Tubal Ligation under Local Anesthesia in a Country with Limited Resources: 56 Cases of Wife and Husband’s Experience in the Gynecology-Obstetrics Department of Ignace Deen National Teaching Hospital, Conakry, Guinea ()
1. Introduction
Female sterilization still known as voluntary surgical contraception (VSC) or tubal ligation by mini-laparotomy is a permanent contraception method for women who no longer wish to have children [1] [2]. It is a minor surgery that involves cutting the fallopian tubes.
VSC is a birth control and prevention of unwanted pregnancies method increasingly used by women. Worldwide, new acceptors were estimated in 1995 at 230,000 [2] [3].
Nowadays different techniques of tubal sterilization are used; these are: mini-laparotomy, laparoscopy and electrocoagulation of the tubal ostium [4].
In recent years, tubal ligation by mini-laparotomy and the sterilization by laparoscopy have rapidly increased. These two sterilization methods are currently the most widely used methods of contraception in the world [5].
Tubal sterilization by mini-laparotomy under local anesthesia presents the advantage of high efficiency, outpatient practice and the simplicity of the materials used to make it an inexpensive method [4].
In the United States, it is the second most common method of contraception used by women. In 1985, 20 to 25% of women of reproductive age opted for this method of contraception. This proportion even reached 67% among women aged between 40 and 45 [6] [7] [8].
There in Belgium in 2000, this contraceptive method was chosen by 6 to 8% of the childbearing age women population [9] [10].
In Senegal (Dakar) in 1996, Cissé C. T. et al. at Dantec Teaching Hospital reported that the tubal sterilization was the second most commonly used family planning method, i.e. 20% [4].
The overwhelming majority of these interventions are motivated, not for medical reasons in the strict sense, but for convenience reasons, foremost among which are the desire for a reliable method of contraception and the problems posed by the long-term use of other contraceptive techniques, whether hormonal or mechanical [11].
In Guinea, according to the 2012 Demographic and Health Survey (DHS) the rate of contraceptive prevalence of modern methods was 7% [12].
The objective of this work was to assess the results of tubal sterilizations by mini-laparotomy under local anesthesia, performed at the Maternity Ward of Ignace Deen National Hospital and more specifically to calculate the frequency of tubal ligations under local anesthesia, determine clients socio-demographic profile, identify the main indications, determine the prognosis and ultimately collect the feelings of clients who received tubal ligation under local anesthesia at the maternity ward of Ignace Deen National Teaching Hospital, Conakry.
2. Method and Clients
This was a retrospective descriptive study conducted from January 1, 2017 to December 31, 2018 at the maternity ward of Ignace Deen National Hospital and made on a continuous series of 56 cases of tubal ligation under local anesthesia.
A duly completed consent form was signed by husband and wife after an interview. A preoperative clinical and paraclinical check-up was systematically performed.
a. Inclusion criterion: Clients who gave voluntary and informed consent and in the absence of contraindications to a preoperative clinical and paraclinical evaluation were included.
b. Non-inclusion criterion: Clients who chose another method of contraception and those who did not provide voluntary informed consent with contraindication to a preoperative clinical and paraclinical evaluation were not included.
The variables studied were age, parity, number of living children, marital status, profession, religion, indications, duration of intervention, complications and feelings of women after ligation.
The results were presented in tabular forms in percentages and in averages.
c. Technique:
In gynecological period we distinguish the following different steps:
- Pre-medication with a valium-atropine combination, 30 minutes before the surgery;
- The patient is laid in a gynecological position; a vaginal touch allows to check the position of the uterus;
- Vulvo-vaginal disinfection;
- Installation of a speculum or vaginal valves;
- Introduction of the uterine elevator; abdominal disinfection;
- Local anesthesia with xylocaine 1% through 2 fingers above the symphysis pubis on a 4 cm transverse path;
- 3-centimeter arciform celiotomy. Using Farabeuf retractors, we maintain the parietal opening.
The handle of the elevator is pulled down: this brings the uterine fundus to the level of the parietal incision.
- The tubes are grasped one after the other for ligation-section according to the POMEROY technique;
- Parietal closure in its different sides.
d. Ethics: the protocol was approved by the National Ethics Committee, confidentiality was observed.
e. Limitations of the study: This work was done in a context of under equipment because in most countries with a laparoscopic column, tubal sterilization is done by electrocautery and section of the tubes by laparoscopy. These results are only applicable in countries with limited resources.
3. Results
a. Frequency: During the study period, 1184 women were consulted for Family planning, of which 56 cases of sterilization by mini-laparotomy under local anesthesia were performed, i.e. a frequency of 4.72%.
b. Patients’ socio-demographic characteristics and religious affiliation:
Clients’ average age was 35 with extremes of 25 and 45. The 30 - 34 age group was the most affected. More than half of the multiparous and major multiparous (52.78%) chose tubal ligation by mini-laparotomy.
Married women made up the bulk of the recruitment (97.36%). Unmarried women and widows accounted for 2.64%. The role of polygamy was not highlighted. In terms of occupation, 35.71% of our clients were housewives.
