World Vasectomy Day: What Difference Does 1,000 Vasectomies Make?

Authors: Dominick Shattuck, Helen Bristow

Affiliation: FHI 360

Overview

World Vasectomy Day provides us with the opportunity to examine the impact of linking vasectomy providers, clients, and those interested in global health around this highly effective and underutilized contraceptive method. Physicians from around the globe are logging the number of vasectomies they provide on October 18th to raise awareness of vasectomy as a viable alternative to hormonal and other female-controlled contraceptives. We believe that in any setting, a healthy contraceptive method mix includes short-term methods (i.e., oral contraceptive pills and injectable contraceptives), long-acting methods (i.e., implants and intrauterine devices) and permanent methods (i.e., female sterilization and vasectomy). Yet, in much of the developing world, the use of vasectomy is negligible at best. No place is this more true than in sub-Saharan Africa.

Vasectomy provides men with the opportunity to share the responsibilities of family planning in a way that has few, if any, side effects. In this paper, we estimate the public health impact that 1,000 vasectomies would have if they were delivered in several sub-Saharan African countries over one year. Vasectomy’s potential in helping prevent unintended pregnancies and reduce maternal and child mortality is well known among reproductive health experts but may not be as familiar to the general public. We hope that our presentation of these data will raise awareness of the potential impact vasectomy can have on health and development in Africa.

Background

Vasectomy is an underused contraceptive method in the developing world, despite being safe and effective and being the least expensive long-acting and permanent method (LAPM) of contraception [1]. Vasectomy is also quicker (taking only 10 to 20 minutes to perform) and safer than female sterilization [2,3]. Yet, vasectomy is half as common as female sterilization in the developed world and even less common in many developing countries [4].

No-scalpel vasectomy (NSV) is the optimal vasectomy technique because it decreases the risk of surgical complications, such as bleeding and infection, and has a low failure rate (0.15 percent)[5]. NSV procedures that use thermal cautery plus fascial interposition further decrease failure rates and have been found to be appropriate for low-technology and low-resource settings. Currently, NSV with thermal cautery plus fascial interposition has been effectively scaled up in many developed settings and some resource-poor settings outside of Africa.

Worldwide, 2.4 percent of men of reproductive age have had a vasectomy. In Africa, the prevalence of vasectomy is negligible, with the exception of South Africa and Namibia, where 0.7 percent and 0.4 percent of married women of reproductive age, respectively, report relying on vasectomy for contraception. In other parts of the world (e.g., Republic of Korea, Bhutan, United Kingdom, United States, Canada, New Zealand, Australia), vasectomy prevalence is more than 12 percent [6] (Table 1). Generally, countries with higher vasectomy prevalence are early adopters of international family planning guidelines, some having adopted them more than 40 years ago.

 

Table 1.  Worldwide Vasectomy Prevalence

  Region

Select Country (or Region)

Prevalence

(Women 15–49 years, married or in a union)

  World Region

2.4%

  Africa Region

0.0%

  Ethiopia

0.0%

  Namibia

0.4%

  Nigeria

0.0%

  Rwanda

0.1%

  South Africa

0.7%

  Asia Region

2.2%

  China

4.5%

  India

1.0%

  Nepal

6.3%

  Butan

13.6%

  Thailand

0.9%

  Europe Region

2.5%

  Denmark

5.0%

  Germany

0.5%

  Italy

0.1%

  Switzerland

8.3%

  UK

21.0%

  Latin America and Caribbean Region

2.3%

  Brazil

5.1%

  Colombia

1.8%

  Honduras

0.3%

  Mexico

Not Reported

  Uruguay

0.8%

  North America Region

13.7%

  Canada

22.0%

  USA

12.7%

  Oceania Region

9.8%

  Melanesia/Micronesia/Polynesia

6.6%

  New Zealand

19.5%

  Source:  World Contraceptive Use, 2011, United Nations, Department of Economic and Social Affairs, Population Division: http://www.un.org/esa/population/publications/contraceptive2011/wallchart_front.pdf

 

Recently, the Rwandan Ministry of Health, with technical assistance from FHI 360, scaled-up vasectomy — NSV with cautery and fascial interposition in particular — across the country. This was one of the first national vasectomy scale-up efforts in sub-Saharan Africa. A total of 64 doctors and 103 nurses from 42 hospitals across all 30 districts in Rwanda were trained in this technique. From 2010 to 2012, 2,523 vasectomies were performed in Rwanda (Figure 1). The success of this program, although still in its early stages, has been lauded by international development experts.

