In a world where reproductive rights intersect with personal autonomy, the decision to undergo permanent contraception stands as a pivotal moment in many individuals’ lives.

Bilateral Tubal Ligation (BTL), often colloquially known as “getting one’s tubes tied,” represents a significant choice for those seeking to take control of their reproductive health journey. 

This was the case for Ebby Grace Weyime, a 36-year-old woman working as a menstrual health entrepreneur. 

“At the age of 33, I found myself grappling with an unexpected pregnancy when I was under a contraceptive pill. I did not want to ever go through that again,” Ebby shares. 

For Ebby, the decision to undergo BTL was deeply rooted in her desire for autonomy over her body and her future. Despite facing societal pressures and familial objections, Ebby remained steadfast in her commitment to assert her reproductive choices. She reclaimed agency over her reproductive health journey by undergoing the procedure at a local hospital. 

According to Dr Daniel Oketch, Technical Services Director at Marie Stopes Kenya, BTL is a surgical procedure performed to permanently prevent pregnancy by blocking or severing the fallopian tubes, which are the tubes that carry eggs from the ovaries to the uterus. 

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“Bilateral Tubal Ligation offers a highly effective method of contraception,” explains Dr Oketch. “It is a surgical procedure performed to permanently prevent pregnancy by blocking or severing the fallopian tubes.” 

He adds that while BTL offers individuals a permanent solution for contraception, individuals must understand the risks and benefits associated with the procedure.

He emphasises the importance of informed decision-making and pre-operative counselling, ensuring individuals are equipped with the necessary knowledge to navigate their reproductive health choices. 

According to the Kenya National Bureau of Statistics (KNBS) official economic data released in 2022, 4,107 women underwent Bilateral Tubal Ligation procedures. The number of women seeking permanent birth control procedures in Kenya increased by 13.5 per cent from the previous years.

Family planning injections were the most popular method of contraception, followed by implant insertions, Pills Combined Oral Contraceptives and Intrauterine devices (IUD). 

Tabitha Njeri*, a 44-year-old mom, shares that the decision to undergo BTL was a culmination of introspection, resilience, and a deep-seated desire for sovereignty. With three children adorning her life like precious jewels, Tabitha found herself at a crossroads, yearning for a future defined by certainty and freedom from contraceptive worries.

Guided by her innate wisdom, she embarked on a journey towards BTL, a choice that echoed the anthem of empowerment in her heart.

“I had my tubes cut and tied after my last born, and it gives me peace of mind because I would not expect any surprises as I wait for my menopause peacefully,” says Tabitha. 

Dr Oketch says that BTL isn’t merely a contraceptive choice; it’s a beacon of empowerment for those navigating complex medical landscapes.

“From individuals facing severe health risks during pregnancy to those firm in their resolve to shape their destiny, BTL offers solace amid uncertainty,” Dr Oketch says.  

Tubal ligation procedures

Tubal ligation procedures can be performed through various methods. These include laparoscopy, where a camera and surgical instruments are inserted through small incisions in the abdomen, and mini-laparotomy techniques, which involve making a small incision of less than two inches in the pubic region. Postpartum tubal ligation is typically done as a mini-laparotomy procedure after childbirth.

During tubal ligation, the fallopian tubes are sealed, tied, clipped, or cut to prevent eggs from reaching the uterus, offering a generally considered permanent method of contraception. While procedures for tubal ligation reversal do exist, they are complex and not always successful. 

The isthmus, located near the uterus, is a crucial segment of the fallopian tube. It serves as a narrow, straight, thin-walled passage where the fertilised egg temporarily halts on its journey to the uterus, awaiting the production of progesterone by the corpus luteum for implantation.

This isthmic portion plays a vital role in sterilisation procedures such as the Pomeroy or Uchida technique, wherein a segment of the tube is removed. This preference is due to the ease of reconnecting the isthmus if reversal is considered in the future. 

Risks and side effects 

As with any surgical procedure, there are potential risks and side effects associated with BTL. These include bleeding, infection, and anesthesia-related complications. The risk of death from tubal sterilization is low, about 1-2 cases per 100,000 procedures, primarily due to complications from general anaesthesia.

In laparoscopic procedures, hypoventilation from anaesthesia is the main cause of death, followed by cardiopulmonary arrest and sepsis related to bowel perforations. Despite these risks, mortality rates are low. 

Common fears and cultural beliefs

Just like any journey, undergoing Bilateral Tubal Ligation (BTL) isn’t without its risks. From concerns about surgical complications to changes in menstrual patterns, each step requires careful consideration. Yet, amidst these challenges, the beacon of informed choice illuminates the path, guiding individuals toward a future of certainty.

Beyond the technical aspects, Ebby’s narrative challenges societal norms and misconceptions surrounding reproductive choices. She addresses cultural expectations and religious beliefs, advocating for unbiased and comprehensive medical care.

“Society will always have opinions, but ultimately, the responsibility for the children you have rests with you. Don’t expect society to help raise them. I believe you should feel confident in choosing if and how many children you want, and in using any family planning method guilt-free,” Ebby says.

She highlights the growing demand for permanent birth control methods among women, alongside the frustrations many face in accessing these services.

“There’s a misconception that multiplying means only having children, but why can’t it extend beyond that?” Ebby questions. “Reproductive choices should not be confined by societal expectations; they’re about autonomy and the right to make informed decisions about our bodies.”

Hurdles such as the high costs of these procedures and denials from medical professionals who claim women are ‘too young’ or might change their minds in the future are among the most common challenges women encounter when seeking these services.

Why is tubal ligation still seen as taboo in many African countries, and what can be done to change this way of thinking?

Dr Kireki Omanwa, a fertility expert and a consultant obstetrician and gynaecologist who also doubles up as the President of the Kenya Obstetrical and Gynecological Society (KOGS) Nairobi says that the method is largely a taboo or least discussed due to a lot of misconceptions about the procedure. Ideologies and cultural beliefs about female roles also add to the complexity of this issue.

“As a nation, we need to have these conversations and not only on Bilateral Tubal Ligation but also on sexual reproductive health, maternal mortality rates, teenage pregnancies and cancer. Tubal ligation should be viewed as a family planning method just like any other. If someone who is legally mature wants to be child-free or has completed their family and is certain they do not want more children, they should consider it,” Dr Omanwa says.

Sterilisation is fraught with many misconceptions. According to experts, patients may choose BTL for personal reasons, such as completing their desired family size, concerns about contraceptive methods, or lifestyle preferences. The procedure is not exclusively for mothers. 

BTL is typically recommended for individuals who are certain they do not want to have biological children in the future. It may also be advised for medical reasons, such as severe health risks associated with pregnancy or childbirth in women for whom other methods of family planning are not suitable.

Additionally, there is a misconception that women who do not reproduce are ‘empty’ or unfulfilled. These cultural norms categorise women who opt for permanent birth control methods into this group.

“Moreover, there are many common misconceptions, such as beliefs that it interferes with sex life (libido), hormones, causes menopause, or makes one unattractive. Some even think that the inability to allow the passage of eggs affects women, like making their skin dry,” added Ebby.

According to Dr Omanwa, there is a common fear that since this is a permanent family planning method, it denies the couple the ability to change their minds and have more children if they decide.

“No one should be denied the procedure or made to feel incapable of making this permanent decision. However, one requirement that must be met before undergoing the procedure is being certain that they do not want to have more children due to the complications of reversibility of the method,” Dr Omanwa states.