Motivation and barriers to vasectomy in low and middle income countries,

a review of the literature.

Emily Jane Sullivan, MSc.London School of Hygiene & Tropical Medicine

Submitted Thesis 2014

Did you know?

Q: Most children born to one women?

A: 69 children by Russian women, Feodor Vassilyev

16 pairs of twins, 7 triplets, & 4 quadruplets

Q: Most children fathered by one man?

A: 1,042 children by Moroccan Sultan Moulay Ismail

4 wives and 500+ partners

*LSTHM Lecture September 2014. Photo Credit: Wikipedia

Value of Male vs. Female Sterilization

Male

Female

Couple Years of Protection = 10-13 Years

Effectiveness = 99%

Cost (direct 3X & indirect bedrest)

Safety (high risk complications 20X)

Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013. Smith GL, Taylor GP, Smith KF. Comparative risks and costs of male and female sterilization. American Journal of Public Health. 1985;75(4):370-4Marie Stopes. What is a couple year of protection? Access: https://mariestopes.org/sites/default/files/MSI-CYP-Infographic.pdf

Value of Male vs. Female Sterilization

Male

Female

Global ; 3%

Global ; 18%

LMIC ; 1%

LMIC ; 13%

Prevalence, 2013

Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013.

Value of Male vs. Female Sterilization

Male

Female

Global ; 3%

Global ; 18%

LMIC ; 1%

LMIC ; 13%

Prevalence, 2013

Note: There are approximately six countries where male sterilization is more common than female.

Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013.

Value of Male vs. Female Sterilization

Male

Female

Global ; 3%

Global ; 18%

LMIC ; 1%

LMIC ; 13%

Prevalence, 2013

?Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013.

Aim

To understand the low prevalence of vasectomy in LMIC:

by identifying the profile of vasectomy users or acceptors, including their

motivations and barriers.

Methods: Inclusion Criteria

• Type: Primary studies, peer-reviewed or grey literature

• Publication date: 1980 to 2014

• Language: English

• Setting: LMIC

• Findings: Quantitative, qualitative, and mixed-methods

• Topic: Focus on describing acceptors or users of vasectomy

• Availability: Full text

Methods: Search, Quality, Analysis

• Systematic Literature Search: – Screen abstracts & full articles: 1,365 studies.– Final inclusion: 18 studies.

• Quality Appraisal: – 8 strong, 8 moderate, 2 poor.

• Data Analysis: Integrated Narrative Approach– Qualitative, Quantitative & Mixed studies.

Results: Study Characteristics

• Study Locations: – Bangladesh, Costa Rica, Ghana (2), Guatemala, India

(4), Iran, Kenya, Mexico, Nepal (2), Nigeria, Philippines, Rwanda, Sri Lanka, Tanzania, Turkey.

• Study Participants: – 12,744 men, 1,322 women, 29 healthcare providers.

• Study Designs:– Qual (8) Quant (6), Mixed Methods (4).

Results: Strong Motivations

Limit number of children, exceeded desired, multiples

Economic Stability

Feeling of responsibility

InformedDifference

between male & female

Misinformation corrected PH

Nurse

Talk with a sterilized man or

couple

Spouse Approval

Aware of man’s other partners

Misinformation Corrected

Man initiate conversation

Diagnosis or illness

Side effects from other methods

(IUDs)

Women’s Health

Near miss mortality or frequent pregnancy

Improve Love Life

Confidently avoid pregnancy with

wife

Or with other partners

Religious Views

Only have children can care for

Education & Services provided

at faith- center

Results: Strong Barriers

Concerned if she gets pregnant

Spouse Disapproves

Misinformation Man will seek out other partners

Keep vasectomy a

secret

Community Perception

Loss on control within family

Loss of authority in community

Religious ViewsHeightened when

confused with castration

Similar to other forms of family

planning

Can’t remarry if wife changes her

mind

Future Uncertainty

Maternal or child

mortality

Improvedeconomic

circumstances

Lack of AccessDelayed, have

unintended children

No designated provider

Discouraged or humiliated by

providers

MisinformationSide effects &

Operation

Procedure is castration

Local language

General poor health, gain or loose weight

Sexual desire or dysfunction

Summary of Results• Frames sterilized men as: – Economically stable, in good health, able to work,

and with normal sexual function.

• Educational resources include: – Procedure details;– Difference between male and female sterilization;– Testimonials from sterilized men or couples; – Endorsement statements from faith leaders.

Recommendations:

• Improve access to services:–Mobile clinics & accepting providers;

• Targeted education: –Adverse health event or FP side effects;

• Continually assess motivations and barriers:–Vasectomy camp users (not static clinics);–Apply nuanced findings to educational

materials and counseling.

Looking Forward: Global Commitments & Local Actions

Commitment: To not make assumptions. Men may be interested

and willing undergo vasectomy.

Action: To incorporate thoughtful and ethical vasectomy awareness,

education, and services into in all family planning programming.

Vasectomy has the potential to alleviate burden from women and healthcare systems.

Thank you! Questions?

Acknowledgements:Joelle Mak, London School of Hygiene & Tropical Medicine;

Susannah Mayhew, PhD, London School of Hygiene & Tropical Medicine;Lynda Clarke, PhD, London School of Hygiene & Tropical Medicine;

Johns Hopkins Bloomberg School of Public Health.

Emily J. Sullivan, MSc.E-mail: emsully71@gmail.com

Photo Credit: International Conference on Family Planning 2015 website