Introduction of Laparoscopic Tubal Sterilization in Nepal’s Family Planning Program

Abstract

Dr. Badri Raj Pande’s experience1 is an example of the ‘hostile’ socio-cultural environment into which the family planning program in Nepal was first introduced – and also an illustration of how the program has continued to grow and flourish over the years. His account also reminded me of some of my own personal experiences in early days of the program.
It was in 1973 that Dr. Wheeles from Johns Hopkins University brought a set of laparoscopic instruments for tubal sterilization to Nepal. He demonstrated the use of the instruments to a few of us – obstetricians and gynecologists – at Paropakar Maternity and Women’s Hospital (commonly referred to as Prasuti Griha or Maternity Hospital) in Kathmandu, where we were working at that time. Dr. Kanti Giri led this ground breaking effort, and I was among the first group of just a few doctors who participated in the training. The successful effort resulted in eventually introducing laparoscopic female sterilization (LFS) under local anesthesia through mobile camps in communities where there were no hospitals or trained doctors to perform sterilization operations.2-6 Nepal became a ‘pioneer’ country to provide LFS as a new permanent method of controlling fertility. Over the years, female sterilization has become the most widely used contractive method in Nepal.7-9
By way of informing the potential female clients of the procedure, we – the attending doctors and nurses – would tell women that a small injection is administered in their umbilical region and a tube will be inserted to look through a ‘durbin’ (telescope) and then a knot would be tied in a safe manner to prevent pregnancy. In doing so, the term ‘operation/surgery’ was purposely avoided so the women would not be scared.
At times I used to ask women why they did not send their husbands for a vasectomy instead of them going for the procedure. Their most common response was that the husband had to work for their livelihood and that they (the women) didn’t want to take any chances, and risk something happening to the family’s source of livelihood. In those days, having multiple wives was also considered a symbol of affluence and wealth. During our ‘camp’ days in Pokhara, in which Dr. Kanti Giri and I were attending surgeons, one person brought two wives over two successive days. He showed up with yet a third wife on the third day, and both Dr. Giri and I insisted that he should get a vasectomy – to which he agreed, reluctantly.
Over the years, as the program expanded, LFS became more popular – and remains so today.9,10 While in the early years, sterilization was accepted only among women who had already given birth to at least four children, perception of the procedure has changed considerably over the years, and as of 2022, the average number of children a sterilized woman has is about two.10 As aptly noted in the “Brief Communication,”1 Nepal’s family planning program has made significant progress over the last five decades. The path to progress has certainly not been easy, but this has been one success story that freed Nepali women from having to bear a large number of children.
The government, international organizations, principally USAID and the International Planned Parenthood Federation, and, most important of all, the providers – nurses, counselors and the doctors – remain the champions of this journey. From the time I was trained in LFS until I stopped doing clinical practice in 2018, I most probably performed nearly 25,000 LFS. After my 45 years of service, I feel both personally feel thankful and professionally satisfied to have contributed to this long national journey towards improving the health and reproductive rights of women in Nepal.