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Bill 20, An Act to Enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation, was introduced to reduce costs associated with Québec's healthcare in general and in vitro fertilisation (IVF) in particular. Passed in November 2015, the new law introduces a number of exclusion criteria for access to and funding for IVF treatment. Remarkably, one exclusion criterion-prior voluntary sterilisation-has prompted little critical commentary. The two justifications offered for restricting funding for IVF on the basis of voluntary sterilisation are that (1) there are cheaper options than IVF for sterilised individuals who want children, and (2) society should not have to pay for IVF for persons who are infertile by choice. I argue that both of these justifications are unsatisfactory, insofar as they contravene the chief value underlying, and current practices of, Canadian healthcare, and rely on problematic ascriptions of personal responsibility for health., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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.

The difficulties in providing readily accessible sterilization services for women in rural settings in developing countries are described; they include: problems with personnel; problems with training; anesthesia difficulties; and cost. For a new method of sterilization to be useful in such situations several criteria concerned with overcoming the perceived problems must be met. Any new procedure should be simple, easily learned, capable of being completed with a single visit, and should require only local anesthesia.

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.