WPRO 9602
ORIGINAL:
ENGLISH
REGIONAL SEMINAR ON THE MEDICAL AND SURGICAL ASPECTS OF FAMILY PLANNING Sponsored by the
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Tokyo, Japan 2 to 8 October 1973
FINAL REPORT
Not for Sale Printed and Distributed by the Regional Offioe for the Western Pacific of the World Health Organ1zation Manila, Philippines October 1973
N~E
The views expressed in this report are those of the consultants and participants at the seminar and do not necessarily reflect the policy of the World Health Organization.
This report has been prepared by the Western Pacific Regional Office of the World Health Organization for Governments of Member States in the Region and for those who participated in the Regional Seminar on the Medical and Surgical Aspects of Family Planning, Tokyo, Japan, from 2 to 8 October 1913.
TABLE OF COlfl'ENTS
1.
INrIlJDUC'I'ION ...................................................... .
1 1 1 2 2
1.1 1.2 1.3 1.4 2.
General ............................................................................. .. Methodology and acceptanoe .•..••...•......•...•....•
Methodology and sooial aooeptance ••••••••••••••••••• Methodology and national/governmental acceptance ••••
ORGANIZATION OF THE SEMINAR .•.....•••••.••..•..•......•.• DISCUSSIONS ............ ,. ..................................................................... .
3
4 4
3.1 Methods ..................................................................................... .. 3.2 Traditional methods of contraception ••••••••••••••••
3.3 Intra-uterine devioes ........................................................... .. 3.4 Steroidal contraoeptives ••.•......••.•.•....••...•.. 3.5 Termination of pregnancy (induced abortion) ••••••••• 3.6 Sexual sterilization (female) ••••••••••••••••••••••• 3.7 Male sterilization (vaseotomy) ••••••••••••••••.••••• 4.. SU*ARY OF CONCLUSIONS ..............................................................
6 6 8 11
12
13 14
4.1 Traditional methods of oontraoeption •••••••••••••••• 4.2 Intra-uterine devices ...................................................... . 4.3 Steroidal contraceptIves .........•.................. 4.4 Termination of pregnanoy (induced abortion) •••.••••• 4.5 Sexual sterilization (female) •••••••••••••••••••••.• 4.6 Male sexual sterilization (vasectomy) ••••••••••••••• ANNEXES: 1
14 15 15 16 16 17
LIST OF PA.Rl'ICIPANTS, OBSERVERS, CONSULTANTS, TEMPORARY ADVISERS AND SECRETARIAT •••••••••••••••.•••.•• SEJIIINAR AGENDA •••.•.•••••••••.•••••••••••••••••••••.••••
18/19 27
2
3 4
LIST OF MATERIALS SUPPLIED TO THE PARTICIPANTS ••••••••••
31
LIST OF WORKING PAPERS AND COIDll'RY REPO.Rl'S ••••••••••••••• 33
1• 1.1 General
INTRODUCTION
The meaning of family planning has been clearly defined in the report of a WHO Expert Committee on Family Planning in Health Services. l The idea is to help individuals and/or couples - within accepted sociocultural, religious, national and/or governmental limitations _ to attain optimum health for themselves and their families. To bring about wanted births and to avoid unwanted ones is the whole objective of the current methodologies of family planning, and the methods that are employed should ideally achieve the objective without causing any harm to the individual. The reasons that prompt a person to seek family planning advice and service will vary with each individual and/or couple. A service that is good for one person need not necessarily be good for another and what may be acceptable in one society and cultural group may not necessarily be accepted in another. How national programmes and governments react to the demands of such services will largely be determined by the people and the prevalent cultural and religious situation. The resources and logistics available in the country are even more important factors that determine a country programme. It may be timely in many situations for countries to review their family planning programmes from the pOint of view of the acceptance, use and effectiveness of the various methodologies. To set targets and specific birth rates first and then to evolve methods for achieving these targets will be fraught with problems. The need for a family planning programme in every country has been thoroughly discussed in countless publications. In ASia, the population has increased by 49 per cent. over the past twenty years and in terms of absolute numbers, the Asian figure surpasses all other regions. Yet it is in Asia that constraints are multiple as compared with European and North American situations. 1.2 Methodology and acoeptanoe
What makes a particular method of family planning - be it a preconceptive or a post-conoeptive method - popular among individuals or couples not only depends on the relative effectiveness of the particular method but also on the logistics of the delivery of the servioe and its economic cost. Often a good method can obtain only a low aooeptance rate because of ill-founded rumours in circulation. In other situations, a particular method may have been accepted because it is the only one available in the country. Motivation and education play very important roles in helping an individual decide the methodology that she or he prefers and the assumption that only the educated are able to think and deoide for themselves does not appear always to be correct. There will be instances where the least educated may well be the best family planner.
lWld Hlth Org.techn. Rep. Ser., 1971, No 476
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In an ideal situation, every acceptable method should be offered and the privilege of making a choice can enhance the status of family planning in general. 1.3 Methodology and social acceptance
Social factors have a great influence on human behaviour in general and even more ao, in any decisIon to accept family planning. There are religious groupe that frown on the total complex of family planning and having no religion would appear to endow individuals with complete liberty and freedom to pick on any methodology they chooee. Ethnio factors, including traditional cuatom. and habits as well as environmental factors, are also important in decision-making for the individual and/or couple. It is useful to remember that these factors also form a motivating force resulting in the development of policies of national and/or governmental programmea in family planning. 1.4 Methodology and national/governmental acceptanoe
There are 39 countries or territories in Asia and only 15 have a pronounced policy for family planning within their health services. Three countries have no policy but provide a service and 21 have neither a policy nor support family planning. The heartening feature appears to be the shift in national and governmental policies towards active family planning programmes and the greatest shift appears to be taking place in Asia. Four countries have legalized post-conceptive methods in their country programmes (although only three offer all methodol~les in their services) and one has yet to approve officially the inclusion of steroids and intra-uterine devices among the pre-conceptive methods. However, it is apparent that countries take into cognizance the relative merits of each meth~ and apply it in their own situations in the hope of attaining their respective targets. A race s;towards targets can only be successful if there is a wide use of methodeiosies with high effectiveness but often the ideal situation fails to materialize because of the limita~ tions of the methodelegi86 and the appearance of undesirable side-effects, both founded and unfounded. Reliance on pre-conceptive methods alone will make it difficult to achieve targets. In the long run, a combination of pre-conceptive and post-conceptive methods will become necessary. A recourse to intensified programmes for sexual sterilization may be required, if not for helping to attain targets, certainly from a preventive point of view in terms of total maternal health. The integration of family planning services within ~al and child-health services finds general favour and acceptance in almost all country situations. The role of voluntary non-governmental institutions in family planning services will become less as governmental participation increases and in some countries even now, voluntary organizations are merely concerned with motivation programmes.
