Exploring Factors in the Decision to Choose Sterilization vs Alternatives in Rural El Salvador

Abstract

Context

To explore the factors that influence rural Salvadoran women to undergo tubal sterilization versus opting for alternative methods of family planning.

Evidence Acquisition

A moderator fluent in English and Spanish conducted eleven 90-minute focus groups consisting of 5-10 women each. Eligible women in the municipality of San Pedro Perulapan, El Salvador, were identified and recruited by local health workers. Participant demographics and information about family planning decisions were collected through detailed notes and tape-recorded sessions. The tapes were transcribed verbatim, and all data were analyzed using grounded theory procedures to identify common themes.

Evidence Synthesis

Eighty women aged 24-45 years who had previously been sterilized participated in the study. Three major themes influenced a woman's decision to undergo sterilization instead of opting for alternative forms of family planning: (1) availability: tubal sterilization is readily available, (2) fears about side effects of other methods: these women associated negative side effects with other forms of family planning, (3) effectiveness: the women in these focus groups thought sterilization was more effective than other forms of family planning.

Conclusions

This study shows that there is a lack of information, and misinformation, about other effective methods of contraception, especially the intrauterine device and oral contraceptives. Reproductive health education projects, especially those providing services in locations similar to rural El Salvador, should focus on providing accurate information about all forms of contraception, including tubal sterilization.

Introduction

El Salvador is a young democracy that continues to struggle for socioeconomic growth and equality. In 2004, 36.1% of El Salvador's 6.8 million citizens lived below poverty level.[1] Such poverty limits healthcare provision in general, and especially restricts access to reproductive health services. To both better meet the reproductive health needs of Salvadoran communities and allocate available resources, it is important to explore factors that influence reproductive health choices among Salvadoran women.

In El Salvador, tubal sterilization is the most widely used method of contraception.[2] Over one third of Salvadoran women aged 15-44 years have undergone the procedure.[3] Approximately 24% of women younger than 29[3] years and 8.5% younger than 24[4] have undergone tubal sterilization compared with 10.3% and 2.2%, respectively, in the United States.[5] Use of alternative forms of contraceptive methods is relatively low: 18.3% hormonal injections, 5.8% oral contraceptive pills, and < 3% intrauterine devices (IUDs).[2]

While tubal sterilization is a good option for some women, there are certain disadvantages to this method, including: (1) customary general anesthesia, (2) lower efficacy in young women, (3) nonreversibility, and (4) potential for regret. The US Collaborative Review of Sterilization (CREST) study demonstrated that the efficacy of tubal sterilization is significantly lower than previously thought. When all methods of tubal sterilization were combined, the 10-year cumulative life-table probability of failure was actually 18.5 per 1000 procedures compared with the 3 per 1000 shown in earlier studies.[6] For younger women, this rate may be even higher.[7] The failure rates for reversible alternatives, such as the levonorgestrel-containing and copper T IUDs, are less than 1%, making them viable alternatives to tubal sterilization.[8]

Several studies have shown that age is a major risk factor associated with sterilization regret.[9–11] In a systematic review of these studies, Curtis and colleagues[9] showed that risk for regret decreased with age, and that women who underwent sterilization before age 30 were approximately twice as likely to express regret as women who had the procedure after 30. A study in Brazil showed that the relative risk for requesting reversal for women sterilized before age 25 was 18 times that of women who were sterilized after age 29. Given the potential for regret, women, especially those under 30, may be better served by methods of reversible contraception.

There is minimal information in the literature regarding attitudes toward sterilization in Latin America. A population-based study was conducted in 1988 in Puerto Rico that showed that 21% of women were somewhat dissatisfied with their decision and 11% were definitely dissatisfied. Factors that influenced regret included young age, absence of daughters, someone else making the decision for them, medically indicated procedure, tubal failure, and presence of a new partner.[12] Another study was conducted using the results of a demographic and health survey in the Dominican Republic.[13] This study showed that the number of young women requesting the procedure is increasing. The rate of tubal sterilization in women younger than 30 was 40%, and these women were significantly more likely to regret their decision.[13]

Almost no data exist about attitudes regarding sterilization procedures in El Salvador. A study in 1990 by Landry and colleagues[14] conducted in multiple countries addressed the question of consent to undergo sterilization. This investigation was based on a 1986 study by Bertrand and coworkers,[15] which found that women did not always consent to the procedure. The Landry study, in contrast, found that most women voluntarily agreed to be sterilized. The goal of this project was to better understand why women in El Salvador choose to undergo tubal sterilization versus opting for reversible alternatives.

