A cross-sectional study to assess choice of tubal ligation over vasectomy in tribal women of Eastern Gujarat

ABSTRACT

Introduction:

Since gaining independence, India has prioritized managing its population growth, becoming the first nation to implement a national family planning program. Despite these efforts, female sterilization remains the predominant method of contraception, with a significant gender disparity in sterilization practices.

Method:

This study focuses on the sociocultural factors influencing indigenous women in Gujarat’s Dahod District to choose tubectomy over vasectomy. A cross-sectional study design was employed, involving 227 tribal women who had undergone tubal ligation. Data were collected through structured interviews conducted in local dialects, focusing on sociocultural norms, reproductive history, and decision-making processes.

Result:

Findings indicated that awareness of vasectomy was limited, with only 24.23% of participants knowing about it, compared to the widespread practice of female sterilization. The study revealed a significant correlation between Higher education levels and increased awareness of male contraception (P = 0.002). Similarly, socioeconomic status played a crucial role, with wealthier individuals more likely to be aware of vasectomy (P = 0.001). However, cultural and sociological barriers, including fears of reduced job efficiency (10.91%) and physical weakness (30.91%) among men, alongside spousal disapproval (58.18%), were major deterrents to the adoption of vasectomy. The significant influence of healthcare personnel in motivating tubectomy (70.04%) also highlights the systemic bias toward female sterilization.

Conclusion:

The study underscores the need for targeted innervations to address the deep-rooted cultural beliefs and gender biases that limit the adoption of male sterilization methods. It suggests that enhancing education outreach and addressing sociocultural barriers could promote more balanced family planning practices. The finding emphasizes the importance of culturally sensitive health policies that respect Indigenous perspectives while promoting informed decision-making and equitable access to reproductive health services. This research contributes to understanding the complex interplay of cultural, educational, and socioeconomic factors in family planning choices among tribal women in India.

Introduction

Since independence, India has been deeply concerned about overpopulation. India was the first country in the world to implement a national family planning program, primarily to manage its quickly growing population.[1] Despite being the world’s first to implement a family planning program and establish a dedicated department for this purpose, the Department of Health and Family Welfare, in India is among the nations with the highest rates of sterilization procedures, both in terms of overall numbers and as a percentage of the population.[2] Although there is evidence throughout family planning history that the method is continuous, there have been notable advancements in this area in recent decades. Several demographers and policy experts supported the natural technique, in particular rhythm, in the program’s early stages.[3] However, because of the uneven use of this technique as well as significant technological advancements, the government began endorsing contemporary techniques like condoms, jelly and diaphragms over older ones.[4]

In India, female sterilization continued to be the most popular method of terminal family planning after that. 37% of Indian women between the ages of 15 and 49 have had their fallopian tubes removed, per data on female sterilization.[5] In India, half of all women are sterilized by the age of 35, with the majority of sterilizations occurring between the ages of 20 and 35.[6] Annually, over 4.5 million women undergo sterilization.[6] As per the NFHS-1 report, the vasectomy rate for men in India was found to be 3.4%.[7] This rate then declined over the course of four rounds, going from 1.9 percent in NFHS-2[8] to 1.1 percent in NFHS-3,[6] 0.3 percent in NFHS-4,[9] and 0.3 percent in NFHS-5.[10]

The Sustainable Development Goal 5 (SDG-5) aims to eradicate all kinds of discrimination against women and girls worldwide and achieve gender equality. However, while examining the use of sterilization services in India, a systematic bias against women has been noted. The National Health Policy (NHP)—2017’s section 4.8 seeks to raise the percentage of male sterilization from less than 5% to at least 30% and, if feasible, significantly higher.[11] Without a well-thought-out plan for intervention, the NHP’s implausible goal of increasing male sterilization (vasectomy) is unlikely to be achieved. Currently, there are programmatic incentives available in India to increase vasectomy adoption, such as conditional financial incentives and service increments.[12]

The study aimed to find out why tribal women in Dahod district, Gujarat, preferred tubectomy over vasectomy for sterilization. It’s focused on understanding the cultural and social reasons behind their choice to help health workers design better family planning programs.

Methodology

The purpose of the study was to investigate the sociocultural elements affecting tribal women in Gujarat, India’s Dahod District’s decision to undergo tubal ligation. Women in this area were frequently permanently sterilized by tubal ligation, also referred to as tubectomy. Comprehensive data were collected via a cross-sectional study to comprehend the factors that led to this common decision.