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,;
Old and new methodologies still mingle in family planning programmes today. More interest is being shown in some old method~Q81es like the rhythm and mechanical methods. Great advances are being made in the technology of post-concertive methods and allied pregnancy terminations, and sophisticated techn~ ~gies have been i~ced into modern day "§'~:lCY~1 sterilization. It seemed timely, therefore, to organize a seminar to discuss the medical and surgical aspects of family planning. This also provided an opportunity for experienced and responsible individuals from the Western Pacific Region of WHO to meet and discuss these methodologies in the light of their own experiences and those of their countries. The participants not only had an opportunity to listen but also to make their own contributions. 2. ORGANIZATION OF THE SEMINAR
The seminar was held in Tokyo, Japan from 2 to 8 October 1973 at the Health and Welfare Statistics Department, Ichigaya, Shinjuku-ku. It was hosted by the Government of Japan. A total of 21 participants from 17 countries were registered (see Annex 1). The seminar was opened by Mr Yoshio Yamaguchi, Vice-Minister, Ministry of Health and Welfare, Japan. He cited his country's policy of a sound family planning programme in order to better "the quality of the population in the future" and emphasized how successful this programme, which is integrated into the maternal and child health services, had been. He welcomed the opportunity for all participants to share the knowledge and long experience obtained in his country on the methods approved by the Eugenic Protection Act, and hoped the seminar would go a long way to promoting "maternal protection" and "improvement of quality of population in other countries." Dr Francisco J. Dy, Director of the WHO Regional Office for the Western Pacific, stated that it was most encouraging to note that most of the governments and peoples in the Western Pacific Region were now making earnest and positive efforts to establish and develop family planning programmes. It was appropriate to have an exchange of information on methods of birth control and the seminar was intended to provide an opportunity for a review and discussion of the various medical and surgical methods being used in national family planning programmes, and to give participants a chance to learn of the latest developments in contraceptive procedures. He stressed the need for a wide range of contraceptive methods to be umed. The individuals accepting these methods would influence the decision of the planners and policy makers. The stated objectives of the seminar were as follows: 1. To provide the participants with information on the latest developments in methods of contraception and on research in contraceptive procedures.
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2.
To review the contraceptive methods being used in national family planning programmes in the participating countries, and to discuss how the various methods available can be more widely used. To discuss, in particular, the client-centred approach to family planning counselling and the choice of method. Based on the discussion, to formulate practical conclusions which can serve as guidelines for the use and selection of contraceptive methods.
3. 4.
The working languages were English and French. The programme appears in Annex 2 and the list of background documentations provided in Annex 3. 3. 3.1 3.1.1 DISCUSSIONS
Methods (Information given in Country Programme Reports) Programmes
All participating countries have a family planning programme except for New Hebrides. These programmes are organized either by the government and/or by other agencies. 3.1.2 3.1.2.1 Methodology Pre-conceptive methods
Generally, as far as available statistics indicate, oral steroids are the first choice and intra-uterine devices run second except in Japan, Papua New Guinea, the Republic of Korea, the Republic of Viet-Nam, Tonga and Western Samoa. There appears to be an increasing acceptor rate for condoms. In Japan the rate is 72% and in Hong Kong, Malaysia and Singapore they appear to be more widely used than the IUD. The IUD programme appears to be extensive in the Republic of Korea with a reported cumulative rate of 82%. The use of injectable steroids appears to be on the increase in some countries. In the Khmer Republic the acceptance rate is 15~ and in Hong Kong, 3~. 3.1.2.2 Other methodology including rhythm
The acceptance rate for rhythm and other methods in most countries is very low except in Japan which has a 32.9% acceptance rate.
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3.1.3
Sterilization
Sterilization is not legal in the Khmer Republic, Laos, Malaysia, Trust Territory of the Pacific Islands and Western Samoa. The policy has yet to be defined in the Philippines, the Republic of Viet-Nam and Tonga. Sterilization is, however, done in these countries when medically indicated. The other countries have liberalized their policy for sterilization and this includes eugenic, medical and socio-economic reasons for the operation. Female sterilization is done in hospitals by trained OB-GYN specialists and male sterilization is done either in hospitals or private clinics. There are plans to expand these servioes. In this group of countries female sterilization is more acceptable than male sterilization with the notable exception of the Republic of Korea where the vasectomy rate is three times higher. Facilities for training in sterilization are available in all countries with national medical schools. 3.1.4 Post-conceptive method
The artificial termination of pregnancy is legal in Guam, Japan, Singapore and the state of South Australia. In Hong Kong an abortion law has been adopted to protect the doctors. These oountries have liberalized their indications for this procedure and provide training and facilities for carrying it out. In the other countries artificial termination of pregnancy is illegal except for strictly medical reasons. The same countries, however, report a continuing praotioe of illegal interruptions of pregnancy with their acoompanying complications. In other countries there are plans to liberalize the indioations for the legal termination of pregnancy. The following countries do not feel the need for artificial interruption of pregnancy as a method of oonception oontrol: Fiji, Laos. Malaysia, New Zealand, Papua New Guinea, the Philippines, Republic of Viet-Nam, Tonga, Trust Territory of the Pacific Islands, Western Samoa and Australia exoept for the state of South Australia. It is clearly evident that of pregnanoy has been used since use of pre-oonoeptive methods in countries where the situation is in Japan, where artifioial termination 1948, there appears to be an inoreasing oontrast to the programmes in some other being reversed.
