No regrets, 12 years after the cut

In the tranquil village of Milo in Bungoma County, Jennifer Lusweti’s story is one of resilience, health challenges, and a conscious decision towards family planning. At 48, she reflects on the past decade of living with tied tubes and the transformative impact it has had on her health and family life.

Jennifer embarked on her family planning journey after delivering her second child, opting for Depo-Provera injections, usually administered every three months. However, her body reacted adversely, causing discomfort and delayed periods. She admits that she received the injections without first consulting a doctor on the best mode of family planning for her body.

For about a year, she tolerated the discomfort until she couldn’t anymore and presented herself to a doctor at Webuye District Hospital. Her doctor told her that her body was incompatible with the injections and that she needed to either use a coil or tie her tubes permanently.

Jennifer went home to her husband with the news. They decided they weren’t ready for a permanent method yet, as they still desired children. The calendar method would suffice, she decided.

When she fell pregnant for the third child, varicose veins showed up, making her pregnancy an uncomfortable experience. Varicose veins are large, gnarled veins that commonly appear in the legs and feet. They may worsen during pregnancy. Concerned, she sought medical advice at Webuye District Hospital. She was informed that there was nothing that could be done. She delivered her baby and continued counting her safe days.

Incurable 

Years later, she got pregnant with her fourth child. The varicose veins came back, this time worse than the previous pregnancy. In the sixth month of the pregnancy, she went to her doctor at Webuye District Hospital to be checked. There, she was informed that the condition was incurable. She was advised to get bandages to wrap around her legs. When she delivered, the veins disappeared.

“I got pregnant a few years later for my fifth child and picked up the bandages again. This time, I would find blood in my urine and the veins would swell so much that someone would think I had been physically abused. Sitting was a problem, requiring me to lie to feel comfortable. I also couldn’t walk for long distances without feeling like I had stitches in my legs,” she narrates.

“The doctor told me that if I got pregnant again, the condition would worsen and that the veins risked bursting and causing major complications. The doctor said that the smaller blood vessels had burst because of the swelling and pressure, and that it was the reason I was seeing traces of blood in my urine. He once again advised me to talk with my husband to consider a permanent method of family planning,” she adds.

When she eventually delivered the fifth child, she told her doctor she was ready to tie her fallopian tubes before she was discharged. She was told to wait for two weeks. This was in 2011. Determined to put childbearing to an end, she went home to start her countdown. 

As the second week neared the end, officials from Marie Stopes Kenya, who had been conducting outreach programmes and promoting the use of family planning, showed up with an offer. They would cater for the costs for those who were willing to use five-year family planning methods and those who wanted to tie their tubes.

“I woke up that morning prepared and left my mother-in-law with my child. At Milo Health Centre, we boarded a vehicle to Webuye District Hospital to join other women from that region who were visiting the hospital for similar procedures. After registering our names, we were taught and prepared about the procedure to ease the anxiety that was mainly driven by myths,” explains Jennifer.

"We would get into the operating room in pairs, undergo the procedure, and then rest for a couple of hours until we felt well enough to be discharged. Upon discharge, I left the hospital and went directly to my shop. I also remember solely preparing supper that night,” she adds. 

As one of five women who have undergone the procedure from her village, she explains that the concept of planning a family is wrought with myths and misconceptions that hinder women from using family planning methods, especially the permanent ones such as bilateral tubal ligation (BTL) and vasectomy for men.

Some women, she says, believe that should one get her tubes tied, one may fall sick, have back pains, struggle to work, or experience body weakness.  “I have never seen anything like that. I still till my land normally, split firewood, and do other house chores. My back is also okay, and I have never experienced any body weakness. In fact, when I had the bilateral tubal ligation, my health started to recover. I also hear people saying that if you have BTL, your libido drops and you no longer desire your husband. That, however, has never happened to me,” she says.

No objection 

Questioned about her opinion on vasectomy, she says she is open to her husband undergoing the procedure when and if he wishes to. “If he wanted to do a vasectomy, I wouldn’t have objected because I was already done having children and I didn’t want any more pain. My husband raised no objection because he had watched me struggle with the varicose veins,” she says.

Coming from Bungoma County, which recently hit the headlines for having over 50 primary school pupils falling pregnant, Jennifer is a champion of sex education in school. She, however, has reservations about contraceptive use among teenagers.

“I blame this on parents who barely have time to interact with their children. If you are raising daughters especially, they need a lot of interaction with parents. If you do not draw them close to you, you will never know the issues they are dealing with. If you are also so strict that they can’t even approach you to talk about menstrual periods, you need to be worried,” she says, noting that she is very free with her children and that they share their private matters with her.

“If we had the space to incorporate sex education and life skills lessons in schools, it would save a lot of girls. Students would learn about the dangers of early sexual engagements and contraceptive use and how they affect their bodies. Currently, it is easy to find pregnant students preparing for their national exams. Some haven’t fully developed and may experience pregnancy and birth complications,” she warns.

“I, however, would not wish for my daughters to use contraceptives because they have side effects. Either way, there is no need for contraceptive use for them before they get married. Even though we talk openly about relationships and sex, I would love for them to stay pure until marriage. If they decide to use contraceptives without my knowledge, it is their decision, and the consequences are theirs to face. I kept myself pure until I met my husband. What challenge is that that they cannot tell me? I was once a girl, so I am better placed to respond to their questions.”

Significant progress 

Jennifer’s story aligns with the broader efforts in Bungoma County to improve family planning services. According to the 2022 Kenya Demographic and Health Survey (KDHS),  there has been significant progress, with the county recording a modern contraceptive rate of 64 per cent — slightly above the national average.