Study design

The study used a cross-sectional design, which entailed gathering information from a particular population at one particular moment. To learn more about the viewpoints, experiences, and sociocultural influences on their decision, a survey was conducted with tribal women who had undergone tubal ligation.

Sample selection

The research population consisted of indigenous women who had undergone tubal ligation and lived in Gujarat’s Dahod District. The selection of participants from several villages in the district was done using a systematic random sample technique, which ensured that diverse tribal tribes were represented.

The target population for the study consisted of tribal women from various villages within Dahod District, Gujarat who had undergone tubal ligation. A systematic random sampling technique was employed to select participants, ensuring representation across diverse tribal groups within the district.

The systematic sampling process involved enumerating eligible women from village healthcare records and selecting every 5^th woman who underwent tubectomy who participated in the study. This technique reduced selection bias and enhanced the generalizability of the finding to the larger tribal population in this region.

Sample size

Due to the high illiteracy rate in Dahod district, the drop out from the study was very high so here we took the study duration as 1 year from 1 May 2023 to 31 Day 2024 for data collection, total of 257 females participated during the study period, 17 out of total 257 study participants left study because they felt it was sensitive and personal matters, which should not be discussed in public, while 13 study participants left the study due to interference of their relative during data collection process. So we excluded them from our analysis so our final sample size was 227.

Data collection

Structured interviews with knowledgeable researchers who were conversant in the regional dialects were used to gather data. The purpose of the interview questionnaire was to collect data on sociocultural norms and attitudes, reproductive history, understanding of family planning techniques, decision-making processes related to sterilization, and access to healthcare facilities.

Ethical considerations

Before data collection ethical permission was obtained from an institutional review board. Informed consent was taken from each participant, with an emphasis on their right to anonymity. Confidentiality, and voluntary participation. Participants were assured that their responses would be kept private and utilized solely for the study.

Data analysis

Open Epi version 3.01 Statistical software was utilized to analyze the quantitative data that was acquired from the structured interviews. To enumerate demographic characteristics and important factors, descriptive statistics were computed, including frequencies, percentages, and measures of central tendency. The choice of vasectomy and socio-cultural characteristics were found to be associated with the use of inferential statistics, such as the Chi-square test.

Data interpretation

The results were analyzed in the context of the body of research on family planning methods, cultural norms, and socioeconomic characteristics common to tribal cultures. We talked about how the study’s findings will affect healthcare policy and practice, pointing out areas that need more investigation and action.

Result

The study analyzed the sociodemographic profile, marital characteristics, contraceptive use, and factors influencing the preference for tubal ligation over vasectomy among 227 participants. Table 1 presents sociodemographic data, indicating a mean age of 35.24±4.88 years, with most participants (68.72%) aged 30-39 years. Hindus comprised 68.28%, while 31.72% were Christians. Education levels varied, with 40.09% having primary education and 28.19% being illiterate. Financial constraints were evident, as 65.20% lived below the poverty line. Regarding occupation, 45.81% were housewives, while 30.40% worked in unskilled labor. Table 2 outlines the marriage profile and number of children. The majority had been married for 12-16 years (34.80%), while 23.79% had been married for 17-21 years. Regarding children, 52.86% had 3-5 children, while 47.14% had 1-2 children. Child spacing varied, with 43.61% maintaining a 2-year gap and 36.56% opting for 3 years. Table 3 details contraceptive use and reasons for preferring tubal ligation over vasectomy. Most participants (77.09%) had not used barrier methods, and 89.87% had never used Copper T. Healthcare workers were the primary motivators (70.04%). Awareness of vasectomy was low (24.23%), with 58.18% citing partner disagreement as the reason for preferring tubal ligation. Table 4 shows that education (p = 0.002), socioeconomic status (p = 0.001), and occupation (p = 0.0001) significantly impacted awareness. Higher awareness was found among educated and financially stable participants. Table 5 highlights that awareness was highest in those married 12-16 years (49.9%). A male child preference was more common among unaware participants (54.65%). These findings highlight financial constraints, lack of education, and misconceptions about vasectomy, emphasizing the need for better awareness of male contraception.

Table 1.

Sociodemographic profile of study participants

Variable	n – 227	Percentages
Age (in years)
20–29	30	13.22
30–39	156	68.72
40–49	41	18.06
Mean age	35.24±4.88	-
Religion
Hindu	155	68.28
Christian	72	31.72
Education
Graduate	11	4.85
Higher Secondary	16	7.05
Primary	91	40.09
Secondary	45	19.82
Illiterate	64	28.19
Socio economic status
Below poverty line	148	65.20
Above poverty line	79	34.80
Occupation
Skilled	32	14.10
Unskilled	69	30.40
Semi-skilled	22	9.69
Housewife	104	45.81

*BPL, Below poverty line (As per government card holder of India). *APL, Above the poverty line (As per government card holder of India)

Table 2.

