By Lynn Bakamjian,Vice President and Director of Field Operations, AVSC
International and Pamela Beyer Harper, Director of Communications, AVSC
International
Because voluntary sterilization is surgical and intended to be permanent, it demands
more from health-care providers than other contraceptive methods. In short, it requires
more care.
The quality of sterilization services is often an indicator of the quality of other
reproductive health services. Aspects of sterilization that are relevant to other
reproductive health services include assuring voluntary decision-making, providing
counseling services, preventing infection, maintaining clinical safety, reducing the
discomfort and pain clients feel, establishing standards and guidelines for care, and
providing follow-up care.
Good access to services is important, but sometimes access is mistakenly equated with
quality. At other times, these two concepts are spoken of as if they were mutually
exclusive. In fact, access and quality are inextricably linked. Increasing access to poor
services does harm to people, and such services will ultimately fail because people will
reject them. Access to a range of method choices, allowing each client to select the most
appropriate method for his or her circumstances, is one important feature of all quality
family planning services, including sterilization.
A review of international work in more than 50 countries during the past 25 years
highlights six important lessons on how to assure quality voluntary sterilization
services: focus on the client, assure informed choice, support providers with training and
other needs, build ownership in the community, use technology that is appropriate for the
setting, and offer services within an integrated reproductive health program.
These vital lessons mirror the spirit of historic resolutions adopted by more than 180
countries during the 1994 International Conference on Population and Development in Cairo
and the 1995 Fourth World Conference on Women in Beijing. What has been learned from
providing sterilization services can be a guidepost for improving reproductive health
services in general. An underlying principle for all of these lessons is that
policy-makers and program staff must pay attention to quality in order to build a
reproductive health program that serves people and meets their needs, as well as the
program's goals.1 There are no shortcuts: Sustainable service
delivery systems that are of good quality and that achieve desirable results take
long-term, steady work.
Focus on the client
Reproductive health services must start with the individual client as a whole person
with changing needs over the course of a lifetime, and must include access to different
contraceptive options throughout a person's reproductive years. In some early family
planning programs, the client was at the periphery, a number to be counted along the way
to achievement of a demographic goal.
 Some
providers have focused too much on the medical status of clients and too little on
clients' personal needs. The surgical nature of sterilization has led providers to dwell
on clinical aspects, such as anesthesia and surgical technology, rather than the needs and
desires of the individual person. Reproductive health choices are highly personal, and
they take place within a web of relationships; with the partner, with the family, and with
the community. As family planning providers begin to offer a broader range of reproductive
health services, they need to take this lesson into account.
Effective client-provider interaction is crucial and proper consideration for the
client is essential. Women should not be left lying naked on examination tables, with no
respect for their privacy. Surgeons should involve the client when talking to associates
in the client's presence, and should look at the client when possible. Every person who
interacts with a client needs to show consideration and respect.
Understanding how clients make decisions about reproductive health has bearing on how
services are delivered, and this decision-making varies from person to person. For
instance, while most women or men who choose sterilization want to involve their partner
in making this decision, some choose not to. A woman may not tell her partner she has
decided to have a tubal ligation because she knows he wants her to keep bearing children.
In other cases, clients may lack a steady partner or have more than one partner. Because
of such differing individual circumstances, programs should not impose rigid requirements,
such as spousal consent or couple counseling. Rather, providers should attempt to
understand the special circumstances of each client that may affect how services are
offered.
When services are isolated and fragmented, providers miss opportunities to provide
much-needed care and follow-up.2 Clients who want
sterilization services, or any other reproductive health service, have other health-care
needs. A woman may require screening for breast or cervical cancer; a man may need a
prostate exam. Both of them may need assessment or treatment for sexually transmitted
diseases (STDs). Yet in many countries, a client may only obtain sterilization at a
sterilization clinic. Similarly, clients who seek other reproductive health services, such
as cancer screening or STD treatment, may have family planning needs that should be
addressed.
Informed choice
When sterilization first became widely available as a contraceptive option,
policy-makers and health-care professionals debated two questions: How was the decision to
be made? Who had the authority to make it? Unfortunately, the history of sterilization
includes noteworthy violations of individual rights.3 Although
the world has made steady progress away from such abuses, the individual's right to an
informed choice will always require vigilant attention.4
Because of concerns about rapid population growth and the strains such growth places
upon limited resources, some sterilization programs in the past have offered providers and
clients special incentives and payments. Furthermore, they have favored sterilization over
other contraceptive methods because of its efficacy. Such practices undermine the client's
right to choose. Demographic goals should not be imposed on family planning services in
the form of targets or quotas, and incentives should not be given to providers, referrers,
or clients.5
The role of counseling is critical. Women and men need to know their options and the
real risks and benefits of any method or procedure; they must be treated respectfully and
without moral judgments. They may need assistance as they make their decisions, but they
do not need to be told what to do.
