1. Session II: Who Can Have Tubal Ligation (Female Sterilization)?
Basic Slides—Female Sterilization Session II: Who Can Have Female Sterilization?
This second set of slides mainly covers medical eligibility for female sterilization.
By the end of this session, participants will be able to:
State who can have female sterilization
Describe the medical eligibility criteria for female sterilization
Use the medical eligibility criteria to screen clients for eligibility
Describe female sterilization use by women living with HIV and AIDS

2. Session II Objectives
By the end of this session, participants will be able to:
State who can have female sterilization
Describe the medical eligibility criteria for female sterilization
Use the medical eligibility criteria to screen clients for eligibility
Describe female sterilization use by women living with HIV and AIDS
Explain:
The objectives of this session are that by the end of the session, participants will be able to:
State who can have female sterilization
Describe the medical eligibility criteria for female sterilization
Use the medical eligibility criteria to screen clients for eligibility
Describe female sterilization use by women living with HIV and AIDS

3. Female Sterilization Is Safe for All Women
With proper counseling and informed consent, any woman can safely have a female sterilization procedure, including women who:
Are not married
Have no children or few children
Do not have spousal permission
Are young
Just gave birth (within the last seven days)
Are breastfeeding
Are infected with HIV, whether or not they are receiving antiretroviral therapy
Explain:
Female sterilization is safe for all women.
With proper counseling and informed consent, any woman can safely have a female sterilization procedure, including women who:
Are not married
Have no children or few children
Do not have spousal permission
Are young
Just gave birth (within the last seven days)
Are breastfeeding
Are infected with HIV, whether or not they are receiving antiretroviral therapy
Ask: Can anyone share with us some of our national laws or legal provisions and policies that state who can have a female sterilization?
Allow a few responses, then share the relevant materials and explain the legal provisions that govern who can have a female sterilization.
In some countries, for example, legal provisions state the minimum number of children that a client must have before she can use female sterilization; others mention a minimum age, while others require spousal consent before sterilization. A few countries also have restrictions on providing such a method to mentally challenged clients.
Review the relevant section of the legal provisions, including national policies, and clarify these as needed.
Note that the discussions may include how such legal provisions address human rights or are in line with the Sustainable Development Goals.

4. When Can Women Have a Sterilization?
Most women can have a sterilization procedure at any time.
But they may need to wait if they:
Explain:
Most women can a have female sterilization at any time, as no condition rules out female sterilization, but some situations may require delay, referral, or special caution.
The client may need to wait if she:
Gave birth 1–6 weeks ago—The sterilization procedure can be done at any time except between seven days to six weeks after delivery.
May be pregnant—The sterilization procedure can only be done at any time that the provider can be reasonably sure the client is not pregnant.
Has an infection or other problem(s) in the genitals—The sterilization procedure should be delayed until the condition or conditions are fully treated.
Has some other serious health conditions—A serious health problem may require a delay in performing steruilization, to allow time for more evaluation of the condition, for further management of the condition, or for specialized care.
Have some other serious health condition
Gave birth 1–6 weeks ago
May be pregnant
Have an infection or other problem
Source: WHO decision making tool for FP2005

5. Medical Eligibility Criteria
What are the Medical Eligibility Criteria (MEC)?
WHO evidence-based guidelines on contraceptive use
5th Edition, 2015
The Quick Guide and MEC Wheel cover nine commonly used contraceptives.
The MEC recommend a different category for permanent methods.
Ask: “What are the Medical Eligibility Criteria (MEC)?” Allow a few responses, then quickly go back to the slide and click to show them the correct response.
Explain:
The MEC are one of the WHO evidence-based guidelines on contraceptive use. They inform the family planning provider if a client with a certain medical or physical condition can use any particular contraceptives effectively and safely.
The most current version is the fifth edition, which was recently launched by WHO.
Job aids on the MEC include the MEC Wheel and the Quick Guide; however, these only cover the most commonly used reversible methods.

6. Medical Eligibility Criteria (cont.)
No medical condition absolutely restrict a woman’s eligibility for sterilization.
Some clients may have a medical condition that requires certain precautions to be taken, such as delaying the procedure or going ahead with it under special conditions.
There are other effective reversible contraceptives that may be appropriate for the client.
Explain:
No medical condition absolutely restricts a woman from adopting sterilization. but some conditions and circumstances require certain precautions to be taken.
Such precautions may include delaying the procedure until the situation changes.
Contraceptive counseling and an alternative method of contraception should be provided to any clients for whom minilaparotomy is delayed.

