VOLUNTARY STERILISATION

531 Between June, 1967, and October, 1968, we interviewed couples. Most of them lived in a poor section of the community, which is served by this hospital. In 40 % of the couples, one or both partners seemed to us to have less96

Special Articles VOLUNTARY STERILISATION W. J. FRASER

JOHN M. BEAZLEY* Northern General

In

Sum ary

a

Hospital, Sheffield

clinic established

to

interview

patients requesting sterilisation, 96 couples were interviewed (76 on two occasions). 76 couples requested sterilisation for familial reasons or convenience. 39 requests were received from couples who were young, or who had only a few children. When sterilisation was advised, tubal occlusion was thought preferable to vasectomy in most patients. Despite certain advantages, it seems that vas ligation as a method of birth control is unacceptable to many men

than-average intelligence. RESULTS

Contraceptive Practice

Only 15 of the serious attempt to remainder,

none

couples interviewed had made any use effective contraception. Of the had sought contraceptive advice

TABLE I-CONTRACEPTIVE PRACTICE

at present. INTRODUCTION

UNTIL recently, any woman seeking sterilisation at the university unit of this hospital made her request at the gynaecological outpatients department, or, more commonly, while attending the antenatal clinic. When sterilisation seemed advisable her name was added to the surgical waiting-list. Commonly, tubal occlusion was done during the early puerperium. Before surgery, the husband was given a brief explanation of the proposed operation, and obliged to sign a form consenting to the procedure. Otherwise, little attention was paid to the husband. In June, 1967, consideration of the increasing number of requests for sterilisation, the increasing use of vasectomy in other centres, and the ignorance of many patients about family planning, led us to conclude that we should interview more husbands of women requesting sterilisation. We set up a special clinic for this purpose.

TABLE

II-REQUESTS

FOR STERILISATION

previously. A request for sterilisation was the help first sought by more than half the group (table I). Requests for Sterilisation Table II shows the primary indications for sterilisation grouped under the four headings proposed by the Simon Population Trusty Of 3 requests for eugenic reasons, 1 of the couples had had five children: three grossly abnormal, one

METHOD

requesting sterilisation were interviewed, together with their spouse. Each couple was seen All

men or women

twice. At the first interview patients were invited to state what help they wanted. They were instructed briefly about contraceptive methods and the operations for vas ligation, and occlusion of the fallopian tubes. At the second interview, the couple were invited to submit a precise request, either for contraception, or for vasectomy or tubal occlusion, and to provide reasons in support of their choice. Each couple was questioned about age, nationality, religion, previous medical, surgical, gynaecological, and obstetric history, income, expenditure, social background, and contraceptive practices. During the ensuing discussion, points raised for their consideration included: the permanence of an operation; the possibility of subsequent remorse, promiscuity, or disaffection arising between the partners; the possible death of one partner or of an existing or unborn child; possible dissatisfaction at the loss of any possible risk of pregnancy; divorce; possible alterations in religious practice. Only after the second interview, when each couple had submitted their formal request, did we consider whether it seemed reasonable, and whether help could be offered for medical indic!’1ti()n*

Present address: Institute of Obstetrics and Gynæcology, Queen Charlotte’s Maternity Hospital, Goldhawk Road, London W.6.

This index is calculated total number of children.

by adding the

age of the wife to the

532

phenotypically normal but abnormal genetically, and one normal. The father had a significant autosomal abnormality. Of the 2 remaining couples, 1 had had five children of whom three died with fibrocystic disease. The other had two living children, both of whom were born with congenital adrenal hyperplasia. 17 patients sterilised for medical indications included 3 couples with severe rhesus incompatibility, and 14 couples where the wife had an incapacitating illness (mitral stenosis, chronic pyelonephritis, respiratory insufficiency, severe epilepsy, or diabetes). Age Incidence 76

and

Parity couples requested sterilisation for familial reasons

for convenience. In this series, the " age plus parity " index was under 35 in 39 requests, and in almost half of these the index was under 31 (see figure). Most young patients with small families were persuaded to use contraception. 5 couples decided in favour of sterilisation despite their youth and small family, but only in 2 instances was sterilisation done.

