Assessment Of Sterilization Services in the Combined Transvaal Area - by J Weinberg

Introduction

The sterilization operation is a safe medical procedure requiring the clipping of the two fallopian tubes on either side of the uterus - or sperm tubes for men. With proper training and experience it can be done quickly and effectively. 

This operation could help men and women to limit their families with the minimum amount of effort. This is crucial to the success and sustainability of the country's social and physical environment.

The operation can, at best, require a few hours in hospital. On the other hand, the organization needed to transport and sterilize women from scattered communities to one hospital on the same day is rarely easily achieved.

Sterilization in the public sector is provided free by the government and motivated in a passive way (information only) as a part of the education programme of the Provincial Administration a government-funded body providing fixed and mobile clinics offering family planning services and counselling, as well as travelling educators who promote 'Primary Health Care' issues.

Sterilization is also provided at private clinics charging individual rates. It is available at a cheaper rate by a NGO (Non Governmental Organization) called Marie Stopes International their vasectomy slightly more expensive than their laparoscopy.

AVSSA - The Association for Voluntary Sterilization of South Africa is an NGO providing free male and female sterilization. They are based in Cape Town. They have been persuaded, by Dr Pohl de Villiers who runs a super-efficient steri-programme in Paarl, to top up the fee of state doctors performing sterilization by R40 per patient (this can only be to state-commissioned private doctors).

AVSSA have had to withdraw their services from the Transvaal area, where large amounts of money were spent on advertising campaigns, including expensive television advertisements. These campaigns rarely reached rural communities and services were removed.

Procedure - Technical

The two types of female sterilization practised in this country, and in most other parts of the world, are: The Mini-laparotomy and the Laparoscopy. 

They both involve the clipping of the fallopian tubes, or Tubal Occlusion, mostly using the Filshie clip. Both require a theatre containing standard equipment. Both are usually reversible. The male sterilization procedure is the Vasectomy and is far less problematic than female sterilization.

Laparoscopy - Of the two methods, the laparoscopy is the more modern as it reduces the amount of 'operating', resulting in a smaller scar. In order to achieve this, the use of a laparoscope is required. 

This is an expensive piece of equipment resembling a long tube. It is inserted through a minute incision in the abdomen. The operator can then look through in order to locate the tubes and expose them for clipping.

This method requires special training and needs to be practised regularly. It also requires updated equipment. If it is learnt properly it can be performed rapidly and effectively. 

It requires less skill to perform under local anaesthetic with the mini-laparotomy, though more training and plenty of experience.

The operation could be made simpler with a short general anaesthetic, i.e. Valium or Pethidine.

Mini-laparotomy (mini-lap) - In this cheaper, more basic method, the womb is exposed to full view by opening the abdomen in an ordinary open-surgery type procedure. The operation uses basic operating instruments. 

It requires an incision, roughly the size of an appendix operation, whereafter the tubes are located and clipped manually. It requires a greater degree of experience to perform this operation under local anaesthetic as the risk of complications is increased. 

For this reason it probably best done under a short general anaesthetic which increases the patient's stay to about a day; if the patient's blood pressure is too high, the operation has to be cancelled.

This method is favoured for post-partum and post-abortion operations by Dr Esther Sapire (Lecturer in gynaecology at the University of Cape Town).

Pre Med - This is a standard dose given to calm the patients down as they may be over-anxious about the procedure. It is the equivalent of two Panado and one Ativan. It is also used to reduce pain or discomfort after the operation as some women want to leave immediately, possibly to be home when their husbands arrive.

Post-operative Condition - Marge Dyer (,Abortion Reform Action Group) says that she has heard reports of heavy periods, but that, medically speaking, there can be no repercussions as the uterine functions have not been interfered with. Post-operative complaints are usually to do with poorly performed steris and are on the decrease (see statistics).

Post-partum - (Dr Esther Sapire). This refers to female sterilization immediately and up to 4 days after birth (vaginal delivery and Caesarean section). Mini-laparotomy is the preferred technique post-partum. Specially trained nurses can perform postpartum tubal ligations (clipping) as safely as doctors, with no increase in morbidity.

