Obstacles for women who don’t want to be mothers – 09/08/2023 – Health

The bleeding started at 10pm on Saturday, July 22nd.

Paula* (Chilean, 30 years old) was at home. She thought it was her period, but after a while she got scared. There was a lot of pain and blood.

He decided to go to the hospital. Upon arrival, the doctors told her, “You’ve had a loss, a miscarriage.”

She was completely surprised. The woman never expected such news.

Paula had made the decision years ago: she didn’t want to be a mother under any circumstances.

Birth control pills failed and, once again, she lamented that no doctor wanted to perform surgical sterilization, better known as tubal ligation, a wish she had since she was 18.

“If my tubes had been tied, none of this would have happened. It was not a pleasant experience and I feel angry because I have been looking for a professional for years to help me fulfill my wish not to be a mother,” she told BBC News Mundo, the Spanish-language service. from the BBC, just days after suffering the loss.

What is it and what are the requirements?

Paula represents thousands of women in Latin America who do not have access to voluntary surgical sterilization, better known as “tubal ligation”.

This procedure is over 99% effective in preventing pregnancy, making it one of the safest methods available.

The WHO (World Health Organization), in fact, places it among the few “very effective” contraceptives.

In addition, it does not affect the body’s hormone levels (as other contraceptives do), which for many women is a considerable advantage, as it has no “side effects”.

How does tubal ligation work?

• Female sterilization prevents eggs from traveling down the fallopian tubes, which connect the ovaries to the uterus;

• This means that a woman’s eggs cannot meet the sperm, so fertilization cannot take place;

• There are different ways to block the tubes, either by applying clips, silicone rings or tying or cutting a small piece of the fallopian tube;

• It is a relatively simple surgery, usually outpatient. It is done by laparoscopy, a procedure in which doctors manipulate surgical instruments through small holes made from the skin.

The main difference compared to other pregnancy prevention methods — such as pills, intrauterine devices, vaginal ring, patches, injectable ampoules or condoms — is that it is permanent and irreversible.

This can be an important benefit for those women who have decided not to have children because they will never have to worry about it again: neither taking the pill daily, nor changing the device every month, nor continuing to spend money on contraceptives.

However, for many doctors it is the main reason that leads them to avoid this procedure.

Even more so if the woman is young and has no children.

This happens even in countries where access to the procedure is supposedly guaranteed by law.

This is a scenario that happens in Brazil, experts point out. In addition, a similar situation also occurs in countries such as Colombia, Argentina, Mexico or Chile. In these Latin American countries, as well as in Brazil, this surgery is considered a “reproductive right”.

To promote responsible motherhood and fatherhood, most of these countries establish a requirement that the woman be of legal age, that she make the request in writing (by signing an informed consent) and that before the procedure she undergoes counseling on sexual issues and reproductive health. by the attending physician.

But, according to the women and experts consulted by BBC News Mundo, this often translates into a series of obstacles that make access to tubal ligation very difficult.

This is the case of Paula, who expressed the desire to be sterilized three times, but always got negative advice from her doctor.

“The first time I tried it was when I was 23 years old, in the Chilean public network. The doctor told me no, that I was too young, that I hadn’t left university yet, that I was going to change my mind”, he says.

“The second time I was 25 years old and the answer was the same: that I didn’t have the maturity to make that decision. And the third time, just 3 years ago, they categorically closed the door on me saying that if I wanted a tubal ligation, should ask abroad (in another country).”

Her recent pregnancy, although unsuccessful, leaves her in a state of alert.

“With other contraceptives, failure can always occur. That’s the problem,” he says.

“I already want to forget about it. And I can’t,” he adds.

Waiting list

One of the biggest problems faced by women who want free access to this procedure is the long queues that exist in most public health institutions in Latin America.

And the situation of women who do not have children is even more complex.

“In the public system, waiting lines are huge and women without children are not a priority. That is why they are encouraged to take care of themselves with other contraceptive methods”, comments obstetrician-gynecologist Gabriel Zambrano, from the Itenü Medical Center in Caracas, about the Venezuelan reality that is repeated in several countries in the region.

According to the latest UN report on family planning, the Covid-19 pandemic has aggravated this situation, reducing the availability and access to contraceptive services for women, especially those with irreversible action, such as tubal ligation.

The UN says that the reality is worse in low- and middle-income countries, and among the most vulnerable.

Given this scenario, voluntary sterilization ends up being much more accessible to women who can pay for it privately.

This is the case of Amanda Trewhela, a Chilean who at the age of 34 got sterilization after requesting it for 16 years.

