Use of Female Sterilization and associated Factors among Women of Reproductive Age in Malawi

1. INTRODUCTION

Female sterilization is a permanent contraceptive method used by women who do not wish to have more children. Globally, female sterilization is the most common contraceptive method used by women. In 2019, 23.7% of the 219 million women using contraception relied on female sterilization [1].

The advantages of using female sterilization as a method of contraception include safety, effectiveness, and no additional cost or medical check-ups [3]. One of the disadvantages associated with female sterilization is that it does not protect against STIs, which are not easily remedied and, hence, the use of condoms is still advocated. The permanent nature of the method is one of the barriers to its uptake.

Globally, there exist continental and regional differences in the use of female sterilization [1]. According to United Nations data on contraceptive use compiled in 2019, the use of female sterilization has been reported as highest in Southern Asia¹ (28.9%), Eastern Asia (26.6%), Latin America, including the Caribbean (25.9%), Northern America (28.9%), Oceania (13.9%) South-eastern Asia (7.2%), and Western Asia (4.4%), and lowest in Africa (1.6%) and Central Asia (1.4%) [1]. The countries having a high prevalence of female sterilization include India (37.9%), Colombia (35%), and El Salvador (36.8%) [1]. Within Africa, studies have indicated the uptake of female sterilization to be highest in Southern Africa (13%), followed by Eastern Africa (1.9%), Northern Africa (1.4%), and Middle Africa (0.5%), and lowest in Western Africa (0.4%) [1]. No country in Africa has been reported with a prevalence of female sterilization higher than 15%. As highlighted in Fig. (1), Malawi is one of the few countries in Africa that has the highest prevalence of female sterilization [9].

In comparison to other African countries, Malawi has witnessed a tremendous increase in contraceptive use. The contraceptive prevalence rate, as shown in Fig. (2), has increased from 7% in 1992 to 22% in 2004, 46% in 2010, and 59.2% in 2015 [2-6]. An unmet need for family planning has declined from 36.3% in 1992 to 29.7% in 2000, 27.6% in 2004, and 26.1% in 2010, reaching 18.7% in 2015 [2-6]. Furthermore, since the adoption of the national family planning program in the 1990s, the contraceptive mix has changed significantly. The most used methods in 1992 were pills (2.2%) and rhythm method (2.2%), while in 2000, the most used methods were injections (13.9%), followed by female sterilization (4.8%). In 2004, the most used methods were injections (29.7%). Followed by implants (12.3%) and female sterilization (10.9%). In 2010, the most used methods were injectables (25.8%), female sterilization (9,7%), traditional methods (3.8%), pills (2.5%), and male condoms (2.4%). The prevalence of female sterilization has increased from 1.7% in 1992 to 4.7% in 2000, 5.8% in 2004, 9.7% in 2010, and 10.9% in 2015 (Fig. 2).

Studies in Malawi have mostly examined social and economic factors that influence modern contraceptive use in the country [7-12]. These studies have shown that contraceptive use in the country is significantly associated with the women’s level of education, wealth status, religion, age, number of surviving children, and exposure to the media [7, 13, 14]. The use of maternal health services, including skilled delivery care and timing of post-delivery care, has also been shown to influence contraceptive use in Malawi [15, 16]. Other studies have focused on specific segments of the Malawian population, such as young people [8, 17, 18], the male population [19], and individual districts [20]. However, no study has explored the determinants of female sterilization despite this being a popular method of contraception in the country. The aim of this study was to explore the factors associated with the uptake of female sterilization in Malawi.

2. MATERIALS AND METHODS

2.3. Data Analysis

A descriptive summary indicating the frequency distribution of women by socio-demographic characteristics was provided. Secondly, Pearson’s chi-square test was used to analyse the association of female sterilization use during the period compared to each explanatory variable. The following logistic regression model was used to establish factors associated with the use of female sterilization in Malawi:

Where, pi is the probability of using the female sterilization contraceptive method based on the respondent’s demographic and socioeconomic characteristics, and 1 − p is the probability of not using sterilization. Xi refers to independent variables, a is a constant, and bi represents coefficients associated with the independent variables. Due to the complexity of the sampling design used in DHS, some areas were more likely to be under-sampled or over-sampled. The data were weighted due to the complex nature of the sampling design. Sample weight was applied by dividing the individual women's sample weight by 1,000,000 (v005/10⁶).

