s h o w s th a t g r o u p s w ith m o r e th a n 5 y e a r s o f m a r ita l u n io n d u r a tio n o b ta in e d p e r m is s io n f o r s u r g e r y in a c o n s id e r a b ly h ig h e r le v e l th a n th e o th e r o n e s ( p
<
0 ,0 0 0 1 ) .B e in g a t le a s t o n e p a th o lo g y p r e s e n t in p a tie n ts a p p ly in g f o r s u r g e r y , th is f a c t h a s a lm o s t n o t in te r f e r e d in th e s u r g e r y in d ic a tio n , e v e n if s ta tis tic te s t g a v e a " p " v a lu e le s s th a n 0 ,0 5 . T h e s e r e s u lts m a y b e o b s e r v e d o n T a b le 6 ( p
<
0 ,0 1 ) .C O N S ID E R A T IO N S
T u b a l s te r iliz a tio n s u r g e r y r e p r e s e n ts a v e r y s ig n if ic a n t c h a n g e in w o m a n 's lif e , in w h a t r e f e r s to h e r r e p r o d u c tiv e lif e , h e r m a r ita l r e la tio n s h ip a n d , o b v io u s ly , .im p o s s ib ility o f b e c o m in g p r e g n a n t b y th e u s u a l w a y .
T h is r e p o r t p r e s e n ts a m e th o d o lo g y o f s e le c tin g p a tie n ts w ith th e p u r p o s e o f r e d u c in g s o r r o w a f te r s u r g e r y is p e r f o r m e d . I t is n o t n e c e s s a r y . to e m p h a s iz e th a t w e d o
2 8 4
1 2 4
4 0 8 T o ta l
3 5
55
9 0
2 4 9
69
3 1 8
(p < 0 ,0 0 1 ) > = 3
< 3
T o ta l
T a b le 3
D is trib u tio n o f n u m b e r o f c h ild re n a n d re s u lts o f th e s te riliz in g e v a lu a tio n
E v a lu a tio n re s u lts
C h ild re n a liv e A p p ro v e d N o t a p p ro v e d
Table 6
Distribution considering patients candidates to
surgery presenting at least one pathology and the
evaluation results
Table 7
Distribution of pathologies, existent or not, and
evaluation results for surgery purposes considering
patients less than 30 years old
E valuation results E valuation results
P athology A pproved N ot approved T otal P athology A pproved N ot approved T otal
P resent 151 29 180 P resent 31 13 44
A bsent 167 61 228 A bsent 12 21 33
T otal 318 90 408 T otal 43 34 77
(p< 0,05) (p < 0,005)
n o t in te n d to d e m o n s tr a te d e c r e a s in g o f th e in s a tis f a c tio n
le v e ls o f p a tie n ts s u b m itte d to s te r iliz a tio n , a s th is m a tte r
w ill b e in v e s tig a te d in th e f u tu r e a m o n g p a tie n ts s e le c te d
u n d e r th e s e s ta n d a r d s .
T h e D T G /F C M /U N I C A M P in te r e s t in th e tu b a l
s te r iliz a tio n b e g a n lo n g a g o , n o t o n ly in w h a t r e f e r s to
. m e d ic a l a s p e c ts f o r its p e r f o r m in g b u t, a ls o , p r o p e r
a d e q u a tio n o f th e m e th o d to p a tie n ts in c lin e d to s u r g e r y
p r o c e d u r e s . T h is o b je c tiv e h a s r e s u lte d in p r o p o s a ls
d ir e c te d b y th is D e p a r tm e n t to th e h e a lth a u th o r itie s , in
o r d e r to r e c o g n iz e th a t s te r iliz a tio n is a f a c t, th a t it m a y
a n d m u s t b e r u le d .