“In the public system, nobody wanted to operate on me because I was too young or because I didn’t have children… So I ended up in the private system. And it’s very expensive. This is the biggest obstacle of all”, he tells BBC News Mundo.

Amanda had to pay 4 million Chilean pesos (approximately R$ 23,000).

“They can tell you everything, the tough questions. And you have to face them. But if you don’t have money, everything goes to the ground”, he says.

Gender bias?

But there is also a cultural problem.

So says Francisca Crispi, physician, academic and president of the Faculty of Medicine of Santiago de Chile, who has been studying the issue of women’s sexual rights for years.

“In Latin America there is a question of women’s autonomy in the doctor-patient relationship. The prejudice that women cannot make decisions alone, that they are very emotional”, he warns.

“There is this idea that every woman should want to be a mother and, if you don’t want to at that moment, you will regret it later”, he adds.

As a matter of fact, obstetrician-gynecologist Gabriel Zambrano states that “the greatest fear we have is that the woman will regret it… We, the doctors, can be accused of cutting off a patient’s fertility”.

However, for the women consulted by BBC News Mundo, this fear of regret that doctors often have means that their reproductive rights and freedom of decision are not respected.

“There is a judgment in relation to women in which they infantilize us, make us think that our decisions are hasty, without thinking about them”, says Paula.

In the midst of all this, there are also religious arguments.

“There are centers that do not provide certain contraceptive benefits for religious reasons, although in this case conscientious objection is not regulated”, says Crispi.

On the other hand, she ensures that, although in many countries the law clarifies that the woman does not need her partner’s consent to undergo this procedure (this is the case in Argentina, Brazil or Colombia, for example), the reality is that there are still health centers that ask for it.

“We have many cases in which they ask the couple’s opinion and this ends up becoming a big barrier”, he says.

In Brazil, this issue is recent: only in March of this year did the law that dispenses with the spouse’s endorsement to perform tubal ligation for women and vasectomy for men come into force. This new rule also reduced the minimum age for performing these procedures in the country from 25 to 21 years.

Chilean Paula recalls that her partner’s consent was precisely one of the questions she received when she expressed her desire to have tubes.

“It’s as if your husband owns your decisions. It’s a very archaic and patriarchal look because it’s a personal decision,” she says.

In the case of Spain, the situation seems to be different.

According to doctor José Cruz Quílez, president of the Spanish Society of Contraception (SEC), there are no additional questions if a woman has not had children.

“Here, if the woman wants tubal ligation, the procedure is done regardless of whether she was a mother or not”, he explains.

“It’s their right,” he adds.

For Francisca Crispi, all existing barriers in Latin America are problematic, as contraception is “time dependent”.

“If a woman is denied, it could mean that she has an unwanted pregnancy in the short term. Therefore, this refusal of certain types of contraception seems problematic to me”, he points out.

This scenario becomes even more relevant if the UN numbers on unwanted pregnancies are taken into account: according to the international organization, between 2015 and 2019, there were 121 million of this type of pregnancy, which represents 48% of all pregnancies.

Some data:

• According to the United Nations, female sterilization is the most widely used contraceptive method in the world.

• According to the latest family planning report, 219 million women accessed female sterilization in 2020, which corresponds to 23% of women using contraceptives.

• Male sterilization is much smaller: it was performed on 17 million men, which represents 1.8%.

• Dominican Republic, El Salvador, Mexico and Colombia are the countries in the region where the prevalence of female sterilizations is highest, according to UN data.

‘Finally it’s over’

Two years after being sterilized, Amanda Trewhela says she feels “calm and happy”.

She recalls that, as she entered the ward to perform the procedure, a 50-year-old midwife approached her to tell her something she will never forget.

“She told me, ‘I think what you’re doing is super valuable. I didn’t get to be part of your generation that can make those decisions. I never wanted children, but nobody ever wanted to operate on me. I’ll take care of you here.”

Amanda claims that there she understood that she was part of a “community of women who live with this pain of obstacles, of questions, as if we were emotionally and hormonally weak”.

Upon waking up from the operation, Amanda started a new life. “I felt infinite tranquility. I thought, ‘It’s finally over’.”

Paula lives a different reality today.

Barely recovered from her recent miscarriage, she says she no longer has the energy to keep trying to get sterilized.

“Maybe in a few years I’ll find someone who thinks I’m old enough — and mature enough — to have my tubes tied.”

“Meanwhile, my partner is going to have a vasectomy, because for him there are no obstacles, they don’t even ask his age, or if he had children or not”, he says, with obvious discomfort.