Informed choice and female sterilization in South Asia and Latin America Apoorva Jadhav, University of Michigan Emily Vala-Haynes, Western Oregon University Corresponding author: Apoorva Jadhav Population Studies Centre 426 Thompson St, Rm 3471 Ann Arbor, MI 48104 USA Page 1 of 25
SUMMARY Globally, female sterilization is one of the most popular contraceptive methods despite concerns about quality of care for women who report being sterilized. We quantify informed choice among sterilized women using Demographic and Health Survey (DHS) data from 2000 to 2012 from countries in South Asia and Latin America. We use three responses to measure informed choice and knowledge about whether women were informed by a health worker or provider that: sterilization is permanent, potential side effects, other methods of contraception. We create an ascending composite Method Information Index with scores ranging from 0 (women received no information) to 3 (women received information across all three indicators). Using ordinal logistic regression analysis we find that women younger than 25 and older than 35 at the time of sterilization, and those at high parities had lower odds of a high score on the index, while the opposite is true for women sterilized in the private sector in Latin America. Educated women in India had higher odds of a high score on the index, while the same is true for educated and wealthy women in Colombia. Our findings indicate that not enough health care providers spend time informing women about different aspects of sterilization, and that there are specific groups of women that are most affected. There is an urgent need to improve quality of care within health systems providing sterilization for this very important and effective type of contraception. Page 2 of 25
INTRODUCTION Female sterilization is one of the most common methods of contraception in the developing world, owing to its long-term effectiveness and low cost (Hosseni, Torabi, & Bagi, 2014; Joshi, Khadilkar, & Patel, 2015). According to United Nations estimates, about 1 out of 5 women worldwide are sterilized, with a large portion in Asia – 28% of women in China and close to 36% in India – and Latin America – 47.4% in the Dominican Republic, 35% in Colombia, and 24% in Nicaragua (United Nations, 2013). It is thus a highly important option for contraception, provided that the decision to undergo sterilization is voluntary and informed. Yet, doubts remain regarding the extent to which this method is promoted through coercion and lack of informed choice regarding the procedure (Hardee et al., 2014; WHO, 2014). There have been allegations and proven cases of coercion associated with female sterilization over the years in countries around the world- Namibia (Mallet & Kalambi, 2008), South Africa (Essack & Strode, 2012), United States (Salvo, Powers, & Cooney, 1992; Stern, 2005), Peru (Miranda & Yamin, 2004), and India (Koenig, Foo, & Joshi, 2000; Singh, Ogollah, Ram, & Pallikadavath, 2012). Yet, it is among the most used methods among women in the developing world, so it is important to ensure that women are making an informed choice to use this method. This paper assesses the recent evidence from countries in the developing world that women are making informed choices about sterilization. In a climate of discussion around the extremes of forced and coerced female sterilization, there remains a lack of empirical research on the topic of informed choice—reports tend to be limited to specific human rights violations, health policy, or analyses of limited samples. In this study, we bridge that gap and provide a comprehensive picture of sterilization using the best and most current quantitative data to examine informed choice and female sterilization in 7 countries in Latin America and South Asia. Our research is motivated by underlying mechanisms of coercion (Hardee et al., 2014; WHO, 2014) and highlights specific groups of women who are not given sufficient information to make informed decisions about this permanent method. Coerced sterilization, informed choice and contraceptive counselling Coercion in the context of sterilization is defined as “actions or factors that compromise individual autonomy, agency or liberty in relation to contraceptive use or reproductive decision making through force, violence, intimidation or manipulation” (Hardee et al., 2014). It has been especially problematic within family planning programs in many countries for decades, in some cases where population control strategies are synonymous with female sterilization (Basu, 1984; Singh et al., 2012). Moreover, incentive payments in India, Bangladesh, Nepal and the Philippines have raised concerns that women in those Page 3 of 25
countries are unduly pressured into being sterilized (Hardee et al., 2014). Throughout the world, women who are poor, indigenous, and/or rural residents have historically been more vulnerable to coercive sterilization (Hardee et al., 2014; Miranda & Yamin, 2004; Pieper Mooney, 2010). Questions thus remain about how to reconcile promotion of female sterilization as a family planning method with this problematic history. As programs move forward, an important place to begin is the interaction between a woman and her health care provider and, specifically, whether that provider ensures the woman receives comprehensive information to make an informed choice about whether or not to be sterilized. A woman’s ability to freely and responsibly choose a contraceptive method depends upon several components, primarily being the information supplied to her by a medical provider. In Brazil, female sterilization is a popular method particularly for women who give birth in a private hospital and who have health insurance (Amaral & Potter, 2015), indicating the importance of discussion about family planning options with a health provider. In Ethiopia, home visits by family planning workers are associated with an increase in long acting reversible and permanent contraceptives, including female sterilization (Teferra & Wondifraw, 2015). While the importance of proper information about family planning methods and choice is an essential factor in deciding to choose sterilization, it is unclear how many women are actually adequately counselled. A review in India found that women were not informed about other methods and spacing options; limited information was passed on from health workers to women about side effects and how to deal with these side effects, and quality of care was poor during and following the operation (Koenig et al., 2000). A case control study in Bangladesh found that sites in which female field workers paid regular visits and emphasized a variety of contraceptive methods, and where awareness of clinics to treat complications arising from sterilization was acute, were more successful in increasing contraceptive use compared to control areas where there were no field workers (Koenig, Rob, Khan, Chakraborty, & Fauveau, 1992). According to this study, these factors even outweighed the importance of socioeconomic status and education on increases in family planning, which is of critical importance, given policy focus on education in increasing contraceptive use. Studies ranging from Pakistan (Saeed, Fakhar, Rahim, & Tabassum, 2008), South Africa (Credé et al., 2012) to the United States (Lee, Parisi, Akers, Borrerro, & Schwarz, 2011) have shown that there is an increase in contraceptive uptake among women who were provided counselling and education about modern family planning methods, pointing to the importance of counselling and speaking to a health provider in informed choice. National family planning programs and the rise of female sterilization Page 4 of 25
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