B a s e d o n d a ta a lr e a d y p u b lis h e d a n d o u r o w n , in w h a t
r e f e r s to m e d ic a l a n d s o c ia l p r o f ile o f p a tie n ts w h o d e c la r e d
u n s a tis f a c tio n w ith th is k in d o f s u r g e r y ( B o r in g , R o c h a t
& B e c e r r a , 1 9 8 8 ; L e a d e r e t a I ., 1 9 8 3 , P in o tti e t a I ., 1 9 8 6 ;
F a u n d e s e t a I ., 1 9 9 1 ) , w e h a v e d e v e lo p e d th e f o llo w in g
p r o c e d u r e s f o r s e le c tio n o f c a n d id a te s , h a v in g in m in d
th r e e o b je c tiv e s . .
F ir s t, a s th is is a n u n i v e r s ita r y s e r v ic e , w e h o p e th a t
o u r in te r n s a n d r e s id e n ts s e r io u s ly c o n s id e r th e
c o n tr a c e p tiv e m e th o d s a s a w h o le a n d d e s c r ib e a d e q u a te
s itu a tio n s f o r th e d e f in iti v e o n e s . W e a r e s u r e th a t th e s e
p r o f e s s io n a ls , in a n e a r f u tu r e , w ill o c c u p y a f u n d a m e n ta l
p o s itio n in w h a t r e f e r s to c o n tr a c e p ti v e m e th o d s in d ic a tio n ,
b e in g e v e n p o s s ib le to m a in ta in a c r itic a l a n d in f o r m a tiv e
p o s itio n in th e c o m m u n ity th e y w ill b e w o r k in g f o r .
S e c o n d , a s w e b e lie v e th a ~ , w h e n a p a tie n t a s k s f o r
s u r g e r y , s h e is m o r e in c lin e d to th in k a b o u t th e r e a s o n s
f o r c h o s in g s te r iliz a tio n , u n d e r a f a v o r a b le c o n d itio n to
e n la r g e h e r k n o w le d g e . B e a r e d b y th is s a m e h o p e , w e
e x p e c t th e s e p a tie n ts p r o p a g a te th e ir k n o w le d g e a n d
f e e lin g s a c q u ir e d d u r in g th e ir c o n f in e m e n t.
L a s t, b u t e x tr e m e ly im p o r ta n t, is th e d if f u s io n o f o th e r
r e v e r s a l b u t n o t le s s f ir m c o n tr a c e p tiv e m e th o d s w h ic h , in
th e ir la r g e s t p a r t, p a tie n ts w e a s s is t a r e n o t a w a r e o f . W ith in
th is s a m e o b je c tiv e , w e w a n t to e m p h a s iz e th a t w o m e n d o
n o t n e e d to b e c o m e p r e g n a n t in o r d e r to c h o o s e a
c o n tr a c e p tiv e m e th o d , d e f in itiv e o r n o t, a n d s p e c ia lly
s te r iliz a tio n is n o t n e c e s s a r ily p r e c e d e d b y a c e s a r e a n
s e c tio n , b e in g p o s s ib le to b e d o n e a f te r a n o r m a .! b ir th
o c c u r s .
T h e d a ta s h o w e d d e m o n s tr a te th a t s p e c if ic
p a r a m e te r s o f a g e , n u m b e r o f c h ild r e n a liv e , th e ir s e x ,
m a r ita l u n io n d u r a tio n a n d p r e s e n c e o f m a te r n a l c lin ic a l
p a th o lo g ie s r e s u lt in th e s e le c tio n o f a q u ite u n if o r m g r o u p
o f c a n d id a te s f o r s u r g e r y .
T a b le 1 r e s u lts d ir e c t o u r a tte n tio n to th e f a c t th a t
a p p r o v a l a m o n g p r e g n a n t w o m e n w a s h ig h e r th a n in th e
g r o u p s o f n o t p r e g n a n t p a tie n ts . H o w e v e r , th is w a s
d e te r m in e d b y a g r e a t r e tir e le v e l o f n o t p r e g n a n t w o m e n .
