A Discussion of Postpartum Sterilization*

A DISCUSSION OF POSTPARTUM STERILIZATION*

T. l\t

BouLWARE,

l\f.D., F.A.C.S., C. D.

HowE,

M.D.,

AND

S. T.

SIMPSON,

M.D.,

BIRMINGHAM, ALA.

(From the Department of Obstetrics, Carraway Methodist Hospital)

is rather general professional agreement that a few medi<:al comT HERE plications render subsequent pregnancy so hazardous as to warrant surgical sterilization. There exists, however, considerable disagreement regarding many borderline medical and socioeconomic indications for such operations. Some hospitals prohibit these operations and others are probably too liberal. Inasmuch as surgical sterilizations are becoming of increasing concern to many hospitals, an evaluation of this subject seems to be timely. In an attempt to secure facts and representative opinions concerning indications, controls, and incidence of postpartum sterilizations, we sent questionnaires to 100 reputable hospitals conducting approved residency training programs. For obvious reasons we excluded certain hospitals whose religious beliefs do not permit sterilization. Our discussion thus concerns our own ideas and those expressed by 100 approved hospitals. A summary of our questionnaire findings appears in Table I, only unequivocal replies being tabulated. Medical Indications

The 84 affirmative replies to Question 1 of the survey indicate professional opinion relative to the validity of definite medical indications for postpartum sterilization. 1 Such indications may include the following: (a) selected cases of organic heart disease; (b) selected cases of cardiovascular-renal disease; (c) some cases of severe chronic pyelonephritis; (d) multiparity with severe chronic hypertensive vascular disease. 2 Less definite medical indications should include : (a) severe diabetes in selected multigravidas; (b) multiple cesarean sections (although there is some diversity of professional opinion, Question 2 of the survey indicates that most obstetricians favor sterilization after a third cesarean section); (c) gross multiparity (para viii or more). Socioeconomic Indications

Replies to Question 3 indicate opinions equally divided about such indications. Frank discussion of this matter is usually avoided at hospital staff meetings and little appears in the literature about it. If the attending obstetrician has definite opinions on such indications, it should be his privilege to express them. *Presented at a meeting of the Blnningham Obstetrical and Gynecological Society, Jan.

14, 1954.

.

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DISCUSSION OF POSTPARTUM STERILIZATION

1125

One may ask, however, whether a request for postpartum sterilization by a couple of rather low economic status with four living children should be dismissed in summary fashion just hecause the mother still enjoys reasonably good health at the moment. What may be the future physical, educational, and social repercussions in this family if unlimited progeny overtax the family budget? Do we, as physicians, have the right to make such decisions even though we are so requested? These are pertinent questions worthy of careful evaluation. Tabulations on Question 4 indicate overwhelming disapproval of postpartum sterilization of any patient under 30 years of age without strict medical justification. Flagrant disregard of this sane policy is not a rarity. At the risk of incurring professional criticism we present the following formulation of a general policy for your consideration: A. Postpartum sterilization may be considered, if requested, provided the mother is at least 30 years of age with 4 living children. B. Postpartum sterilization may be justified in selected cases of mental inadequacy. 3 • 4 Each year our local health agencies are confronted with the problem of mental defectives who periodjcally reproduce offspring of doubtful paternity. Should such persons be permitted to reproduce social and economic liabilities indefinitely'? Some of us would answer in the negative. TABLE

I.

QUESTIONNAIRE FINDINGS

1. Does your hospital permit female sterilization by tubal ligation and/or resection for definite medical indicationsf NO ( 0) YES (84) 2. In genel'al, would you sterilize a patient at time of: (a) a second cesarean section (b) a third cesarean section (c) a fourth cesarean section 3. Does your hospital permit postpartum sterilization for socioeconomic NO (36) YES (38)

( 7) (53) (10) indications~

4. In general, would your hospital permit sterilization, for nonmedical reasons, of any patient under 30 years of age' NO (73) YES ( 8) 5. Do you feel that postpartum sterilization carries any risk to the physical, mental, or emotional future welfare of such patientsJ NO (45) YES (34) 6. Does your hospital exercise any staff control over postpartum sterilizations' NO (13) YES (70) 7. Staff control is exercised by: (a) special staff committee (b) ' 1 tissue committee'' (c) any three staff members (d) judgment of the surgeon

(29) ( 2)

(39) (13)

8, What is the incidence of postpartum sterilization in your hospital f

1.7% of all viable births (average) 9. Is it your feeling that too many postpartum sterilizations are now being done. in your hospitaH NO (59) YES (19)

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BOULWARE, HOWE, AND SIMPSON

Am.