It has been shown that in Japan the use of rhythm and oondoms has resulted in a high failure rate requiring artifioial termination of pregnanoy. It appears that in most countries with national medioal sohools, training is available for the artificial termination of pregnancy.
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3.2
Traditional methods of contraception (Document WPR/HR/MCH(FP)/44) Traditional methods implied the following I (a) (b) (c ) chemical methods, mechanical methods, rhythm method.
The unsatisfactory situation with chemioal and mechanioal methods as judged by the high pregnanoy rates - 16 to 44 for chemical methods and 6 to 18 for mechanical methods, the ritualistic preparations required, and the sometimes uncomfortable and sensitizing skin reactions to these methods have caused their waning popularity. Condom usage, however, is finding greater popularity despite its relative inefficiency for causes yet to be verified. The rhythm method can become uaeful, acceptable and effective if an easy and accurate method is available to pinpoint OVUlation. Its limitations must make it less appealing for the poorly motivated and poorly taught couple. The reported relationship in respect of a higher incidence of spontaneous abortions and malformed foetuses with the failure cases will require more intensive study. 3.3 3.3.1 Intra-uterine devices Intra-uterine contraceptive devices (Document WPR/HR/MCH(FP)/42)
The increasing popularity and aoceptance of the intra-uterine device have been evident since 1959. At present some twelve million women throughout the world are using the IUD. The IUD has advantages in that it is a fully reversible method requiring one decision and one action. It permits ooital independenoe and does no harm to general health. It has relatively high use-effectiveness and except for the initial cost of service for insertion, its cost is low. There are residual problems with the IUD in a sense that the ideal device has not yet been found. Meno-metrostaxis, pelv10 pain and resurgence of low-grade pelvic infections are gynaeoological problems that need to be contended with in IUD usage. The designs and types of IUDs were desoribed, including the second generation IUDs which are coated with progestational agents and metallic ions like copper. It was pointed out that it is useful to remember that the larger the size of the IUD, the higher the effectiveness and also the rate of untoward effects.
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3.3.2
Historical background (Document WPR/HR/MCH(FP)/46)
The history and the development of the IUD in Japan were traced. The resistance encountered to its use was a factor which had probably stagnated its further development and wider use in the country. Some early misuse before the advent of inert materials with concomitant undesirable side-effects had also been a factor in militating against its use. Hopefully, approval would be forthcoming resulting in a greater acceptance of this method. Professor S. Matsumoto, Chairman of the Special Committee for the Study of Intra-uterine Devices in Japan, gave a br1ef report on the technology of the insertion of the Ota ring. The Special Committee had recommended to the Japanese Government that the IUD be approved for official use and the Committee hoped its recommendations would be accepted. In the meantime IUDs were being used in Japan for research purposes. 3.3.3 3.3.3.1 Summary of country reports Acceptance
The acceptance rate varies from 2% to 8l~. Papua New Guinea and the Republic of Korea have the highest rates; Hong Kong and Malaysia the lowest. 3.3.3.2 Continuation rate The rate after one year
Accurate figures are difficult to obtain. varies from 50% to 9O~. 3.3.3.3 Pregnancy rate
Statistics indicate a rate of from 3.3.3.4 Type of IUD
2%
to
5~.
The Lippes loop is used almost exclusively in most countries. The Dalkon shield is being used in Australia, Hong Kong, and New Zealand. Copper-loaded devices and hormone-loaded devices are being used in researoh programmes in some countries. 3.3.3.5 Delivery of service
In most countries IUDs are inserted by doctors (somet1mes only by specialist gynaecolog1sts). In an increas1ng number of countries IUDs are now being inserted by nurses and midw1ves, under supervis1on, after a suitable training period. 3.).3.6 Time of insert10n
In most countries IUDs are inserted immediately after the menstrual period. Post-partum insertion is also practiced in a few countries.
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3.3.3.7
Follow-up
There is considerable variation in follow-up programmes. This is determined and influenced by administrative logistics. The interval between insertion and the first follow-up visit varies from one month to one year. 3.3.4 3.3.4.1 Summary of discussion Acceptance rate
The acoeptanoe rate is influenoed by many faotors, the most important of which are proper motivation and adequate counselling. Acceptanoe of the device should not be motivated by monetary inoentives either on the part of the patient or the dootor who inserts the device. 3.3.4.2 Continuation rate
As with the acceptance rate, much depends on proper motivation and adequate counselling. Adequate follow-up is an added important factor. 3.3.4.3 Copper-loaded devices
No evidence was presented that these have any feto-toxic effect. 3.3.4.4 TYpe of IUD
The Lippes loop is easiest to insert. Difficulties are sometimes encountered with insertion and removal of Dalkon shields and ota rings. Anaesthesia may be required for these procedures. 3.4 3.4.1 Steroidal contraceptives Steroid hormones in human reproduction (Document WPR/HR!MCH(FP)/43) The role of steroidal hormones, in particular oestrodiol-1TB and in the normal menstrual cycle was outlined.
~rogesterone,
The 'ovulation method an improved form described, particular attention being given to self-recognition of oestrogen and progesterone mucus secretion and the post-OVUlation rise in
I.
of the rhythm method. was OVUlation detection by induced ohanges in oervioal basal body temperature.