Dr Sapire describes laparoscopy as inappropriate post-partum due to greater frequency of technical problems encountered immediately after delivery - she mentions meso-salpingeal tears, haemorrhage, incomplete application of occlusive clips due to enlargement of the tubes, uterine perforation with the insufflation needle, gas embolism and higher pregnancy rates. Nevertheless, Dr Marianne Duys who performs most of the post-partum sterilizations in the Transvaal favours and teaches this method (see 'Doctors and Training').

Interval - This refers to all female steris done at times other than around pregnancy, i.e. clients would make a special trip to the hospital.

The majority of hospitals in the rural areas use the mini-lap method as it does not require extra training, modern equipment and consistent upkeep. One hospital may have many doctors able to do the mini-lap, but no chance to practise them regularly. This is either because there is not enough demand for them due to the lack of a good promotion system, or because they have no time (Sekukune, Lebowa).

Doctors/Training

Dr Marianne Duys has been performing sterilizations for the last ten years, and she is the resident sterilization doctor of the TPA. She has perfected the laparoscopy method and uses it for postpartum steris. She favours the post-partum operation as it saves both clients and staff time and energy. She works with a highly efficient team which is pre-booked to perform steris at hospitals throughout the Transvaal.

The team is based at Hendrik Verwoed Hospital in Pretoria. Although there are other doctors who are commissioned from the private sector on a part-time basis, Dr Duys is the only doctor working for the TPA full-time. She performs approximately 5 000 Laparoscopies per annum.

Much like family planning, the government has only a vague commitment to training programmes for sterilization doctors. Dr Duys has tried to push for a better service that is given priority by the state (Provincial Administration). She feels it comes down to money made available for gynaecologists or doctors to specialize. In this way, we will achieve maximum cost-efficacy as well as provide the best service.

Steris should be done quickly and competently. She cannot, as the TPA would like her to do, train more doctors to go into private practice. She can train somebody who will undertake a 'sub-team' who could thereafter train other doctors in other places. Someone even once suggested to her that a team travel out with the 'eye-train', which gives optical aid to far-out communities, and perform steris along the way!

Dr Duys stresses, as do all other experienced sterilization doctors, that steris cannot be learnt by merely doing one or two with another doctor. Gynaecology students from Stellenbosch University had a high failure rate with sterilizations. 

People have to be trained properly. She says the training is inadequate in many places as follow-ups are not made. Some will lose interest after a few months and come back to her two years later to 'start again'. She receives one registrar per month (from the Pretoria area).

They accompany her on her trips out with the team. Some do not quite have the knack needed to grasp the laparoscopy method quickly. On the other hand, she might have them doing it perfectly on the first day. 

Whatever the case, she routinely checks 100-150 steris by registrars. Sadly, the registrars mostly go into private practice. In the total Transvaal region there are 2 167 doctors in the private sector and only 1 405 in the public sector.

Having doctors working in public facilities is dependent on their commitment. Most doctors are reluctant to leave their private practices as a lot of money is spent on their training and poorly paid government sterilizations are not a financially attractive prospect. Some doctors feel that sterilization is an unnatural and unhealthy process. 

This perception may be influenced by allegedly poor past service e.g. stories told by women concerning unsatisfactory treatment, of pain suffered after local anaesthetic or dissatisfaction with lengthy procedures done under general anaesthetic (sometimes for tutorial purposes) which may take a large part of a morning.

Some doctors object to steris being done under local anaesthetic - it is a tricky process and may have complications if it is not done properly, which is why training must be good and follow-ups made it is a high failure rate that gives the operation a bad name. Dr Duys says that even doing them once a week is not enough. "If a doctor is adequately trained and skilled this operation takes five minutes, otherwise it can take thirty to forty minutes."

The only other person attempting to offer any training in the laparoscopic method is Professor Hofmeyr of J G Strydom Hospital. Doctors interested in sterilization were to be referred to him by Bev Pepper (National Health), but she says they are few and far between. Professor Hofmeyr has presently trained one doctor in the method. This doctor is stationed in Brits and will no doubt be helping with the new health scheme in the North West.

He is taking sabbatical leave, but has two doctors at his hospital who are keen to take over the training programme. He personally feels that the mini-lap can be specifically trained to be done under local anaesthetic and cuts out much of the expensive, more sophisticated equipment. He has just come back from Zimbabwe where he found that Harare Hospital still uses the mini-lap quite effectively.