Decision-making about sterilization points to the broad context in which choices about
reproductive health are made and to the critical role of the provider. The client is not
simply choosing to have or not to have the procedure. Rather he or she is thinking about
many private and, sometimes, sexual issues. What will my partner think? What about other
family members? Will they disapprove? Which friends can I talk to about my choice? Will I
be sad if I end my fertility? What will sexual intercourse be like after the surgery? Am I
making this choice only because I cannot obtain another, more preferable method? Am I
making this choice because the doctor is telling me to do so? The provider's role is to
help the client navigate these often difficult waters.
It must also be remembered that denying sterilization or other reproductive health
services unreasonably also violates informed choice. Irrationally strict eligibility
requirements, excessive waiting periods, and mandatory spousal consent are three examples
of ways in which access is hampered.6
Provider needs
The rights and needs of clients cannot be honored unless the needs of providers are
adequately addressed.7 Most providers want to offer good
services to clients, but all too often lack the support they need. Institutions and
governments must serve the provider so the provider can serve the client.
In the 1970s and 1980s, AVSC International (AVSC) monitored medical quality in hundreds
of service sites around the world. We learned over time that our approach was ineffective.
An AVSC staff member or consultant would evaluate services, leave recommendations and
depart. Months later, a return inspection would typically show that very little had
changed. From this monitoring, AVSC learned that providers must take responsibility for
improvements, but to do so they must receive training and evaluation, and be rewarded
accordingly. Whenever possible, they should learn new skills in the workplace, not in
facilities markedly different from their daily surroundings.
Providers need clear guidelines and standards that are developed or adapted for the
context in which they work. They need reliable and ongoing supervision that facilitates
work, helps resolve problems, and develops their knowledge and skills. They must have the
opportunity for special training when indicated. This requires strong in-country
institutions that can deliver effective supervision, problem-solving, and training.
Community ownership
Before sterilization became more widely available, it was often controversial. New to
many countries, it violated deeply felt beliefs and generations of culturally significant
fertility practices.
AVSC staff would begin working in a country, firm in the belief that sterilization was
a legitimate and safe contraceptive choice. But our belief was not enough. Until providers
and clients in the country shared that conviction, we were unable to help establish
services. We could not succeed unless we joined as partners with clients, with local
leaders, and with local organizations. Ownership is achieved through participatory program
development, in-country formulation of standards and guidelines, and local problem-solving
approaches.
Medical standards and guidelines illustrate the necessity of local commitment. A broad
international community of experts, including AVSC, has developed a consensus regarding
safety standards for sterilization and other contraceptive methods. Support for the local
application of these guidelines has also been essential. Each country should draw on
internationally set standards to decide for itself what fits its own needs and
circumstances, and this should be shaped by the needs and wishes of the women and men to
be served.8
In recent years, much of the momentum supporting broader reproductive health services
has come from the developing world. We all have much to learn from developing countries,
whose leadership is essential if the aspirations of Cairo and Beijing are to be met.
Appropriate technology
The technology must be appropriate to the setting -- an old lesson worth remembering,
especially as health-care institutions around the world expand reproductive health
services. In the case of sterilization, the 1970s and 1980s were times of great debate:
Which was best: laparoscopy or minilaparotomy; general anesthesia or local anesthesia? Of
course, there were no simple answers to these questions. Technologies that offer the
greatest benefit at the most reasonable cost, that can be sustained, that offer better
safeguards for the client, that increase access without jeopardizing quality are the ones
to use.
Too often, a program is designed around a single technology. In fact, what usually
works best is an array of offerings, based on the variety of clients, facilities,
personnel, and practices. Thus, laparoscopic sterilization may be appropriate in an urban
hospital, while minilaparotomy may be the best procedure for a small rural clinic.
As reproductive health services expand, technological debates abound. What is the
simplest and most effective way to screen for cervical cancer in low-resource settings, or
to assess clients for STDs, or to treat incomplete abortion? In each of these instances,
complex service-delivery issues interface with technology to make sustainability and
quality significant challenges.
Integrated systems
In the developing world, sterilization services of the 1970s and 1980s were typically
vertical programs; single-purpose and one-dimensional, often supported with donor funds
and rarely integrated into the health structure of the country. The problems with this
strategy are obvious. Personnel in such programs often had little connection with other
reproductive health services. They were trained in sterilization, but lacked other
important knowledge and skills. Clients were typically treated only in relation to their
needs as a sterilization patient; other health concerns were marginalized. One of the
hallmarks of the Beijing and Cairo resolutions was emphasizing the need to integrate
services, growing out of a concern that an individual's needs are multi-dimensional.