A s s e le c tio n r e q u ir e m e n ts a r e th e s a m e f o r b o th o f
th e g r o u p s , w e h a v e c o n c lu d e d th a t g r o u p o f n o t p r e g n a n t
w o m e n d e c id e d f o r a n o th e r m o r e a d e q u a te m e th o d d u r in g
th e p r o c e s s o r f o u n d th a t th e m o m e n t w a s n o t e x a c tly th e
m o s t in d ic a te d o n e f o r s u r g e r y p r o c e d u r e .
T h is r e s u lt r e in f o r c e s a s w e ll th e o p in io n o f th e s ta f f
in v o lv e d in th e s e le c tio n p r o c e s s - th a t th e p r e g n a n c y
p e r io d is th e m o s t in a d e q u a te o n e to ta k e s u c h d e c is io n ,
a s it s till r e s ts s o m e tim e b e f o r e th e b ir th o c c u r s .
I n f o r m a tio n s s h o w n in T a b le s 2 till 5 d e m o n s tr a te
th a t th e g r o u p in v o lv e d in th e s e le c tiv e p r o c e s s m a in ta in e d
a c o h e r e n t p o s itio n in w h a t r e f e r s to c r ite r ia a d o p te d f o r
s u c h a c tiv itie s . W e m u s t o b s e r v e m o r e c a r e f u lly T a b le s 6
a n d 7 , w h ic h d e s c r ib e s e le c tiv e r e s u lts w h e n e x is tin g s o m e
m a te r n a l c lin ic a l p a th o lo g ie s . I t m a y b e s e e n th a t in w o m e n
le ss th a n 3 0 y e a rs o ld , th e e x iste n c e o f a t le a st o n e
p a th o lo g y , g ra n te d in d ic a tio n fo r su rg e ry in a sig n ific a n tly
h ig h e r p ro p o rtio n th a n in th e g ro u p p re se n tin g n o c lin ic a l
p a th o lo g ie s.
CONCLUSION
T u b a l ste riliz a tio n is a c o n tra c e p tiv e m e th o d
d e e p ly d iffu se d in o u r c o m m o n w e a lth p re se n tin g , h o w e v e r,
a h ig h re g re t p e rc e n ta g e if c o n d itio n s u n d e r w h ic h it is
in d ic a te d p e rsist, i.e ., p a tie n ts w e re n o t in fo rm e d a b o u t
o th e r m e th o d s.
H e a lth a u th o ritie s sh o u ld d e fin itiv e ly re c o g n iz e
th e e x iste n c e o f ste riliz a tio n a s a p ro b le m to b e fa c e d a n d
w id e ly d isc u sse d , p ro p o sin g m o d ific a tio n s to th e te x t o f
A rtic le 1 2 9 o f th e P e n a l C o d e , e n a b lin g le g a liz a tio n o f
p ro c e d u re s, so th a t its fin a n c in g m a y b e a llo w e d b y th e
h e a lth sy ste m o n d isp o sa l fo r o u r p e o p le , i.e ., S U S (H e a lth
U n ifie d S y ste m ) to g e th e r w ith o th e r re v e rsa l c o n tra c e p tiv e
m e th o d s.
S e le c ti v e p ro c e ss p ro p o se d b y th is re p o rt m a y b e
u se d a s m o d e l b y th e c o m m o n w e a lth se rv ic e s o n d isp o sa l
fo r w o m e n , re su ltin g in le ss re g re ttin g risk s.
REFERENCES
1 . B O R IN G , C .C .; R O C H A T , R .W .
&
B E C E R R A , J. -S te riliz a tio n re g re t a m o n g P u e rto R ic a n w o m n . F e rtil -S te ril 4 9 :9 7 3 , 1 9 8 8 .2 . B R A H A M S , D . - S te riliz a tio n o f a m e n ta lly in c a p a b le w o m a n . L a n c e t 1 0 8 9 :1 2 7 5 ,1 9 8 9 .
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