J. Obst. & Gynec.

October, 1954

Dangers to Future Health Does sterilization by tubal ligation actually jeopardize the future physical or menta] health of such patients¥ In spite of some professional expressions to the contrary, we cannot visualize any possible physical ill effects from mere tubal resection. It is quite conceivable however, that simple knowledge of induced sterility could have some psychic effects in later years. The age of the patient at the time of the operation could be a major factor in any such effects. Replies to Question 5 show that 43 per cent of hospitals interrogated had some fear of physical or psychic ill effects. Such expressions of opinion must have some basis in fact or reason. Although none of our own patients have yet requested that their tubes be untied, a full and understandable explanation of the operation should be careful1y given the patient and her husband before surgery. 5 Hospital Controls There are two occasions for surgical sterilization in the female, (1) postpartum sterilization within 24 hours after normal delivery or at the time of cesarean section, and (2) surgical sterilization unassociated with recent pregnancy but incidental to other surgery. The obstetrician who carelessly approves every request for postpartum sterilization is no more guilty of incorrect practice than is the surgeon who seeks an indication :for laparotomy when the sterilization element is the real reason :for surgery. As an example of laxity we cite the case of a recent patient whose request for postpartum sterilization we refused about a month prior to her estimated date of confinement. Following our refusal, a telephone call by this patient to a local colleague obtained his immediate promise to perform the desired operation. With such inconsistencies of professional opinion and hospital supervision, it appears logical for each hospital to activate some method of control over all postpartum sterilizations. 6 The various inspection and accreditation groups are becoming increasingly aware of this problem. Question 6 indicates that most approved hospitals already exercise some staff control over postpartum sterilizations; Question 7 suggests that the two most common methods of control are by prior written approval of any three staff members or by a special staff committee. It is our own belief that a carefully selected and representative staff committee can best effect control over postpartum sterilizations and therapeutic abortions with a minimum of friction or controversy. We also suggest that a psychiatrist and internist be included in the membership of this committee. A properly functioning "tissue committee" may be relied upon to make careful inquiry into all sterilizations other than postpartum ones. Incidence

There have been few published data relative to actual incidence of this operation. Replies to Question 8 enabled us to figure incidence in terms of percentage of viable births that were followed by postpartum sterilization.

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Hospitals reporting these data had incidence rates which varied from 0 to 7.2 per cent; the average incidence was 1.7 per cent. These representative figures :suggest that any incidence above 3.0 per cent could well merit careful analysis by the hospital concerned. We do not imply that this figure should always be the yardstick of comparison because variable local factors may well increase the incidence in some hospitals. Some reasonable incidence figure will doubtless be eventually agreed upon by the proper accreditation group. Question 9 indicates that 24 per cent of hospitals queried felt they permit too many postpartum sterilizations.

Legal Considerations The actual legal aspects of surgical sterilizatkm are not the concern of this study. States have varied laws relating to such operations7• 8• 9 and some states require a prior court order. Strictly speaking, laws of most states afford little protection for a surgeon who performs surgical sterilization. Reliable legal advice in Alabama suggests that any jury here would be most unlikely to censure such a surgeon if there was a clear medical reason for the sterilization. The legality of a sterilization for nonmedical indications is most questivnable and 100 per cent protection is not afforded by any operative permit. Such facts emphasize the importance of adequate hospital records. Data From Carraway Methodist Hospital Data from Carraway Hospital is probably fairly representative for a 250 bed general hospital. Five of our patients were referred from County Health Department antenatal clinics because sterilization could not be effected at the local "city hospital." Our Obstetric Staff consider the modified Pomeroy operation to be simple, bloodless, and effective. During the period Oct. 1, 1951, to Oct. 1, 1952, there were 1,733 viable births and 43 postpartum sterilizations (Tables II and III). This gave an incidence of 2.4 per cent which is a little too high. TABLE

II.

MEDICAL INDICATIONS AT CARRAWAY METHODIST HOSPITAL

cesarean hypertensive vascular disease Cardiovascular renal disease Organic heart disease Erythroblastosis fetalis Extensive vaginal plastic Esophageal stricture Uterine rupture, repaired Total TABl~E

III.

9 5 3 1 1 1 1

28

SOCIOECONOMIC INDICATIONS AT CARRAWAY METHODIST HOSPITAL

2

iv v

vi

1 3 1 2 3 3

112k

Summary 1. The valid indications for postpartum stm·iliza t it~n tnel'it fnmk P\ a hwtion, discussion, and clarification. 2. Opinions are about equally dhide
References 1. Committee on :Maternal and Child Health (Medical Association of State of Alabama)

2. 3. 4. 5. 6. 7. 8. 9. 10.

and the Alabama Department of Public Health: Maternal Mortality Survey in Alabama, 1952. Donnelly, J. F., and Lock, F'. R.: North Carolina 1\f. J. 14: 1, 195::1. Gamble, C. J.: Am. J. Ment. Deficiency 56: 192, 1951. Gamble, C. J.: Am .•J. Ment. Deficiency 57: 123, 1953. Butler, F. 0., and Gamble, C. J.: AM. ,J. OBST. & GYNEG. 62: 420, 1951. Pearse, H. A., and Ott, H. A.: AM. J. OBST. & GY~~c. 60: 285-,1950. Jardine, C. W.: Rocky Mountain M. J. 48: 183, 1951. Donnelly, R. C.: Virginia M. Monthly 78: 24, 1951. Harshman, L. P.: Am. J . .Ment. Deficiency 55: 377, 1951. Personal comments and suggestions on the questionnaire Survey: Willard M. Allen, L. H. Biskind, W. E. Brown, E. H. Countiss, Nicholson J, Eastman, 'f. 0. Gamble, .T. K. Hoerner, .T. J. Kocyan, A. C. Posner, H. Picot, .T. H. Randall, H. C. Taylor, C. B. Upshaw, H. H. Ware, Jr., F. E. \Vhitacre, .J. R. Wilson, and E. G. Winkler. 1529 NORTH 25TH STREE'r