Abstract

An early experience of camp laparoscopic sterilization in Gujarat State, India, resulted in 22 deaths among 106,500 women undergoing the operation during 1979 and 1980. Increased risk of death was seen when larger numbers of procedures were performed by year or month of year. The least experienced surgeons had the highest case-fatality rate. Improvised settings (i.e., school buildings) exacerbated the risk of death, as did advanced age, and, to a lesser extent, high parity. Errors in clinical judgment were identified in some fatal procedures. A system of health audit of large sterilization programs is needed.

PIP:

A physician analyzed 1978-80 data on 22 laparoscopic deaths among 106,500 women who underwent sterilization at camps in Gujarat State in India to determine the programmatic and clinical risk factors in these camps. The death rate stood at 20.65/1000,000 procedures compared with 1.5/1000,000 for the US. The laparoscopic sterilization camps were set up in district hospitals, primary health centers, and school buildings. The leading causes of death were peritonitis (9), septicemia (4), and tetanus (2). 5 women also died on the operating table of lignocaine sensitivity (2), cardiac arrest (2), and air embolism (1). The death rate climbed with age (0 deaths for 25 year old, 17 for 26-30 year old, 25.2 for 31-35 year old, and 40.4 for 36-40 year old). It also increased with parity (11.9 for women with 2 living children and 29.8 for those with at least 5 children). 10 of the 22 sterilization deaths were women =or 30 years old with at least 4 children. The number of sterilizations grew 3-fold between 1979-80 and the risk of death grew almost 2-fold. The risk of deaths was especially high during the campaign season (December-March) indicating an increased risk of speedy completions to meet quotas. Surgeons with 6 months experience in laparoscopic sterilization were responsible for most deaths (67%) in camps with 50-100 sterilizations. The case fatality rate for these surgeons was 54.2/1000,000 compared with 8.1 for surgeons with at least 25 months, experience. The same percentage of deaths in these camps occurred to women operated on in school buildings. The case fatality rate for school building operations was 71/1000,000 compared with 15.4 for district hospitals and 13.5 for primary health centers. An unacceptable risk would remain even if school buildings were excluded and laparoscopic sterilization training would not occur at sterilization camps. Improved sterilization of equipment and improved surgical judgment of complications could have prevented many deaths. A medical audit of camps services is justified.