Offering a Woman Sterilization During an Emergency Cesarean Section May Sometimes Be Appropriate
High-parity Zimbabwean women who accepted surgical contraception during an emergency cesarean section were no more likely to regret having done so than similar women who underwent the procedure during an elective cesarean (2.5% vs. 3.2%). According to data collected from the women an average of 32 months after they gave birth,1 emergency cesarean patients who had not been offered a tubal ligation were six times as likely to be unhappy about their fecundity status as those who had been offered the procedure. In resource-poor settings, the researcher suggests, it may be unethical not to offer emergency cesarean patients of high parity a tubal ligation.
To examine the long-term reproductive satisfaction of high-parity women in a variety of birth circumstances, the researcher gathered retrospective data on the incidence of regret--both of having had a tubal ligation and of not having had one--among those who needed an emergency cesarean, those who had a planned cesarean and those who delivered vaginally. The researchers surveyed women who delivered at a tertiary hospital in Bulawayo, Zimbabwe, from December 1990 to July 2000; to be eligible for the study, women had to be giving birth to their fourth or higher-order child (or third or higher for women aged 30 or older).
The data, which were collected by mail or by in-person visits, if needed, were available for three groups of new mothers--418 women who had had an emergency cesarean section, 366 who had had an elective cesarean and 749 who had delivered vaginally. These sample sizes reflect varying attempts to contact sterilized and nonsterilized women for follow-up. (For example, 80% of sterilized women were successfully followed up, compared with 38% of nonsterilized women. Although the researchers tried to contact all nonsterilized cesarean patients of high parity, they attempted to reach a random sample of 20% of the far higher number of women who had delivered vaginally.) The mean length of time between the index delivery and completion of the study questionnaire was 32 months.
The women in the three delivery groups were further classified by sterilization status. Women in all six of the resulting groups were in their mid-30s (mean ages of 32-37). At follow-up, women who had delivered vaginally and elected a postpartum sterilization had the most children (a mean of 6.0), whereas planned cesarean patients who chose sterilization had the fewest (a mean of 4.0). Moreover, the proportion of women whose last pregnancy had been unwanted ranged from 64% among sterilized women who had delivered vaginally to 9% among planned cesarean patients who had either declined or had not been offered a tubal ligation.
Among the 301 emergency cesarean patients who had been offered the option of a postpartum tubal ligation, 11% were unhappy with their situation at follow-up--8% regretted having declined it, 2% regretted their decision to accept it and 1% were unhappy because the clinician had forgotten to perform the requested ligation. On the other hand, 64% of the 117 emergency cesarean patients who had not been given the option of sterilization regretted not having had one. Thus, women who had not been offered sterilization were six times as likely to be dissatisfied as those who had.
Among the 346 patients with planned cesareans whose doctor had offered them a tubal ligation during the cesarean section, 4% were unhappy with their decision (3% regretted having accepted the procedure and 1% regretted having declined it), whereas 65% of the 20 women who had not been offered a tubal ligation regretted not having had one. Thus, among women having an elective cesarean, the risk of dissatisfaction was 15 times as high among those who had not been offered the option of sterilization as it was among those who had been offered the procedure.
Finally, among the 590 women who had delivered vaginally and had been offered a tubal ligation, 11% were unhappy with their subsequent fertility situation (97% of whom regretted having declined that offer), whereas 53% of 159 similar women who had not been given the option of sterilization regretted that omission. Thus, among women who had delivered vaginally, those who had not been offered postpartum sterilization were 4.7 times as likely to experience regret as those who had been offered the procedure.
The general rate of sterilization regret among women who had had the procedure was no higher among those who had had an emergency cesarean (2.5%) than among those who had had an elective cesarean (3.2%), although the proportion expressing regret was far lower among women who had delivered vaginally (0.5%). (All sterilized women who regretted having had the operation were offered a reversal at no cost; 18 women accepted this offer. Finally, the proportion of nonsterilized women who regretted their lack of permanent protection was significantly higher among women who had had an emergency cesarean (56%) than among those who had delivered vaginally (45%) or by elective cesarean (35%).
The investigator acknowledges the limitations of a nonrandomized, observational study and the bias caused by the disproportionate loss to follow-up of nonsterilized women. He nonetheless asserts that the results show that deciding on a tubal ligation during a stressful situation does not necessarily lead to regret. Indeed, he suggests that the subject be broached in discussions of the possibility of an emergency section during a prenatal care visit.
Among emergency cesarean patients who had been offered a tubal ligation, the proportion who regretted having accepted it (3%) was far lower than the proportion who regretted having turned it down (40%). The researcher concludes that in settings with limited health resources and high levels of maternal mortality, especially deaths related to complications from repeat cesareans, "it is unethical not to offer tubal ligation [to] women of high parity at the time of an emergency cesarean section." The author of a related editorial2 agrees, pointing out that the limited availability of interval sterilization facilities, the scarcity of hospitals and the high rates of maternal morbidity and mortality in much of the developing world alter the traditional interpretation that offering postpartum sterilization to women having an emergency cesarean is necessarily unethical.--L. Remez
1. Verkuyl DAA, Sterilization during unplanned cesarean sections for women likely to have a completed family--should they be offered? experience in a country with limited resources, BJOG: an International Journal of Obstetrics and Gynaecology, 2002, 109(8):900-904.
2. Grant JM, Different ethics of consent in the developing world, editorial, BJOG: an International Journal of Obstetrics and Gynaecology, 2002, 109(8):xiii-xv.