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Background: Large scale public investment in family welfare programme has made female sterilization a free service in public health centers in India. Besides, it also provides financial compensation to acceptors. Despite these interventions, the use of contraception from private health centers has increased over time, across states and socio-economic groups in India. Though many studies have examined trends, patterns, and determinants of female sterilization services, studies on out-of-pocket payment (OOP) and compensations on sterilisation are limited in India. This paper examines the trends and variations in out-of-pocket payment (OOP) and compensations associated with female sterilization in India., Methods: Data from the National Family Health Survey - 4, 2015-16 was used for the analyses. A composite variable based on compensation received and amount paid by users was computed and categorized into four distinct groups. Multivariate analyses were used to understand the significant predictors of OOP of female sterilization., Results: Public health centers continued to be the major providers of female sterilization services; nearly 77.8% had availed themselves of free sterilization and 61.6% had received compensation for female sterilization. About two-fifths of the women in the economically well-off state like Kerala and one-third of the women in a poor state like Bihar had paid but did not receive any compensation for female sterilization. The OOP on female sterilization varies from 70 to 79% across India. The OOP on female sterilization was significantly higher among the educated and women belonging to the higher wealth quintile linking OOP to ability to pay for better quality of care., Conclusion: Public sector investment in family planning is required to provide free or subsidized provision of family welfare services, especially to women from a poor household. Improving the quality of female sterilization services in public health centers and rationalizing the compensation may extend the reach of family planning services in India.

OBJECTIVE To determine characteristics of cats sterilized through a subsidized, reduced-cost spay-neuter program in Massachusetts and of owners who had their cats sterilized through this program. DESIGN Cross-sectional anonymous survey and telephone interviews. SAMPLE 1,188 (anonymous surveys) and 99 (telephone interviews) cat owners. PROCEDURES Owners who had a cat sterilized at clinics held between January 2006 and December 2008 were invited to complete anonymous surveys. Semistructured telephone interviews were conducted with owners who had a cat sterilized during clinics held in 2009. RESULTS Most cats had never been seen by a veterinarian previously; "too expensive" was the most common reason for this. Total annual household income was significantly associated with the number of times the cat had been examined by a veterinarian and reason why the cat had not been spayed or neutered previously. Most cats were acquired through informal means and without actively being sought, and there was often a time lag between acquisition and sterilization. Undesirable behavior and avoiding pregnancy were primary motivations for neutering and spaying, respectively. Nearly half of owners who indicated they would have had their cat sterilized through a private veterinarian if the clinic had not been available stated that the surgery would have been delayed because of cost. CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that spay-neuter decisions were related to owner income and procedure cost, that elimination of the reduced-cost spay-neuter program would likely have exacerbated the spay-delay problem, and that gradations of financial need should be considered when evaluating relationships between income and spay-neuter decisions.

Background: The recent decline in fertility in India has been unprecedented especially in southern India, where fertility is almost exclusively controlled by means of permanent contraceptive methods, mainly female sterilization, which constitutes about two-thirds of overall contraceptive use. Many Indian women undergo sterilization at relatively young ages as a consequence of early marriage and childbearing in short birth intervals. This research aims to investigate the socioeconomic factors determining the choices for alternative contraceptive choices against the dominant preference for sterilization among married women in India., Methods: Data for this study are drawn from the 2005-06 National Family Health Surveys focusing on a sample of married women who reported having used a method of contraception in the five years preceding the survey. A multilevel multinomial logit regression is used to estimate the impact of socioeconomic factors on contraceptive choices, differentiating temporary modern or traditional methods versus sterilization., Findings: Religious affiliation, women's education and occupation had overarching influence on method choices amongst recent users. Muslim women were at higher odds of choosing a traditional or modern temporary method than sterilization. Higher level of women's education increased the odds of modern temporary method choices but the education effect on traditional method choices was only marginally significant. Recent users belonging to wealthier households had higher odds of choosing modern methods over sterilization. Exposure to family planning messages through radio had a positive effect on modern and traditional method choices. Community variations in method choices were highly significant., Conclusion: The persistent dominance of sterilization in the Indian family planning programme is largely determined by socioeconomic conditions. Reproductive health programmes should address the socioeconomic barriers and consider multiple cost-effective strategies such as mass media to promote awareness of modern temporary methods.

