Exploring Factors in the Decision to Choose Sterilization vs Alternatives in Rural El Salvador

Miriam L. Cremer, MD, MPH; Erica Holland, BA; Maritza Monterroza, MA; Sonia Duran, MPH; Rameet Singh, MD, MPH; Heather Terbell, MD; Alison Edelman, MD, MPH

Disclosures

Medscape J Med. 2008;10(8):183

Materials and Methods

We explored factors influencing women to undergo tubal sterilization in addition to their knowledge about the procedure in 11 focus groups in January 2005. The study was approved by the Institutional Review Board of The University of Southern California as well as a committee representing the community in El Salvador. Women verbally consented to participate in the study.

All focus groups were conducted during a week-long health fair in the rural community of San Pedro Perulapan, a municipality in the Cuscatlan department of El Salvador (Figure 1). Local healthcare workers advertised the health fair. Women between the ages of 20 and 45 years with a history of tubal sterilization were offered to participate in the study. Study participation did not affect the ability to receive healthcare. Women were sequentially recruited to fill 11 focus groups of 5 to 10 individuals each (Figure 2).

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San Pedro Perulapan is in the Department of Cuscatlan in El Salvador. Image courtesy of Miriam Cremer, MD, MPH.

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Women in San Pedro Perulapan wait to participate in focus groups and to be screened for cervical cancer. Image courtesy of Miriam Cremer, MD, MPH.

A moderator fluent in Spanish and English who had experience in conducting focus groups facilitated eleven 90-minute focus groups. All sessions were held behind closed doors to ensure privacy and confidentiality. The demographic information of each participant was obtained (current age, age at tubal sterilization, number of children, education level, and occupation). Validated discussion questions were used with permission from EngenderHealth (New York, NY; Attitudes towards tubal ligation among users, potential users, and husbands in Jordan. October 2003 site email). The questions, listed in the Table , were used to guide the discussions.

Each session was tape-recorded, and additional information was collected through detailed notes. Separate transcriptions in Spanish were created for each of the 11 focus groups. All transcriptions were coded manually using grounded theory coding procedures.^[16] Primary endpoints to each question were identified, and key words were coded to represent common thematic categories. Subthemes were also collected and summarized.

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Instrument Used to Guide Focus Group Discussions
1. KNOWLEDGE AND CHOICE OF TUBAL LIGATION(30 minutes) A.When and how did you first hear about tubal ligation? What were you told about it? What was your initial impression of the method? B.What family planning methods (if any) had you used prior to tubal ligation? What were your experiences with these methods? What did you like about these methods? What did you not like about these methods? Why did you stop using these methods? C.How many children did you have when you first decided to have a tubal ligation? How long did you wait before making the decision and having the operation? Did you have any children between the time you decided and when you had the procedure? What do you think is an ideal number of children and did you have more or less than that? D.At the time you decided to have tubal ligation, how certain were you that you wanted to have no more children? How did you come to this decision? E.Who was involved in the decision to have a tubal ligation? Was it your idea or someone else's? If someone else, then who? F.What did your husband think of the idea? Did he want to have any more children? G.Did you discuss the decision to get a tubal ligation with anyone else? With family or friends? What were their reactions? H.What were you told are the advantages of tubal ligation? Why did the provider say women choose this method? I.What were you told are the disadvantages of tubal ligation? What did the provider say that women like least about this method? J.What were you told about the procedure itself? What were you told about the risks of this procedure? What did you think about these risks? K.What were you told to expect after the procedure? What questions, if any, did you ask of the provider? Did the provider answer your questions to your satisfaction?How did he/she treat you? 2. EXPERIENCES WITH TUBAL LIGATION (40 minutes) L.Tell us about your experiences finding a provider to perform the procedure. Did you have any trouble scheduling the procedure? M.How did you feel about the care you received during the procedure? How about after? How long were you in the recovery room before going home? N.What problems or complications (if any) were there after the procedure? What did you do about these problems? O.What health changes (if any) did you feel after tubal ligation? Have there been any changes to your menstrual cycle? What positive changes have you felt? What negative changes have you felt? P.What impact (if any) had tubal ligation had on your marriage? Does your husband treat you differently? Do you treat him differently? Did your husband decide he wanted more children after you got the tubal ligation? Q.What impact (if any) has your choice of tubal ligation had on your economic status? R.What impact (if any) has your choice of tubal ligation had on your education or job status? Did getting a tubal ligation allow them to pursue or continue education or get a better job? S.Who have you told about having a tubal ligation? What were their reactions? T.How satisfied are you with your decision to use tubal ligation? If not very satisfied, why? U.If you had to do it all over again, would you make the same decision again? What regrets (if any) have you had about the decision to use tubal ligation? Would you like to have more children? V.Would you recommend tubal ligation to a friend or relative? Why? 3. LAST QUESTIONS (10 minutes) W.What, in your opinion, should couples know about tubal ligation? What is the best way to inform them? X.What (if anything) had you heard about vasectomy? Did you ever discuss this option with your husband? If yes, why did you choose tubal ligation instead of vasectomy? Y.What suggestions do you have for improving tubal ligation services?

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