Transcript Slide 1

Contraceptive Sterilization in
Low Development Settings:
Case study in Uganda
Nalwadda Gorrette (RN, BscN, Msc PRH)
JHU Forgaty African Bioethics program
Email: [email protected]
Presented at Faith-Based Organizations as Pioneers and Partners in Health
Systems Development, May 31, 2005, Omni Shoreham Hotel, Washington DC
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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
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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 contraceptiv
use
UDHS 2000/1
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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
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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
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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 6th child
Lack of resources to take care of other children
She confided in a member of the clergy
about possibility of surgical sterilization
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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
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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
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Issues
Choices: woman's ability to make plausible
choice
Individual need vs. faith community
position
Faith influence on decision making
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Case study part II
Mrs. Mukasa become pregnant again for 7th 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
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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
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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
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Justice issues
Equitable distribution of burdens and
benefits
Ethical obligation of obstetrician
Social justice
Fair equality of opportunities
Distributive justice
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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
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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
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Opponents claim cont’
Individual’s human dignity and right to
bodily integrity overrides therapeutic need
© 2001 H.
Kakande/DISH II
Project
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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 contraceptionpartner dependent
Justice in context of poverty would demand that
women access contraception
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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?
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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
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Our challenge...
Integrating the Sacred and the Secular
bioethical concepts
Harmonization of contraceptive technology,
faith and values in a mutually beneficial
engagement
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Summary
Sterilization is the most
efficient birth control
available.
Window of hope for
poor burdened by
excessive fertility
We can all help
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References
Beauchamp T. & Childress J. Principles of
Biomedical Ethics. 4th 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.
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