Access to Male & Female Sterilisation

Access to Male & Female Sterilisation The number of female sterilisation procedures and male vasectomies performed by each NHS board per women and men of reproductive age and the waiting times for these procedures. Evidence Base The ONS Omnibus Survey on Contraception and Sexual Health reports that in the UK in 2006/2007: 9% of women under 50 were sterilised 17% of men under 70 had undergone a vasectomy Sterilisation, particularly male sterilisation, is highly cost effective, and failure rates are extremely low (Male and Female Sterilisation Guidelines, Royal College of Obstetricians and Gynaecologists, January 2004). These data are presented by NHS board of residence and NHS board of treatment. The rates for NHS board of treatment are calculated using board of residence population data so may not account for those patients who have cross border treatment. Female Sterilisation Data collection Female sterilisation data are routinely collected by Information Services Division (ISD) and these data are available from Scottish Morbidity Records (SMR) for acute hospital discharge (SMR01) and for maternity episodes (SMR02). The denominator used for calculating the rate per 10,000 women is those aged 15-49 years, to reflect the age band used for women of reproductive age. SMR02 Data Very few sterilisations are recorded on SMR02 and waiting times are not applicable for SMR02 as the sterilisation procedure in this instance takes place during the maternity episode. Data therefore are published by SMR01 only. Data for 2009 Important note: Until 2008 waiting times data for female sterilisation procedures had only been obtainable from SMR01, which is where almost all female sterilisations are recorded. However, with the introduction of New Ways (www.isdscotland.org/newways) to record waiting times, the recording of waiting times data is no longer attached to SMR01 data. In 2008 comparison of data between New Ways recording and SMR01 showed significant under recording in New Ways. The under recording experienced was attributed to the change in the data collection method and it was not expected to affect future year s data however the same comparison using 2009 data shows a similar under recording in New Ways. As a result it is not possible to report on waiting times for female or male sterilisation procedures for the second consecutive year. 1

SMR01 Acute Discharge Summary Table 2.1 Rates of female sterilisation episodes per 10,000 women (aged 15-49) by NHS board of treatment, 2009 NHS Board Rate Rates 95% Confidence Intervals Ayrshire & Arran 16.2 13.6 to 19.2 Borders 21.3 15.9 to 28.0 Dumfries & Galloway 15.0 11.0 to 20.0 Fife 17.9 15.2 to 21.0 Forth Valley 9.9 7.7 to 12.5 Grampian 6.6 5.2 to 8.1 Greater Glasgow & Clyde 11.7 10.5 to 13.0 Highland 5.2 3.6 to 7.3 Lanarkshire 9.8 8.2 to 11.6 Lothian 7.4 6.3 to 8.6 Orkney Islands * * Shetland Islands * * Tayside 13.3 11.1 to 15.9 Western Isles * * Scotland 10.9 10.3 to 11.5 * Less than 10 records data not disclosed. Table 2.2 Rates of female sterilisation episodes per 10,000 women (aged 15-49) by NHS board of residence, 2009 NHS Board Rate Rates 95% Confidence Intervals Ayrshire & Arran 16.2 13.6 to 19.2 Borders 20.5 15.2 to 27.1 Dumfries & Galloway 15.7 11.6 to 20.8 Fife 19.0 16.2 to 22.2 Forth Valley 10.6 8.3 to 13.3 Grampian 6.3 5.0 to 7.8 Greater Glasgow & Clyde 10.1 9.0 to 11.3 Highland 9.2 7.0 to 11.9 Lanarkshire 11.1 9.4 to 13.0 Lothian 7.4 6.3 to 8.6 Orkney Islands * * Shetland Islands * * Tayside 12.3 10.2 to 14.8 Western Isles * * Scotland 10.9 10.3 to 11.5 * Less than 10 records data not disclosed. Commentary 10.9 women per 10,000 (aged 15-49) had a sterilisation procedure in 2009, compared with 12.3 in 2008. Five NHS boards of treatment (NHS Forth Valley, Grampian, Highland, Lanarkshire and Lothian) recorded rates lower than this, however it is not possible to determine whether this is due to lack of availability of the procedure or good availability of other long term contraceptive options such as LARC (long acting reversible contraception). NHS Borders had the highest rate of sterilisation per 10,000 women at 21.3 (showing an increase of 2.3 from 2008), followed by NHS Fife at 17.9 (showing an increase of 0.8 from 2008). Waiting times data for female sterilisations in 2009 is unavailable for comparison to previous years. 2