The various forms of steroidal oontraoeptives (oombination, sequential, mini-pill, morning-after pill, and long-aoting injeotable) were described. The meohanism of oontraceptive action of each form may involve some or all of the following funotions: (1) (2) suppression of OVUlation by inhibiting gonadotrophin secretion; the action of progestagens on oervioal mucus and, possibly, endometrial and tubal seoretions to produoe ohanges that interfere with sperm transport;
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(3) (4)
effect on the uterine endometrium; effect on ovum and zygote transport.
Data on the use-effectiveness of each form were presented, illustrating the extremely high reliability that can be achieved with this form of contraception. Long-acting injectable progestational agents would appear to have a potentially useful application with the woman who cannot remember to take her pill. It was, however, pointed out that there should be oare in selecting such women, if continuing use is contemplated, because of the long-term infertility that may follow. Use should generally be restricted to those women who have completed their family. The wider use of injectable progestational agents to ensure an infertility state during the post-partum period was discussed. An immediate post-partum injection of the three-monthly preparation may offer an extended period of infertility without suppressing lactation (the milk supply may actually be enhanoed). This would provide an opportunity for the woman and her husband to decide on the family planning method most acceptable to them for long-term use. The failure of return of fertility associated with prolonged use of the injectable preparation may not be a significant problem with this single shot applioation. Suitable trials to investigate this application should be carried out. The side effects, major and minor, and the metabolic changes attributed to the use of steroidal contraceptives were disoussed. In respeot to thrombo-embolio disorders, it was stressed that while available information suggests that there is a definite serious side effeot assooiated with the use of steroidal contraoeptives, particularly when they have an oestrogenic component, the incidence was exoeedingly low (in a number of countries the risk of lethal occurrence was less than the risk of death in a motor vehiole accident). It was pointed out that not all side effects of steroidal contraception are undesirable. The woman who suffers from extensive menstrual loss, dysmenorrhoea, pre-menstrual tension, acne or hirsutism, or who is underweight and suffers neurotio symptoms attributed to fear of pregnanoy may, if the type of steroidal contraceptive, is prudently seleoted, achieve better health as well as fertility oontrol. 3.4.2 Long-acting inJeotable steroids (Dooument WPR/HR/MCH(FP)!4S)
•
Long-acting Injectab1es of a progestational agent (currently available - medroxy-progesterone-acetate) have a definite p1aoe in family planning programmes for oertain individuals. The method enjoys a definite contraception action and a relatively high protection rate.
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Easy logistics are entailed if given at the time of parturition. The situation of improved lactation in a good series of cases and the definite prevention of a !loaby a year" situation makes the method particularly useful for ~hose who want to limit their families. This method, however, is less effective than sexual sterilization. Problems remain as to the side effects of irregular and prolonged cycles of amenorrhoea and to the more serious situation of the slow return to fertility. 3.4.3 3.4.3.1 Summary of discussions on background papers Improved rhythm method based on ovulation and fertility detection
Fertility detection by means of self-examination by the woman of pre-ovulatory changes in her cervical mucus was reviewed. This approach to improving the reliability of the rhythm method should be particularly welcome in countries where there is a significant Catholic population. In such countries the rhythm method may well be the only available method of family planning. 3.4.3.2 The acceptance Find 'xmtinua tion rates of oral contraceptives are adversely affected by the emphasis given by the news media to serious side effects. In certain countries there are laws limitinp; the distribution and use of oral contra~eptlves. 3.4.4 3.4.4.1 Summary of country reports Acceptance rate
This ranges from 7.0% (Republic of Korea) to 89.7% (Malaysia). In Japan, where steroidal contraception has not yet been officially approved, the reported acceptance rate is 2.4%. 3.4.4.2 Continuation rc"l+..e
Available data suggest that the continuation rate varies from 16% (Tonga) to 80% (Australia). 3.4.4.3 Pregnancy rate
This ranges from less than 1% (Australia and New Zealand) to 12% (Tonga). Almost all the failures have been due to factors other than the efficacy of the preparation. 3.4.4.4 Delivery and availability
In practically all countries oral contraceptives appear to be readily available. In Japan, availability is confined to the treatment of gynaecological disorders. In some countries there are distribution problems in remote areas.
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3.4.4.5
Follow-up schedules
These show a great variability depending on the sophistication of the medical services of the countries concerned. It was generally agreed that yearly follow-up is desirable. 3.4.4.6 Manner of follow-up In some countries
Most countries perform routine vaginal cytology. follow-up appears to be inadequate. 3.4.4.7 Side effects
There appears to be a markedly lower incidence of serious sideeffeots, such as thrombo-embolic disease and infertility, in the nonCauoasian populations. Minor side effects appeared equally common in all populations. 3.5 Termination of pregnancy (induced abortion) (Doouments WPR/HR!MCH(FP)!39) WPR/HR/MCH(FP)/4l, WPR/HR/MCH(FP)/47 and Menstrual Extraction - Population Report, Series F, No.2, April 1973). If a fertility control programme is to succeed, a combination of pre-conceptive and post-conceptive methods must be considered. However, the view was expressed that in some countries the targets might possibly be achieved by pre-conceptive measures alone. The Japanese experience demonstrates a significant fall in the use of post-conceptive methods with a concurrent increase in the utilization of pre~conceptive techniques. The practices employed are dilatation and curettage or aspiration during the first trimester. In the second trimester the predominant technique is gradual oervioal dilatation, under antibiotic cover, with laminaria tents followed by metrerynter bags. Recent developments seemed to indicate that prostaglandin analogues could be the agents of choice for second trimester termination. However, opinions differed as to the ideal route and dosage of administration. Menstrual extraotion as a new innovation for fertility control was noted with considerable interest. It was considered safe and effective. However, its applicability appeared to vary greatly. in the oountries represented at the seminar. The data presented showed a wide range of mortality and morbidity rates. The main relevant factors include parity, method employed, skill and experience of the operator, and conditions under which the termination is performed. It was emphasized that the period of gestation was of particular importance in reduoing the risks of the prooedure - "the earlier the better".