Marriage profile and number of Children

	n - 227	Percentage (%)
Married life (Years)
2–6	8	3.52
7–11	52	22.91
12–16	79	34.80
17–21	54	23.79
22–26	29	12.78
27–31	5	2.20
Total child
1–2	107	47.14
3–5	120	52.86
Spacing between children (in years)
1	16	7.05
2	99	43.61
3	83	36.56
4	16	7.05
5	7	3.08
6	6	2.64

Table 3.

Details regarding Contraceptive use and preference of tubectomy over vasectomy

Contraception use before tubal ligation
Barrier methods
Yes	52	22.91
No	175	77.09
Cupper T
Yes	23	10.13
No	204	89.87
Oral contraceptive pills
Yes	32	14.10
No	195	85.90
Natural method (calendar)
Yes	22	9.69
No	205	90.31
Motivator for Tubal ligation
Self	19	8.37
Husband	7	3.08
Mother	15	6.61
Mother-in-law	27	11.89
Health care worker	159	70.04
Awareness for VS
Yes	55	24.23
No	172	75.77
Reason for choosing tubectomy over vasectomy	n – 55
Disagreement with the partner	32	58.18
Fear of Weakness in the partner	17	30.91
Fear of Decrease work capacity in the partner	6	10.91

Table 4.

Comparison of factors influencing tubal ligation over vasectomy among study participants

	Are you aware of male contraception (VS)?		Total	P
	No	Yes
Age (in years)
20–29	26 (15.11%)	4 (7.27%)	30 (13.21%)	0.136
30–39	115 (66.86%)	41 (74.74%)	156 (68.72%)
40–49	31 (18.02%)	10 (18.18%)	41 (78.06%)
Total	172 (100%)	55 (100%)	227 (100%)
Religion				0.227
Hindu	115 (66.86%)	42 (76.36%)	157 (69.16%)
Christian	57 (33.13%)	13 (23.63%)	70 (30.83%)
Total	172 (100%)	55 (100%)	227 (100%)
Education Status				0.002
College	10 (6.13%)	9 (14.06%)	19 (8.37%)
Higher Secondary	13 (7.97%)	9 (14.06%)	22 (9.69%)
Primary	66 (40.49%)	33 (51.56%)	99 (43.61%)
Secondary	36 (22.08%)	10 (15.62%)	46 (20.26%)
Illiterate	38 (23.31%)	3 (4.68%)	41 (18.06%)
Total	163 (100%)	64 (100%)	227 (100%)
Socio economic status
BPL	103 (72.02%)	45 (53.57%)	148 (65.19%)	0.001
APL	40 (27.97%)	39 (46.42%)	79 (34.80%)
Total	143 (100%)	84 (100%)	227 (100%)
Occupation status				0.0001
Skilled	18 (10.46%)	15 (15.62%)	33 (15.53%)
Unskilled	29 (22.13%)	40 (41.66%)	69 (30.39%)
Semi- skilled	13 (9.92%)	9 (9.37%)	22 (9.69%)
Housewife	71 (54.19%)	32 (33.33%)	103 (71.80%)
Total	131 (100%)	96 (100%)	227 (100%)

Table 5.

Comparison of factors related to influencing tubal ligation over vasectomy among study participants according to years of marriage and number of children

	Are you aware of male contraception (VS)?		Total	P
	No	Yes
Married life (in years)				0.066
2–6	3 (1.74%)	1 (1.81%)	4 (1.76%)
7–11	47 (27.32%)	16 (29.09%)	63 (27.75%)
12–16	54 (31.39%)	27 (49.9%)	81 (35.68%)
17–21	50 (29.06%)	6 (10.93%)	56 (24.66%)
22–26	17 (9.88%)	4 (7.27%)	21 (9.25%)
27–31	1 (0.58%)	1 (1.81%)	2 (0.88%)
Total	172 (100%)	55 (100%)	227 (100%)
Spacing between children (in years)				0.745
1	15 (8.72%)	5 (9.09%)	20 (8.81%)
2	63 (36.62%)	26 (47.27%)	89 (39.20%)
3	66 (3.83%)	18 (32.72%)	84 (37.37%)
4	15 (8.72%)	4 (7.27%)	19 (8.37%)
5	8 (4.65%)	1 (1.81%)	9 (3.96%)
6	5 (2.90%)	1 (1.81%)	6 (2.64%)
Total	172 (100%)	55 (100%)	227 (100%)
Total child				0.001
1–2	77 (44.76%)	37 (67.27%)	114 (50.22%)
3–5	95 (55.23%)	18 (32.72%)	113 (49.77%)
Total	172 (100%)	55 (100%)	227 (100%)
Any strong preference for the male child before Tubal ligation				0.0001
No	78 (45.34%)	39 (70.90%)	117 (51.54%)
Yes	94 (54.65%)	16 (29.09%)	110 (48.45%)
Total	172 (100%)	55 (100%)	227 (100%)
If their husband ready for VS will she prefers VS for him				0.0001
No	130 (76.47%)	28 (49.12%)	158 (69.60%)
Yes	40 (23.52%)	29 (50.87%)	69 (30.39%)
Total	170 (100%)	57 (100%)	227 (100%)

