BOOKS & ELETRONIC MEDIA
Alison Scott, Anna Glasier
Lothian Primary Care NHS Trust, Family Planning and Well Woman Services, 18 Dean Terrace, Edinburgh EH4 1NL,Scotland
Contraceptive sterilization: global issues and trends
Author: EngenderHealth. Publisher: EngenderHealth, New York, USA (www.engengerhealth.org). ISBN 1-885063-31-8, price: US$ 27
Sterilization is still the most widely used method of fertility regulation in the world. The method currently provides contraception for some 223 million couples. For many women in developing countries sterilization is the first method of contraception that they will use. This new book, written and published by EngenderHealth, a non-profit organization for women's health with its headquarters in New York, is a scholarly review of contraceptive sterilization from a global perspective. It is more than just a reference book although it serves well as one. It contains a large number of very clearly laid out tables covering such issues as the worldwide prevalence of both male and female sterilization, the characteristics of female sterilization users and the current legal status of sterilization by country. The tables are interesting and useful but it is the emphasis on sterilization in the context of the broad meaning of reproductive health that makes this more than just a reference book.
In the executive summary of the book the authors observe that after the International Conference on Population and Development (in Cairo in 1994) there was a shift of focus from family planning and population control to rights and needs. Male and female sterilization, since both are irreversible, raise perhaps more issues of reproductive rights than other methods of contraception. There is accordingly a strong emphasis throughout the book on consent, informed choice, and counselling. The other new emphasis is on recognition that men and women who have been sterilized continue to have reproductive health needs, especially those relating to the prevention of sexually transmitted infections including HIV/AIDS.
This book reviews current trends, and speculates on future trends in the prevalence of sterilization around the world. It highlights a decline in sterilization prevalence in Asia and an increase in Latin America and sub-Saharan Africa. This change in incidence is a result of demographic, policy and programme factors. The book cites clear examples illustrating each of these factors. The number of couples in Latin American countries seeking to limit their family size has increased since the 1960s, and more and more couples are seeking female sterilization. In India a decline in sterilization incidence coincides with a government policy of abolishing the method-specific contraceptive targets which characterized the country's family planning programmes in the 1970s. In Indonesia the decline in sterilization incidence is probably due to an increased availability of long-acting and highly effective but reversible methods of contraception, particularly contraceptive implants.
With a thorough reading, some fascinating facts about sterilization come to light. The highest prevalence of female sterilization in the world is in Puerto Rico (48.7% of women of reproductive age who were ever in a union are sterilized) and yet most of us associate Puerto Rico with the development of the combined oral contraceptive pill. Male sterilization continues to be much less used but still represents an important family planning method (42 million men have undergone vasectomy). We have always known that vasectomy tends to be more popular in industrialized countries New Zealand and the United Kingdom top the vasectomy league with a prevalence of 18% vasectomy among men who are married or in union, but it came as a surprise to learn that the figure is as high as 8% for Bhutan and 5.4% for Nepal.
While there is a lengthy chapter on the demographic characteristics of women who are sterilized there are no data on the characteristics of men. The authors say it is much more difficult to collect data on vasectomy than on female sterilization but it is surprising to learn that there are no data which tell us anything very meaningful about the characteristics of men who are sterilized.
One of the most interesting chapters is the one on law and policy. The tables give a great deal of detail on the legal status of male and female sterilization in every country in the world. Only eight countries still forbid sterilization (compared with 28 in 1985) for anything other than medical reasons. Since 1985 sterilization has been legalized for contraceptive purposes in Brazil, Chile, Mongolia, Nicaragua and Peru. It is still restricted in Japan, and there is a minimum age requirement in many countries including eight countries in Europe with an age threshold of 25 years and Slovenia with an age threshold of 35 years. Interestingly, three countries impose restrictions on parity. One of them, Mongolia, simply states that a woman must have "many" children to be eligible for sterilization. Perhaps not surprisingly, many of the restrictions relate only to female sterilization. Permission is rarely, if ever, required from anyone other than the individual if a man wishes to be sterilized, and in most countries his age and the number of children he has do not matter even though the country may have strict laws about female sterilization. For those of us living in industrialized countries with governments becoming nervous about total fertility rates falling below replacement levels, it is interesting to speculate whether there may be an increase in the number of restrictions placed on sterilization in a subtle attempt to try to halt the population decline in the Western world.
The authors highlight gaps in research on sterilization and make some suggestions for additional topics, particularly for more longitudinal research on sterilization and more studies on provider attitudes. The reproductive health needs of sterilized men and women are also highlighted as an additional area which requires research.
The book is well presented and clearly laid out with useful boxes containing highlights at the start of each chapter. We would recommend it to policy-makers and to academics working in reproductive health. The two technical chapters on male and female sterilization are a very up-to-date and useful review of "how to do it". However this is probably not a book that will be tempting to the average provider. In some ways this is rather a pity since it is perhaps the providers who most need to be aware of the continuing reproductive health needs of couples, and the issues of choice and consent involved. 
Address to correspondence
Alison Scott
Email: Anna.Glasier@lpct.scot.nhs.uk