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Based on the successful scale-up program, we decided to calculate figures to help policymakers understand the value of vasectomy as part of a diverse contraceptive method mix. We had three goals: 1) to calculate the health benefits of 1,000 vasectomies, including pregnancies averted and maternal and child mortality averted, in seven countries in sub-Saharan Africa; 2) to identify the possible pool of eligible vasectomy clients in those seven countries; and 3) to describe key messages about vasectomy that were learned through the Rwanda program and earlier vasectomy activities in Africa and that can be used to improve community awareness about the method.

Couple Years of Protection and Health Impact

Using U.S. Agency for International Development (USAID) conversion factors we calculated the couple years of protection (CYP) and health outcomes of 1,000 vasectomies [6].  Calculating the CYP required us to multiply the number of vasectomies by the vasectomy-specific CYP conversion factor. The conversion factor for vasectomy was 10, meaning that 1 vasectomy was equivalent to 10 CYP. Thus, 1,000 vasectomies were equivalent to 10,000 CYP.

We then used the CYP value for vasectomy to calculate the number of pregnancies averted, according to procedures described by Darroch and Singh [7]. Each CYP was equivalent to 0.25 averted pregnancies. We therefore multiplied 10,000 CYP by 0.25 to estimate 2,500 averted pregnancies. Our calculations did not consider the impact of contraceptive method switching.

We then calculated maternal and infant mortality rates using the most recent Demographic and Health Survey (DHS) data for the seven countries listed in Table 2 [8-14]. (Each country in the table has enhanced its health sectors and integrated family planning into a variety of types of service delivery.) For example, in the 2010 Rwanda DHS report, maternal mortality was reported at 4.87 deaths per 1,000 live births and infant mortality at 50 deaths (before the age of 1) per 1,000 live births. To calculate the health benefits of 1,000 vasectomies, we multiplied the number of averted pregnancies by the maternal and infant mortality rates. We thus estimated that 1,000 vasectomies would avert 12 maternal deaths and 125 infant deaths in Rwanda.

Table 2. Pregnancies, Maternal Deaths, and Infant Deaths Averted from 1,000 Vasectomies in Seven African Countries

Country

Number of Vasectomies

Couple Years of Protection

Pregnancies Averted

Maternal Mortality Rate

Maternal Deaths Averted

Infant Mortality Rate

Infant Deaths Averted

Ethiopia

1,000

10,000

2,500

4.13

10

59

148

Kenya

1,000

10,000

2,500

5.8

15

52

130

Malawi

1,000

10,000

2,500

8.4

21

66

165

Mozambique

1,000

10,000

2,500

5.71

14

64

160

Nigeria

1,000

10,000

2,500

4.7

12

88

220

Rwanda

1,000

10,000

2,500

4.87

12

50

125

Sengal

1,000

10,000

2,500

2.9

7

47

118

 

Typical Vasectomy Clients

To understand the characteristics of possible vasectomy clients in seven selected countries, we relied on data from the Rwanda vasectomy program and international data. In Rwanda, men were older (mean age of 45 years), were married, and had large families (mean of 5.5 children). In addition, 59 percent of the men had children under 3 years old [15]. Internationally, vasectomy clients tend to be educated (primary education), of a mature age (more than 30 years and, in some cases, more than 40 years), and in long-term marriages (married for more than 12 years) [16]. Vasectomy clients in Rwanda had similar demographics with the exception of mean educational level, which was somewhat lower than the international mean and was more reflective of the general population in Rwanda.

In Rwanda, national guidelines require each vasectomy client to be more than 30 years old and to have the signed consent of his wife or partner. Of the 2,523 clients who received a vasectomy during the scale-up program, approximately 90 percent were between 30 and 55 years old.

As a result, we restricted the number of eligible men to those 30–55 years old who were married or in a union as reported in the country Demographic and Health Surveys (DHS) [8-14]. We used this approach to calculate both the number of potential clients and the number of men that would be required to reach a prevalence of 1 percent in seven countries (Table 3).

Table 3. Number of Men Required to Meet 1% Vasectomy Prevalence in Seven African Countries
Country

Total No. of Men

No. of Men

Ages 30–55

No. of Married Men Ages 30–55

No. of Men Needed to Reach 1% Prevalence

Ethiopia

35,864,037

6,885,895

3,683,954

36,840

Kenya

19,175,101

3,969,246

1,931,744

19,317

Malawi

6,362,277

1,170,659

669,617

6,696

Mozambique

9,846,800

1,969,360

1,299,778

12,998

Nigeria

69,705,031

15,404,812

7,825,644

78,256

Rwanda

4,895,766

920,404

432,590

4,326

Sengal

3,252,259

601,668

219,007

2,190

Messaging to Facilitate Vasectomy Uptake

Research on vasectomy in Africa has shown that increasing vasectomy uptake requires orienting family planning services toward men, increasing men’s knowledge of the method through various media outlets, and targeting spouses in tandem with potential clients. Rarely is vasectomy considered a viable contraceptive option in this region of the world [16] . Rumors, misconceptions, and the lack of vasectomy promotion during family planning counseling restricts vasectomy uptake [17, 18]. Increasing awareness about where to get a vasectomy, combatting misconceptions, and promoting the method’s benefits through community awareness campaigns can help overcome some of these barriers. Following are some key messages that can be used in these campaigns.

