Contraceptive sterilization: global issues and trends.

Books & Electronic Media Contraceptive sterilization: global issues and trends Author: EngenderHealth. Publisher: EngenderHealth, New York, USA (www.engengerhealth.org). ISBN 1-885063-31-8, price: US$ 27 Sterilization is still the most widely used method of fertility regulation in the world. The method currently provides contra- ception for some 223 million couples. For many women in developing countries sterilization is the first method of contra- ception that they will use. This new book, written and published by Engen- derHealth, a non-profit organization for women’s health with its headquarters in New York, is a scholarly review of contraceptive sterilization from a global perspective. It is more than just a reference book although it serves well as one. It contains a large number of very clearly laid out tables covering such issues as the worldwide prevalence of both male and female sterilization, the char- acteristics of female sterilization users and the current legal status of sterilization by country. The tables are interesting and useful but it is the emphasis on steriliza- tion in the context of the broad meaning of reproductive health that makes this more than just a reference book. In the executive summary of the book the authors observe that after the International Conference on Population and Development (in Cairo in 1994) there was a shift of focus from family planning and population control to rights and needs. Male and female sterilization, since both are irreversible, raise perhaps more issues of reproductive rights than other methods of contraception. There is accordingly a strong emphasis throughout the book on consent, informed choice, and counselling. The other new emphasis is on recognition that men and women who have been sterilized continue to have reproductive health needs, especially those relating to the prevention of sexually transmitted infections including HIV/ AIDS. This book reviews current trends, and speculates on future trends in the prevalence of sterilization around the world. It highlights a decline in steriliza- tion prevalence in Asia and an increase in Latin America and sub-Saharan Africa. This change in incidence is a result of demographic, policy and programme factors. The book cites clear examples illustrating each of these factors. The number of couples in Latin American countries seeking to limit their family size has increased since the 1960s, and more and more couples are seeking female sterilization. In India a decline in ster- ilization incidence coincides with a gov- ernment policy of abolishing the method- specific contraceptive targets which char- acterized the country’s family planning programmes in the 1970s. In Indonesia the decline in sterilization incidence is probably due to an increased availability of long-acting and highly effective but reversible methods of contraception, particularly contraceptive implants. With a thorough reading, some fascinating facts about sterilization come to light. The highest prevalence of female sterilization in the world is in Puerto Rico (48.7% of women of reproductive age who were ever in a union are sterilized) and yet most of us associate Puerto Rico with the development of the combined oral contraceptive pill. Male sterilization continues to be much less used but still represents an important family planning method (42 million men have undergone vasectomy). We have always known that vasectomy tends to be more popular in industrialized countries — New Zealand and the United Kingdom top the vasectomy league with a prevalence of 18% vasectomy among men who are married or in union, but it came as a surprise to learn that the figure is as high as 8% for Bhutan and 5.4% for Nepal. While there is a lengthy chapter on the demographic characteristics of women who are sterilized there are no data on the characteristics of men. The authors say it is much more difficult to collect data on vasectomy than on female sterilization but it is surprising to learn that there are no data which tell us anything very meaningful about the characteristics of men who are sterilized. One of the most interesting chapters is the one on law and policy. The tables give a great deal of detail on the legal status of male and female sterilization in every country in the world. Only eight countries still forbid sterilization (compared with 28 in 1985) for anything other than medical reasons. Since 1985 sterilization has been legalized for contraceptive purposes in Brazil, Chile, Mongolia, Nicaragua and Peru. It is still restricted in Japan, and there is a minimum age requirement in many countries including eight countries in Europe with an age threshold of 25 years and Slovenia with an age threshold of 35 years. Interestingly, three countries impose restrictions on parity. One of them, Mongolia, simply states that a woman must have ‘‘many’’ children to be eligible for sterilization. Perhaps not surprisingly, many of the restrictions relate only to female steriliza- tion. Permission is rarely, if ever, required from anyone other than the individual if a man wishes to be sterilized, and in most countries his age and the number of children he has do not matter even though the country may have strict laws about female sterilization. For those of us living in industrialized countries with governments becoming nervous about total fertility rates falling below replace- ment levels, it is interesting to speculate whether there may be an increase in the number of restrictions placed on sterili- zation in a subtle attempt to try to halt the population decline in the Western world. The authors highlight gaps in research on sterilization and make some suggestions for additional topics, particu- larly for more longitudinal research on sterilization and more studies on provider attitudes. The reproductive health needs of sterilized men and women are also highlighted as an additional area which requires research. The book is well presented and clearly laid out with useful boxes con- taining highlights at the start of each chapter. We would recommend it to policy-makers and to academics working in reproductive health. The two technical chapters on male and female sterilization are a very up-to-date and useful review of ‘‘how to do it’’. However this is probably not a book that will be tempting to the average provider. In some ways this is rather a pity since it is perhaps the providers who most need to be aware of the continuing reproductive health needs of couples, and the issues of choice and consent involved. n Alison Scott1 & Anna Glasier1 1 Lothian Primary Care NHS Trust, Family Planning and Well Woman Services, 18 Dean Terrace, Edinburgh EH4 1NL,Scotland (email: Anna.Glasier@lpct.scot.nhs.uk). 