Male Sterilisation (Vasectomy) Data Collection Information on those patients who have their procedure as an inpatient/daycase patient in hospital can be reliably obtained from SMR01. However the procedure is also performed in other settings, including sexual and reproductive health clinics and GP surgeries, where SMR01 data are not routinely collected. A number of vasectomies are performed as outpatients but it not currently possible to obtain accurate data on this from SMR00. In order to obtain information on procedures performed outwith the acute setting, the Lead Clinicians for Sexual Health were asked to collate these data for their NHS board and return it to ISD. Data for 2009 Information on vasectomy procedures has been obtained in two ways SMR01 Directly from the NHS boards It should be noted that at this time it is not possible to quality assure the data provided directly by the NHS boards to the same extent as the national data returns (SMR01). Where possible any known caveats with the data are explained. Important note: Until 2008 waiting times data for male sterilisation procedures had only been obtainable from SMR01, which is where the majority of male sterilisations are recorded. However, with the introduction of New Ways (www.isdscotland.org/newways) to record waiting times, the recording of waiting times data is no longer attached to SMR01 data. In 2008 comparison of data between New Ways recording and SMR01 showed significant under recording in New Ways. The under recording experienced was attributed to the change in the data collection method and it was not expected to affect future year s data however the same comparison using 2009 data shows a similar under recording in New Ways. As a result it is not possible to report on waiting times for female or male sterilisation procedures for the second consecutive year. There has been a revision to the NHS Forth Valley number of procedures reported for vasectomies in 2008 not performed as inpatient or daycase attendance. Figures in this report referring to 2008 data which have been affected by this revision are labelled so. 3

Table 2.3 Total vasectomy numbers by NHS board of treatment, 2009 NHS Board Number Number Where recorded Total performed inhospital (SMR01 HBT) recorded elsewhere Ayrshire & Arran 383 0 SMR01 383 Borders 135 0 SMR01 135 Dumfries & Galloway 177 0 SMR01 177 Fife 252 0 SMR01 252 Forth Valley 193 303 SMR01 & SMR00 496 Grampian 105 742 SMR01, SMR00 & Primary care 847 Greater Glasgow & SMR01 & NaSH Clyde 330 1,097 1,427 Highland 315 0 SMR01 315 Lanarkshire 14 328 SMR01 & Primary care 342 Lothian 48 700 SMR01 & Local systems 748 Orkney Islands 18 0 SMR01 18 Shetland Islands 40 0 SMR01 40 Tayside 542 223 SMR01 & SMR00 765 Western Isles 29 0 SMR01 29 Scotland 2581 3393-5974 In 2009 SMR01 recorded a total of 2,581 vasectomies in Scotland performed in hospital. The data supplied by the NHS boards in addition to SMR01 shows that 5974 vasectomies were carried out in total in 2009 across multiple settings in Scotland. This compares with 6,359 r vasectomies performed in 2008. Table 2.4 Total rates of vasectomy per 10,000 men (aged 15-59) by NHS board of treatment, 2009 NHS Board Rate Rates 95% Confidence Interval Ayrshire & Arran 37.0 33.4 to 40.9 Borders 43.5 36.5 to 51.5 Dumfries & Galloway 44.4 38.1 to 51.4 Fife 23.8 21.0 to 26.9 Forth Valley 57.9 52.9 to 63.2 Grampian 50.0 46.7 to 53.5 Greater Glasgow & Clyde 38.5 36.5 to 40.5 Highland 35.2 31.4 to 39.3 Lanarkshire 20.5 18.4 to 22.8 Lothian 28.9 26.9 to 31.1 Orkney Islands 31.6 18.7 to 50.0 Shetland Islands 59.6 42.6 to 81.1 Tayside 66.7 62.1 to 71.6 Western Isles 39.2 26.3 to 56.4 Scotland 38.4 37.4 to 39.4 Table 2.4 presents the information supplied directly from the NHS boards combined with the SMR01 data. r Revised total due to error in NHS Forth Valley reporting 4