In hospitals short of staff, doctors get called away for more important cases, or may only be able to do steris in the afternoon. This is inadequate when many patients have to be done in one day. Some hospitals operate on less than a third of the required doctors who, furthermore, have to double-up as anaesthetists - requiring two for every operation.

A disturbing example of this is the Sekukune area of Lebowa where all four hospitals servicing its vast rural community are experiencing serious shortages and cannot perform any 'cool cases' (operations of a non-emergency nature which lack adequate staff and/or facilities). The birth rate in Sekukune is extremely high. There is no water and very little fertile land, due to past overgrazing.

The Association of Voluntary Surgical Contraception is a USAID-funded organization and would be willing to provide training for male and female sterilization doctors.

Motivation (Provincial Administration)

i. Advisors (and Non-departmentals)

Motivation is done by the Primary Health Care 'Advisors' of the Provincial Administration in the four Transvaal regions. In the Gauteng region it is done by the educational sector (under Ms L Enslin) of Provincial Administration Community Health Services. Their male and female advisors educate the public on all primary health care aspects in clinics, during house-to-house visits, in community centres and mobile clinics.

Their target groups vary from the school-going youth, non-school-going youth and teenage mothers to farmers, farmworkers, business people and industrial workers. This outreach takes the form of personal and group motivation. 

The education includes information on mother-and-child-health services, family planning, food and correct nutrition, personal and environmental hygiene, safety in the home and health care issues e.g. oral rehydration, AIDS and other STDs.

Advisors will talk about sexual responsibility in relation to scarce resources, water, for example. They do not preach small families, rather point out the advantages of them. Similarly, they will not preach sterilization although they will be quick to 'spot' a potential client - the typical model being the grande multipare (i.e. dangerous to the health of the mother to bear more than four children), but a woman could also 'qualify' through, for instance, extremely poor financial circumstances. Says Louise van Tonder Chief Community Liaison Officer of the East Rand in Gauteng - "We do not force steris down people's throats, especially not older women who are more resistant, although we do start off by telling them about limited water resources.

We have been accused of concentrating only on older women and are now concentrating on younger women. I would not recommend sterilization for a young women with one child." This is partly contradicted by Marge van Vuuren who says that older women with four or more children will consequently become targets for intensive family planning and lifeskills education. Quoted from the 1993/94 PA Education report:

"The role of the female advisor concerning the steri-patient is vital and indispensable. It is mostly the advisor who identifies the possible steri-patient on a house-to-house visit, at the mobile clinic, the fixed clinic, or the hospital clinic while giving education on contraceptive methods."

The advisor must participate in the sterilization process (see Procedure - logistical) and return to the client at a later date to follow up on her condition and schedule another visit to the clinic. Funding shortages affect the training of advisors. 

In the Gauteng region, they are paying for training and refresher courses out of their furniture budget. In some places, Boksburg, for example, the TPA is receiving supplements from the PDP by way of motivators and nursing sisters.

Programmes which target male industrial workers in the workplace have been focusing largely on AIDS, STDs and sexual responsibility. These efforts have had great successes in handing out condoms, thereby reducing STDs.

Lack of funds have obliged the TPA to use volunteers called 'Non-departmental Advisors' (NDAs). NDAs are not actually employed by the PA and therefore work wholly on a volunteer basis. Inevitably, they require consistent support and encouragement from TPA staff. They are usually security or personnel officers. They are given one week's training in three STDs, AIDS, family planning and sexual responsibility.

They are expected to do at least 2 hours of consultation per week, and meet with TPA advisors once a month to discuss 'different focuses'. They are instrumental with regard to reaching the men but are only volunteer workers and may be released when managers make structural changes. Ultimately, the employer in question has to agree that this service is necessary at all. There are only 28 NDAs in the legion of Gauteng.

Aubrey is an advisor in the Boksburg area. He works alone as the six NDAs which they had up until a few months ago could not be maintained. Even though the vasectomy clients are mostly white, he feels he has had a "cultural breakthrough". 

He is himself black and he says that ten years ago the concept of sterilization could never have been introduced to a traditional culture. Men always come and ask for more information following his visits to mines and industry - "It only takes one visit to explain that the operation does not decrease sexual potency or affect their married life".

