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.

Retrospective study from Harare Central Maternity Hospital comparing symphysiotomies with Caesarean Sections for similar indications.

OBJECTIVE: To explore the possibility that in obstructed labour with a live baby, a delivery by symphysiotomy is an ethical option. DESIGN: Retrospective cohort study. SETTING: Teaching hospital with busy maternity wards. SUBJECTS: Women in (nearly) second stage obstructed labour who were either delivered by Caesarean Section (79), or symphysiotomy, (172). MAIN OUTCOME MEASURES: Comparing perinatal mortality and morbidity and maternal complications, pain, long term morbidity and subsequent reproductive behaviour. RESULTS: There is no evidence of more foetal mortality or morbidity after a symphysiotomy. Short term maternal morbidity is more serious after Caesarean Section. Long term maternal morbidity might be increased after symphysiotomies, compared with Caesarean Section. Because there are more repeat operative deliveries and trials of scar after a Caesarean Section, future maternal, foetal and infant mortality is higher. CONCLUSION: Rejection of symphysiotomies as an option for delivery in cases of obstructed labour is not evidence based. It is very likely that lives could be saved if symphysiotomies were taught in the sub-Saharan teaching hospitals and practiced in the district hospitals. Those who oppose symphysiotomies should provide the relevant data.

Sterilisation during unplanned caesarean sections for women likely to have a completed family--should they be offered? Experience in a country with limited health resources.

OBJECTIVE: To determine if it is proper to give a woman of higher parity who needs at short notice a caesarean section the option of a tubal ligation. DESIGN: Retrospective study. SETTING: Maternity unit of a tertiary hospital in Bulawayo, Zimbabwe. POPULATION: Women of higher parity who were delivered by an emergency caesarean section, by an elective caesarean section or vaginally and who had been asked or not asked whether they wanted a tubal ligation. METHODS: A postal questionnaire and visits to the participants. MAIN OUTCOME MEASURES: Satisfaction with (in)fertility after having had, or not had, the option of a tubal ligation with the last delivery. RESULTS: In women who had an emergency caesarean section and who were successfully followed up, 301/418 (72.0%) had been offered a tubal ligation and 241/301 (80.1%) accepted. Of the 301 women, 269 (89.4%) were happy with the outcome. Thirty-two women were unhappy (of whom 6 had tubal ligation, 24 had declined a sterilisation and in 2 cases the doctor forgot to do the sterilisation). Of the 117/418 women not offered a tubal ligation, 75/117 (64.1%) regretted not having had one. The relative risk of being unhappy with the consequences of not being offered tubal ligation compared with being given this option was 6.0 (95% CI 4.2-8.6, P < 0.001). Tubal ligations performed during emergency caesarean sections had no higher regret rate (2.5%) in this setting than those performed during elective caesarean sections (3.2%) and not much higher than postpartum sterilizations (0.5%). Women who did not have a tubal ligation during an emergency caesarean section regretted this (56.4%) significantly more often than women who did not have a tubal ligation with an elective caesarean section (34.6%) or after vaginal delivery (45.0%) (P < 0.01 and P < 0.02, respectively). CONCLUSIONS: We found no evidence that the need to take an urgent decision resulted in more regret following tubal ligation. Women were far more likely to regret declining a tubal ligation (40%) than regret accepting one (2.5%). In this setting, some women are more likely to die of the next pregnancy than to regret an emergency tubal ligation.

Self reported sexual and reproductive behaviour of male and female student nurses and midwives in Bulawayo.

OBJECTIVE: To find out more about sexual and reproductive behaviour in male and female student nurses and midwives in Bulawayo. DESIGN: Anonymous self administered questionnaire. SETTING: Schools of Nursing Mpilo and Bulawayo Central Hospitals. SUBJECTS: Three hundred and twenty four students, student nurses (n = 99) and student midwives (n = 225). MAIN OUTCOME MEASURES: Preferred family size, enjoyment and frequency of sexual behaviour, induced abortion, masturbation, pre- and extramarital sex and HIV risk. RESULTS: Male student nurses have far more pre- and extramarital sexual contacts than their female counterparts. Of the married females 67% had only ever had one sexual partner, (this figure was 15% in married males) and 33%, suspect or know that their husband has another sexual partner sometimes. CONCLUSION: Promiscuity is rare in female student nurses. Their risk factors, if any, related to HIV infection are mainly caused by their partners' pre- and extramarital behaviour. HIV testing of these partners is their only realistic hope of reducing their risk. The enjoyment of heterosexual activity is like that in Western Countries although it starts at a later age.

