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THE ATTITUDE OF FERTILE NIGERIAN WOMEN TO STERILIZATION O. K. OGEDENGBE, Senior Lecturer/Consultant O. F. GIWA-OSAGIE, Professor and Head of Department C. A. USIFOH, Matron Family Planning Clinic Unit of Reproductive Endocrinology & Fertility Regulation, Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, P.M.B. 12003, LAGOS, Nigeria. Summary Attitudes to sterilisation were investigated among patients attending the outpatient clinic of the Department of Obstetrics and Gynaecology, Lagos. The most frequently mentioned factors that would affect a patient’s decision on sterilisation were the number of living children, her age, and her health. Cultural beliefs, particularly belief in reincarnation, were also relevant. Introduction Sterilization is the commonest form of contraception in some developed countries such as the USA where as many as 10 million are sterilized per annum, although a proportion (0.1 - 10%) subsequently regret the decision1. In most third world countries there is also an increasing acceptance2. The current population annual growth rate in Nigeria of 3% will, if continued, give rise to overpopulation in the near future3. The Department of Obstetrics and Gynaecology at Lagos Teaching Hospital has provided a family planning clinic since 1980. Analysis of the contraceptive methods chosen showed that there was little interest in surgical intervention4. With the adoption of a programme of fertility counselling of patients and the introduction of outpatient interval, sterilization, although the acceptability of family planning increased as shown by an increase in clinic attendances, that of sterilization only increased slightly to 5%5. In order to determine the reasons for this low acceptability rate for surgical contraception as a form of family limitation the following pilot survey was carried out. The results provide the first step towards a strategy to increase the acceptance of this method of contraception, so that it can make a greater contribution to population control. Material and Methods The patients were attending the outpatient clinic of the Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, and were randomly recruited, except for the exclusion of those with infertility problems. As a large percentage of gynaecological outpatients are infertile6 they would have introduced a bias. The counsellors were the nursing staff of the family planning clinic and they filled out a questionnaire for each patient. Two hundred and fifty patients were interviewed, and asked about their use of contraception, and why they had not requested sterilization. The characteristics of the sample are set out in Table 1. The subjects were not representative of the population generally in several ways. In education, only 4 patients(1.6%) had no education whatsoever, 149 (59.6%) had post-secondary school education, 60 (24%) secondary school education, and 37 patients (14.8%) primary school education. In age distribution, younger women were under-represented, for 241 (96.4%) were between 21 and 40 years. In reproductive performance, 161(64.4%) patients had delivered three or more children, and 148 (59.2%) had three or more children alive. When asked the ideal number of children per family, 121(48.4%) thought at least five children. As for religion, 206 (82.4%) patients were Christian, whilst 25 (10%) were Moslem. Nineteen patients (7.6%) belonged to other religions.
Results One hundred and twenty one patients (48.4%) had used some recognised contraceptive device prior to being interviewed. Two hundred and nineteen (87.6%) of those interviewed had heard of female sterilization and 164(65.6%) had heard also of male sterilization. Of these, 156 (62.5%) had gained the information through medical personnel, 63 (25%) through the media and (12.3%) through friends. Seventy nine (3 1.6%) of the patients disapproved of both male and female sterilization, whilst three patients disapproved of male sterilization only. Factors affecting the patients’ attitudes (Table 2) in many cases were multiple. The commonest factors were the number of living children, maternal age (the acceptable lower limit being 50 years), pregnancy complications and maternal ill health.
Discussion This being a pilot study, analysis of variations in responses according to the patient’s characteristics was not undertaken. The fertility rate in Nigeria of 6.3 is very high3, other third world countries have successfully used sterilization as part of a strategy to control over-population, and there appears a clear case for its expansion in Nigeria. It is therefore important to understand the factors influencing the acceptability of sterilization. The most frequent were the number of living children and the patients’ age; these have been suggested as relevant factors in selecting patients for sterilization7,8• The third commonest was the presence of ill health and pregnancy complications, and again it has been suggested that this affects the attitude to the procedure9. In a different culture belief in reincarnation was important, not only to promote resistant attitudes but also in producing adverse symptoms post-operatively10,8. The effect of this is not so apparent in this study. It has already been suggested that the relationship between acceptance of sterilization and education need not be direct, and the results of this survey are apparently in agreement. If knowledge of sterilization were to come more from friends who had been helped by the procedure, this might improve its accept ability by counteracting cultural beliefs9. There is also a place for a publicity campaign for sterilization. One of the reasons for an increased acceptance of sterilization in Lagos University Teaching Hospital has been a more positive attitude towards it by the nursing staff on the wards - some of whom are happy to tell the patients that they too have had tubal ligation. The mean age for acceptance of sterilization in Nigerians is as high as 40 years11 which implies some cultural antipathy to the procedure, and possibly fear of child death. From the results of this pilot study it appears that a more comprehensive survey, on a larger sample, to examine the ways in which patients’ attitudes are affected by their personal and socioeconomic characteristics, is desirable. References 1. Population Information Program (1980). Reversing female sterilization. Popul. Rep. 8: 98. 2. Ross, J. A., Hong, S. and Huber, D. H. (1985). Voluntary Sterilization: An International Factbook A.V.S.C. 2. 3. Nigerian Fertility Survey 198 1-82. Principal Report Vol 1. World Fertility Survey/International Statistical Institute, London PIR (1984). 4. Ogedengbe, O. K., Giwa-Osagie, O. F. and Adeyemi, M. A. (1987). Internal Out-Patient Female Sterilization in Lagos. Contraception 35: 6, 581. 5. Ogedengbe, O. K., Giwa-Osagie, O. F., Ola, R and Fasan, M. O. (1987). Contraceptive Choice in an Urban Clinic in Nigeria. J. Biosoc. Sci. 19: 89. 6. Akinkugbe, A., Evoh, N. J. and Banjoko, M. D. et al (1979). The role of laparoscopy in diagnosis and patient management. West Afr. J. Surg. 3: 131. 7. Leader, A., Galan, N. and George, Ret al(1983). A comparison of definable traits in women requesting reversal of sterilization and women satisfied with sterilization. Am. J. Obstet. Gynaecol. 145: 198. 8. Myre Sim, Emens, J. M. and Jordan, J. A. (1973). Psychiatric aspects of female sterilization. Br. Med J. (iii) 220. 9. Shane, R. N. and Dickson, H. D. (1982). Tubal Sterilization. Characteristics of women most affected by the option of reversibility. Soc. Sci. Med 16: 1067. 10. Lu, T. and Chun, D. (1967). Long term follow-up of 1005 cases of post-partum sterilization. Br. .J. Obstet. Gynaecol. 74: 875. 11. Ogedengbe, O. K., Giwa-Osagie, O. F. and Emuveyan, E. E. (1983). Initial Experience with Out-Patient Laparoscopic Sterilization at Lagos University Teaching Hospital. Nig. Med Practnr. VoL 6.1, 13. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||