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Essential Surgery Table 7.1 Primary Contraceptive Methods by Degree of Surgical Involvement

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Essential Surgery Table 7.1 Primary Contraceptive Methods by Degree of Surgical Involvement Chapter 7 Surgery for Family Planning, Abortion, and Postabortion Care Joseph B. Babigumira, Michael Vlassoff, Asa Ahimbisibwe, and Andy Stergachis INTRODUCTION complications from clandestine, unsafe procedures (Grimes and others 2006; Shah and Ahman 2009; Singh This chapter discusses two related but conceptually and others 2006; Singh 2010). Therefore, postabortion distinct health concerns in low- and middle-income care is a significant health issue in LMICs. Timely, safe countries (LMICs): (a) voluntary family planning, and surgical interventions can reduce the morbidity and (b) abortion, including postabortion care. In the first mortality associated with unsafe abortions. section, on family planning, the health condition of The same surgical procedures used for abortion are interest is unmet need: the percentage of women who also used to manage incomplete abortion, which is one would like to either stop or delay childbearing but of the most common postabortion complications and who are not using any contraceptive method to pre- is often accompanied by other complications such as vent pregnancy. The unmet need for family planning bleeding, sepsis, and genital injury. The surgical pro- (to either limit family size or determine the intervals cedures used to manage such complications include between children) results in unintended and unwanted laparotomy for sepsis and uterine injury and a wide pregnancies, which in turn lead to a broad range of range of minor procedures to repair injuries to the prox- maternal and child conditions that increase morbidity imal birth canal. and mortality. Surgical procedures for family planning Both sections discuss the burden of reproductive can help reduce this unmet need, particularly the need health conditions, including morbidity, mortality, and to limit childbirth. other effects. We discuss surgical procedures (their The second section concerns surgery for induced performance, inputs, and implementation) and the abortion (as opposed to spontaneous abortion, or mis- health workforce implications of scaling up those pro- carriage) and the surgical management of the compli- cedures in LMICs. We also explore evidence on the 1 cations of induced, mostly unsafe, abortion. Unsafe procedures’ effectiveness in reducing morbidity and abortion is defined as abortion performed outside of mortality and improving quality of life as well as evi- health facilities (or any other place legally recognized dence on their cost-effectiveness. Finally, we outline for the procedure) or by an unskilled person (WHO future directions—including implementation challenges 1992). The demand for abortion is high in many and considerations for increasing access to these surgical LMICs, and the illegality of the procedure in most of interventions—and conclude by summarizing the find- these countries increases the likelihood of postabortion ings and recommendations. Corresponding author: Joseph B. Babigumira, PhD, MS, MBChB, University of Washington, [email protected] 109 SURGERY FOR FAMILY PLANNING schooling and body mass indexes (Canning and Schultz 2012). At the macroeconomic level, it reduces Importance of Family Planning youth dependency and increases labor force participa- Family planning is a pillar of reproductive and overall tion by women, thereby enhancing economic growth health in several ways: (Canning and Schultz 2012). Increasing access to family planning will slow population growth, convey- • Reducing maternal mortality by reducing the number ing environmental benefits such as substantial reduc- of times women are pregnant, including high-risk tions in global carbon dioxide emissions (O’Neill and pregnancies associated with very young or older others 2012). women (Ahmed and others 2012) Conversely, when LMICs lack affordable, acces- • Preventing high parity (among the potential factors sible, acceptable, and sustainable family planning meth- leading to anemia in pregnancy)2 ods, tangible economic development becomes more • Lengthening the intervals between pregnancies, difficult: without low fertility, countries cannot attain which also improves perinatal outcomes and reduces the well-documented “demographic dividend” that child mortality (Cleland and others 2012) has benefited several formerly low-income countries • Decreasing the number of pregnancies that would (Bloom, Canning, and Sevilla 2003).4 have ended in induced, mostly unsafe, abortions in LMICs. Family Planning Methods Recent data illustrate how high the stakes can be, Family planning comprises both traditional and mod- although some trends have improved during the past ern methods of contraception. Traditional