Our goal was to determine whether it is more cost-effective to control feral cat abundance with trap-neuter-release programs or trap and euthanize programs. Using STELLA 7, systems modeling software, we modeled changes over 30 years in abundance of cats in a feral colony in response to each management method and the costs and benefits associated with each method . We included costs associated with providing food, veterinary care, and microchips to the colony cats and the cost of euthanasia, wages, and trapping equipment in the model. Due to a lack of data on predation rates and disease transmission by feral cats the only benefits incorporated into the analyses were reduced predation on Wedge-tailed Shearwaters (Puffinus pacificus). When no additional domestic cats were abandoned by owners and the trap and euthanize program removed 30,000 cats in the first year, the colony was extirpated in at least 75% of model simulations within the second year. It took 30 years for trap-neuter-release to extirpate the colony. When the cat population was supplemented with 10% of the initial population size per year, the colony returned to carrying capacity within 6 years and the trap and euthanize program had to be repeated, whereas trap-neuter-release never reduced the number of cats to near zero within the 30-year time frame of the model. The abandonment of domestic cats reduced the cost effectiveness of both trap-neuter-release and trap and euthanize. Trap-neuter-release was approximately twice as expensive to implement as a trap and euthanize program. Results of sensitivity analyses suggested trap-neuter-release programs that employ volunteers are still less cost-effective than trap and euthanize programs that employ paid professionals and that trap-neuter-release was only effective when the total number of colony cats in an area was below 1000. Reducing the rate of abandonment of domestic cats appears to be a more effective solution for reducing the abundance of feral cats., (©2012 Society for Conservation Biology.)

In the 1970s, concern about coercive sterilization of low-income and minority women in the United States led the US Department of Health, Education, and Welfare to create strict regulations for federally funded sterilization procedures. Although these policies were instituted to secure informed consent and protect women from involuntary sterilization, there are significant data indicating that these policies may not, in fact, ensure that consent is truly informed and, further, may prevent many low-income women from getting a desired sterilization procedure. Given the alarmingly high rates of unintended pregnancy in the United States, especially among low-income populations, we feel that restrictive federal sterilization policies should be reexamined and modified to simultaneously ensure informed decision-making and honor women's reproductive choices.

Background: January 1, 2002, copayment for outpatient female sterilization in Norwegian public hospitals increased from 33 euro to 750 euro after a revision of the health care system. The aim of the present study was to investigate the effect of the new copayment system on female sterilization epidemiology., Methods: We retrieved data on all female sterilizations 1999-2005 (N = 23 1333) from the Norwegian Patient Register, an administrative register to which it is mandatory for all hospitals to report. Sterilizations with diagnostic codes indicative of vaginal delivery, caesarean section, spontaneous abortion, ectopic pregnancy, and termination of pregnancy were analyzed separately. All other sterilizations were defined as "interval sterilization"., Results: An abrupt fall in female sterilization was observed after the raise in copayment. Age-adjusted incidence rates dropped from 6.3-6.8 per 1000 women in 1999-2001 to 2.2-2.3 per 1000 women during 2002-2005. Interval sterilizations dropped to 25% of the previous level after the rise in copayment while sterilizations in conjunction with caesarean section and postpartum sterilization remained constant., Conclusion: For many Norwegian women seeking contraception, sterilization is no longer an available alternative.