7. Medical Eligibility Criteria (cont.)
Categories
A—Accept There is no medical reason to deny sterilization to a person with this condition.
C—Caution The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
D—Delay Postpone the female sterilization procedure. These conditions must be treated and resolved before female sterilization can be performed.
S—Special The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anesthesia, and other back- up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anesthesia regimen is also needed. Give the client another method to use until the procedure can be performed.
Explain:
Categories that are recommended for use to determine client eligibility for male and female sterilization are different from those used for nearly all other contraceptive methods (except the natural methods). These categories are as follows:
A—Accept. There is no medical reason to deny sterilization to a person with this condition.
C—Caution. The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
D—Delay. The female sterilization procedure should be postponed. The condition must be treated and resolved before the procedure can be performed. The client should receive another method to use until the procedure can be performed and/or the problem corrected.
S—Special. The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anesthesia, and other back-up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anesthesia regimen is also needed. The client should receive another method to use until the procedure can be performed.
Refer participants to Handout #3, which is adapted from the WHO’s MEC, 5th edition, and explain what is covered and how the guide may be used.
Read through some of the conditions in the guide and ask participants to take turns in reading about the selected conditions in the handout.
Inform the participants that the national guidelines were developed using evidence-based resource materials such as the latest version of the WHO MEC guidelines, if this was the case.
If the National Family Planning Guidelines for Service Providers are available, spend some time reviewing the female sterilization section of the guidelines with the participants.
Encourage the participants to ask questions.
Ask: “Do you know where to refer clients for specialized care.” Allow a few responses, then provide additional information on referral of clients who need special attention, as needed.

8. Case Studies on MEC Instructions:
Read the case allocated to your group carefully, discuss the condition(s), and agree on the category that fits the client’s condition, based on MEC classification.
List your comments and reasons for the classification, and summarize your plan for managing the client, including the minilaparotomy procedure.
When you are through with your assigned case, review the other cases also. This will allow you to participate in the plenary discussions.
After the title (Case Studies on MEC) appears on the screen, inform the participants that they will now work in small groups.
Divide the participants into groups of two, preferably with the participants sitting next to each other to form teams.
Distribute Handout #4 and review the instructions.
Allow 10 minutes for group work, then call the participants to plenary.
For discussion in plenary:
Ask each group representative to read the case study, then give the MEC category that they have selected, and state some of the rationale for the categorization and how and where the client should be offered her method of choice. Refer participants to the relevant section of Handout #3 and read through the condition and classification.
Conclude by stating that for all clients opting for female sterilization, the provider must determine their eligibility for use of the preferred method by applying the MEC. Explain that the participants will have an opportunity to practice this process during model practice and in the clinical area when they work with clients.

9. Female Sterilization Use by Postpartum and Postabortion Clients
Condition
Category
A=Accept; D=Delay;
C=Caution; S=Special
Clarification/ Evidence
Postpartum 1-7 days A
Postpartum 7–42 days D
Postpartum >42 days
Manage as interval client
Postpartum with other medical condition (e.g., severe anemia, sepsis, severe hypertension)
Postabortion (uncomplicated) 1–7 days
Postabortion (complicated, with severe anemia, sepsis, genital trauma)
Increased risk of complications
Postabortion (complicated, with uterine perforation) S
May include perforation of other viscera and increased risk of complications
Explain:
Postpartum and postabortion clients can also use sterilization; however, these are stressful situations, and clients need to make a well-considered decision. Such clients are prone to regret later if the decision is rushed.
Postpartum clients can have the procedure between delivery and the seventh day following delivery.
After the first seven days following childbirth, it is advisable to delay and perform the procedure after 42 days. The client may be advised to choose a back-up method to use as they wait for the sterilization procedure.
After 42 days postpartum, the client should be managed as an interval client—that is, the procedure should be planned for whenever the client feels she can have it, preferably in the proliferative phase of the menstrual cycle.
A postabortion client ora client who has had a miscarriage can also have the procedure within the first week after the abortion.
The procedure should be delayed if the client has other severe medical conditions, such as sepsis, anemia, genial trauma, etc.