Please help, our condom tore last night.

To identify bottlenecks in the delivery of comprehensive reproductive health care in Bulawayo, Zimbabwe's second city, a study was performed utilising volunteers pretending to be in need of emergency contraception. A total of 55 private, Zimbabwe National Family Planning Council, municipal and government health facilities were visited. These consultations resulted in 9 (16%) correct, 1 possibly correct and 15 wrong prescriptions for the morning-after pill (MAP); no treatment was prescribed in 30 instances. Public sector health personnel were very judgemental in their attitude toward sexually active teenagers. Although the Essential Drug List of Zimbabwe is quite clear about the MAP, many health providers are not aware of this, and others do not even have/use this book.

Youth, sex, taboos and condoms.

PIP: This paper compares the two main approaches that prevent the exposure of youths to the risks related to sex as well as their effectiveness in educating young people about sex. Approach A is to equip young people before they have sex with enough knowledge, moral standards, and materials to make sex enjoyable without exposing them to too much risk. Approach B is to create taboos about sexual relationships outside formal marriage and enforce the taboos using culture or religion. This method often results in people being given little information and even misinformation. It is shown that approach A is more highly favored than approach B and showed better results in reduction of sex risks. However, approach B is not a complete nonsense since it was successful in many religious communities such as the Moslem world, and some claim this system used to work widely in Africa in the past. Overall, it is noted that the people either need a whole-hearted B-type approach, necessitating a complete transformation of the society or the A approach of openness, everybody being informed, and 100% support for condoms in all sexual relations with any risk.^ieng

Tubal ligation candidates who did not get their operation.

OBJECTIVE: To identify bottlenecks in the delivery of comprehensive family planning to women in contact with the Health Services and to find ways to reduce unmet demand for contraception. DESIGN: Exploratory descriptive study. SETTING: Large Bulawayo Government Hospital and the high density areas in the same city. SUBJECTS: Case notes of 284 women who indicated together with their partners that they had completed families and who had their tubal ligation forms duly signed but who never had their operation. Follow up of a sample of patients. INTERVENTIONS: Non intervention study. MAIN OUTCOME MEASURES: Are reproductive rights taken seriously? Is there service related unmet demand for family planning. RESULTS: Even those who had all their paperwork in order for a durante or post partum sterilization did not have any guarantee that this service would be given. The main reason was found to be lack of well motivated health staff. CONCLUSION: Much can be improved in contraceptive service delivery. Reproductive rights are not respected.

PIP: Family planning staff in a Bulawayo hospital were interviewed during June 1994 in order to identify bottlenecks in providing good contraceptive service. A file was produced by the family planning nurses [corrected] with 284 used tubal ligation (TL) forms covering the period September 1989-June 1994. Although each form was signed ante natally before labour [corrected] by the woman, [corrected] her partner or guardian, two witnesses, a junior doctor, a consultant in obstetric and gynecology, and the superintendent or his deputy, the TLs never took place. One woman had filled out a form twice with 3 years in between. The women were on average 35.5 years and had on average 6.6 children at the time the TO was supposed to happen. [sentence added] Case notes on these women were analyzed. Additionally, 34 of the women who had [corrected] sought postpartum sterilization or during caesarean section [corrected] were contacted and interviewed. The case notes and the [corrected] women gave a wide range of reasons why [corrected] they were not sterilized: delivered vaginally on a Friday, given preoperative breakfast by accident, doctors on strike, consent forms lost, doctors forgot, other operations having priority [corrected]. The main reason, however, why these women did not receive a[[corrected] TL is because the attending health personnel were poorly motivated. There is clearly much which can be done to improve the delivery of family planning services at the hospital.