Arguments against restricting tubal sterilisation

National policies related to sterilisation differ in Latin America. Many countries have specific sterilisation regulations that are usually related to age or number of children, while other countries combine parity and age requirements. In Argentina, Guyana and Bolivia, the legal situation is unclear. Peru is known for its liberal legislation. Many countries such as Brazil, Chile and Ecuador require spousal consent for voluntary sterilisation.9 To our knowledge, no other country has a specific limiting sterilisation during childbirth.

Brazilian law provided only two criteria for performing tubal sterilisation during pregnancy: risk to the life or health of the mother or fetus and the completion of two successive caesareans. The apparent rationale of the law is to avoid an increase in the number of caesarean sections.

The first argument against this restriction is the fact that it is not effective. Tubal sterilisation is still performed during caesarean sections in Brazil. The difficulties imposed by the law do not mean that fewer women will choose sterilisation during pregnancy because most sterilised women choose to undergo the procedure during delivery and then pay for it separately.

Fernandes et al10 interviewed 335 sterilised women and noted that of the intrapartum procedures performed, 76% occurred during caesarean delivery. This fact plays an important link with female sterilisation performed during delivery in Brazil, where the public hospitalisation sector has been largely used; even so, there is the payment procedure. Although the sample comprised women who attended public hospitals and had characteristically low education levels, few reported economic factors justified the sterilisation choice. Satisfaction with the number of children was cited most often.

The second argument is that it is not necessary to perform a caesarean section to perform sterilisation procedure because the current techniques allow the dissociation between sterilisation and caesarean sections. If the aim is to avoid increasing caesarean sections, sterilisation by other techniques need not be restricted.

The third argument is that many caesareans are already performed in Brazil and changing the law to allow tubal sterilisation during childbirth will not further increase the number of caesareans being performed. Brazil is already known as ‘the world champion of caesareans’.11 Women in Brazil are choosing to undergo sterilisation during caesarean sections and, in most cases, pay for it separately.

According to Fernandes et al,10 the consequence of prohibiting postpartum tubal sterilisation may be increases in the number of caesareans that involve the performance of sterilisations that are not recorded in patients’ medical records.

The fourth argument is that outside that period, people interested in the procedure fail to access it. Because this access is not provided, the choice is not respected and couples seek alternative ways to sterilisation. Despite the law, tubal sterilisation although legal is not really available. According to Berquó et al12 in an unsupported health system, women take advantage of any opportunity where they are already using it. Childbirth and abortion procedures are conditions in which women are already enrolled for health services. By not allowing surgical sterilisation during these periods, the law creates an obstacle to rather than an expansion of access.

There are several difficulties to meeting the demand for surgical sterilisation in Brazil, including a lack of infrastructure and problems to enable the delivery of services to the people of reference.3 The law cannot extend the right of Brazilian women regarding the definitive methods.

Describing the perceptions of public health services managers and professionals concerning the provision of voluntary surgical sterilisation in the Campinas metropolitan area, Osis et al13 observed that people criticised that the impediment was established by the family planning law to perform sterilisation during delivery when a woman does not have multiple prior caesareans. In the interviewees’ opinion, this stipulation penalises women who have only vaginal deliveries. Moreover, this situation sometimes resulted in another pregnancy in women waiting to be able to undergo tubal sterilisation.13

The last argument is the issue of regret. Although sterilisation is intended to be permanent, expression of regret and requests for reversal are not uncommon, and this is an issue that causes concern. Regret is difficult to measure because feelings can change over time.7

Expanding the availability of tubal sterilisation would possibly result in more regret. Many problems involve choices between uncertain alternatives. Every day we are faced with decisions, some which have the potential to change our lives. Health services have the task of enabling people to make such choices. As such, counselling is essential. Information about alternatives must be given and tubal sterilisation cannot be the only choice.

Because autonomy and dignity are recognised as constitutional principles (in Articles 1 and 5) and the two are achieved through laws, the family planning law should be revised.2 Article 13 of the Brazilian Civil Code restricts corporal autonomy, allowing only those acts that do not cause decreased physical integrity.14 The fact that voluntary sterilisation is permitted by the Brazilian Constitution indicates that this procedure is not considered a constraint to this integrity and that pregnancy does not change this interpretation.

Pregnant women should be able to choose sterilisation in the same way as non-pregnant women. This does not mean an increase in caesarean sections rates; rather, it means increased access. There is no justification for denying individuals fertility control methods, nor is there justification not to honour women's reproductive choices.

Forbidding sterilisation during the delivery period appears to create an access barrier, thus making the law only an intention but not a true right. Revision of this restriction will arguably not contribute to increase caesarean rates but will increase the choice available to couples.