Camp laparoscopic sterilization deaths in Gujarat State, India, 1978-1980

An early experience of camp laparoscopic sterilization in Gujarat State, India, resulted in 22 deaths among 106,500 women undergoing the operation during 1979 and 1980. Increased risk of death was seen when larger numbers of procedures were performed by year or month of year. The least experienced surgeons had the highest case-fatality rate. Improvised settings (i.e., school buildings) exacerbated the risk of death, as did advanced age, and, to a lesser extent, high parity. Errors in clinical judgment were identified in some fatal procedures. A system of health audit of large sterilization programs is needed.