With the increase in the number of women undergoing cesarean section deliveries at the national referral hospital in Thimphu every year, many women opt for sterilisation after delivering the second child.
Gynaecologist at the national referral hospital in Thimphu, Dr Ugyen Tshomo, during an advocacy programme in Thimphu last month said our women are not giving birth to several children and undergoing sterilisation early in their reproductive age.
Records with JDWNRH show that women in their 20s undergoing sterilisation at the hospital are slowly declining while women in their 30s undergoing tubal ligation (TL) or tubectomy is increasing.
According to the hospital’s OT (operation theatre) registers, a total of 1,400 women between 20 and 29 years have undergone sterilisation in the last eight years.
Since 2010, about 1,721 women between 30 and 39 years underwent sterilisation at the hospital until last year while about 181 women aged 40 and above got sterilised in the same period.
Records with the hospital show that most of the TL is done with a cesarean section delivery but after 2013, there was a gradual decrease in women having TL after caesarian. However, the number of women requesting for TL without caesarian delivery is increasing.
Of the 3,368 women who underwent TL in the last eight years at the hospital, about 2,752 underwent TL during cesarean deliveries. Meanwhile, the number of women undergoing TL alone increased from 28 in 2010 to 127 last year.
Medical superintendent with the hospital, Dr Gosar Pemba said considering the population growth rate in the country, permanent contraception like tubectomy and vasectomy is not encouraged. The focus is on birth spacing in order to have a healthy mother and healthy baby.
Dr Ugyen Tshomo said that before performing TL surgery, the health staff now make sure that the woman is more than 25-years-old and her youngest child is more than five-years-old.
“Here, we have more say but during caesarian delivery, women have more say,” she said. “We tell them they are young and they may want more children later and confirm if they really want to undergo sterilisation.”
If the woman still says yes, then a health staff is sent out to ask the husband’s decision. “Why I am insisting on not letting women undergo sterilisation at an early reproductive age is because it is bringing down our fertility rate,” she said.
She said many women in their 20s have opted for the permanent method of family planning especially those who have cesarean deliveries saying they don’t want to have the second child.
Lack of informed decision, fear of another surgery or lack of family planning choices could be some of the reasons for women to undergo sterilisation in their early age, she said. “They could have adopted long-acting reversible contraceptives (LARC).
She said women in early 20s need to have family planning for the next three decades and whichever temporary family planning method they opt for, they are going to make mistakes. “So, there is a need for more choices of LARC.”
Currently, copper-T is the only LARC available in Bhutan and it is not popular with Bhutanese women. Only about 6 percent of the women use Copper-T.
Dr Ugyen Tshomo said copper-T doesn’t have side effects. Oral contraceptive pills and Depot Medroxyprogesterone Acetate (DMPA) injectable affect the whole body and do have some side effects if used for a longer period of time.
She pointed out that many women started coming back to the hospital for reversal of TL wanting more children. “We realised that many have not made informed decisions.” Some are forced to undergo TL by their parents, she said.
It was learnt that TL reversal is requested due to change in women’s lives like a death of spouse or children and divorce followed by second marriages.
Dr Ugyen Tshomo said that about 25 percent of the women who underwent sterilisation regret their decision and come back to the hospital saying they have made a mistake and they want a child. Due to these reasons, Dr Ugyen Tshomo said the hospital counsels women not to have TL.
She said that most women who remarry don’t tell their new husbands that they have undergone sterilisation. “When the husband pressures them to have a baby then they come to the hospital. So, we ask the women who comes to hospital for reversal of TL to bring along their husband.”
Having very limited choices, Dr Ugyen Tshomo said the hospital introduced another LARC (implant) since copper-T is not popular among the Bhutanese women.
“We insert something like a matchstick on the left upper arm of a woman which will prevent the woman from getting pregnant for three to five years,” she said. “If the woman wants children then the stick can be removed and they can get pregnant, just like copper-T.”
While for those who underwent sterilisation, she said even if TL is reversed, there are less chances of getting pregnant. Of the 15 women who get the TL reversed, only two to three would conceive.
Dr Ugyen Tshomo said the hospital faces difficulty in treating women who come for pap smear test, finds out that she has a high risk of cancer and that she doesn’t have any children. “If we treat them then they will not have a child so we urge them to have a child early if they want, before the treatment.”
After 30 years, she said women’s fertility drastically decreases so they are urged to have children before 30.