Muslim women were highly represented i.e. 46 cases (86.49%); Christian women accounted for 13.51%.
The indications of convenience were the most encountered followed by high blood pressure and diabetes.
Most women who underwent ligation had at least 6 living children.
c. Distribution of tubal ligation cases according to Period of Surgery Performance:
Interval surgical contraception was more commonly used in this study. This may be explained by the fact that most pregnant women were not counselled during ANC sessions.
d. Duration of the surgical performance and complications:
The average duration of our surgical operations was 30 minutes in 87% of cases with extremes of 20 and 40 minutes. In 10 cases, the duration was more than 40 mn, and it was due to the client’s anxiety.
e. Pre- and post-op complications:
The evolution was without complications in 98.2% of cases.
The complication recorded was parietal haematoma due to a haemostasis defect, which accounted for 1.8% of cases.
The success rate of this method was high.
Most clients were satisfied with this method.
4. Discussion
During the study period, 1184 women were received in the gynecology and obstetrics department of Ignace Deen Teaching Hospital for contraception among which 7 56 benefited from a VSC by mini-laparotomy under local anesthesia, i.e. a frequency of 4.72%.
This result shows that female sterilization is gaining ground in our country as well as in other African countries such as Kenya, Mauritius or Tunisia [13].
The success rate of the method was 99% (Table 1).
The highest utilization rates in the world are recorded in Panama (28.5%) of married couples, in China (27%), in Brazil (18%), in the United States (17%).
Tubal sterilization is also possible by laparoscopy. In laparoscopy, complications are less frequent, but this method is more expensive and less accessible, especially in our context of under-equipment (18).
a. Sociodemographic Characteristics
The profile of patients who accepted was that of a 35-year-old female multiparous with at least 6 living children. This profile is comparable to those reported by other studies in Black Africa [13] [14] [15] [16] [17].
Most clients had 6 or more living children (64.28%) (Table 2).
Asian studies [18] [19] [20] [21] show a more accepting average age of 26 young population with 2 - 3 living children. In these densely populated countries, there is a policy based on limiting the number of children per woman.
Our attitude is not to apply a selection policy based on age or the number of living children, but on the absolute necessity of voluntary and informed consent after a period of thinking.
b. Indications
Indications of convenience were the most encountered (62.50%) followed by high blood pressure (14.21%) and diabetes (10.71%) (Table 3).
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Table 1. Distribution of tubal ligation cases by outcome.
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Table 2. Distribution of tubal ligation cases by number of living children.
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Table 3. Distribution of tubal ligation cases by indications.
The decision to resort to sterilization was most often motivated by a family size and composition considered sufficient. The current context of economic crisis with a gradual decline in income has certainly contributed to the predominance of the selection of this method.
But whatever the reason, in accordance with our socio-cultural experience, the final decision always remained with the husband. This justifies our attitude of seeking his voluntary consent if necessary, after interview sessions.
This element must be taken into account in the family planning policy in order to develop information strategies aimed at the male target group, which is often ignored.
The only recorded complication was a parietal hematoma due to a lack of hemostasis, which accounted for 1.32% of cases.
Our complication rate is close to those reported by Jack [14] and Saiffudin [22]. Complications following tubal ligation are rare and include infection (1% of total cases), minor or major bleeding (0.6% to 1%), and anesthesia events (1 to 2%) [6].
We did not record any death in our series but Khairullah [23] reported a global death rate after tubal sterilization of 4.7 per 100,000 cases. According to Turney [24], this rate was 1/5000 in Bangladesh, 1/10,000 in the United Kingdom and 1/10,000 and 1/25,000 in the United States.
c. Failure
Our failure rate was 1.78% and lower than that of M. Sangaré et al. [25] in Senegal (4.05%). According to Darbois [26], simple ligation exposes to 8% failure; whereas section-ligation, which model is the POMEROY method, is safer with less than 1% of failure rate. Furthermore, authors agree to recognize the possibility of permeabilization by tubo-tubal anastomosis to explain failures.
Women’s feelings after tubal ligation.
During our study, 40 couples expressed their feelings of satisfaction i.e. 71.42% versus 6 cases of regret (10.71%) (Table 4).
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Table 4. Women’s feelings after tubal ligation.
Such feelings of regret were related to the unfortunate events that occurred in the couple’s life, events such as:
- Divorce, but also and especially the death of a child which prompts a desire to procreate.
Some factors such as age at sterilization, the death of a child, the number of children at birth, remarriage, changes in socio-economic status, and the lack of information about surgical sterilization contribute to post-sterilization regret [27].
5. Conclusion
Contraceptive prevalence is low in our country. VSC represents 4.71%. Its ambulatory practice and the simplicity of the equipment used make it a cheap method. It can help reduce maternal morbidity and mortality by preventing high-risk pregnancies. However, the irreversible nature of the method imposes a rigorous selection of clients based on complete and good quality information during interviews to avoid cases of regret and requests for tubal permeabilization.