10. Female Sterilization: Use by Interval Clients
Sterilization can be performed:
At any time, if the provider is certain that the client is not pregnant and that no other medical condition is present
Preferably in the first half, or proliferative phase, of the menstrual cycle
However, providers should exercise caution if the client is young, to avoid regret in the future.
Explain:
Interval clients can use sterilization at any time they choose, as long as the trained provider can be reasonably certain that the client is not pregnant.
The procedure should be performed in the first half of the menstrual cycle (the proliferative phase) if a client who is sexually active has not been using a highly effective method of contraception. If the procedure is performed after ovulation, there is a chance that the client may have conceived just before the procedure.
The health care provider should make especially sure that young clients, have been counseled about the permanence of the procedure and the availability of other highly effective long-acting methods. Providers must ensure that such clients make informed and thoughtful choices. According to WHO’s MEC, young age is one of the strongest predictors of regret following sterilization.

11. Female Sterilization Use by Clients with HIV
Sterilization does not protect against STIs
Condition
Category
A=Accept; D=Delay;
C=Caution; S=Special
Clarification/Evidence
High risk of HIV A
No routine screening needed.
HIV infected (asymptomatic or mild HIV clinical disease—WHO stages 1 or 2)
Severe or advanced HIV clinical disease (WHO stages 3 or 4) S
Condition may require delay of procedure to manage AIDS-related illness.
Explain:
Clients at risk of HIV infection and those infected and asymptomatic or taking antiretroviral drugs can safely use female sterilization.
Special arrangements are needed to perform female sterilization on a woman with severe or advanced HIV clinical disease.
While female sterilization offers highly effective protection from pregnancy, it does not guard against transmission of HIV and other STIs.
Clients should be counseled and urged to use condoms in addition to female sterilization.
Consistent and correct use will prevent transmission of HIV and other STIs
No woman or couple should be coerced or pressured into adopting female sterilization, including women living with HIV.

12. Understanding the MEC for Female Sterilization Checklist
How to determine client eligibility for female sterilization
Ask about known medical conditions
WHO checklist on MEC for female sterilization
Explain:
Earlier, we stated that all women can have a female sterilization procedure and that no medical condition can prevent a woman from adopting female sterilization.
We have also learned that some medical conditions may require a client to wait until the condition has been fully treated or resolved or until the client is evaluated further for the condition and the procedure can be performed in a setting where she can receive special care.
We shall now discuss how to determine if the client opting for female sterilization is eligible for the procedure in routine settings at any time, if the procedure needs be to delayed, or if the client should be referred for special care.
We determine eligibility for female sterilization by asking the client a series of questions to learn if she has any medical conditions, and then use the MEC to make a recommendation based on the outcome of this exercise.
WHO has developed a checklist for screening clients who choose to adopt female sterilization.
Ask the participants to look at Handout #5. Explain:
This checklist is a tool that a provider should use to determine whether a client is medically eligible to use female sterilization (which she must have selected voluntarily as the result of an informed decision-making process).
The checklist’s introductory section explains how the tool can be applied for screening. To use this checklist, to the provider asks questions and follows instructions based on the client’s responses. The checklist has only three questions, which make it easier to remember what to ask.
If you ask the three questions and the client answers “no” to all three, the female sterilization procedure can be performed in a routine setting without delay.
If, however, the answer to any question is “yes,” the provider must follow the instructions recommending caution, delay, or special arrangements.
Read the first question and review all of the possible responses. Explain that clients may not use the medical terminology, but having them describe the condition will give you an impression of whatever problem they may have (e.g., endometriosis).
Inform the participants that you now want them to work in groups to familiarize themselves with the tool.
Divide the participants into groups of two, by asking them to pair up with the person sitting next to them. They are to read through the checklist and using Handout #3, verify if all conditions mentioned in that handout are represented in the checklist. They should make a list of any condition that does not appear on the checklist for discussion in plenary. Inform them that they have 10 minutes for the exercise.
After 10 minutes, call the participants into plenary and ask any of the groups to present their findings.
Participants may observe that some conditions appear in the MEC but not on the checklist. This is because the majority of such conditions do not fall into the categories of Caution, Delay, or Special and thus are most likely in the Accept category. A few conditions may be relevant to the situation at the time the provider is performing a procedure (e.g., sterilization with concurrent emergency abdominal surgery, without previous counseling). Explain that this condition does not relate to the client’s medical history, but is a situation that the provider may face while providing care to a client. Emphasize that clients who are eligible for sterilization must provide written informed consent prior to surgery, in addition to consent for general anesthesia, and that the surgeon should verify this consent before beginning the procedure.
Ask if there are any questions, and respond to these as needed.
Conclude by stating: “Now that we have confirmed that all conditions are included in the checklist, you will have the chance to use this important tool during the practical sessions.”
Source: Adapted from WHO, Family Planning: A Global Handbook for Providers 2018