SMR01 (Acute Discharge Summary) Table 2.5 Vasectomy rates per 10,000 men (aged 15-59) by NHS board of treatment, 2009 NHS Board Rate Rates 95% Confidence Interval Ayrshire & Arran 37.0 33.4 to 40.9 Borders 43.5 36.5 to 51.5 Dumfries & Galloway 44.4 38.1 to 51.4 Fife 23.8 21.0 to 26.9 Forth Valley 22.5 19.5 to 25.9 Grampian 6.2 5.1 to 7.5 Greater Glasgow & Clyde 8.9 8.0 to 9.9 Highland 35.2 31.4 to 39.3 Lanarkshire 0.8 0.5 to 1.4 Lothian 1.9 1.4 to 2.5 Orkney Islands 31.6 18.7 to 50.0 Shetland Islands 59.6 42.6 to 81.1 Tayside 47.3 43.4 to 51.4 Western Isles 39.2 26.3 to 56.4 Scotland 16.6 16.0 to 17.2 Table 2.6 Vasectomy rates per 10,000 men (aged 15-59) by NHS board of residence, 2009 NHS Board Rate Rates 95% Confidence Interval Ayrshire & Arran 38.8 35.1 to 42.8 Borders 42.6 35.6 to 50.5 Dumfries & Galloway 43.9 37.6 to 50.9 Fife 42.6 38.8 to 46.7 Forth Valley 3.7 2.6 to 5.3 Grampian 11.8 10.2 to 13.6 Greater Glasgow & Clyde 6.9 6.1 to 7.8 Highland 41.3 37.2 to 45.7 Lanarkshire 0.8 0.5 to 1.4 Lothian 1.9 1.4 to 2.5 Orkney Islands 31.6 18.7 to 50.0 Shetland Islands 59.6 42.6 to 81.1 Tayside 35.9 32.5 to 39.5 Western Isles 39.2 26.3 to 56.4 Scotland 16.6 15.9 to 17.2 Tables 2.5 and 2.6 show the rates per 10,000 based on those procedures recorded by SMR01 (i.e. inpatient/day case). Commentary Data were requested from the NHS boards as SMR01 only records those patients who have the procedure in hospital. Two major referral pathways can be identified: 1. GP/ Sexual and Reproductive health clinic Outpatient consultation Hospital procedure GP/ Sexual and Reproductive health clinic Hospital procedure 2. Self-referral/GP/Hospital Sexual and Reproductive health clinic Where patients are referred by a GP or a sexual and reproductive health clinic to a hospital for their procedure they are either invited for an initial outpatient consultation appointment after which they are then placed on a waiting list for the procedure; or they are sent an information pack containing a consent form to return back to the hospital. On receipt of the completed consent form the patient is then placed on a 5