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3.6 Sexual sterilization (female) (Documents WPR/HR/MCH(FP)/40, Sterilization - Population Report. Series C-D, April 1973; Japan Laws on Sterilization (Eugenic Proteotion Law, Chapters I and II and Film Commentary on Teohnique of Female Sterilization) •. The topics oovered inoluded terminology, legal aspeots, teohnology and training. The term sexual sterilization was not generally favoured. Other terms suggested inoluded fertility termination, tubal ooolusion. 3.6.1 Legal aSpeots
Laws relating to sexual sterilization are relatively olear in Japan and Singapore. In Japan, the ohief oonsiderations are maternal health and hereditary transmission of serious illness. The Singapore regulations. take socio-economio oircumst.ances also into consideration. In these oountries the law provides that the ciroumstanoes relating to sexual sterilization should be explained to the patient, who is warned that the prooedure is irreversible. While oonfidentiality is preserved, dootors must report cases of sexual sterilization to the government authority concerned. In Singapore, the qualifioations whioh permit a dootor to perform this operation have been set out. If these oonditions are met, the dootor is protected by law against a possible negligenoe suit. A dootor is free to opt out of the sterilization programme. The husband's consent is required in Japan, but not in Singapore. With referenoe to oompulsory sexual sterilization, it was thought that the Proolamation of Teheran (1968) was quite appropriate. This proclamation states that "parents have a basic human right to determine freely and responsibly the number and spaoing of their children." Laws in other countries were considered to be not as olear as those in Singapore and Japan. 3.6.2 Technology
The oonventional trans-abdominal surgical approach was considered to be still the most appropriate as compared to other approaches, inoluding endoscopic techniques. The Uchida teohnique, in the author's own experienoe, appeared to be associated with zero failure rate. Different forms of anaesthesia were oonsidered; looal anaesthesia was considered most suitable for post-partum sterilization. The timing of sexual sterilization was considered to be influenced by the praotices and customs of different countries and also by logistic factors.
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The hazards of the conventional surgical procedures were generally regarded as infrequent. The socio-psychological complications, such as complaints af ~educed libido. were considered difficult to define; improved education and motivation were seen as possible approaches in reducing these complications. Pregnancy was reported to occur in 0-2 per cent. of patients who had conventional surgical sterilizatic~. Some surgical procedures which have become more popular in recent years were discussed. They included: laparoscopic and culdoscopic sterilization; colpotomy sterilization; hysteroscopic sterilization; ovarian isolation or displacement. These techniques were noted to require additional equipment and training and their evaluation has, hitherto, been less extensive than that of the conventional surgical procedures. A more careful selection of patients is also desirable. 3.6.3 Training and training facilities
It was felt that as circumstances varied in different countries, each country would have to determine the need and scope of its training programme. It was considered that some countries in the Region had potentialities for the establishment of training centres. A few guidelines were considered in relation to this organization. 8terilization should preferably have been officially approved by the country and clinical material should be available without much difficulty. There should also be opportunities for surgical practice by graduates from foreign medical schools, even if only on a limited scale. It would be more profitable if the organizers and teachers in a training centre had long-term appointments. It would also be desirable to provide funds to supply equipment for the trainees to carry out the procedures they had learnt, thus improving the standard of their national training programme when they returned home. 3.7 Male sterilization (vasectomy) (Document Film on Vasectomy Technique). WPR/HR/MCH(FP)/40 and
In some countries there were no laws relating to male sterilization; in others, they were not very clear. Male sterilization was legal in countries like Fiji, Japan, Republic of Korea and Singapore. In most countries motivation seemed not to be very intensive; in the Republic of Korea it appeared to be most sophisticated and successful. Acceptance of vasectomy was relatively poor except in the Republic of Korea where the operation was considered convenient and reliable. In Japan, some men consented to the operation to prevent their wives from undergoing repeated abortions. In some countries the men left more of the responsibility for family planning to their Wives. Common reasons for poor acceptance appeared to be the fear of loss of libido or interference with physical work.
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The operation can be carried out by any doctor in Japan although urologists are by far the most experienced. A similar situation prevailed in the Republic of Korea. It was felt that any qualified doctor with special interest in vasectomy could carry out the operation after adequate training. If facilities and clinical material are available, the following training might be considered adequate fo~ a dootor: to observe ten operations; to carry out with assistance, another ten, and to perform without assistance, but under supervision, fifteen operations. The technique of vasectomy was generally regarded as simple, but caution was expressed against exaggeration of this view as the general principles of surgical procedures might become relaxed. Local anaesthesia was preferred in most instances. Available data suggested that the spontaneous recanalization rate was less than one per cent. Prospects for reversibility were more promising after vasectomy than after female sterilization. The duration of persistence of active spermatozoa in the ejaculate after sterilization was not clear. It was felt that this aspect and other problems, such as reversibility and rising antibody titres, required further study. 4. 4.1 SUMMARY OF CONCLUSIONS
Tradi tional methods of contraception
Three fields for further investigation are suggested to increase the use-effectiveness of the traditional methods as follows: (1) (2) An accurate method to pinpoint the day of ovulation. Collection of data on the outcome of pregnancies following the use of the rhythm method. Some studies report the occurrence of spontaneous abortion and/or defective or malformed offsprings with the employment of this method. This has been attributed to fertilization of an aging ovum by a fresh sperm or of a fresh ovum by an aging sperm. There is a need to establish the validity of this report. proper family size is related to the appearance of a male child. A method for the pre-conception determination of the sex of the child would accelerate the adoption of permanent methods by the couple.