Single-focus services and approaches often arise because the intervention is seen as a
"magic bullet:" sterilization as a solution to population problems; syndromic
charts as a sufficient tool for screening all STDs; or limited analytical approaches as a
complete cure for a variety of management problems. Such thinking is simplistic and rarely
addresses the multiple needs of the client.
To improve the reproductive health of women and men, a range of services must be
available, supported by the necessary infrastructure and staffed by a cadre of
well-trained professionals. Small doses of one-time-only training, quick infusions of
money, and occasional inspection visits by supervisors do not build programs with the
capacity or ability to sustain any level of quality that clients have a right to expect.
Millions of dollars have been invested to introduce and expand family planning
services, yet we know that in many programs the potential from those investments is not
fully realized. The resources and various components for a successful program may all be
there, but there is widespread neglect of the everyday, routine systems for maximizing
access, serving clients efficiently, catering to client needs and assuring quality.
Services must be developed in a phased manner, building on the success of pilot efforts
and involving all health sectors, from nongovernmental organizations to private providers
to major national health systems. Staff need continuous training and retraining -- to
replace personnel who have departed and to improve knowledge and skills. Services need to
be assessed and evaluated, both by staff and by outside observers, to identify what is
working and what is not. The holistic and ever-changing needs of individual clients must
drive the design of service delivery.
AVSC has seen the value of "systems" thinking in something as basic as a
counseling session. For several years, we focused on training cadres of staff identified
as "counselors." Within months, the "counselor" would resign or be
promoted, perhaps leaving a clinic without anyone who knew what counseling was or why it
mattered. Today, we approach counseling differently. It is infused throughout our training
and supervision work; our goal is to have every staff member of a clinic know what
counseling is and why it is important. This approach is more likely to ensure that
counseling is sustained and that all staff support the ultimate goal; the client's
informed choice.
These six lessons teach us that, in order to have lasting impact, programs need to
"go slow to go fast." Implementing reproductive health services is multifaceted,
and large health systems are slow to change. Sustainable programs take long-term, steady,
evolutionary work. Service delivery systems that work efficiently and preserve resources
and time, that involve and create job satisfaction for managers and providers, and are of
good quality oriented to client needs are much more likely to endure. There are few
shortcuts to providing good quality services -- whether for voluntary sterilization or any
other reproductive health service -- if these are to be widely available and used by those
who need and want them.
References
- Bruce J. Fundamental elements of the quality of care: a
simple framework. Stud Fam Plann 1990;21(2):61-91; Dwyer J, Jezowski T. Quality
Management for Family Planning Services: Practical Experience from Africa. AVSC Working
Paper #7. New York: AVSC International, 1995.
- Surgical sterilization among women and use of condoms,
Baltimore, 1989-1990. MMW 1992;41(31):568-75; Diaz T, Schable B, Chu SY, et al.
Relationship between the use of condoms and other forms of contraception among human
immunodeficiency virus-infected women. Obstet Gynecol 1995;86(2):277-82.
- Reilly P. The Surgical Solution: A History of
Involuntary Sterilization in the United States. Baltimore: Johns Hopkins University
Press, 1991; Benagiano G, Cottingham J. Contraceptive methods: potential for abuse. Int
J Gynecol Obstet 1997;56(1):39-46.
- Butta, P. Informed Consent and Voluntary
Sterilization: An Implementation Guide for Managers. New York: AVSC International,
1995; U.S. Agency for International Development. Voluntary Sterilization: Policy
Determination 3. Washington: U.S. Agency for International Development, 1982.
- Hoogenboom H, Antarsh L, Harper PB, et al. Population,
Family Planning, and Women's Health: Finding and Pursuing Common Goals. Report of a
Symposium. New York: Association for Voluntary Surgical Contraception, 1994.
- Jezowski T, Hollerbach P. Operational Policies for
Effective Voluntary Sterilization Services in Family Planning Programs: First Draft. New
York: Association for Voluntary Surgical Contraception, 1991.
- AVSC International. COPE: Client-oriented,
Provider-efficient Services. New York: AVSC International, 1995; Ben Salem B, Beattie
KJ. Facilitative Supervision: A Vital Link in Quality Reproductive Health Service
Delivery. AVSC Working Paper #10. New York: AVSC International, 1996; Huezo C, Diáz
S. Quality of care in family planning: clients' rights and providers' needs. Adv
Contracept 1993;9(2):129-39.
- Carignan CS, Ippolito L, Nersesian, PV. SEATS II
Clinical Protocols for Family Planning Programs: A Resource Book. New York and
Arlington, VA: AVSC International and John Snow, Inc., 1995.
For more information, visit Family Health International's Website at www.fhi.org
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