3. RESULTS

4. DISCUSSION

The findings of this study have revealed the age of women to be significantly related to female sterilization. Female sterilization was higher among older women (>30 years) than younger women. This result is in agreement with the findings from other studies, including Columbia [24], Ethiopia [25], India [26], Uganda [22], Pakistan [27], and Bangladesh [23]. This may be because a sizeable proportion of the younger women have not yet started childbearing and are yet to implement their fertility desires and aspirations. They may choose short-term reversible methods that are suitable for spacing between childbirths over those that limit childbirths.

This finding may also be linked to differences in onset and intervals of childbearing between young and older women. Older women are more likely to have exceeded their ideal number of children, whereas young women are just beginning their childbearing careers and have been recently exposed to contraceptive knowledge and services. In addition, the finding that female sterilization was high among old women may be attributed to some service providers who feel that a woman should have permanent contraception after a certain age bracket. Furthermore, older women are likely to have explored all other temporary contraceptive options and experienced adverse effects, yet they harbour no intentions of bearing more children, compared to their young counterparts who may want to have space for a short time. In some communities, women are afraid to undergo sterilization for fear that if they are divorced and remarry, the new husband may want to have a child with them, and if they are sterilized, then this may not be possible. This hindrance may be more serious among younger women than older women who may consider themselves to be outside the marriage market.

The number of CEB was found to be associated with female sterilization uptake. This finding is in agreement with results from other studies, including Brazil [28, 29], Columbia [24], Ethiopia [25], India [30, 31], Nigeria [32], Uganda [22], Pakistan [27], Iran [33], and Bangladesh [23]. This may be probably because the use of female sterilization is based on the achieved fertility. Given that female sterilization is permanent and irreversible, women who have not yet accomplished their desired or wanted fertility are less likely to use it. Furthermore, women with many children may decide to stop childbearing and choose to use sterilization. It is perhaps not very surprising since most users of female sterilization are those who do not wish to have any more children.

This study has also revealed the relationship between female sterilization and wealth status to be positive and significant. With the rising wealth status of women, the uptake of female sterilization also increases. This finding is consistent with results from Bangladesh [23], Ethiopia [34], and Zambia [35], but in opposition to findings from Uganda [22] and India [26, 30, 36] that have shown a higher use of female sterilization among poor than rich women. Earlier studies in Malawi have shown the importance of wealth status in influencing the contraceptive use [7, 14]. A study conducted in Zambia claimed that the positive relationship between female sterilization and wealth status could be explained in terms of the theory of wealth flow, which argues that in poor communities, wealth flows from children to parents, whereas in rich societies, the opposite is true. In such cases, among rich families, women are more likely not to desire more children and, as such, resort to using female sterilization. In addition, women from rich households tend to have bigger aspirations; they enter marriages late and delay childbearing probably because they are in school or busy looking for jobs and money. On the other hand, women from poor households enter marriages early and also begin childbearing early and desire more children. It is poor women who are likely to regard children as a source of wealth and a means of old age security.

The uptake of female sterilization was also found to be significantly related to the work status of women in this study. The use of female sterilization was observed to be higher among working women than non-working women. This is consistent with findings from other studies [23, 30, 34]. One possible explanation may be that childbearing and rearing compete with work aspirations. As such, working women would rather use female sterilization to limit the number of CEB in order for them to concentrate on their careers and work. Working women are also likely to have financial and material resources that they can use to access female sterilization. Another factor could also explain this relationship, that is, high-status women have easy access to family planning methods, including female sterilization, compared to low-status women who may have financial constraints.

This study has also found a negative significant relationship between education and female sterilization. The prevalence of female sterilization has been found to be higher among women with no education than women with some education and, as female education has increased, the uptake of female sterilization has been found to decrease. This is rather unexpected, but it has been found in other studies [24, 29, 31, 33, 36]. One possible explanation could be the consequence of the design of family planning programs, which tend to target underprivileged communities. It is also possible that women who are educated are not only knowledgeable of various types of contraceptives and their merits, but also use other methods.