Materials and Methods

We explored factors influencing women to undergo tubal sterilization in addition to their knowledge about the procedure in 11 focus groups in January 2005. The study was approved by the Institutional Review Board of The University of Southern California as well as a committee representing the community in El Salvador. Women verbally consented to participate in the study.

All focus groups were conducted during a week-long health fair in the rural community of San Pedro Perulapan, a municipality in the Cuscatlan department of El Salvador (Figure 1). Local healthcare workers advertised the health fair. Women between the ages of 20 and 45 years with a history of tubal sterilization were offered to participate in the study. Study participation did not affect the ability to receive healthcare. Women were sequentially recruited to fill 11 focus groups of 5 to 10 individuals each (Figure 2).

Figure 1.

San Pedro Perulapan is in the Department of Cuscatlan in El Salvador. Image courtesy of Miriam Cremer, MD, MPH.

Figure 2.

Women in San Pedro Perulapan wait to participate in focus groups and to be screened for cervical cancer. Image courtesy of Miriam Cremer, MD, MPH.

A moderator fluent in Spanish and English who had experience in conducting focus groups facilitated eleven 90-minute focus groups. All sessions were held behind closed doors to ensure privacy and confidentiality. The demographic information of each participant was obtained (current age, age at tubal sterilization, number of children, education level, and occupation). Validated discussion questions were used with permission from EngenderHealth (New York, NY; Attitudes towards tubal ligation among users, potential users, and husbands in Jordan. October 2003 site email). The questions, listed in the Table, were used to guide the discussions.

Table.

Instrument Used to Guide Focus Group Discussions

1. KNOWLEDGE AND CHOICE OF TUBAL LIGATION (30 minutes)
A.	When and how did you first hear about tubal ligation? What were you told about it? What was your initial impression of the method?
B.	What family planning methods (if any) had you used prior to tubal ligation? What were your experiences with these methods? What did you like about these methods? What did you not like about these methods? Why did you stop using these methods?
C.	How many children did you have when you first decided to have a tubal ligation? How long did you wait before making the decision and having the operation? Did you have any children between the time you decided and when you had the procedure? What do you think is an ideal number of children and did you have more or less than that?
D.	At the time you decided to have tubal ligation, how certain were you that you wanted to have no more children? How did you come to this decision?
E.	Who was involved in the decision to have a tubal ligation? Was it your idea or someone else's? If someone else, then who?
F.	What did your husband think of the idea? Did he want to have any more children?
G.	Did you discuss the decision to get a tubal ligation with anyone else? With family or friends? What were their reactions?
H.	What were you told are the advantages of tubal ligation? Why did the provider say women choose this method?
I.	What were you told are the disadvantages of tubal ligation? What did the provider say that women like least about this method?
J.	What were you told about the procedure itself? What were you told about the risks of this procedure? What did you think about these risks?
K.	What were you told to expect after the procedure? What questions, if any, did you ask of the provider? Did the provider answer your questions to your satisfaction? How did he/she treat you?
2. EXPERIENCES WITH TUBAL LIGATION (40 minutes)
L.	Tell us about your experiences finding a provider to perform the procedure. Did you have any trouble scheduling the procedure?
M.	How did you feel about the care you received during the procedure? How about after? How long were you in the recovery room before going home?
N.	What problems or complications (if any) were there after the procedure? What did you do about these problems?
O.	What health changes (if any) did you feel after tubal ligation? Have there been any changes to your menstrual cycle? What positive changes have you felt? What negative changes have you felt?
P.	What impact (if any) had tubal ligation had on your marriage? Does your husband treat you differently? Do you treat him differently? Did your husband decide he wanted more children after you got the tubal ligation?
Q.	What impact (if any) has your choice of tubal ligation had on your economic status?
R.	What impact (if any) has your choice of tubal ligation had on your education or job status? Did getting a tubal ligation allow them to pursue or continue education or get a better job?
S.	Who have you told about having a tubal ligation? What were their reactions?
T.	How satisfied are you with your decision to use tubal ligation? If not very satisfied, why?
U.	If you had to do it all over again, would you make the same decision again? What regrets (if any) have you had about the decision to use tubal ligation? Would you like to have more children?
V.	Would you recommend tubal ligation to a friend or relative? Why?
3. LAST QUESTIONS (10 minutes)
W.	What, in your opinion, should couples know about tubal ligation? What is the best way to inform them?
X.	What (if anything) had you heard about vasectomy? Did you ever discuss this option with your husband? If yes, why did you choose tubal ligation instead of vasectomy?
Y.	What suggestions do you have for improving tubal ligation services?