methods, two decades. The Global Burden of Disease (GBD) including withdrawal and fertility awareness, have low Study 2010 estimated that almost 254,700 deaths (4 per efficacy; up to 24 percent of women who use them will 100,000) globally were attributable to maternal condi- have unintended pregnancies within one year (Trussell tions in 2010, a 29 percent decrease from 1990, when 2011a). Modern methods—including sterilization, there were 358,600 maternal deaths (7 per 100,000) intrauterine devices (IUDs), injections, implants, pills, (Lozano and others 2013). Almost 1.8 million years and mechanical methods such as condoms—have higher lived with disability (YLDs) globally were attributable to effectiveness, resulting in lower rates of unintended maternal conditions in 2010, a 28 percent increase from pregnancies (Trussell 2011a). 1990, when there were nearly 1.4 million YLDs (Vos and Sterilization is the most common method of per- others 2013).3 manent family planning; most other methods are tem- Family planning is one of the most effective, and porary. Permanent methods are indicated for couples cost-effective, interventions against maternal mortality who consider their families to be complete and would and disability. Increasing contraceptive coverage was pri- like to stop childbirth (limit the number of children). marily responsible for a substantial reduction in global Temporary methods are indicated for couples who fertility rates (from 3.63 births per woman in 1990 to would like to delay childbirth to space children further 2.83 in 2005), also averting 1.2 million deaths (Stover and apart or for other reasons. Ross 2010). Despite a 42 percent increase in the number Contraception can also be divided into surgical meth- of women of reproductive age (15–49 years old) between ods, methods that employ minor surgery (for insertion 1990 and 2008, the number of births per year remained and removal), and nonsurgical methods (table 7.1). constant, and the mortality risk per birth decreased (Ross Methods involving surgery or minor surgery are generally and Blanc 2012). Meeting the need for family planning more effective than the nonsurgical methods. Surgery is globally would further reduce maternal mortality by an employed primarily for sterilization. The most common estimated 29 percent, a reduction of more than 100,000 male sterilization procedure is vasectomy, and the most deaths annually (Ahmed and others 2012). common female sterilization procedure is tubal ligation. Moreover, family planning has both household and Vasectomy and tubal ligation are among the most macroeconomic benefits. At the household level, it effective of the modern contraceptive methods, having reduces fertility—an important attribute given that first-year failure rates of 0.15 percent and 0.5 percent, women in LMICs increasingly desire better-planned respectively (Trussell 2011b). Although some nonsurgi- and better-spaced families (Darroch 2013; Darroch cal forms of female sterilization exist, they are either not and Singh 2013). Family planning not only improves available or not practicable for LMICs in the foreseeable birth spacing but also increases women’s earnings, future.5 Therefore, this chapter focuses on tubal ligation assets, and body mass indexes, and improves children’s and vasectomy. 110 Essential Surgery Table 7.1 Primary Contraceptive Methods by Degree of Surgical Involvement Surgery Minor surgery Nonsurgical Female sterilization: tubal ligation Intrauterine device (IUD) Fertility awareness • Copper IUD • Standard days methoda • Hormonal IUD (for example, Mirena) • Symptothermalb • Ovulationc Male sterilization: vasectomy Subdermal implant (for example, Implanon, Jadelle) Barrier • Spermicide • Sponge • Male condom • Female condom • Diaphragm Hormonal • Injection (for example, Depo-Provera) • Birth control pill • Vaginal ring (for example, NuvaRing) • Transdermal patch (for example, Ortho Evra) Other • Lactational amenorrhead • Withdrawal a. In the “standard days” method, a calendar (using colored beads, for example) is used to track the menstrual cycle as an aid to abstinence from unprotected vaginal intercourse during peak fertility periods. b. The symptothermal method usually combines a number of fertility awareness methods, including observation of primary fertility signs (such as basal body temperature and cervical mucus) and the calendar-based methods. c. The ovulation method identifies patterns of relative fertility and infertility during the menstrual cycle based on vulvar sensation and the appearance of vaginal discharge. d. Lactational amenorrhea is the temporary postnatal infertility that occurs when women are actively breastfeeding. Contraceptive Prevalence and Unmet Need or female sterilization: 10 percent in Sub-Saharan Africa, Contraceptive Prevalence. Globally, total contracep- 64 percent in South and Central Asia, and 13 percent in
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