(3) An important factor in oriental culture in deciding on of a
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4.2
Intra-uterine devices
4.2.1 The high use-effectiveness and the safety of the IUD are olearly established. 4.2.2 The ideal IUD has yet to be produoed. Japan with its high standard of technology should mobilize its resouroes in the searoh for an ideal device. 4.2.3 The use of trained health Workers other than dootors for the insertion of IUDs is generally aooepted and should be enoouraged in all programmes. 4.2.4 The optimal time for insertion of IUDs is not absolutely olear although in most countries they are inserted after the menstrual period. 4.2.5 The optimal re-cheoking time for an IUD aooeptor has been suggested as a minimum of twelve months, but aooeptors should be seen as and when they wish. It is recommended that IUDs be replaoed not later than three years after insertion. 4.2.6 In country programmes, concerted attempts should be made to counteract ill-founded rumours about the use of IUDs. National programmes should enoourage a wider aooeptanoe of this method of family planning. 4.3 SterOidal contraceptives 4.3.1 Steroid hormones are the most effeotive agents available for contraceptive purposes. 4.3.2 In certain oountries with predominantly rural populations continuation rates are disappointingly low. In these situations inJeotable steroids may prove more suitable. 4.3.3 Strong support was expressed for the distribution of steroidal contraceptives by trained health workers other than dootors in oountries with high maternal and infant mortality rates. 4.3.4 These drugs appear particularly free from serious side effects innon-Cauoasians; a fact that should inorease their acceptability. However, it is desirable that further studies be made in this field. 4.3.5 Whenever exaggerated reports are published on serious side effects and these are attributed to steroids or any other form of contraoeption, efforts should be made by appropriate bodies to put the problem in its true perspective. 4.3.6 In view of the large Catholic population in the Western Paoifio Region research is urgently required to develop means of reliably determining the fertile phase of the menstrual oyole.
- 16 -
4.4 Termination of pregnancy (induoed abortion) 4.4.1 An obligation exists for programmes to "back-up" pre-conoeptive method failures with post-oonoeptive measures. 4.4.2 It was reoognized that legal, religious, oultural and other factors playa significant role in the adoption of post-oonceptive fertility regulation. 4.4.3 In countries contemplating modifioations of their laws on abortion, it is reoommended that consideration be given to restrioting termination to pregnanoies of less than twenty weeks' gestation. 4.4.4 In the light of present knowledge, menstrual extraotion appears promising and warrants further study. 4.4.5 The ideal method of pregnancy termination, espeoially in the second trimester, has yet to be found. 4.4.6 Early post-conceptive fertility control would greatly reduce the inc~dence of complications and, indeed, the need for second trimester termination. 4.4.7 Adequate training of physicians in pregnancy termination is a prerequisite, although the actual duration of training appears to vary from six months to three years depending on oircumstances. 4.4.8 The anesthesia employed varies from naroosis, looal, regional to general, depending on the availability of personnel. Paraoervioal block is adequate in countries where anaesthetiats are not readily available. It would be beneficial to conduot oomparative studies to evaluate the relative safety and effectiveness of various methodology. 4.5 Sexual sterilization (female) 4.5.1 Sexual sterilization was regarded as a very important decision for the patient. 4.5.2 There is a need for a less offending or less misleading alternative to the term sexual sterilization. 4.5.3 The laws ooncerning sexual sterilization in many oountries would benefit from a review and oould probably be rendered more clear. Although the prevailing circumstanoes in a country are of paramount importance, the experienoes in Japan and Singapore could serve as useful pointers. It was felt that the oonoept of the basio human right should also be taken into consideration. Periodic review of the laws was seen as desirable. 4.5. 4 There is no ideal method for female steri11zation. It was generally agreed that the doctor should help the pat1ent choose the partioular method.
- 17 -
4.5.5 The conventional surgical procedure was thought to have sufficient merit to be adopted widely. Refinements in techniques, as for example in the Uchida procedure, could improve effectiveness. 4.5.6 Endoscopic and chemical methods of sterilization require further evaluation. It was emphasized that endoscopic techniques should preferably be carried out in areas where facilities for prompt general surgical treatment are available. The cost and maintenance of sophisticated instruments were added factors for consideration. 4.5.7 The opportunities for setting up training centres might profitably be explored. Some provisions governing the establishment of such centres were considered. 4.6 Male sexual sterilization (vasectomy)
4.6.1 There was a definite place for vasectomy in family planning. Motivation and education were among the factors which could help remove some fears and misconceptions associated with the operation. 4.6.2 A review of the laws would be helpful in some countries, full consideration being given to local circumstances. 4.6.3 Training facilities for any interested doctor should be made available and training centres set up in suitable countries. 4.6.4 The procedure was generally regarded as very simple.
4.6.5 Organized follow-up studies with respect to long-term sequelae were felt to be desirable.
- 18/19 -
ANNEX 1
LIST OF PARTICIPANTS, OBSERVERS, CONSULTANTS, TEMPORARY ADVISERS AND SECREl'ARIAT I.
