Where We Work

Choosing long-term contraception in Tajikistan

"I have all the children I want—girls and boys. I don't want to have any more children and I don't want to worry about birth control ever again," said a 30-year old mother of four in Tajikistan.

This is a common sentiment in Tajikistan, where numerous pregnancies and large families are the norm. Many cultural factors contribute to this: early marriage, pressure for women to demonstrate fertility, preference for male children, and women's low societal status. As a result, most Tajik women complete their families at an early age, requiring the use of an effective method of contraception for many years thereafter. Voluntary surgical contraception (VSC)—more commonly known as having one's "tubes tied"—can be a good option for such women.

A 35-year old mother of six talked about the appeal of a one-time, permanent procedure. "Pills are expensive. With sterilization, I just do not have to worry about pregnancy anymore."



Providers learn how to properly assemble their surgical instruments prior to performing with models before performing the procedure in the operating room. Photo: Vera Zlidar, JSI

In Tajikistan, the USAID-funded Europe and Eurasia Regional Family Planning Activity works to improve family planning services by updating the medical community's knowledge about the latest developments in contraceptive technology.

In 2008, JSI conducted a desk review, which revealed a need for accessible, quality VSC services in Tajikistan. Surprisingly, use of VSC is low: In 2005, only 0.4% of women in Tajikistan reported having used the method. Provider bias against VSC, lack of training, and a shortage of necessary medical equipment all contribute to low use.

Responding to the desk review's findings, JSI approached two local Obstetrician-Gynecologists—virtually the only ones in Tajikistan who provide VSC—about giving a VSC training for interested local doctors. The OB/GYNs agree with the desk review and are convinced that demand for VSC would be higher if providers could shed their own biases and openly counsel women to inform them about this method. Of course, the OB/GYNs jumped at the chance to participate in a VSC training initiative. In September 2008, JSI held a training for eight OB/GYNs in all aspects of performing voluntary surgical contraception. The training was led by the two local OB/GYNs and one American doctor who provided technical and clinical oversight.

The training consisted of teaching the providers how to use the World Health Organization's evidence-based guidelines for safe provision of VSC. It included how to properly screen clients, counsel patients about the procedure, obtain informed consent, and prevent infection.

There is thought to be considerable latent demand for VSC among women in Tajikistan, where they complete their families at a relatively young age.
 
Additionally, eight VSC procedures were performed during the training. Each trainee assisted in one procedure and was the lead surgeon in another. In each procedure, the trainers answered questions, corrected technique, and helped the trainees learn how to do the procedure safely and properly. After the surgeries, those performing the procedure talked about what they did, how it felt, and what they learned. The trainees observing the procedure made comments and, finally, the trainers provided their feedback.

The EE/EA Regional Activity seized a unique opportunity in Tajikistan to support local doctors whom want to offer their patients more contraceptive choices. "We see so many women who have completed their families at a young age. We feel strongly that VSC should be presented as a safe, healthy, and low cost choice for these women," said one of the OB/GYNs after the training.

Indeed, there is a need to tap into and fulfill what is likely considerable latent demand for VSC in Tajikistan (and other countries in Central Asia). To do so, provider bias must be overcome, a cadre of competent providers for counseling and performing the procedure must be developed, and facilities must have the proper equipment and program support.