or

Vasectomy Vas ligation was done on 12 men, the predominant indication being " familial " (10 cases), " eugenic and " convenience " being the indications in the other 2. 4 more husbands requesting vasectomy would have been operated on if the wife had not objected to the proposed surgery. 1 of these women, who had oligomenorrhoea, was so unsure about the efficacy of vasectomy that she claimed even if her husband was sterilised she would think she was pregnant every time menstruation was overdue. The remaining 3 women were so concerned about their husbands’ psychological reactions to vasectomy, that tubal ligation was thought to be preferable for these couples. Amongst the 96 couples requesting sterilisation there were 3 husbands who, within the preceding six months, "

TABLE III-RESULTS OF INTERVIEW

undergone an inguinal hernia repair, at which operation the surgeon had purposely avoided ligating

had

the vas. We find very few Jamaican men are prepared to accept responsibility for birth control, and will rarely countenance the possibility of vasectomy. Results of Interview Table ill summarises the results of interviewing 96 couples. 20 couples did not attend for a second interview: under the pre-vasectomy regimen J. M. B. would have advised tubal occlusion in 15 cases and contraception in 5. DISCUSSION

To

assess

appropriate

need for sterilisation and the most operative method, and to avoid undesirable the

true

postoperative sequelae, couples requesting sterilisation should be interviewed together. We believe that unwillingness of either the husband or wife to attend for interview may be regarded, usually, as a contraindication to sterilisation. One advantage of a two-interview system is that couples can consider all the facts before coming to a final decision. In some difficult cases we found it helpful to defer a final decision until the youngest child was one year old. The couple were assisted with suitable contraception during the interim, and their case was reviewed at three-monthly intervals. It is debatable whether a two-interview system always results in the best management. Among the 20 couples who did not return for their second interview, 15 women probably would have undergone tubal occlusion had they not been required to attend with their husbands or on two occasions. It is often difficult to distinguish precisely between familial and therapeutic indications for sterilisation, especially when anxiety can adversely affect the mental or physical health of the husband and wife. Neither vas ligation nor tubal occlusion for purely familial reasons is permitted under the National Health Service. It is our experience, however, that most tubal occlusions performed under the N.H.S. are in fact done mainly for familial reasons but justified, if necessary, by invoking rather vague therapeutic indications. Vasectomy for familial reasons rarely seems to be done under the N.H.S., although similar vague therapeutic indications could be invoked in most instances. In practice, we have found this difference in management sometimes influences couples to request tubal occlusion to avoid the significant financial burden of vasectomy done privately. We believe that requests for sterilisation, especially for familial reasons, but also for convenience, will increase in the future. People now marry young and quickly have the desired number of children. Many parents subsequently rely on contraception to limit their family. Some intelligent, young couples would, however, prefer the freedom offered by sterilisation. Optimal family size, or the acceptability of a calculated genetic risk are further very personal matters, and, in our experience, they too may lead to a conflict of opinion which the clinician often finds difficult to resolve impersonally. More than 700 years ago St. Thomas Aquinas suggested families should restrict their children to a number they can nourish, protect, and educate until adulthood. We consider this to be good advice still. Although vasectomy is more simple, safer, cheaper for the State, and quicker than tubal occlusion, it does not confer immediate protectionand it is inappropriate if either the husband or wife believe the operation may change the man in some indefinable way. We would urge general surgeons, however, to inquire about the possibility of vasectomy before they operate on men with families to repair inguinal hernias, and also to discuss tubal occlusion with parous women who are to

undergo laparotomy. In this series, men, even professional men, often failed to distinguish between fertility and virility or impotence.3 Thus, vasectomy, when mentioned at the first interview, was met by many husbands with

533

expressions

of incredulous disbelief,

or

else

ignorance

CHOICE OF PATIENTS

and male prejudice. They rarely objected to tubal occlusion on their wives. Most male patients, however,

We consider the following situations priate for day-hospital management:

discovered in themselves genuine, if ill-defined

(1) Patients needing hospital services, but who are not acutely ill or who do not require twenty-four-hour nursingcare, may often be manageable on a day-patient basis, especially where the disabling condition is predominantly physical such as arthropathies, many neurological disorders, and limb amputations. (2) Detailed investigations in the aged are justified if the

ligation. In our view, many Englishmen are not yet wholly prepared to accept male sterilisation; nor should they be persuaded to accept vasectomy against their will.

antagonism

to vas

REFERENCES 1. 2. 3.