According to the Ministry of Health, the figures of women who have resorted to tying their tubes has been increasing since 2021. In 2020, the ministry registered 5,574 women in the country going for BTL. This figure dropped to 3,664 in 2021 and rose to 4,104 in 2022. From January to September this year, it recorded 3,615 cases. The KDHS report states that sterilisation accounts for two per cent of the contraceptive method mix.

However, men are yet to embrace vasectomy the way women have embraced BTL. The figures keep fluctuating. In 2020, the Health ministry recorded 416 vasectomies, which dropped to 251 in 2021 before rising to 547 in 2022. Between January and September 2023, the country recorded 280 cases. 

Dr Boniface Odira, a medical officer at Bungoma County Referral Hospital, has been offering bilateral tubal ligation services for the past three years and vasectomy services for one year. He tells Healthy Nation that while he conducts between two and three bilateral tubal ligation procedures every Tuesday, he has only conducted five vasectomies in the past year.

This, he says, is because of myths surrounding the procedures, with men believing that vasectomy equals castration. Men also believe that since the sperm ducts are severed, sperms would accumulate in the testicles, causing health problems.

“This is because they relate vasectomy to castration that is done to livestock and pets. Veterinarians destroy blood vessels and nerves around the testicles. Men equate it to that, but in vasectomy, we only cut the tubes that carry the sperms. We leave blood vessels and nerves around the testicles intact. The testicles continue to produce hormones that make a man a man, and can produce sperms. These sperms are eventually absorbed by the body,” he explains.

BTL is also fraught with the belief that it results in lower back pains and body weakness, a myth that Dr Odira says is a result of advancement in age. 

“As age advances, women may get lower back problems as a result of age-degenerative arthritis. But because somebody has undergone BTL, they often blame it on the procedure. The truth is that the tubes are not related to your lower back and they do not affect it in any way,” he explains.

Dr Odira also explains that while women from the county are warming up to the procedure, most of them are unable to afford the costs. Thus, they often opt to wait for medical camps where the service is offered for free. “We may get five bookings for BTL and end up doing between two and four procedures,” says Dr Odira. 

Desired family size

He explains that before c.onducting BTL, they begin with counselling the patient, which involves informing them about other methods of family planning and how the procedure will be conducted to ease their worries. They also have to confirm that they have achieved their desired family size and inform the doctor whether it is a decision that has been made with the consent of their partners. 

Once written consent is given, medical officers then look into the person’s medical history to rule out any medical conditions that may exclude them from undergoing the surgical intervention.

These may include outliers such as previous pregnancy conditions that are risky,  for instance hypertensive issues which may lead to loss of life should another pregnancy occur. Hypertension is the second-leading cause of maternal deaths in Bungoma County.

BTL involves tying and cutting both the fallopian tubes, the communication channels from the ovary to the uterus. A woman produces an ovum from an ovary.  For fertilisation to happen, the ovum has to meet the sperm. BTL is like putting a roadblock on the pathway to stop the ovum from meeting the sperm. For vasectomy, the pathway of the sperm from the testicles to the ejaculate is blocked.

“While doing BTL, a one-centimetre incision is made on the area just above the pubic hair for the ladies. Through that opening, a doctor can access the pelvis, hook the fallopian tubes, bring them out, tie, cut, ensure there is no bleeding, return the tubes and close the site. The vasectomy procedure is, however, non-scalpel. We don’t make any incisions on the body. Instead, we puncture a small hole and use it to access the two sperm ducts. This process is simpler, faster and minimally invasive as compared to BTL,” explains Dr Odira.

“As a practitioner, I encourage Kenyan men to change their mindset about vasectomy. If you have achieved the desired family size, take up vasectomy, which is simpler, faster, less invasive, has no side effects, and allows you to resume your bedroom duties in one or two days. This is unlike BTL which takes a woman a week to recover. Women are usually the ones who take contraceptives throughout the childbirth journey, but once you have achieved your desired family size, lift that burden off their shoulders. Do not let women take all family planning choices,” he urges.

“Besides, the time taken for a vasectomy is shorter. A vasectomy can even be done in five minutes, depending on a medic’s skill, experience and speed. But on average, it takes between 10 and 15 minutes. It can also be done in an office. A BTL, however, takes between half an hour to about 40 minutes, and requires a minor theatre.”

Besides married couples, Dr Odira says that the hospital also receives people, both men and women who are not married, do not wish to have children, and want a vasectomy, or BTL.

“In such cases, we dig deep into their medical history to know whether they have psychiatric or psychological issues that have made them go for this decision that our society would term erratic. We refer them to psychologists or psychiatrists for guidance,” he narrates.

“If, after digging into their mental history, we find that there is no psychological issues, they are adults that can give informed consent, that they are well oriented, not disabled in any way in their mental thinking, they have been informed about all available family planning methods, including short- and long-term methods and their side effects, we respect their choice and offer them the service,” he says.

Having been stationed in the hospital’s maternity ward for nine years, he explains that most maternal deaths that result from birth and pregnancy complications could be prevented if couples planned their families.

“Most mothers who die are those with about 10 children, have never done family planning and their families are against the procedure. Due to the uterus having carried many children, it predisposes them to more postpartum haemorrhage (bleeding after birth) compared to mothers having their first, second or third children. If such women took contraceptives to plan their families, it would cut down on the risk of postpartum haemorrhage,” he says.

He explains that when faced with a situation where he is certain that a mother can die if she gets pregnant again and that they seek BTL but the family disapproves, medical officers may be compelled to offer the service so long as the mothers have been counseled and have provided written consent.

“We, however, encourage them to make peace with the family for informed onset because she belongs to a family and we wouldn’t want a family to fight. We also encourage men, before coming for vasectomy, to agree with their wives.”

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