He recently followed up on a mine worker who was sterilized and whose sex life was fine and suffered no side-effects. He says that the people he reaches mostly come from farout places. 

Many have come from Pietersburg, saying that they no longer 'trusted' their wives to take responsibility for their fertility. People have approached him after having heard or seen family planning messages on radio or television.

Recently, upon going to talk at West Rietfontein Mine, people rushed up to him before he had even begun, demanding steris on the spot. Many of their wives have been having children through Caesarean section for years. 

He gets calls from people referred from Rietfontein, Vosloorus, Brakpan and Germiston who are interested to know more. "Even if they are not keen to sterilize, they seem to understand the issue, the fact that only one or two actually sterilize per month is not an adequate reflection of progress made.

They want to take responsibility for their behaviour. Give them the facts and they will take action." Aubrey agrees that the problem lies with not enough advisors. Few have taken note of Aubrey's success. In the past, vasectomies have been practically all European and Indian. Very few vasectomies take place in rural areas (this excludes those at private clinics).

On the other hand, say the TPA (Gauteng), most women who do sterilize do so behind the husbands backs (in most places it is not necessary for husbands to sign the sterilization forms). This is another reasons why sterilization may not seem a viable option i.e women rush out after the operation in great discomfort, in the effort to be home before their husbands are back.

ii. Pre/Post-natal Motivation

Marge van Vuuren, head of family planning in the Gauteng region, says that the PA do not usually favour puerperal motivation. She says that women admitted for childbirth are there for a short time usually a few hours - as there is competition for the beds. 

To bring up the prospect of sterilizing at this time would be, according to the TPA's principles, unethical. This is a general statement based on the fact that the women will then be making an emotionally charged decision that they may later regret.

In fact, a woman may ask for a sterilization herself in which case she will get one. Some hospitals believe that it is in a woman's interest to sterilize after four and more children and may encourage it at this time (a view held by many non-urban hospitals). This will mean less trouble for the women in the long term as they are already admitted to the hospital and will not have to make another trip for the operation.

It may be difficult for a woman to return with a small baby. Rural women do not generally like to leave their homes unnecessarily as they have households or children to look after and  extra trips are expensive., unpleasant and time-consuming. Post-partum sterilization also saves the various TPA staff time which could be spent in further outreach or upgrading. It could also save further screening and administrative work.

Ms G. Waste of the TPA in Johannesburg, says it is usually older women who have post-partum steris, and are physically ready to stop having children. "If, all of a sudden, the number of 23-year-olds being sterilized started increasing, it would have to be looked into, but things like this have to be subjected to another individual survey." (The average age of women sterilizing has dropped slightly since 1984). She states that pregnant women discuss the issue of stopping children with the PHC staff whom they should, ideally, visit throughout their pregnancy depending on availability of services.

iii. General

Despite shortages, the TPA Education Programme (Gauteng) has reached 220 715 people on the subject of  'Time Births' (family planning education) and 109 262 on the subject of AIDS/STDs.

Provincial Administrations in the other three regions experience the same shortages of funds, facilities, doctors and advisors. All advisors have to have cars due to the scattered nature of the farm communities. They also cover schools and youth groups, often using videos.

Jacqui Greyling, head of TPA education in the Eastern Transvaal, says that, because of a realised need for more services, smaller organizations are trying to train community workers. They receive three weeks' training, then try to get jobs with the TPA to whom they are more or less useless (they are able to keep records and sometimes end up doing translation,).

Sometimes sterilizations fail and the advisors are blamed rather than the doctors. The TPA says they have little credibility, especially on farms where the farmer will choose who is to be the Induna. The Induna will then be regarded as a traitor by the rest of the community and cannot act as mediator. Vasectomies are extremely scarce; the most they have ever had in one year was 13.

It is mainly communities in the deep rural areas who lack some form of motivation. These were not reached by the TPA in the old Transvaal region and have not yet been tackled as part of the new system (probably because of funding shortages). The superintendent of Malamulele Hospital in the N.Transvaal states that all the doctors in the hospital can do sterilizations (minilap).

He says the problem is that nobody wants to be sterilized. They do not have any field workers of any kind. When I asked him if he would like help from the TPA he said that he would most like someone to come and give a training course in his area. Everybody who comes to the hospital comes on a word-of-mouth basis - they did 15 mini-laps in 1994.