Objectives: The aim of this study was to establish and evaluate a direct access service for laparoscopic sterilization., Methods: A pragmatic randomized controlled trial was carried out on a total of 232 women referred to Aberdeen Royal Infirmary for sterilization between 1 June 1996 and 31 March 1997, from 57 general practices around Aberdeen, Scotland, comprising 75 from general practices that had received criteria for direct access, and 157 from control practices. The main outcome measures were: patients' waiting times to appointments and operation, satisfaction, short-term regret, operative complications and costs; conjoint analysis of patient preferences; GPs' adherence to referral criteria; GP and gynaecologist satisfaction; and NHS costs., Results: Analysis was by intention to treat. There were no inappropriate direct referrals. Waiting time was lower in the intervention group, but there were more visits post-operatively to the GP. Patient and doctor satisfaction was equally high in both groups. There was no difference in operative complication rate, nor in total cost to patients or to the NHS. GPs and gynaecologists strongly supported direct access, but women preferred to meet both a gynaecologist and a GP before sterilization (routine referral). Other attributes of care important to patients included written information, although waiting time was not important. Of all women referred for sterilization during the study period, only 31% were suitable for direct referral., Conclusions: Patients preferred routine referral, and there were no differences in patient costs or satisfaction. There was, however, strong medical support for direct referral. Restrictive direct referral criteria may limit the uptake. These findings are important for future planning of direct referral services. Important methodological lessons were also learnt about the conduct of trials involving the primary-secondary care interface.

In 1992, the federal and state governments spent $645 million to provide contraceptive services. According to the results of a survey of health, social service and Medicaid agencies conducted by The Alan Guttmacher Institute, Medicaid accounted for 50% of all public spending on family planning services. State governments, which spent a total of $155 million of their own revenues for contraceptives services, accounted for 24% of public funding, Title X for 17%, and the social services and maternal and child health block-grant programs for nearly 10%. Medicaid expenditures for contraceptive services increased dramatically between 1990 and 1992, and were responsible for a 28% rise in total expenditures for contraceptive services during that period. However, when inflation is taken into account, total public expenditures for contraceptive services have decreased by 27% since 1980, and Medicaid has replaced Title X as the primary source of funding for such services. The federal and state governments together spent $138 million to subsidize sterilization services in 1992, an increase of 46% from 1990. The federal and state governments also spent $80 million to provide 202,622 abortions to poor women; less than 1% was contributed by the federal government. These estimates of expenditures are approximations that, because of methodologic problems and changes over time, may overstate public expenditures for contraceptive services.

The Association for Voluntary Surgical Contraception retrospectively examined the impact of funding decreases on access to sterilization services at 20 nongovernmental family planning clinics in Mexico, the Dominican Republic, and Brazil. Clinic staff were asked questions about client fees, caseloads, availability of comparable low-cost or free services nearby, cost-recovery activities, and the socioeconomic profile of clients before, during the time, and after subsidies were lowered or eliminated. Funding reductions were followed by decreased caseloads at 14 of the 20 sites studied. Of the six others, four experienced an increase in caseloads, one saw no perceptible change, and one experienced a decrease only as a result of management policy to cut the caseload to improve quality. The most common response to the decrease in funding (shared by 17 sites) was an increase in client fees. In all but three of the 17 clinics, the increase in fees was met with a decline in caseloads. Moreover, at nine of these 17 sites, the fee increase effected a change in client mix; anecdotal evidence suggests that more middle-income and fewer lower-income clients were using sterilization services. Four lessons can be drawn from this study: Donors need to plan funding phase-outs carefully, in conjunction with grantees; grantees need to assess the costs of the procedure realistically, and assign fees accordingly; management needs to seek alternative funding sources in lieu of, or in addition to, increasing fees; and caseloads can be increased and costs recovered by diversifying services.