Each session was tape-recorded, and additional information was collected through detailed notes. Separate transcriptions in Spanish were created for each of the 11 focus groups. All transcriptions were coded manually using grounded theory coding procedures.[16] Primary endpoints to each question were identified, and key words were coded to represent common thematic categories. Subthemes were also collected and summarized.

Results

A total of 80 women participated in the study. The median age of participants was 37 years (range, 24-45). Median age at sterilization was 26 years (range, 20-45), and median number of offspring was 3 (range, 1-12). Most women reported that they worked in the home and had a median of 4 years of education (range, 0-9).

Three major themes influenced a woman's decision to undergo sterilization: (1) availability; (2) fears about side effects of oral contraceptives, hormonal injections and IUDs; and (3) fears about efficacy of oral contraceptives, hormonal injections and IUDs.

Women reported that a greater infrastructure exists to provide sterilization than other methods of contraception. For example, many commented that sterilization is available through prenatal services in their community clinics and hospitals. Some women were offered the procedure during labor. Others were offered sterilization while still recuperating from delivery. Many women who requested sterilization had the procedure the same day that their request was made. Several women also mentioned that a sterilization campaign exists in their community, enabling them to easily access providers as well as information about the procedure. One woman mentioned that a health promoter had come to her house and offered transportation to a clinic where sterilization was available.

Most of the experiences related about hormonal contraception were accompanied by descriptions of nuisance side effects about which the women were not properly counseled before and during use. Several women mentioned headaches associated with reversible contraception. Other common complaints linked to reversible methods were vomiting, heavy bleeding, and weight gain. Women reported that these types of negative side effects led them to abandon their method of reversible contraception for an alternative – often sterilization.

The IUD, which is long-acting and reversible, was seldom used among women in the focus groups because they perceived it as being harmful. Several women believed that the IUD can cause cancer: “I would rather die [than use an IUD]…those devices are said to cause cancer.” Others reported that the IUD “is very uncomfortable” and “feels awful.” Still others feared that the IUD could become “stuck” or lodged in the cervix, uterus, or penis. Several women expressed fear that failure of an IUD would result in the fetus being born with the IUD lodged in its head.

Many women reported that experiences with, or fears about, failure of reversible methods led them to undergo surgical sterilization. For example, many women expressed fears that the IUD is not an effective method of birth control. One woman commented that “I heard that many people have become pregnant and that they had [an IUD].” Another reported that “one always comes out pregnant [when using an IUD].” As another example, one woman expressed a preference for condoms because they prevent sexually transmitted disease. However, she chose sterilization after she became pregnant using a condom. Another woman said that she liked hormonal injections because they only needed to be administered every 3 months, but that she became pregnant and opted for sterilization following her pregnancy.