The study has also found the use of female sterilization to be high among women who have not been visited by a field worker in the past twelve months. In addition, the use of female sterilization has been found to be high among women who have not visited a health facility in the past twelve months. These results are unexpected since one would expect the uptake of sterilization to be high among those women who may have been visited by a field worker in the past twelve months, or women who had visited a health facility in the past twelve months. It is possible that these women were not visited by field workers or they did not visit a health facility simply because they were sterilized. Often, when one is using female sterilization, the cost of accessing a health centre is minimised.

Region of residence has been observed to be one of the factors influencing the use of female sterilization. Women residing in the Central region and the Northern region were more likely to use female sterilization than their counterparts in the Southern region. Regional differences in the use of female sterilization have also been reported in other countries, including Bangladesh [23], Brazil [28, 29], India [30, 36], and Zambia [35]. This could be attributed to the distribution of health facilities and the characteristics of the population residing in each region. Studies indicate that in most developing countries, there are regional disparities in the distribution of medical and health facilities. In Malawi, in the 70s and 80s, the distribution of health facilities was better in the Northern region, followed by the Central region, and worst in the Southern region. The regions that are better served with medical and health facilities tend to have a higher use of female sterilization than their counterparts. In addition, other characteristics of the region of residence may help to increase the use of female sterilization. A study in India reported a higher contraceptive use in the more developed and urbanized state of Andhra Pradesh (63%) than in Uttar Pradesh, one of the most economically and socially underdeveloped states [36].

Lastly, the study found media exposure to not be significantly associated with the uptake of sterilization. The same can be said for such variables as having read regarding family planning in the newspaper and having heard about it on the radio. However, having heard about family planning on the TV in the last few months was marginally associated with the uptake of sterilization. Exposure to media has been shown in previous studies to have a positive association with the uptake of sterilization [26]. However, in this study, the fact that over 82.2% of the women resided in rural areas, where access to media is hard and not sustainable due to the costs involved, might partly explain the non-significant findings. The finding of the high use of female sterilization among those who had heard about family planning on the TV in the last few months could be attributed to the high association of TV ownership with other social and economic factors.

5. STRENGTH AND LIMITATIONS

One strength of this study is that the analysis used the nationally representative data from the latest round of MDHS, which has enabled to understand the association of female sterilization with selected social and economic factors. However, there are some limitations associated with this study. First, the study did not collect information on the attitudes towards female sterilization and why women decided to use this method. Second, although there are certain variables that could have been used to enrich this study, such variables, like women's autonomy and decision-making power in this aspect, were excluded. Third, given that contraceptive use is still a sensitive subject in Malawi, there may be a high likelihood of underreporting, as it cannot be denied that some women may refuse to divulge their responses on this topic.

CONCLUSION AND FUTURE IMPLICATIONS

The use of female sterilization has increased among women in Malawi over the past two decades (1992–2016). However, there is still a need for efforts to increase contraceptive prevalence in the country in order to allow women to meet their fertility desire and improve their quality of life. The findings indicate that while female sterilization uptake in Malawi is low by global standards, it is high with respect to African standards. The uptake of female sterilization has been found to be higher among older women, women with more CEB, women residing in the Central region and Northern region, uneducated women, rich women, women who had not been visited by a field worker, and women who had not visited a health facility. Age, number of CEB, region of residence, education, wealth status, having been visited by a field worker, and having visited a health facility in the past twelve months have been observed to be significant predictors of sterilization uptake among the women. These significant factors need to be considered in designing programs to strengthen the existing national family planning program. For instance, the findings of this study suggest targeted interventions, such as facilitating access to female sterilization of women younger than 30 years of age, especially those who have achieved the desired family size, and improving the regional health services of the Southern region to improve access to sterilization and quality of family planning. The government and other implementing partners should offer awareness campaigns and counselling services related to female sterilization targeting higher parity women (4+ CEB) residing in under-served areas, such as the Southern region. In order to promote the use of female sterilization, there is a need for integrating economic empowerment activities and family planning services. There is also a need for a qualitative study to determine the characteristics of users of female sterilization and the factors related to high sterilization prevalence in Malawi.

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