Easy Medical Procedure

  • Low-risk procedure
  • Not painful
  • Limited side effects, with many men returning to full activity in 1–2 days

 

Permanent Method

  • One-time procedure
  • Removes family planning burden from female partner

 

Sexual Experience

  • Similar or improved sexual experience after vasectomy, with many men reporting an improvement in both their sex lives and the frequency of sex  (Figure 2)

General Messages

 

      • Does not affect enjoyment of sex after vasectomy
      • Does not affect sexual performance
      • Enables men to share in family planning responsibilities
      • Allows “a man to remain a man” after vasectomy
      • Limited side effects
      • Low-risk procedure
      • Not painful
      • Permanent
      • Short recovery period

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Source:  Rwanda Vasectomy Scale-up Program, 2010 – 2012(Clients (n=316), Wives (n=300)

Conclusion

In sub-Saharan Africa today, men and women have increased knowledge of the types of contraceptive methods and the benefits associated with spacing and limiting family size. Increasing access to LAPMs is the next step in establishing the enabling environment needed to improve contraceptive uptake. Equipping policymakers with a better understanding of the benefits of these methods, particularly vasectomy, can help facilitate discussions and provide a foundation for scaling up this service. Our research in Rwanda suggests that vasectomy is a method that many couples want to utilize and that should be available within the full mix of contraceptive methods. Additionally, understanding the characteristics of potential vasectomy clients can help policymakers create appropriate vasectomy services.

References

1.            Trussell J. Update on and correction to the cost-effectiveness of contraceptives in the United States. Contraception. 2012;85(6):611. Epub 2012/03/31.

2.            Shih G, Dube K, Dehlendorf C. “We never thought of a vasectomy”: a qualitative study of men and women’s counseling around sterilization. Contraception. 2012. Epub 2012/11/28.

3.            Shih G, Turok DK, Parker WJ. Vasectomy: the other (better) form of sterilization. Contraception. 2011;83(4):310-5. Epub 2011/03/15.

4.            Pile JM, Barone MA. Demographics of vasectomy–USA and international. The Urologic clinics of North America. [Review].  2009;36:295-305.

5.            Sokal DC, Labrecque M. Effectiveness of vasectomy techniques. The Urologic clinics of North America. 2009;36(3):317-29. Epub 2009/08/01.

6.            USAID. Couple Years of Protection. 2013 [cited 2013 May 31, 2013]; Available from: http://transition.usaid.gov/our_work/global_health/pop/techareas/cyp.html .

7.            Darroch JE, Singh S. Estimating Unintended Pregnancies Averted from Couple-Years of Protection (CYP). Guttmacher Institute. 2011. p. 10.

8.            Central Statistical Agency [Ethiopia] and ICF International. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International.

9.            Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro.

10.          National Statistical Office (NSO) and ICF Macro. 2011. Malawi Demographic and Health Survey 2010. Zomba,Malawi, and Calverton, Maryland, USA: NSO and ICF Macro.

11.          Ministerio da Saude (MISAU), Instituto Nacional de Estatística (INE) e ICF International (ICFI). Moçambique InquéritoDemográfico e de Saúde 2011. Calverton, Maryland, USA: MISAU, INE e ICFI.

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14.          Agence Nationale de la Statistique et de la Démographie (ANSD) [Sénégal], et ICF International. 2012. Enquête Démographique et de Santé à Indicateurs Multiples au Sénégal (EDS-MICS) 2010-2011. Calverton, Maryland,USA: ANSD et ICF International.

15.          Shattuck D, Wesson J, Nsengiyumva T, Kagabo L, Bristow H, Zan T, et al. Who Chooses Vasectomy in Rwanda?  Survey data for couples who chose vasectomy, 2010-2012. Submitted to Contraception. 2013.

16.          Dunmoye OO, Moodley J, Popis M. Vasectomy in developing countries. Journal of Obstetrics Gynaecology. 2001;21(3):295-7. Epub 2003/01/11.

17.          Olukoya AA. The changing attitude and practice of men regarding family planning in Lagos, Nigeria. Public Health. 1985;99(6):349-55. Epub 1985/11/01.

18.          Bunce A, Guest G, Searing H, Frajzyngier V, Riwa P, Kanama J, et al. Factors affecting vasectomy acceptability in Tanzania. Int Fam Plan Perspect. 2007;33(1):13-21. Epub 2007/04/28.

 

 

 

 

 

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