The kindest cut: global need to increase vasectomy availability
Authors: Roy Jacobstein
Journal: The Lancet Global Health (2015)

Family planning programmes in low-resource countries have notably expanded access to modern contraception. The modern method contraceptive prevalence rate (MCPR) is now 56% in UN-designated least developing regions (61% in developed regions).1UN Department of Economic and Social AffairsPopulation Division2014. World contraceptive patterns wall chart.http://www.un.org/en/development/desa/population/publications/pdf/family/worldContraceptivePatternsWallChart2013.pdfDate: 2013Google Scholar In least developed countries, the rate has risen from negligible proportions in the 1970s to 30% in 2011. A bedrock principle of family planning programmes is to ensure individuals and couples seeking contraception are able to make a voluntary and informed choice from a wide range of methods to meet their reproductive goals. This principle was endorsed by 179 countries in the Programme of Action of the 1994 Cairo International Conference on Population and Development, and has been reiterated often.2UNFPAUN Population Fund Programme of Action of the International Conference on Population and Development, 20th Anniversary Edition 2014. Isbn 978-0-89714-022-5.http://www.unfpa.org/sites/default/files/pub-pdf/programme_of_action_Web%20ENGLISH.pdfGoogle Scholar There is also longstanding international consensus on the importance of gender equity. From the standpoint of vasectomy (male sterilisation), however, there has been a disconnect between stated commitments to choice and equity and programme realities. Almost all men are eligible to have a vasectomy.3WHOMedical eligibility criteria for contraceptive use. 5th edn. WHO, Geneva2015Google Scholar It is highly effective, convenient, and easy to provide, and is also, along with female sterilisation, one of only two permanent methods of contraception. For these reasons, and to share contraceptive responsibilities, vasectomy is widely chosen in regions and countries with high socioeconomic development and gender equality. Vasectomy prevalence is 12% in Northern America and 11% in Oceania and Northern Europe.1UN Department of Economic and Social AffairsPopulation Division2014. World contraceptive patterns wall chart.http://www.un.org/en/development/desa/population/publications/pdf/family/worldContraceptivePatternsWallChart2013.pdfDate: 2013Google Scholar In Canada it is the most widely used method: 22% of women rely on vasectomy, accounting for 31% of all modern method use. The UK, New Zealand, and South Korea have similar profiles, with vasectomy prevalence ranging from 17% to 21%, comprising 24% to 27% of modern method use. Australia, Belgium, Denmark, Spain, Switzerland, and the USA also have substantial vasectomy use, with prevalence ranging from 8% to 11%. In the USA, 175 000 to 350 000 vasectomies are done every year.4Eisenberg ML Lipshultz LI Estimating the number of vasectomies performed annually in the United States: data from the National Survey of Family Growth.J Urol. 2010; 84: 2068-2072Summary Full Text Full Text PDF Scopus (69) Google Scholar The situation differs markedly in the world's 69 least developed countries: only 0·7% of women are able to rely on a partner's vasectomy. Vasectomy prevalence in Africa is 0·0%, with fewer than 100 000 men having accessed it.5UN Department of Economic and Social Affairs, Population Division, 2012. World Contraceptive Use 2011.http://www.un.org/esa/population/publications/contraceptive2011/contraceptive2011.htmGoogle Scholar Of 54 African countries, only ten report measurable vasectomy use and only Swaziland (0·3%), Botswana (0·4%), and South Africa (0·7%) exceed 0·1% prevalence. Vasectomy is the least known modern method in most low-resource countries.6Measure DHS, 2015. STATcompiler. Calverton, MD.http://www.statcompiler.comGoogle Scholar Furthermore, the knowledge (or, more accurately, awareness) that does exist, among women and men alike, is often burdened by erroneous understandings that equate vasectomy with castration, impotence, and weakness (inability to work).7The RESPOND Project. A matter of fact, a matter of choice: The case for investing in permanent contraceptive methods. EngenderHealth White Paper. EngenderHealth, New York2014Google Scholar When a man does desire vasectomy, skilled providers are generally unavailable to provide services. Although vasectomy is simpler to perform, less invasive, safer, and more cost effective than female sterilisation, less than one in 11 users of permanent methods in developing regions relies on vasectomy. However, all is not bleak. As greater education and participation of women, rapid urbanisation, and the spread of global communication continue to drive smaller desired family size in almost all countries, demand to limit future childbearing among married women continues to rise and now exceeds demand to space births in all regions except western Africa and middle Africa. The average age at which this occurs can be surprisingly low—eg, 29 years in Malawi, 28 years in Namibia, 24 years in Lesotho, and 23 years in Swaziland.8Van Lith LM Yahner M Bakamjian L Women's growing desire to limit further births in sub-Saharan Africa: meeting the challenge.Glob Health Sci Pract. 2013; 1: 97-107Crossref Scopus (58) Google Scholar Female sterilisation is the most widely used method worldwide, with 223 million women relying on it; another 28 million women rely on their partner's vasectomy.5UN Department of Economic and Social Affairs, Population Division, 2012. World Contraceptive Use 2011.http://www.un.org/esa/population/publications/contraceptive2011/contraceptive2011.htmGoogle Scholar Malawi, one of the world's ten poorest countries, has achieved 9·7% female sterilisation prevalence; more than 170 000 procedures were provided there from 2008 to 2011 via public–private partnerships, free mobile services, and family planning-dedicated, non-physician providers.9Jacobstein R Lessons from the recent rise in use of female sterilization in Malawi.Stud Fam Plann. 2013; 44: 85-95Crossref PubMed Scopus (19) Google Scholar Thoughtful, male-centred programming has resulted in greater vasectomy use in Nepal (7·8% prevalence), Brazil (5·1%), and Colombia (3·4%). In Rwanda, pilot programmes have provided more than 1000 vasectomies annually.10Shattuck D Wesson J Nsengiyumva T Kagabo L Bristow H Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010–2012.Contraception. 2014; 89: 564-571Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar What, then, needs to be done for vasectomy to become a routinely available, readily accessible method option in low-income countries? First, policymakers, donors, and programme leaders and implementers must appreciate the current and likely future extent of demand for preventing future pregnancies. Second, they need to understand that quality vasectomy services can feasibly be introduced, scaled up, and, ultimately, sustained. This will require adequate time and resource commitment to address provider, client, and health-system factors. Third, they need to appreciate that vasectomy unavailability is a gender issue as well as a programme issue. Perhaps we can emulate Bhutan, known for its index—and achievement—of Gross National Happiness, and with a vasectomy prevalence of 13%, 19% of its overall MMCR of 65%. From a woman's perspective in low-income countries, after having borne her desired number of children, and, typically, the lion's share of contraceptive responsibility, vasectomy can indeed be the kindest cut. This online publication has been corrected. The corrected version first appeared at thelancet.com on Jan 26, 2016 This online publication has been corrected. The corrected version first appeared at thelancet.com on Jan 26, 2016 I declare no competing interests. Correction to Lancet Glob Health 2015; 3: e733–34Jacobstein R. The kindest cut: global need to increase vasectomy availability. Lancet Glob Health 2015; 3: e733–34—The fourth sentence of the second paragraph should have read "Vasectomy prevalence is 12% in Northern America and 11% in Oceania and Northern Europe"; "Northern America" is the UN-designated name for the USA and Canada combined. A citation to reference 1 has also been added. This has been corrected online as of Jan 26, 2016. Full-Text PDF Open Access