1	Contraceptive Sterilization in Low Development Settings: Case study in Uganda Nalwadda Gorrette (RN, BscN, Msc PRH) JHU Forgaty African Bioethics program Email: gnalwadd@jhsph.edu
2	Background Excessive fertility is a pressing matter of social, public and political concern in low development settings, Uganda in particular Historical role of the faith and values in health care Faith influence medical/fertility outcomes NB Faith is optional- welcome to join or not
3	Uganda health indicators Population growth rate: 3.4% Total fertility rate: 7 children per woman IMR: 91/1000 LB Maternal Mortality: Rate 506/100,000 LB Skilled attendance at delivery:38% Population below poverty line:38% CPR: modern 18%; Natural 5% Causes maternal deaths: appalling health status of women, absence of emergency obstetric care in the event of complications of pregnancy, low contraceptive use UDHS 2000/1
4	Need for contraception Prevention of fertility is so important to: Break patterns excessive and unwanted fertility Address: falling health indicators disturbingly high child and maternal mortality an overall rise of extreme poverty continuing food insecurity growing numbers of people living in slums
5	Why Contraceptive sterilization? Permanent/effective without continual expense, effort or motivation 0.4% failure rate compared to natural methods 20% failure rate Window of opportunity
6	Case study –part I Mrs. Mukasa a 39 year old, high parity (6 children). She lives in a rural village, no employment, illiterate and malnourished. She did not want to have more children Bad last experience- hemorrhage 6^th child Lack of resources to take care of other children She confided in a member of the clergy about possibility of surgical sterilization
7	Case study cont’ Clergy member retaliated church position that sterilization act is intrinsically evil and is always a mortal sin. Faith is optional- welcome to join or not Clergy member advised her to use natural methods of contraception and control her sexual appetite Faith and religious values were very important to Mrs. Mukasa
8	What do we know? Sterilization remains absolutely forbidden to the doctrine of Mrs. Mukasa’s faith Disagreement about contraceptive approaches but not benefits Religious bioethics is based on faith and in reason mainly on: ethics of human reproduction and end-of-life decisions duty to preserve life and the limits of that duty social justice right to health care
9	Issues Choices: woman's ability to make plausible choice Individual need vs. faith community position Faith influence on decision making
10	Case study part II Mrs. Mukasa become pregnant again for 7^th time She was rushed to government hospital after she developed complications prolonged and difficulty delivery at a TBA. She was delivered by C-section Considering her fertility history, the obstetrician performed surgical sterilization procedure with out consulting her- while on the delivery table
11	Ethical Issues Physicians did not acknowledge or respect choice of poor patient and her beliefs Clash between autonomy and beneficence Autonomy – demands that the patient is informed, and free from interference and control by others in order to act intentionally Beneficence – requires physicians to take positive actions for the benefit and in the best interest of patients
12	Ethical issues cont’ Paternalism: Obstetrician action showed total lack of regard for the mother's feelings Risk benefit assessment Value to patient Value to individual/family/nation Alternatives
13	Justice issues Equitable distribution of burdens and benefits Ethical obligation of obstetrician Social justice Fair equality of opportunities Distributive justice
14	Paradox Removing childbearing capability raises moral, ethical, and legal questions Surgical sterilization offers prospects for improved health Reasonable decision on fertility are based on logistics, health outcome, burden & cost Financial and non financial conflict of interest for faithful-individual needs vs. religious/societal Exceptional circumstances: special contraceptive needs for poor- human rights lens
15	Opponents claim Self-determination: the dignity of the human person are compatible with faith and health care ethics Physicians practicing evidence based malpractice? Best interest of woman purely speculative Possible social, religious, or marital conflict Risk distortion (patient and provider) Patient and family decide Autonomy, informed consent
16	Opponents claim cont’ Individual’s human dignity and right to bodily integrity overrides therapeutic need
17	Proponents Decision making: Vulnerable women not completely autonomous Medical utility Choices of woman Paternalism approach is consequential Financial justification vs. ethical justification Medical need: Ineffective natural contraception- partner dependent Justice in context of poverty would demand that women access contraception
18	Ethical questions Should obstetricians permit women with more than 6 children to undergo consequences of unwanted birth? therapeutic need or necessity How will values change? Decision making process taking into account proven technology and common good Which way do we go? Prophylactics interventions vs. Values How to integrate faith in prudent innovations to address true social, economic, political roots of problems?
19	Summary Conflict over medical and religious decisions on contraception issues Need for dialogue Faith mainly address spiritual issues but social, economical and medical issues may override in decision making Couples who tend to have completed their family size, and in many cases already have more children could benefit from contraceptive sterilization
20	Our challenge... Integrating the Sacred and the Secular bioethical concepts Harmonization of contraceptive technology, faith and values in a mutually beneficial engagement
21	Summary Sterilization is the most efficient birth control available. Window of hope for poor burdened by excessive fertility We can all help
22	References Beauchamp T. & Childress J. Principles of Biomedical Ethics. 4^th Edition. Oxford University Press. 2001 Lo Bernard. “Chapter 41: Ethical Issues in Obstetrics and Gynecology.” Resolving Ethical Dilemmas – A Guide for Clinicians, 2000, Lippincott Williams & Wilkins.