Discussion

In our study total of 227 individuals participated, whose mean age was 35.24 years (SD = 4.88), and were included in the research. According to the age distribution, 18.06% of people were 40–49 years old, 13.22% were 20–29 years old, and the majority 68.72% were between the ages of 30–39. The awareness of the terminal method of male contraception across different age groups of study participants. Most respondents, about 68.72%, belonged to the 30–39 years age group, with 74.74% of them being aware of male contraception, and vasectomy. The 20–29 years age group has the lowest awareness, at just 7.27%, awareness appears to increase with age, especially in the 30–39 years age group. However, the P value of 0.136 indicates that these differences in awareness between age groups were not statistically significant.

In terms of religious affiliation, 31.72% of Christians and 68.28% of Hindus were involved. Comparison of awareness of male terminal method contraception among Hindu and Christian respondents. Hindu makes up 69.16% of the total, with 76.36% of them being aware of male contraception, and vasectomy. Christians account for 30.83%, with 23.63% awareness. The P value of 0.227 suggests that the difference in awareness between these religious groups was not statistically significant, meaning religion likely doesn’t play a major role in determining awareness levels. As per Shafi S, et al.[13] study the majority of married men (50.3%) belonged to the 36–40 age group, and more than half (55.7%) of Hindus (83.1%) belonged to the OBC caste.

In our study finding the distribution of educational attainment showed that elementary education accounted for the largest percentage (40.09%), followed by secondary education (19.82%), illiteracy (28.19%), upper secondary (7.05%), and college education (4.85%). In addition to the relationship between education level and awareness of male contraception. Among those aware, 51.56% had only primary education, while 23.31% of the unaware were illiterate. The P value of 0.002 indicated a statistically significant difference, suggesting that higher education levels were strongly associated with greater awareness of male contraception.

According to socioeconomic status, 65.20 percent of the participants lived in poverty. While the comparison between socioeconomic status and awareness of male contraception. Of those aware, 46.42% were above the poverty line, compared to 27.97% among the unaware. The P value 0.001 indicated a significant difference showing that individuals with higher socio-economic status were more likely to be aware of male contraception. As per Shafi S et al.[13] study a significant portion of the research participants 29.2% had only completed high school, 23.7% had only completed basic education, and 13.5% were illiterate. Just 15.9% of people completed middle school education, whereas 9.1% completed post-high school education.

The majority of participants (34.80%) had been married for 12–16 years, but the period of marriage varied from 2 to 31 years. The distribution of respondents is based on the number of years they have been married; the majority of participants have been married for 7–16 years. Notably, those married between 12 and 16 years were the most aware of male contraception. The P value of 0.066 suggests there was no significant statistical difference between the groups. In terms of the size of the family, 47.14% had 1–2 children and 52.86% had 3–5 children. According to child spacing, 36.56% of participants had a three-year gap between children, compared to 43.61% who had a two-year gap. While the spacing between children in a group focuses on the number of years between births. The most common intervals were 2 and 3 years, reflecting typical spacing preferences. The P value of 0.745 suggests no statistically significant differences between those aware of male contraception and those who were not, concerning their child spacing practices. Furthermore, the number of children per family, comparing those aware of male contraception with those who were not. The majority 67.27% of those aware have 1–2 children, while those unaware have higher percentages 55.23% with 3–5 children. The P value of 0.001 suggests statistically significant differences between the two groups, indicating that awareness of male contraception may be associated with smaller family sizes. While a wife would prefer vasectomy for her husband if he was willing among those who prefer it 50.87% of wives would opt for VS, while only 23.52% would choose it if not. The significant P value of 0.001 suggests a strong correlation between the husband’s willingness and the wife’s preference for VS, indicating that spousal support plays a crucial role in such decisions.