PARTICIPANTS Dr John David Martin Professor Department of Obstetrics & Gynaecology University of Western Australia King Edward Memorial Hospital for Women Subiaco, Western Australia 6008 Dr Sefanaia B. Tabua Consultant Obstetrician/Gynaecologist Fiji Medical Service Fiji Government c/o Lautoka Hospital Fiji Islands Dr Chow Sau Ha Medical and Health Officer Maternal and Child Health Centre 2nd Floor, Tang Shiu Kin Hospital Queen's Road, E. Hong Kong Dr Kiyoshi Arai Professor Department of Obstetrics & Gynaecology Teikyo University, School of Medicine Kaga 2-11-1, Itabashi-ku Tokyo 173 Dr Ichiro Mori Professor Department of Obstetrics & Gynaecology Kagoshima University, Faculty of Medicine c/o International Affairs Division Ministry of Health and Welfare 1-2-2, Kasumigaseki, Chiyoda-ku Tokyo
AUSTRALIA
FIJI
HONG KONG
JAPAN
- 20 -
Annex 1 KHMER REPUBLIC Dr Inn<cunlay Assistant de gym;cologie et d' obstetrique Hopital de l'Amitie khmero-sovietique Botte postale 143 Phnom P::;-;h Dr Chantho Professeur a l'Ecole royale de Medecine Hopital Mahosot Vientiane Dr Ahmad bin Adnan Director of Medical and Health Services, Perlis c/o General Hospital Kangar Perl1s Dr Thomas Ni,; Khoon Fong Senior Consultant Obstetrician & Gynaecologist General Hospital KUala Lumpur NEVI HEBRIDES
LAO!:'
MALAYSIA
Dr E. Dorney c/o BDA Lakatoro via Vila Dr J. Lawrence Wright Professor, Head Department of Obstetrics & Gynaecology Medical School, University of Otago P.O. Box. 913 Dunedin Dr G.C. Bird Senior Obstetrician & Gynaecologist Department of Public Health of Papua New Guinea Port Moresby General Hospital Free Mail Bag Boroko
NEW ZEALAND
PAPUA NEW GUINEA
- 21 -
Annex 1
FHILIPPINES
Dr Tagumpay R. Esguerra Chief of Clinics Dr Jose Fabella Memorial Hospital Lope de Vega, corner F. Huertas Manila Dr Alicia de la Paz Associate Professor Department of Obstetrics & Gynaecology Far Eastern University c/o Dr Nicanor Reyes Medical Foundation P.O. Box 609 Manila
REPUBLIC OF KOREA
Dr Jin Yong Lee Instructor Department of Obstetrics & Gynaecology Seoul National University College of Medicine Seoul -Dr Sang-Keun Lee Associate Professor Department of Obstetrics & Gynaecology Chonnam National University, Medical School Kwangju
REPUBLIC OF VIET-NAM
Professeur a la Faculte de Medecine de Saigon Saigon Dr R. Sivasamboo Consultant and Head Department of Obstetrics & Gynaecology Thomson Road General Hospital Singapore 11 Dr 'Alo 'Eva Acting Director of Health Ministry of Health Nuku'alofa Dr Ulai T. Otobed Obstetrics & Gynaecology Specialist I Macdonal Memorial Hospital P.O. Box 39 Koror, Palau Western Caroline Islands 96940
Dr HO-Trung-Dung
SINGAPORE
TONGA
TRUST TERRITORY OF THE PACIFIC ISLANDS
- 22 -
Annex 1
WESTERN SAMOA
Dr Tu'u'u Faleto'ese Medical Officer-in-Charge Obstetrics & Gynaecology School Government Hospital Apia II. OBSERVERS
MINISTRY OF HEALTH AND WELFARE, JAPAN
Dr Hiroshi Furuya Chairman and Professor Department of Obstetrics & Gynaecology Juntendo University Medical School 2-1-1, Hongo, Bunkyo-ku Tokyo Mr Chojiro Kunii Secretary-General Family Planning Federation of Japan c/o Hoken Kaikan 1-2, Ichigaya, Sadohara-cho Shinjiku-ku Tokyo Dr Tetsuya Matsuwura Executive Member of Board of Trustees The Japan Medical Association 5, 2-chome Kanda-Surugadai Chiyoda-ku Tokyo 101 Dr Seiichi Matsumoto Professor of Jichi Medical University c/o Mr T. Katagiri Regional Executive Secretary Hoken Kaikan 1-2, Ichigaya Sadohara-cho ShinJiku-ku Tokyo 162 Dr Willard H. Boynton Deputy Director Office of Population United States Agency for International Development Department of State Washington, D.C. 20320
FAMILY PLANNING FEDERATION OF JAPAN
JAPAN MEDICAL ASSOCIATION
INTERNATIONAL PLANNED PARENTHOOD FEDERATION
UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT
- 23 -
Annex 1
III.
CONSULTANTS Mr T.H. Lean Clinical Professor of Obstetrics and Gynaecology University of Singapore and Senior Consultant Obstetrician and Gynaecologist Kandang Kerbau Hospital Singapore 2 Republic of Singapore Dr Takashi Wagatsuma Associate Professor Obstetrics-Gynaecology Department University of Tokyo 7-3-1, Hongo Bunkyo-ku Tokyo, Japan Dr John T. France Senior Lecturer in Steroid Biochemistry Postgraduate School of Obstetrics & Gynaecology National Women's Hospital University of Auckland School of Medicine Auckland, New Zealand
~,
....." I' II
~
IV.
TEMPORARY ADVISERS
Dr Shoichi Sakamoto Professor and Chairman Department of Obstetrics & Gynaecology University of Tokyo, Faculty of Medicine 7-3-1, Hongo, Bunkyo-ku Tokyo, Japan Dr Atsumi Ishihama Assistant Professor Department of Obstetrics & Gynaecology Iwate Medical College 19-1, Uchimaru Morioka City, Japan
- 24 -
Annex 1
Dr Hajime Uchida Director Uchida Hospital 7-30, Kenroku Motomachi Kanazawa City, Ishikawa-Pref. Japan V.
SECRETARIAT Dr T.C. Hsu Regional Adviser on Maternal and Child Health/Family Planning WHO Regional Offioe for the Western Pacific Manila Dr H.M.C. Poortman Consultant on Maternal and Child Health/Family Planning WHO Regional Office for the Western Pacific Manila Mr Y. Sato
Statistician Regional Family Planning Field Advisory Services WHO Regional Office for the Western Pacific Manila Dr P.J. Rowe Medical Officer Human Reproduction Unit WHO Headquarters Geneva Miss Gloria Mariano Secretary WHO Regional Office for the Western Pacific Manila Miss Estrella Sedano Secretary WHO Regional Office for the Western Pacific Manila
- 25/26 -
Annex 1
Mr Jesus Gatmaltan Technician WHO Regional Office for the Western Pacific Manila Mrs Nicole L. Ongpln Interpreter WHO Regional Office for the Western Pacific Manila Mr Bernard Radoff Interpreter Paris Mr Henry Zwerner Interpreter Geneva
- 27 -
ANNEX 2
SEMINAR PROGRAMME **************************************************** * Sessions will be from 9.00 a.m. - 1.00 p.m., and * : : from 2.30 - 5.30 p.m. Coffee breaks from * : 11.00 - 11.30 a.m., and from 4.00 - 4.15 p.m. : ***************************************************!