Blacker, C. P., Jackson, L. N. Lancet, 1966, i, Hanley, H. G. ibid. 1968, ii, 207. Peberdy, M. ibid. 1968, i, 1363.

Hospital

971.

Service

DAY HOSPITALS FOR GERIATRIC PATIENTS M. S. PATHY

Department of Geriatrics, St.

David’s

Hospital, Cardiff

For the past few years a day-hospital service for the elderly has been in Patients requiring major investiCardiff. operating or from assistance gations specialist services attend the main day unit in a large general hospital; more routine attention is provided at a peripheral day hospital; and longer-term daytime care is provided at an annexe to a long-stay hospital. These three units managed nearly 1000 new cases in the latest full year, and only a few of these were transfers from other day units. Patients attend, on average, on two days (out of a maximum of five each week), and in the main and peripheral units each patient attends for an average 10 and 20 sessions, respectively. Almost half the cases are referred from iripatient wards. Patients attending day units for six weeks or more are reviewed at intervals thereafter. Coordination with local services is stressed, and the part played by day centres is discussed. Summary

INTRODUCTION

outpatient services are rarely suited for the detailed investigation of the elderly. Slowly and begrudgingly, an alternative method of dispensing hospital care is establishing itself with the recognition HOSPITAL

that many diseases of later life can be treated on a day-patient basis. However, the full potential of a day-hospital service has not yet been exploited. In this department, we think of the day unit as a ward where patients are given sleeping-out passes. However, there seems to be no consensus among physicians as to what is the proper function of a geriatric day hospital, and as a result these units vary from little more than a social day centre or adult creche to an extended outpatient department. Many factors seem to influence policy-population density and its propinquity to the hospital; the personal views of the physician on what should be the functions of a day hospital; the availability of other hospital services and staff to a department of geriatrics; and the quality and quantity of community services. I describe here experience with day hospitals in Cardiff since 1964.

to

be appro-

results enable effective treatment to be undertaken with the prospect of worthwhile improvement. Many investigations are too demanding or the range too extensive to be performed on the frail elderly in an average outpatient department. Hospital admission is expensive and frequently hazardous. The advent of the day hospital has made possible comprehensive investigations in many older patients who live within fifteen miles of the hospital. Barium studies, lumbar puncture, diagnostic pleural or abdominal aspiration, biopsies, and many similar procedures which may subsequently require skilled observation for several hours are readily undertaken in a day hospital without undue disturbance to the elderly patient. Diseases, especially haematological disorders, which must be controlled by repeated blood examinations, can be effectively managed

by day-patient care. (3) Patients who have recovered from the acute phase of an illness may spend additional days in a hospital ward because the disease is not fully under control, or await the results of investigations before the next stage of treatment, or because extensive physical therapy is required. Frequently these men and women can, with advantage, continue to receive the technical services of a hospital and medical and nursing supervision on a day basis. (4) Many old people who normally live alone and who have spent several weeks in hospital fear the prospect of trying to live independently again. The gulf between the protective organised atmosphere of the hospital and the patient’s home is often bridged by temporary support in a day hospital. In such cases one or more visits to the day hospital before discharge from the wards is sometimes of crucial importance in restoring confidence.

people contend that both the mentally and physically disabled can be treated within the same day hospital provided that the building is designed for this purpose. In 1963 a day hospital for confused, elderly patients was set up in a Cardiff psychiatric hospital for a trial period of two years. The unit was jointly supervised by psychiatrists and the department of geriatrics. The attendance-rate rapidly rose to an average of 35 patients a day. The trial was successful, Some

but the average duration of attendance was 7-7 times greater than for patients attending the geriatric day " hospital. In a mixed unit the mentally disabled tend to displace the physically sick patients. In general, the chronically confused elderly patient is most suitably managed in a separate day unit. "

THE CARDIFF SERVICE

department of geriatrics is served by two day hospitals and a day annexe. The central or main day hospital, opened in 1964, is situated in the grounds of a 490-bed general hospital. A large range of medical and paramedical services are freely available to this unit. A second day hospital was opened in May, 1968, and is situated four miles from the main day unit. A day hospital annexe was developed in 1966 and forms part of a small hospital for long-stay elderly patients. The