Female Sterilization Tragedy

Female sterilization is one of the most commonly used contraceptive methods in our country. Since it is one of the healthcare programs run by the Government, it has acquired a unique status. Actually it is a minor procedure that we were required to perform as first post residents. We used to perform puerperal sterilizations in seven minutes each, and would be shouted at by the seniors if we took longer. There used to be only one student nurse to assist us. Now that it is a part of an important program, each sterilization is done by a qualified doctor or resident doctor assisted by a qualified doctor. The Government has laid down guidelines about who can perform it and who cannot. The rules are quite stringent about laparoscopic sterilization. There is a rule which states that no matter what the degree of training of the gynecologist, he or she must be trained to perform laparoscopic sterilization in a course conducted after one obtains a postgraduate degree. One has to perform 95 sterilizations in that course before one can be certified to perform it independently. Nowhere does one get so many sterilization operations, and I suspect all the certifications currently done in any institutes recognized for this purpose are done without meeting this criterion. The rule pertains only to laparoscopic sterilization. One may perform laparoscopic hysterectomy or pelvic lymph node dissection without any such certification, but not a sterilization operation. It is special. Not only is the person to be trained officially for this operation, but the institute must be accredited for that purpose too. The institute may be performing open heart surgery without such certification, but not a sterilization operation. It is special. The anesthesia fitness requirements are hemoglobin and urinalysis. Hemoglobin level of 9 g% is enough. I wonder why the operation which is so special can be performed when the woman is unfit because she is anemic. I also wonder why the stringent criteria for fitness for anesthesia are not applied to this operation, even if it is so special. The Government has laid down a list of conditions in which a sterilization must not be performed on a woman. There is an additional list in which there are conditions in which sterilization should be performed with caution. A doctor is expected exercise utmost caution in everything he does. There cannot be extra caution in any situation. What the rule means is that if one performs a sterilization in such a patient and the patient remains well, there will not be any problem for the doctor. However if the patient dies or gets any complication, the doctor hangs. If the woman who undergoes a sterilization dies, an enquiry is conducted by a quality assurance committee. The members of the committee are selected by the government. They are selected because they are in government service, not because they are experts on this issue. They conduct enquiry of the team of the gynecologists concerned including the head of the department who may have nothing whatsoever to do with the operation. They question everything that happened and did not happen. They split hair no end. All that is justified, since no young woman should die or even become seriously ill after an elective procedure like sterilization. She leaves behind a family including her young ones with perhaps no one to care for them. She does not need this operation for any health related problem. She would be alive and well if her husband had undergone this operation with practically no risk of any complications and death. Unfortunately husbands don't undergo this operation because they wrongly fear that it may cause impotency. The other unfortunate part of this is that the enquiry business is applied even when the woman dies of disease not related to the sterilization procedure. For example, if the woman is undergoing a laparotomy for a ruptured ectopic pregnancy with shock, and she desires a sterilization operation too, one may do it in an additional two minutes without increasing the morbidity. But if she dies due to shock, her death is considered as that due to sterilization and an enquiry is held. If the woman had a medical condition that contraindicates pregnancy, and she undergoes a cesarean section for obstetric reasons, one would want to perform a sterilization operation at the same time in her interest, without any increase in her morbidity. One wants to do this because her husband invariably does not undergo a sterilization himself, and she will get pregnant some time later and may die. But the Government prohibits this sterilization. She can undergo a cesarean section, but not a sterilization along with it. I don't think the Government has really understood this issue well. Our letters are never answered, so we cannot do anything much about it. The result of treating highly qualified and competent doctors like criminals and holding their enqiries in a derogatory manner, often stressing unimportant points has resulted in a setback for the programme. The sterilization rate has dropped drastically. Women badly in need of controlling their family size are refused sterilization. The nations' population is on the rise while the Government machinery is set only on following the guidelines blindly. Something needs to be done to set things right, or the country's population control will be an unrealistic dream.