In addition to the 3 major themes that surfaced as explanations for why women undergo sterilization instead of an alternate method of contraception, 3 subthemes emerged. Women in 2 of the 11 groups mentioned that they were sterilized without consent. The women's husbands granted the physician permission to sterilize while their wives were giving birth. One woman reported, “They asked [my husband] if they could sterilize me. Then, he gave the permission, and I was unaware. I was already sterilized and I didn't even know it.” This type of experience was not mentioned in the other 9 groups, but it was not asked about directly.

Many women said that they were sterilized because the doctor presented the procedure as the only method of pregnancy prevention. In 8 of the 11 focus groups, 1 or more women stated that they had not used any family planning methods until sterilization. All of these women were introduced to the procedure as if it were the only available option for birth control.

Many women mentioned that poverty, in conjunction with previous pregnancies, led them to undergo sterilization. They did not say, however, that this combination motivated them to choose sterilization over alternative forms of pregnancy prevention, although this question was never directly asked. Rather, they mentioned poverty when asked generally about why they had decided to be sterilized.

Discussion

The intention of this study was to begin an exploration into the factors influencing reproductive healthcare decisions in rural El Salvador. Through focus groups, we were able to gather a significant amount of in-depth information on reproductive health from 80 women. In general, decisions to choose sterilization over alternative methods of contraception were marked by lack of accurate information regarding options. Women were also inclined to choose sterilization because of its availability and accessibility. To our knowledge, information about this issue has never been investigated and reported for rural communities in Latin America.

This study was conducted in one small community, and our findings may not be representative of Salvadoran women in general. While we tried to obtain a cross-section of women with tubal sterilization in the community, there may have been bias on the part of the local healthcare workers who recruited the participants. In addition, not all of the women in each focus group participated equally. Some individuals were more vocal and outgoing than others, which is a recognized problem among focus groups.[17] The sensitivity of the subject or conflicting opinions expressed within the focus groups may have affected the level of participation.

Our results show that tubal sterilization is widely available to women in rural El Salvador. While this accessibility benefits women by providing them with at least one option, it introduces problems as well. Women on Medicaid in the United States are required to wait 30 days after requesting tubal sterilization to undergo the procedure.[18] This measure is ultimately designed to protect the woman from regret. Are women in rural El Salvador being coerced into sterilization by its relative availability, or are they making an informed decision to control their fertility? Our study suggests that the answer lies somewhere between the two.

The study also showed that fears of side effects related to oral contraceptives, hormonal injections, and IUDs prevent women from choosing these alternatives. Some of these fears are founded. Hormonal injections can lead to weight gain, and both IUDs and injections may cause changes in menstrual flow. These side effects, however, do not occur in all patients and can be minimized by providing accurate counseling before the patient begins the method. Katz and colleagues[19] found that provider counseling played a key role in the development of women's attitudes toward different contraceptives.

Other myths that surfaced during this study are more concerning because they are not based in fact – for example, that the IUDs and oral contraceptives cause cancer; that IUDs can become lodged in the cervix or penis; and that if an IUD fails to prevent pregnancy, the baby will be affected. Additional myths have evolved about method efficacy. While sterilization is extremely effective, the IUD is equally if not more effective and has the benefit of reversibility. A recent article in Contraception concluded that young women especially should be counseled to consider an IUD rather than sterilization.[20] Accurate, accessible, contraception education, in the form of local health campaigns and provider counseling, is critical to debunking myths and expanding options for women.

Poverty is a factor that invariably affects women's healthcare choices. Study participants mentioned poverty, paired with previous pregnancies, as an influence leading them to undergo sterilization. Since the relative availability of alternative forms of pregnancy prevention is so low, and misinformation about these methods is so prevalent, it is difficult to know whether women in rural El Salvador would choose an IUD, hormonal injections, or oral contraceptives over sterilization if all were equally available and relevant myths had been clarified and corrected. It is safe to assume, however, that women would be unable to choose from these options if their cost greatly exceeded that of sterilization.

Based on this study, it is evident that improvements in the quantity and quality of reproductive health resources are needed in rural El Salvador, including educational programs, provider training, and provider counseling. It is also evident that an increase in the availability of affordable, reversible forms of contraception is needed in rural El Salvador. These resources are crucial in enabling women to make informed decisions about their health.