In FY 1990, the federal and state governments spent $504 million to provide contraceptive services and supplies, according to results of a survey of state health, social services and Medicaid agencies conducted by The Alan Guttmacher Institute. Medicaid accounted for 38 percent of all public funds spent on contraceptive services, Title X provided 22 percent, and two federal block-grant programs--Social Services and Maternal and Child Health--together were responsible for 12 percent of public expenditures. State governments accounted for the remaining 28 percent of public funding. Although public expenditures for contraceptive services have risen by $154 million over the past decade, when inflation is taken into account, expenditures have actually fallen by one-third. Since 1980, the proportion of public contraceptive expenditures contributed by Title X has been cut virtually in half, while the proportion contributed by state governments has nearly doubled. When inflation is taken into account, Title X expenditures for contraceptive services have fallen by almost two-thirds since 1980. The federal and state governments together spent $95 million to subsidize sterilization services in 1990, and $65 million to provide abortion services. The federal government was the major source of funding for sterilization services but provided less than one percent of the cost of abortion services. Because of changes over time in survey methodology and the difficulties some states had in separating out expenditures by type of care, these data are approximations.

The government of Bangladesh and the World Bank commissioned a Compensation Payments Study, carried out in 1987, to assess the merits and demerits of payments for sterilizations to clients, medical personnel, and intermediaries who motivate and refer clients. The study conclusively shows that the decision of Bangladeshi men and women to undergo sterilization is a considered and voluntary act, taken in knowledge of the nature and implications of the procedure, and in knowledge of alternative methods of regulating fertility. There is a high degree of client satisfaction among those who have been sterilized, although among clients who had fewer than three children, 25 percent expressed regret that they had been sterilized. Money may be a contributing factor to the decision to become sterilized in a large majority of cases, but a dominant motive for only a very small minority. Payments to referrers have fostered a large number of unofficial, self-employed agents--particularly men who recruit vasectomy cases. These agents provide information about the procedures for being sterilized, particularly to the poor. They also concentrate on sterilizations to the exclusion of other methods, and are prone to minimize the disadvantages and exaggerate the attractions of sterilization.

In FY 1987, the federal and state governments spent +386 million to provide family planning services. Medicaid was the leading source of public funding, accounting for 36 percent of all public monies spent on family planning. Title X of the Public Health Service Act provided 34 percent of total public funds, and two block-grant programs--Social Services and Maternal and Child Health--together were responsible for 17 percent of public support in this area. State governments, which spent a total of +50 million of their own revenues for family planning services, accounted for the remaining 13 percent of public funding. The federal and state governments together spent +65 million to subsidize contraceptive sterilization services in FY 1987. The federal government provided 97 percent of the funding, 88 percent through the Medicaid program. In addition, the federal and state governments spent +64 million to provide 189,000 abortions to poor women; less than one percent of these funds were contributed by the federal government. These data come from a survey of state health, welfare and Medicaid agencies carried out by The Alan Guttmacher Institute and should be viewed as approximations rather than as precise figures.

The cost of contraception is one factor that affects the choice of a birth control method. An analysis of the first-year costs for the various methods, based on fees charged by private physicians and supplies purchased at drugstores, shows that the cost can be considerable and that there are large differences in cost between methods. Prescription contraceptives--the pill, IUD and diaphragm--are by far the most expensive of the reversible methods because they require medical supervision, but supplies alone are also more expensive for prescription methods than for nonprescription methods. First-year cost is highest for the pill-$172, compared with $160 for the diaphragm and $131 for the IUD. The mean of $154 for these three prescription methods is almost four times the mean first-year cost of $40 for condoms and foam. Sterilization necessitates the largest initial expenditure, and the cost of tubal ligation-$1,180-is almost five times the cost of vasectomy-$241. However, sterilization represents a one-time cost, while the other methods involve recurring expenses that may add up to more than the cost of sterilization over time. The methods that are associated with the lowest failure rates-sterilization, the pill and the IUD-are among the most expensive. To offset the costs of contraception, 4.6 million American women obtained low-cost care from subsidized family planning clinics in 1980.