==:=======---=====
Tuesday, 2 October
9.00 -
9.30
Registration Opening ceremony Address by the Regional Director, Regional Office for the Western Pacific Welcome to Seminar by the Ministry of Health and Welfare, Japan
9.30 - 10.00
(10.00 - 10.30 10.30 - 11.30
Break) Election of seminar chairmen and rapporteurs Introduction of consultants Self-introduction of participants General statement of the objectives of the seminar
11.30 1.00 2.30 (4.00 4.15 -
1.00 2.30 4.00 4.15 5.30
Presentation of country reports by the participants Lunch Presentation of country reports (continued) Break) Traditional Methods of Contraception
- 28 -
Annex 2
Wednesday, 3 October ==~===============~=
9.00 - 11.00
Intra-Uterine Devices:
Introduced by Professor T. Wagatsuma Dr Atsumi Ishihama
( 11 .00 - 11. 30 1.00 2.30 2.30 5 • .30
Break) Lunch Intra-Uterine Devices (continued) Break)
(4.00 -
4.15
Thursdali 4 October ===~7==--=:========
9.00 -
1.00 -
Steroid Hormones in Human Reproduction Introduced by Dr John T. France Break) Lunch Steroid Hormones in Human Reproduction (continued) Break)
(ll.OO - 11.30 1.00 -
2.30 5.30 4.15
2.30 (4.00 -
=========~~=====
Friday, 5 October 9.00 1.00
Termination of Pregnancy (Induced Abortion) Introduced by: Professor T.H. Lean Professor S. Sakamoto Professor T. Wagatsuma Break) Lunch Termination of Pregnancy (continued) Break)
(11.00 - 11.30 1.00 2 • .30
2.30 (4.00 -
5 •.30 4.15
- 29/30 -
Annex 2
9.00 -
1.00
Sexual Ster:lization - Introduced by: Professor T.H. Lean Dr HaJime Uchida Break)
(11.00 - 11.30
9.00 -
1.00
Sexual Sterilization (continued) i3reak)
(11.00 - 11.30 _1.00 2.30 2.30 5.)0
Final discussions Conclusions Adjourrunent
(4.00 -
4.15
Break)
- 31 -
ANNEX
3
LIST OF MATERIALS SUPPLIED 1'0 THE PARTICIPANTS A. Reference materials WHO Technical Report Series No. 461: Spontaneous and Induced Abortion, Report of a WHO Scientific Group, World Health Organization, Geneva, 1970 WHO Technical Report Series No. 471: Endocrine Regulation of Human Gestation, Report of a WHO Scientific Group, World Health Organization, Geneva, 1971 WHO Technical Report Series No. 473: Methods of Fertility Regulation: Advances in Research and Clinical Experience, Report of a WHO Scientific Group, World Health Organization, Geneva, 1971 WHO Technical Report Series No. 527: Advances in Methods of Fertility Regulation, Report of a WHO Scientifio Group, World Health Organization, Geneva, 1973 Abortion Laws, A Survey of CUrrent World Legislation, World Health Organization, Geneva, 1971 Vasectomy by Dr R.L. Kleinman, International Planned Parenthood Federation, London, 1972 Prostaglandins in Fertility Control: Reports from a conference on analytical procedures, metabolism and clinical evaluation, Stockholm, 18-20 January 1972 Prostaglandins and Contraception by V.R. Pickles, reproduced from Research in Reproduction, Vol. 5, No.3, May 1973 Population Reports on Sterilization: Series C, No.1, January 1973; Series C, No.2, March 1973; Series C, No.3, June 1973; Series C-D, No.2, Apr!l 1973 B. Handouts Address by the Regional Director (Opening Session) Address by the Ministry of Health and Welfare (Opening Session) Population programme assistance, Agency for International Development Bureau for Population and Humanitarian Assistance, Office of Population, Washington, D.C. 20523, December 1972
- 32 -
Annex 3
AID April 21. 1973 memorandum re oral contraceptive procurement Rupply and usage (from Dr W. Boynton) Classification of oral contraceptive side effects
- 33 -
ANNEX 4
LIST OF WORKING PAPERS AND OOUNTRY REPORTS 1 A. Working papers WPR/HR/MCH(FP)/39 Post-Conception Control of Fertility in a Maternity-Centred Family Planning Programme by Dr T.H. Lean Sexual Sterilization by Dr T.H. Lean Prostaglandins in Fertility Control by Dr To Wagatsuma Intra-Uterine Contraceptive Devices by Dr T. Wagatsuma Steroid Hormones in Human Reproduction by Dr J .T. France Traditional Methods of Contraception by Dr T.H. Lean (English Only) Long-acting Injectable Steroids by Dr T.H. Lean (English Only) Developaent of Intra-Uterine Devices in Japan by Dr A. Ishihama (English Only) Social and Medical Problems in Induced Abortion by Dr S. Sakamoto (English only)
WPR/HR!MCH(FP)!40 WPR/HR/MCH(FP)/4l WPR/HR/MCH(FP)/42 WPR/HR/MCH(FP)/43 WPR/HR/MCH(FP)/44 wPR/HR/MCH(FP)/45 wPB/HRIMCH(FP)/46 WPR/HR/MCH(FP)/47
-
B.
Country reports Australia Fiji Guam
Hong Kong Khmer Republic Japan (English Only) Laos Malaysia New Hebrides New Zealand 1
Papua New Guinea Philippines Republic of Korea Republic of Viet-Nam Singapore Tonga Trust Territory of the Pacific Islands United States of America Western Samoa
Copies of the working papers and country reports can be obtained by requesting them from the Regional Adviser, MCH/FP, WHO Regional Office for the Western Pacific, P.O. Box 2932, Manila.