Women's health is a topic which is receiving much interest worldwide. Reproductive health and contraception makes up part of women's health. Availability of and access to contraception is a global matter of importance.
The Millennium Development Goals (MDG’s) set in 2000 included universal access to sexual and reproductive health, highlighting its importance . Progress made towards reaching the MDG was assessed in 2015. Results showed that contraception use among women in Sub-Saharan Africa in the age group 15–49 years more than doubled from 1990, yet an unmet need for contraception remained in 24% of these women .
In response to what was deemed a lack of sufficient progress towards the MDG, the Sustainable Development Goals were set in place in 2015 – which included universal access to sexual and reproductive health .
The South African government made a pledge at the Family Planning London Summit in 2012 to prioritize the need to strengthen family planning services. The aim would be that the full range of family planning services would be made available to patients at public health facilities .
The contraceptive use of South African women specifically was last studied and published in 2003 in the South Africa Demographic and Health Survey. The most used form of contraceptive was the injectables − 53% of all women using contraception at the time were using injectables . At the time only 7.3% of all South African women aged 15–49 years had tubal ligation or sterilization as their contraceptive method.
Data derived from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey showed that 8.1% of South African women of child bearing age were sterilized .
Contraceptive Prevalence Rate (CPR) is defined as the percentage of women of childbearing age using any form of contraception at a given point in time . The CPR in South Africa in 2010 was 63.7%. In comparison the CPR for the whole of the African continent was much lower, at 30.9%. South African CPR, in turn, was much lower compared to upper-middle-income countries like Brazil (79.5%) or Russia (78.6%) .
The unmet need for family planning is defined as the proportion of women who are fecund who want to terminate or postpone child bearing, but who are not using a contraceptive method . Estimated data from low-middle-income countries, which include South Africa, showed that in 2019, out of 923 million women of reproductive age in these countries who want to avoid having a pregnancy, 218 million have an unmet need for modern contraception—that is, they want to avoid a pregnancy but are not using a modern method. The proportion of women with unmet need for contraception in 2012 was 53% in Africa and 17% in Southern Africa .
An unmet need for contraception leads to unintended pregnancies. The South African National HIV Prevalence, Incidence and Behaviour Survey published in 2012 showed that around 50% of pregnancies at the time were unplanned. The rate of unintended pregnancies in women above the age of 35 years was 44.9% . Unintended pregnancies have a negative effect on the health, social and economic systems of countries .
Adequate family planning, like sterilization can directly reduce the maternal mortality rate. Preventing unplanned pregnancies reduces the risk of early pregnancy complications and unsafe abortions . Thirteen percent of the annual global maternal mortality results from complications of unsafe abortions . Studies from Bangladesh show that maternal deaths can be reduced by 26% if grandmultiparous women of advanced maternal age were sterilized .
In order to decrease maternal mortality and reduce unintended pregnancies, barriers to the uptake of sterilization should be addressed. Ongoing counselling and education prevent misinformation, misconceptions and fear of side-effects as a cause for poor uptake of family planning . Sterilization includes bilateral tubal ligation and vasectomy. It is an option for couples who have completed their family and want permanent contraception.
Current barriers to these forms of contraception may include accessing services. Patients should have adequate access to tubal ligation services. This includes adequate information on where to access these services and referral to relevant facilities . Training more health care providers and having more health care facilities provide sterilization services will increase the uptake thereof .
The Cairo Declaration on population development issued in 1994 states that all barriers preventing access to family planning services should be addressed and removed while recognising international human rights . The 1995 Beijing Declaration and Platform for Action aim to promote gender equality and women’s rights. The human rights of women include their freedom to decide responsibly on matters relating to their sexuality and reproductive health, free from discrimination, violence and coercion . Patients should not be coerced into signing consent for a sterilisation. India and other countries like South Africa, Namibia and Chile have been abusing forced sterilisation as form of population control and prevention of HIV transmission . Informed consent should be obtained – the patient must be given accurate, adequate and understandable information. The person taking consent should be open to questions and further explanation of the procedure. The patient should feel free to make a voluntary choice which includes refusal of treatment .
Some women receiving antenatal care in Metro West choose bilateral tubal ligation as form of contraception during their pregnancy. Not all of these women receive their tubal ligation. Different levels of health care facilities offer different methods of immediate postpartum contraception. Primary health care facilities like Midwife Obstetric Units do not have the staff or infrastructure to offer immediate postpartum tubal ligation services. Patients requesting bilateral tubal ligation who deliver at primary health care facilities should be referred to secondary level centres for their interval sterilization. Immediate postpartum tubal ligation can be performed at secondary level facilities either at the time of caesarean delivery or as postpartum procedure prior to discharge. If the sterilization does not occur immediately, these women are discharged on an alternative form of contraceptive and ideally an interval bilateral tubal ligation date is given.
In the Metro West area of Cape Town, there is currently no data available on:
how many women receive the requested bilateral tubal ligation;
the number of women who have recurrent pregnancies if the bilateral tubal ligation was not done and;
the alternative forms of contraception women received if bilateral tubal ligation was not performed.
The aim of this study is to assess the access to tubal ligation services in the Western Sub-District of the Metro West in women who request permanent contraception following delivery. The Metro West is a large urban area around Cape Town with a population of 4,801,000. The annual delivery data from Metro West reports 3500 deliveries at GSH, 6400 at NSH, 1800 at WFH and 1300 at VGMOU.
The objectives included:
1. assessing the demographics of the population requesting bilateral tubal ligation as form of contraception;
2. determining the number of women requesting bilateral tubal ligation who receive the procedure intrapartum, immediately postpartum or as an interval procedure;
3. determining the reproductive outcomes if bilateral tubal ligation was not performed, including early pregnancy complication or termination of pregnancy;
4. and investigating alternative forms of contraception provided.