Our study found that regarding occupation, 45.81% of participants were housewives, 30.40% were unskilled laborers, 14.10% were skilled workers, and 9.69% were semi-skilled workers. Before tubal ligation, oral contraceptive pills were used by 14.10%, barrier techniques by 22.91%, Copper T by 10.13%, and natural methods by 9.69%. Furthermore, the relationship between occupation status and awareness of male contraception among the participants. A significant was unskilled workers 41.66% were more likely to be aware of male contraception, while housewives 51.19% were less aware. The P value 0.001 suggested a statistically significant association between occupation and awareness indicating that the differences observed were unlikely to be due to chance. As per Shafi S. et al.[13] study the majority of participants (34.1%) were employed as clerks, shop employees, or farmers. The next group of participants (20.8%) was skilled, while the remaining (28.6%) were unskilled.

Our study revealed that in 70.04% of study participants, tubal ligation was seen in participants motivated mostly by healthcare personnel; self-motivation accounted for 8.37% of cases. Vasectomy knowledge was minimal, with just 24.23% of people knowing about it. Knowing this, the primary motivations for choosing a tubectomy over a vasectomy were perceived as diminished job efficiency among partners (10.91%), fear of weakness among partners following the procedure (30.91%), and spouses’ disapproval (58.18%). According to research conducted in Uttar Pradesh by the “State Innovation in Family Planning Services Project Agency” (2014), 14% of survey participants thought that NSV causes weakness and results in a decline in physical strength. The majority of research participants in this investigation were found to have inadequate information on NSV. The respondent’s level of education was shown to be the most significant predictor of their perception of sociocultural obstacles.[14] As per Shafi S. et al.[13] study it was noted that the respondents intended to use NSV going forward. Only 9.1% of respondents were genuinely prepared to embrace NSV, compared to the majority (89.3%) who were not. As a result, 343 (89.3%) out of 384 participants were not prepared to use NSV in the future. In terms of the distribution of barriers, it was found that, out of the 343 study participants, the greatest number (89.2%), or 306, identified sociocultural barriers as the primary reason for NSV’s low acceptance, while the least number (0.6%) thought service delivery barriers were the primary reason. According to research by Dasgupta et al. (2015),[15] 22% of participants said that a person’s “personal beliefs” were a significant contributing reason to their poor use of NSV.

As per Shafi S. et al.[13] study majority of the study participant’s perceived sociocultural barriers as one of the most important causes for low acceptance of NSV. Within the socio-cultural barriers majority (35.9%) perceived that NSV diminishes the ability to perform manual work, while 35% also personally believed that due to the availability of other FP methods, NSV is less needed. Among the study participants, who perceived procedure-related barriers, 12.5% stated the risk of surgery as a cause related to low acceptance of NSV.

Limitation of study

The research was subject to numerous limitations, including memory bias that is inherent in self-reported data, the potential for replies to be influenced by social desirability bias, and the cross-sectional design’s inability to demonstrate causation. Furthermore, the results can only be applied to the indigenous groups in Gujarat’s Eastern tribal belt.

Conclusion

Our study highlighted key factors influencing contraceptive choices among participants predominantly; tubal ligation was preferred due to sociocultural barriers against vasectomy, such as perceived job inefficiency and fear of male sexual performance weakness. Education, socioeconomic status, and occupation significantly impacted awareness of male contraceptive methods. Higher awareness was observed among the educated and those above the poverty line. Age, religion, marital duration, and child spacing had less influence. This finding suggests the need for targeted education to address misconceptions and promote vasectomy as a viable family planning option.

Recommendations

Increase awareness – implement compressive educational programs to address misconceptions about vasectomy, particularly in Tribal and slum populations and promote its benefits.

Expand study area – Conduct similar studies in diverse regions to enhance the generalizability of the study findings.

Longitudinal studies – Perform long-term follow-up studies to better understand the sustained impact of contraceptive choices and intervention.

Improved data collection – Use more robust and diverse data collection methods to reduce self-reporting biases.

Targeted intervention – Develop targeted intervention for different demographic groups, particularly focusing on educational attainment and sociocultural barriers.

Policy advocacy – Advocate for policies that support broader access to male contraceptive methods and address sociocultural barriers particularly tribal and slum populations.

Engage men in family planning – Design and implement programs that actively involve men in family planning discussions and decisions.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.