In 1983, the federal and state governments spent +340 million to provide contraceptive services--four percent more than they spent during the previous year. Title X of the Public Health Service Act, still the leading source of funding, accounted for +117 million, or 34 percent of all public expenditures. Almost as important was the +108 million (32 percent of total expenditures) provided through Title XIX of the Social Security Act (Medicaid). Two block-grant programs--Social Services and Maternal and Child Health--provided +38 million and +19 million, respectively; together, the two were responsible for 17 percent of public support for contraceptive services. State governments, which spent +58 million of their own revenues, provided an additional 17 percent of funding. Some public expenditures for contraceptive services were made in all the states. Nearly all of the four percent increase in total public funds between 1982 and 1983 was due to a 15 percent rise in Medicaid reimbursements. The federal and state governments together spent +69 million to provide about 73,000 sterilizations in 1983. Ninety percent of sterilization expenditures were made by the federal government--86 percent through the Medicaid program. In addition, the states and the federal government spent +71 million to provide 216,000 abortions in 1983. Unlike public funding for either contraceptive services or sterilization, almost all of the funding for abortion came from the states rather than from the federal government.

The federal government and the states spent $328 million to support the provision of contraceptive services in fiscal 1982, 13 percent less than they had spent the previous year. Federal funds for family planning services came from Title X of the Public Health Service Act, Title XIX of the Social Security Act (Medicaid), and the Maternal and Child Health (MCH) and Social Services block grants, which are administered by the states. Title X continued to provide the largest, although a diminishing, share of public funds for contraceptive services--36 percent of all such funds in 1982. (In 1980, Title X had accounted for 44 percent of public funding.) Medicaid expenditures for family planning totaled $94 million; $17 million was spent under the MCH block grant, and $46 million under the Social Services block grant. State governments contributed an additional $53 million, about the same figure reported for the previous year, indicating that the states did not use their own funds to soften the impact of cuts in federal expenditures for contraceptive services in 1982. The federal government and the states spent an estimated $55 million, almost all of it through Medicaid, to provide sterilization services for poor women. The states spent $67 million and the federal government spent $1 million to provide abortions for 210,000 indigent women. These figures come from the 11th annual survey of state health and welfare agencies and state Medicaid programs by The Alan Guttmacher Institute (AGI). The AGI conducted this survey in January 1983 to determine the levels and sources of public funding for contraceptive, sterilization and abortion services in each state during FY 1982.

The Indian family welfare program has offered financial incentives since the early 1960s to both family planning motivators and acceptors of sterilization and the IUD. This article reviews the available evidence regarding the impact of incentives on the quality and quantity of family planning services in India. Administrative concerns related to the implementation of incentive programs are discussed, and the current debate on disincentives, as well as the brief period when disincentives were used, is summarized. The studies reviewed, though few in number and varying in quality and methodology, indicate that incentives to acceptors help to increase the level of contraceptive acceptance, especially when they are part of a well designed strategy of service delivery and client motivation. Incentives do not appear to have an adverse effect on quality of services and acceptors, and they do not seem to influence method choice. Disincentives, if they are used, should not impinge on fundamental individual rights of either the parents or the child.

In FY 1985, the federal and state governments spent $398 million to provide contraceptive services and supplies. The two leading sources of funding were the Medicaid program and Title X of the Public Health Service Act. The former accounted for $137 million, or 34 percent of all public expenditures; and the latter program accounted for $133 million, also 34 percent. Two blockgrant programs--Social Services and Maternal and child Health--provided $40 million and $23 million, respectively; together, they were responsible for 16 percent of public support for contraceptive services. State governments, which spent $64 million of their own revenues, accounted for another 16 percent of funding. The federal and state governments together spent $64 million to subsidize sterilizations in FY 1985. The federal government provided 94 percent of the funding--84 percent through the Medicaid program. In addition, the states and the federal government spent $66 million to subsidize 188,000 abortions; in this case, however, the federal government contributed less than one percent of the funds used. These data come from a survey of state agencies, and should be viewed as approximations rather than as precise figures.