In the Shilubani area in Gazankulu they have three in service facilities consisting of two hospitals and a clinic. Most of the motivation happens at these facilities. They also have Community Health Workers (CHWs) working outside the clinics. These have to graduate as qualified assistant nurses first, training for which takes at least a year. They then promote issues dealing with education, 'underdevelopmental theory' and health.

Mrs Malekuti of  Shilubani Hospital says that she would advise a woman to sterilize after three children as she has three herself, though she agrees that it is probably not enough towards future sustainability: "It is still a very rural area and things are slow in getting started." They have not yet done male motivation but are considering it for 1995.

Ithuseng Community near Tzaneen, Lebowa, does motivation within clinic services and also has CHWs out in the villages. The four main hospitals providing sterilization in Sister Mankuba's area (Phalaborwa to Tzaneen) are Shulweni, Letaba, Siebororo and C N Phathtidi.

Elim Hospital near Pietersburg does steris every month. Most are post-partum. The nurses advise at the hospital and the clinics, to which people make their own way. They give them all the information they can on responsibility, disadvantages of large families etc. They are reluctant to encourage a single mother with two children because 'someone might still come along'.

Many will decide on sterilization when they come to the ante-natal clinic. They will then have to go home and talk it over with their husbands. Some of the nurses believe it should be solely the woman's choice, but most believe it best if the husband's consent is acquired or they might bring their wives back asking for a reversal. Ms Sithole says it is a rural area and one cannot talk to the men. She has never heard of 'male motivation'.

Themba and Ferreira Hospitals in KaNgwane both do steris but have no motivation at all because both the Catholic nurses and the Chiefs oppose it and therefore also do the people.

Shongwe Hospital in the E.Tvl has been doing steris for many years (,mini-lap), having done at least 15 per month since 1993. They have largely voluntary CHWs (usually married women) who are overworked and underpaid, if at all, due to lack of hospital funds.

The North West region also consists of outspread, farm-style areas, again making transport essential. The North West has shortages of both transport and motivators. In addition to this, a nurse and an assistant nurse have to accompany the motivation process - if they were able to train more motivators who could then work in their immediate communities, the need for extra transport for motivation, follow-ups and booking would become unnecessary. The N.West is aiming to integrate all Bophuthatswana health facilities into the region on 1 April- 1995.

It is the general feeling amongst members of the Provincial Administrations that the reduction in their budget about four years ago was harmful to their ability to provide an efficient service said one: "The incorporation of the PA into the government health department has had a negative influence on our ability to open clinics, start up services and access training and funding."

These changes were the result of a badly researched belief that all 'basic' health services should be integrated into one and provided by the same service provider. The family planning sector of the PA was then incorporated into 'Primary Health Care' which is now the only service of the Provincial Administration.

This service is theoretically supposed to be provided everywhere, but because it is so condensed it can never adequately reach clients with the quality needed to be helpful, efficient and geographically thorough especially regarding mobile clinics. 

Upon visiting a farm in the Walkerville area, I found that out of a farming community of roughly sixty, there were five women who positively wanted sterilization. but no one had told them how to go about it or offered assistance.

The mobile clinic had stopped coming over a year before, and the only source of family planning involved a 10 km walk to a Monday morning pick-up point at the local showground. This is an example of an unmet need. 

Following incorporation, funding, which was never enough to begin with, was neglected in the area of family planning. One of the first items slashed from the Gauteng region were the youth clinics. This has led to a despondency over the various shortages, which ultimately comes down to budget. Said one: "Ours is a daunting task."

Referrals

Ideally, the best way to gauge the progress made by the TPA's motivational outreach would be to have an written account of how many service-users came about as a result (directly or indirectly) of their education programme. Hence, the system of referral cards was introduced whereby clients would fill in the origins of their presence at the clinic.

This system has not worked for a number of reasons. Gillian Waste described a scenario whereby clients will deny they have come via a PA advisor. "The clients like to take their health into their own hands." She says that the advisors were once paid for the number of referrals produced and would sometimes stand outside the clinic collecting names of people who went in, causing tremendous dissatisfaction amongst the clients. The PA receives reports of lost or neglected cards. It is extra work for the hospital staff and they are sometimes reluctant.

