Female Sterilisation – policy alignment survey

On 1 July 2022, the two clinical commissioning groups (CCGs) known as Bassetlaw CCG and Nottingham and Nottinghamshire CCG, which served the population of Nottingham and Nottinghamshire, were brought together and replaced by a new organisation called NHS Nottingham and Nottinghamshire Integrated Care Board (ICB).

Previously, the separate CCGs had different commissioning policies. Since the establishment of the ICB, efforts have been made to harmonise all internal and external policies for the new organisation. The goal is to ensure that people in Nottingham and Nottinghamshire have fair and equal access to healthcare within the same timeframe and based on the same clinical reasons.

Many of these policies have already been integrated into approved policy documents. In these cases, there have been no changes to the treatment, eligibility, or pathway. The only difference is that now the same policy applies to all residents of Nottingham and Nottinghamshire.

To ensure the policies align with strong clinical evidence and national guidance, NHS Nottingham and Nottinghamshire staff, including doctors and nurses, have reviewed them. This ensures that the policies apply equally to all patients in the area, with minimal impact in most cases.

However, one policy difference requires potential changes for patients: Access to Female Sterilisation. The former Bassetlaw CCG had no specific rules for approving this procedure, whereas the former Nottingham and Nottinghamshire CCG required patients to try an Intrauterine Device (IUD) (e.g., a Mirena coil) for one year before considering sterilisation.

From April 2022 to March 2023, Nottingham and Nottinghamshire ICB received 287 applications for female sterilisation. Of these, 93 were rejected (32%) due to the requirement of the 12-month IUD trial.

Desktop research revealed that no other ICB has this requirement in their policies—a stance that is further supported by NICE (National Institute for Health and Care Excellence) guidance.

Instead, the NICE guidance encourages patients to consider all possibilities for long-acting reversible contraception (LARC) prior to being referred for permanent sterilisation. It also suggests providing patients with information about the risks, benefits, and success rates of sterilisation in contrast to alternative contraception methods such as LARC and male vasectomy.

In addition to the clinical review, the ICB could be at risk of legal challenge by not upholding equality standards if the requirement criteria were to continue, as it misaligns with the ICB’s statutory duties under the NHS Act 2006 and the Equality Act 2010.

Removing the mandatory IUD trial could potentially benefit patients in specific diverse communities who do not believe in, or hold reservations about, the use of IUDs. Moreover, survivors of sexual abuse and trauma (such as Female Genital Mutilation) might consider the use of an IUD to be invasive and unsuitable. Increasing the choice and accessibility of LARC and sterilisation services could also help reduce unwanted pregnancies or the need for terminations arising from them.

To address the disparity between the policies and align with national guidance, a recommendation has been made to remove the mandatory trial period and instead propose that patients “explore all suitable contraceptive options before considering sterilisation.”

On 5 July 2023, the ICB launched an online survey to gather feedback and comments on the proposed change to the female sterilisation policy. The survey included two questions on the policy and a set of demographic questions. Information was made available on the ICB website to promote participation, with hard copies and translations available upon request.

The opportunity to participate was shared with the Mid Nottinghamshire Health Inequalities meeting, Citycare Partnership, Nottinghamshire Healthcare Trust, Community Voluntary Sector colleagues, the RAPID group (Chairs of all the Patient Participation Groups), the Engagement Practitioners Forum, and the East Midlands Academic Health Science Network. It was also promoted on the ICB intranet and in staff news.

To ensure input from those most affected, the survey was specifically disseminated to:

• Maternity Voices Partnership and Local Maternity & Neonatal System contacts
• Nottinghamshire County Council Children and Women’s contacts
• Miscarriage Association
• Local baby and toddler groups
• JUNO Women’s Aid
• She UK
• Heya
• Nottingham Women’s Centre

The survey closed on 26 July 2023. A total of 36 people responded:

• 24 (67%) were members of the public
• 8 (22%) worked within the NHS
• 2 (6%) worked in the voluntary, community, and social enterprise sector
• 1 (3%) worked on behalf of an NHS organisation
• 1 (3%) preferred not to say

80% of respondents support the recommendation, 61% (22) of respondents strongly support and 19% (7) somewhat support the recommendation. 8% (3) of respondents strongly oppose the recommendation and 11% (4) somewhat oppose as depicted in figure 1. No respondents selected a neutral response of ‘neither support nor oppose’.
Figure 1. Support for recommendation (n=36)
“Women will have a very good reason for wanting sterilisation and will normally have already considered other options. They will not make this decision lightly. They should not be forced to do something that they already decided they do not want (i.e. have a coil).”

• Bodily autonomy was the reason just over half (54%) of respondents ‘strongly support’ the recommendation, closely followed by patient choice (45%).
• Others also cited that the recommendation is a sensible and logical update to the current policy.
• Many also supported the policy change as it would decrease barriers to accessing female sterilisation.

One of the reasons put forward for somewhat opposing the change was the detrimental impact on resources:

“it will cause more sterilisation operations, which will cost more money and unnecessary General Anaesthetic when it is not as effective as something like the coil which is a 10 minute procedure”

The importance of accurate, timely information was emphasised with many who either supported or opposed the recommendation.

“I strongly support the recommendation with a caveat. As a clinician who has worked in the area of women’s health, I am aware there are varying degrees of knowledge and expertise around intrauterine contraception. This is often a very suitable method with very low failure rates and LNG coils are excellent for heavy menstrual bleeding. Women who are properly counselled will sometimes choose this method over sterilisation, even if sterilisation was their initial preferred option. So the caveat would be around the requirement for high quality counselling as part of the pathway.”

“It seems more vague. If a person knows they want to be sterilised, are we expecting them to try all other options first? Will there be a timeframe? Whose discretion is it at? This seems like it might be making the process harder for women to access the treatment they want.”

“I have been sterilised and I would not have wanted intrauterine contraception or any other contraception in case it failed. I made this informed decision with support from my GP. It is my body and I do not wish to be forced into having options around my health. I feel it is more about practitioners educating women on the choices of contraception rather than stipulating that we have to trial intrauterine contraception for one year before considering sterilisation. I question the equality in such decision making when male counterparts health is becoming more readily available yet women’s are becoming more restrictive: mensuration [sic], abortion, menopause and now contraception.”

The above response is also an example of a few respondents’ sentiments querying whether equivalent mandatory service criteria was replicated for policies relating to male services.

Conclusion 1: 32% of people wanting female sterilisation were not able to access the service because of the IUD requirement in Nottingham and Nottinghamshire. Clinical review indicated that the current Nottingham and Nottinghamshire criteria differs from national guidance. The majority of survey respondents supported the change to the sterilisation policy, mostly citing support due to bodily autonomy and patient choice.

Recommendation 1: To remove the requirement for patients to trial the IUD for 12 months.

Conclusion 2: Many noted that it is vital there is sufficient high-quality and timely information regarding contraception and sterilisation so that patients and clinicians can be confident they are making an informed choice.