Obstetrician-gynecologists are 4-5 times more likely to perform female sterilizations, and urologists are 2-3 times more likely to perform vasectomies, than are general surgeons or general or family practitioners. Catholics are less likely to perform either procedure than are non-Catholics. Participation in a group practice and having a practice in the North Central region of the country are associated with carrying out a larger average number of both male and female sterilizations. More than half of female sterilizations are performed as inpatient hospital procedures, and most of the remainder are done in hospitals on an outpatient basis. Two-thirds of vasectomies, on the other hand, are performed in doctors' offices, while most of the rest are performed as hospital outpatient procedures. About one vasectomy in 12, however, is performed on an inpatient basis--possibly because general anesthesia is used, or the procedure is performed along with other surgery. The average cost for an inpatient female sterilization in 1982 was $1,335. The cost for a hospital outpatient sterilization was not much less than that. The total cost of a vasectomy ranged from an average of $511 for an inpatient procedure to $240 for one performed in the office. The average cost is higher when the sterilization is performed by an obstetrician-gynecologist or a urologist than when the service is provided by a general surgeon or general/family practitioner. Fifty-eight percent of physicians performing female sterilizations accept Medicaid reimbursement, and 12 percent reduce their fees to accommodate low-income patients. The proportions for doctors who perform vasectomies are 51 percent and 12 percent.(ABSTRACT TRUNCATED AT 250 WORDS)

All women hospitalized for delivery over a ten-week period at the largest maternity hospital in Campinas in the State of São Paulo, Brazil, were questioned about their interest in and plans for sterilization. Results from a categorical data analysis indicate that among the study variables, cesarean delivery was the necessary condition for postpartum sterilization and was significantly associated with the patient's ability to pay for services. Further, the variability in the proportion of women sterilized postpartum was almost perfectly explained by a linear model with main effects for parity and for the patient's ability to pay for services.

Using data that cover the period 1978 to 1986, this article assesses the effect of policies concerning the provision of female sterilization during the early 1980s. The annual rate of sterilization among ever-married women aged 20-39 in Costa Rica was approximately one-fifth lower in 1985 than in 1982, when sterilization became illegal. Medical committees continued to review each case individually, and sterilizations were still available, especially to less educated women, among whom prevalence increased slightly between 1981 and 1986. However, sterilization prevalence decreased modestly among women aged 35-39 and among the better educated. As of 1986, 16.7 percent of all women who were currently in union relied on sterilization, compared with 17.3 percent in 1981. In Colombia, annual rates of sterilization rose by less than 4 percent from 16.9 in 1977 to 17.5 in 1979, and prevalence increased among women at all educational levels, in rural and urban areas, and especially among women aged 30-44. As a result of the adoption of flexible eligibility criteria, minimal cost, and accessibility in both rural and urban areas in Colombia since 1984, sterilization is now the most preferred contraceptive method there, used by approximately 18.3 percent of all women currently in union as of 1986.

The study compares 709 males and 546 females recruited from a well-defined geographic area and sterilized during a 5-year period at the same hospital. Medical records were reviewed and questionnaires sent out. Widespread satisfaction with the sterilization was found. The sterilized women had experienced contraceptive side effects and failures more often than the men. Only 70% of the laparoscopic sterilizations could be carried out during a 1-day admission, 25% of the women complained about long-term sequelae, and there were 1% failures. The vasectomies were carried out on an outpatient basis, there were few postoperative symptoms, and 0.5% failures were recorded. Female sterilization was at least four times as expensive as vasectomy. It is concluded that vasectomy is generally to be preferred to female sterilization, and that the preoperative guidance should involve both man and wife.

In her paper, Sue Teper outlines the various methods of contraception or fertility control and their relationship to sterilisation. She also considers a particular group of women in Aberdeen as a mini case-study. From these two aspects of sterilization develops a third--that of broader medical and economic issues. Sterilisation usually concerns patients who are free from illness, therefore the attitudes of medical personnel are much more relevant to whether or not the operation is performed on request purely as a means of fertility control, rather than for medical reasons where the patient may be at risk were a pregnancy to occur. Ms Teper calls for medical staff in this instance to clarify their own attitudes in decisions which involve surgical skills and healthy patients.