146 Bulletin of the World Health Organization 2003, 81 (2) One world: the ethics of globalization By Peter Singer Published by Yale University Press, New Haven and London, 2002 ISBN 0-300-09686-0, price: US$ 21.95 Behind much of the discussion about globalization is a deep ethical concern. People are rightly worried about the impact of globalization on human well- being and the natural environment. And people who work in public health are especially worried about its impact on the health of those who are least advan- taged, who often have the shortest life expectancies and the greatest burden of disease. In his new book, Peter Singer examines some of the ethical issues involved. He devotes one chapter to climate change, first summarizing, in a very concise and fair way, the scientific evidence on global warming. He then notes some of the probable consequences: sea levels will rise and inundate areas of human habitation; weather patterns will become more volatile; food production will fall at some latitudes, though it may rise at others; and tropical diseases will spread. Rich nations will be better able than poor nations to deal with these changes. At present, Americans emit about 5 tonnes of carbon per person, while Chinese emit 0.76, and Indians 0.29. Singer finds no ethical justification for the present system that allows some people to emit a large share of the greenhouse gases, and others to bear more of the costs. So he asks what a fair distribution would be. He argues in favour of allocat- ing ‘‘equal per capita future entitlements to a share of the capacity of the atmospheric sink.’’ In the chapter devoted to economic globalization, Singer poses questions about environmental protection, national sovereignty, democratic practices, and the well-being of the poorest people in the world. Then he sorts through the evidence to answer these questions. Although World Trade Organization (WTO) rules allow member countries to take measures to protect human health and the natural environment, WTO practices often invoke a ‘‘product-versus- process’’ distinction that has the effect of limiting themeasures that members can adopt. Singer finds that the use of this argument tends to devalue environmental protection, national sovereignty, and democratic control. How has economic globalization affected the poorest people in the world? Singer considers the effect on both inequality in relative terms and well- being in absolute terms. He reviews the methods people have used to assess inequality, measure poverty, and deter- mine causality. His conclusion is sceptical: without better data on household incomes, we cannot knowwhat the overall impact has been. Since the Second World War, a kind of legal globalization has been taking place. Ideas about human rights, crimes against humanity, and international courts have begun to limit the old idea of national sovereignty. We have come to see that there must be ethical and legal limits to what nations can do, even to their own citizens. In a chapter entitled ‘‘One Law,’’ Singer focuses attention on this development and tries to specify guide- lines for military interventions for huma- nitarian reasons. When do outsiders have a right and a responsibility to intervene? Singer believes that humani- tarian intervention ‘‘is justified when it is a response (with reasonable expecta- tions of success) to acts that kill or inflict serious bodily or mental harm on large numbers of people,’’ though of course this answer raises further questions. One of the most interesting parts of this book is his discussion of foreign aid. Singer has lectured and written about this issue for over 30 years. During this time, he has changed some of the policies he advocates, but he has not changed his ethical view: when we can help people in great need without sacrificing some- thing of comparable moral worth, we have a moral duty to do so. Not to help in such circumstances is wrong. Singer sees no reason for assigning much moral weight to national bound- aries. Although he recognizes impartial reasons for giving some preference to family members and close friends, he argues that the strong preference we often give to fellow citizens is unjustified, especially when we consider the pressing needs of the 1.2 billion people living in poverty. He thinks that wealthy countries are morally required to give more aid to low-income countries. And he thinks ‘‘that anyone who has enough money to spend on the luxuries and frivolities so common in affluent societies should give at least 1 cent in every dollar of their income to those who have trouble getting enough to eat, clean water to drink, shelter from the elements, and basic health care.’’ There are points where I disagreed with Singer, but my disagreements are more about emphasis than policy. I would place more emphasis on the importance of face-to-face communities. Families, neighbourhoods, and local associations are settings in which people develop dispositions that are vital for ethical life and civil society. I realize that local associations can also foster hatred, racism, and indifference, but I’m concerned that social changes are disrupting the good as well as the bad. We need to combine caring local communities with ideals of global justice. More than Singer does, I would emphasize two important roles for moral philosophers. The first, in which Singer excels, is formulating, analysing, and evaluating ethical arguments. In doing this, he very usefully exposes confusions and double standards. But there is a second role: good philosophy can capture its time in thought, interpreting historical change in ways that show what is at stake. Others can then make practical use of that interpretation as they strive to fashion a more just and liveable world. n James Dwyer1 1 Associate Director, Consortium Ethics Program, University of Pittsburgh, 3708 Fifth Avenue, Suite 300, Pittsburgh, PA 15213, USA (email: jdwyer@pitt.edu)j. 147Bulletin of the World Health Organization 2003, 81 (2) Books & Electronic Media