It is difficult to quantify the exact ratio of those who attend clinics through outreach and those who attend through word of mouth.

Procedure - Logistical

Hospitals which fall under the TPA sterilization scheme have a sterilization day every one to four months. The regularity will depend on the number of clients booked, but also on proximity to Pretoria because the team has to travel to far-out regions and is booked for the year, so it would be impossible to travel to some regions more often.

It is the advisor's job, once a woman has 'indicated' that she may be interested in sterilization, to provide her with all the information and book her for a day at the clinic. It is also their job to transport the clients to the clinic, assist in the theatre and afterwards in the ward. 

The advisor of the relevant area (this could be a hundred-kilometer radius) must then take them back to their various homes. Transport is always a problem. 

Few of the Administrations have proper buses and most use their own vehicles. Often the Community Liaison Officer (these supervise the advisors from collective areas) must take clients home. Quoted from the 93/94 PA Education report:

"On 24 March 1993 the male adviser in Vanderbijlpark transported 93 sterilization patients to the hospital and back to their different homes (Sebokeng, Orange Farm, Poortjie, Ennerdale, Rust-ter-Vaal, Vereeniging, Vanderbijlpark)."

On sterilization days (Gauteng region) officials will start the process of transporting at 6.00am and will never be finished before 6.00pm. Once the clients are at the clinic, advisors will supervise undressing/dressing of patients, sit with them in the waiting room, wheel them through to the theatre, assist in the process inside the theatre and in the post-operative phase.

They could not possibly get any more done. If the advisors book 50 for a day, there will always be 10-15 who arrive at the hospital having heard through word of mouth. 

They cannot turn these people away for they may never see them again. They have to then fill them in on the process, interview them, screen them and take vital statistics on the spot. The clients also have to be booked for counselling and a follow-up visit, then escorted home afterwards.

At Sabie Hospital in the Eastern Transvaal, steris are done every three months. The PA (Provincial Authority) of that area do have a Hi-Ace van. Officials have to begin at four in the morning carrying usually fairly weighty women with baggage and children from Pilgrim's Rest, Graskop and Hazyview. Up to 45 women are sterilized in a session. PA staff are sometimes only finished by 10.00pm.

In the North West region, shortages of advisors are made more apparent by the fact that they sometimes have to spend two days at the hospital. 

This happens because, depending on the region, there are too many sterilization clients so they have to start the steris early in the morning which means that the clients have to sleep over the night before. Some of the clinics do not have sleeping facilities, or the ones that do only have room for half the patients.

Clients end up sleeping in PA offices near the hospital - mattresses, food and toilet facilities have to be organized. Facilities provided by the hospital are often poor, for instance, at Potchefstroom Hospital. 

The Hendrik Verwoed team comes every two months. They do an average of forty-three steris per session, but the hospital only has beds for twenty and the toilet facilities are usually locked. Zeerust do an average of sixty steris per session and have no sleep-in facilities.

Says Sister Gurschler of North West Health Services: "Sterilization requires the presence of the entire PA staff. They are provided with one nurse for the theatre and they have to do the rest. They get despondent from the lack of assistance from the facility sector."

Carting clients to and from the clinic for appointments and follow-ups, as well as the necessary mobility of advisors, requires much transport. 

Many PA employees feel that they are doing people favours by transporting people back and forth. Some feel that the operation is free and people should get themselves to the clinics.

They feel it is additional pressure on manpower and resources already stretched by an inadequate budget. Says Mrs Wolmarans of the North West Health Services: "Advisors end up pushing trollies and taking care of babies when they should be working out in the field. 

We understand that there is a nursing shortage, but we have shortages of our own." Because of the progressive inaccessibility of rural areas, the advisor who already provides a sort of 'double service' carries a 'double load'.

Marge van Vuuren says that the PA (.Gauteng region) is even thinking of stopping vasectomies in some places because all the 'borderline' middle-class men (usually white,) are making use of the free service, and it is not getting to the target group for whom it was intended.

Statistics Statistics may differ slightly depending on the source.

i) Public Facilities (November 1994)

These include a private clinic in Klerksdorp where a doctor is commissioned to do mini-laps and vasectomies. Although they do about one hundred per month, the clients are mostly white.