waiting list for the procedure. This results in the procedure being performed on the patient s initial visit. Vasectomies are performed as inpatient/daycase in all of the boards, with 8 out of 14 (57%) performing the procedures only as inpatient/daycase (i.e. they do not perform any of the procedures as outpatient appointments). GPs GPs perform vasectomies in 2 NHS board, NHS Grampian and NHS Lanarkshire. Sexual and Reproductive health clinics Refer patients to hospital for vasectomy Offer a vasectomy service within the clinic Two boards, NHS Lothian and NHS Greater Glasgow & Clyde, offer vasectomies in sexual and reproductive health clinics. It is worth noting that tables 2.3 and 2.4 show low numbers and rates for NHS Lanarkshire as vasectomy procedures for men residing in this health board are performed at the Sandyford clinic in NHS Greater Glasgow & Clyde due to a contract which exists between the two health boards. NHS Greater Glasgow & Clyde reported that 505 of their 1,097 vasectomies performed in their sexual and reproductive health clinics were on residents of other health board. Due to the data collection method it is not possible to say how many of the 505 procedures were on residents from NHS Lanarkshire health board. Similarly tables 2.5 and 2.6 show low rates based on SMR01 data as the majority of NHS Lanarkshire residents have their vasectomy performed either in NHS Greater Glasgow & Clyde or in primary care with NHS Lanarkshire. 6

Long term data male and female sterilisation since 2000 Figure 2.1 Numbers of female and male sterilisations 2000-2009, by NHS board of treatment 7000 6000 5000 4000 3000 2000 1000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 All Vasectomies SMR01 Males SMR01 Females Figure 2.1 shows the national trend in male and female sterilisation since 2000 using SMR01 data and data supplied directly by the boards. It should be noted that SMR01 only covers NHS hospital procedures and does not include all vasectomies undertaken since 2000. Since 2000, female sterilisations have reduced by 71%. From 2008 to 2009 there has been a 12% reduction in female sterilisations. Vasectomies performed in hospitals have decreased by 55.2% since 2000. From 2008 and 2009 there has been a 2% reduction in vasectomies performed in hospitals. In 2009, 56.8% of all vasectomy procedures were not performed as inpatient or daycase procedures (i.e. not recorded on SMR01). This is a decrease from 58.5% r in 2008 but an increase from 54% in 2007. It is worth noting that NHS Lothian provided a best guess figure for their procedures in 2008 that were not performed as an inpatient or daycase attendance. The reduction in their 2009 figure may genuinely be a reduction in the numbers performed or it may be due to data collection/reporting issues. This affects the overall total for vasectomies performed in Scotland. A total of 38.4 per 10,000 men (aged 15-59) in Scotland had a vasectomy in 2009, compared with 41.0 r in 2008. 7

2009 data shows a slight decrease in the numbers of vasectomies performed inhospital since 2008 (2,581 v 2,636). The total number performed also show a decrease (5,974 v 6,359 r ). Figure 2.1 clearly shows the downward trend in female sterilisation. The possible reasons for these changes are discussed in the commentary below, the most significant being the increasing popularity of long acting reversible methods of contraception (LARC). The report published on the LARC indicator, in 2010, shows the uptake of very long acting reversible methods of contraception in Scotland is increasing. The report can be found at www.isdscotland.org/kci Conclusion The reduction in female sterilisation since 2000 implies that women may be looking for less intrusive ways of ensuring long term contraception, such as long acting reversible methods of contraception. Although it cannot be proven that the decline in numbers of sterilisations and the increase seen in the uptake of LARC are directly related, the relationship between these statistics should not be dismissed. Vasectomy offers men a safe and reliable method of contraception and should be easy and quick to access. A number of boards offer the procedure via general and urology lists indicating that the availability of this procedure may be restricted. Those services outwith hospitals are offering a more easily accessible service, for example in NHS Lothian and NHS Greater Glasgow & Clyde, to which the patient can self-refer or be referred via the GP. This also means that the patient is not sharing a hospital waiting list with other patients who might be deemed to be of higher priority surgically. These services outwith hospital, however are limited in terms of geographical availability. The development of more community services, including GPs, offering vasectomies has the potential to significant increase the availability and accessibility of vasectomies. Thanks to: The lead clinicians for Sexual Health in Scotland for providing their local vasectomy data. r Revised total due to error in NHS Forth Valley reporting 8