Most facilities recorded are PA clinics or public hospitals (code 07 and 08.). Some are code 16 facilities. These are usually small hospitals or clinics with a theatre only doing sterilizations. 

The PA team no longer regarded it as worthwhile to visit them as they were doing too few steris, which means that there may be facilities which could be used if they had either sterilization doctors or community workers to bring clients in.

Government statistics still recorded the following steris done at code 16 facilities - though the only code 16 facility in the Gauteng region stopped in September 1993 (they did 8 that month and 12 the month before).

April to March 1993/94 (excludes homelands)

ii) Sterilizations

Total state sterilizations in the Transvaal region excluding homelands for April to March 1991/92/93/94:

Gazankulu recorded 420 female sterilizations for January to September 1994.

There seems to be a trend whereby over the past two years post-partum has increased by 6,32% and interval has decreased by 6,18%. This trend is not characteristic of Paarl Hospital in Stellenbosch, where both intervals and post-partum are on the increase.

Vasectomies decreased by 27,85%.

iii) TPA Sterilization Team Research 1983-1988

This report notes that the average age of steri-clients dropped from 37 yrs in 1983 to 36 yrs in 1988.

In 1988 the percentage of Asians using steri-services was 2,7. Whites showed a usage of 2,9% (many may have been using the services of private clinics,). Coloureds showed a usage of 10,1 (a significant increase in service usage from 5,9 in 1987). Blacks stood at 81%.

Literacy has seemed not to play a large part in client willingness to accept steris. In 1984 51% of all clients had no education. In 1988 the figure had dropped to 23,4% but still remained the dominant figure out of the various groups, i.e. grade 1 to tertiary.

No use of the mini-lap was recorded until 1988 when a use of 0,1% was recorded. The most popular type of clip used in 1988 was the Falope Ring at 89%, the second was the Filshie Clip at 6,1%. Complications with interval sterilizations dropped from 22,2% in 1983 to 4,4% in 1988 and with post-partum from 4,7% in 1983 to 0,1% in 1988.

The survey records most clients as not staying overnight, only 9,7% in 1988. The rate of failure increased from 1,5% to 2,8% in 1985, dropped to 0,5% in 1987 and rose to 1,6% in 1988.

Complaints over the procedure stood at 0,1% in 1983, rose to 0,6% in 1986 and fell back to 0,1% in 1988. Post-operative problems consisted of gynaecological/menstrual which dropped from 3,9% in 1983 to 0,8% in 1988; menstrual deviation dropped from 7,9% in 1983 to 1,4% in 1988.

Reported post-operative pregnancies:

Regarding women who were sterilized in 1988, the youngest children of 32% were toddlers, 27,8% were babies, 21,3% were children, 10,6% were infants, 5,7% were teenagers and 0,7% were adults.

Regarding people's reasons for sterilizing, there was a steady increase in those originating from TPA motivation - up from 45,1% in 1983 to 57,1% in 1988. This was probably considerably more, but because of the lack of an adequate system of documentation, it is impossible to prove.

 Conclusion

Although the PA in the central region increased their outreach by 58,53% over 1992/3, the number of sterilizations only increased by a few hundred. The overall sterilizations for the Transvaal region has come down in the last year.

The population in the combined Transvaal region, according to the April elections, stood at 15 615 283. Sterilization for the last year stood at around 17 000. The birth rate was probably twenty-five times that.

Nowhere during the course of this survey did there appear a hospital that did not have the facilities to perform sterilizations. The shortage lies in well-trained and adequately paid doctors, specializing in sterilization. 

Marge Dyer says that in a country like India sterilization doctors are almost certainly prioritized and ubiquitous. This may only happen in South Africa at such time as the urgent family planning requirements of rural areas are realised, and the need for a cost-effective population programme is literally forced upon us.

 Sources - Various levels of Provincial Administration officials from the Gauteng, North West and Eastern Transvaal regions; nursing and supervisional authorities from public hospitals throughout the Transvaal area; informed and qualified individuals knowledgeable in the area of sterilization, i.e. Marge Dyer (ARAG), Dr Marianne Duys (Hendrik Verwoed sterilization team), Molly Smit (Superintendent of Themba Hospital/KaNgwane); Sexuality and Contraception by Dr Esther Sapire; Provincial Administration and government statistics.

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