The Global Pattern of Vasectomy Use
Vasectomies, or male sterilization, are a highly underutilized method of family planning, although they are safer, simpler, less expensive and equally as effective as female sterilization. Throughout the world, vasectomies are one of the least used and least known methods of contraception1. The number of female sterilizations exceeds the number of male sterilization in a 5 to 1 ratio. This divide has been increasing since 1982 (Figure 1). In the developed world, female sterilization is twice as common as male sterilization. In Asia, it is 8 times more common, while in Latin America and the Caribbean it is 15 times more common. The rates of male sterilization in sub-Saharan Africa are too low for an accurate comparison. Worldwide, approximately 43 million couples rely on vasectomy, while approximately 210 million couples rely on female sterilization as their method of family planning.
Figure 1: Estimated Number of Couples Worldwide Relying on Vasectomy and Female Sterilization (in millions), 1982-2007
The need for family planning services will continue to rise as desire for contraceptive use grows and as the population of the world increases. While the need will increase, the donor assistance for family planning is projected to decline and in many areas health care resources will become increasingly constrained. Vasectomy use should be promoted because it is one of the most cost-effective contraceptive methods and it is low-cost for clients over time. Due to the relative simplicity of performing a vasectomy, it can be offered in a wide variety of settings including primary health care clinics and private physicians’ offices.
The percentage of women who are relying on vasectomy as their method of contraception is higher in developing countries than it is in developed countries (2.5% vs. 4.5%). The vasectomy prevalence is highest in Oceania and North America (United States and Canada) (Figure 2). In North America, 12% of married women of reproductive age are using vasectomy as their contraceptive method, while in Oceania 10% of women are using this method. In Africa, the prevalence of vasectomy is extremely low. While the percentage of individuals who rely on vasectomies is fairly low in Asia, the number of people who have received vasectomies is high at 22.5 million. Asia accounts for 77% of vasectomies worldwide. China and India alone have 70% of the world’s vasectomy users.
Figure 2: The Global Pattern of Vasectomy Use
Vasectomy is more common than female sterilization in only 5 countries. These countries are Bhutan, Denmark, the Netherlands, New Zealand and Great Britain. In 8 countries worldwide, (Australia, Bhutan, Canada, the Netherlands, New Zealand, the Republic of Korea, Great Britain and the United States), the prevalence of vasectomy use exceeds 10%. New Zealand has the highest prevalence of vasectomy at 19.3%. It has been a widely used method of contraception since the 1970s. In the 1980s, it became more widely used than female sterilization2. A survey conducted in the late 1990s in New Zealand found that 57% of men aged 40 to 49 had received vasectomies.
Overall the prevalence of vasectomy is lower in developing countries. The use of vasectomy is particularly low in sub-Saharan Africa. Even though vasectomy services have been introduced in some sub-Saharan African countries such as Ghana, Kenya, Malawi, Rwanda and Tanzania, in the vast majority of sub-Saharan Africa the prevalence rarely exceed 0.1% and has remained relatively stable throughout the past decade. The two African countries with a slightly higher rate of vasectomy are Namibia and South Africa at 0.8%. The prevalence of vasectomies also remains low in Latin America and the Caribbean. The vast majority of countries in this region have a vasectomy prevalence lower than 1% with the exception of Brazil, Columbia, Guatemala and Mexico. These countries have a slightly higher prevalence due to an increase in donor support programs for vasectomies during the 1980s and the early 1990s. Furthermore, with the exception of Bhutan, Iran, and the Republic of Korea, the vasectomy prevalence has steadily declined in Asia over the past 15 years.
The vasectomy is underutilized because of various service-delivery and cultural and community barriers. While the blame for underutilization has been placed on men, various studies have suggested that men would like to become more involved in family planning and become active participants in avoiding unintended pregnancies.
One group of barriers encompasses those relating to the service-delivery of vasectomies. In many countries, there is a shortage of committed and skilled providers. The providers may have little knowledge about counseling men on the advantages and disadvantages of vasectomies. Even if the providers are trained, their working environment may not be conducive for counseling or surgical procedures. Furthermore, the providers’ attitudes serve as a barrier to vasectomies in many locations. The providers may hold an indifference to vasectomies, a bias against vasectomies, or they may have untested theories about what people want as a method of family planning. Overall, vasectomies are more difficult to obtain than nearly every other family planning method worldwide.
Culture and community aspects influence the ability and willingness of men to obtain a vasectomy. According to Demographic and Health Surveys (DHS), vasectomies are the least known method of family planning. Fewer women said that they had heard of vasectomies than oral contraceptives, IUDs, injectables, condoms or female sterilization. Additionally, vasectomy use can be undermined by cultural ethos and beliefs. In many cultures, men dictate if their wife uses family planning, but do not believe that utilizing a method is their responsibility. Some men hold misconceptions or they believe cultural myths about vasectomies. In certain societies, a widely held belief is that vasectomies are equivalent to castration. Other popular myths include that castration negatively affects sexual function and that it decreases physical strength.
Various strategies should be implemented that aim to increase vasectomy use. Men should be the target of educational campaigns to increase acceptance of and knowledge surrounding vasectomies. Multimedia campaigns have been proven to increase vasectomy use in Brazil, Columbia and Guatemala. When these campaigns were implemented, vasectomy use increased by two fold. Men are generally easier to reach with multimedia campaigns because they usually have an increased access to mass-media and community-level communication. Information should be delivered to men through community talks, home visits, and the mass media to create awareness about vasectomy. Additionally, telephone hotlines can be an effective tool to increase vasectomy use. Telephone hotlines offer men a private and confidential session to learn about vasectomies. Furthermore, men who are satisfied with their vasectomy can be recruited to educate others about their experience in order to increase vasectomy use. Programs in Asia, Latin America and Africa have demonstrated the success of this method.
Vasectomy use can also be increased through targeting the staff and clinics at healthcare centers. Additional trainings should be offered for staff in order to create competent, committed staff who can effectively communicate with men. The staff members should hold positive attitudes towards vasectomy. The staff should be periodically updated about men’s reproductive health. Staff members should be responsible for fostering a positive attitude about vasectomies in their clients. The staff should also be trained on how to counsel men about the various vasectomy options. It is often times beneficial to promote the “no-scalpel” method. Also, staff that provides family planning services to women should be trained to discuss vasectomies as a contraceptive option Changes should be made in clinics to promote vasectomy use. The clinics should be spacious and contain the necessary supplies and equipment needed to perform vasectomies.
Vasectomy use can also increased by making services more “male-friendly.” The vasectomy service should encourage the participation of men and treat all men politely and courteously. Providers should encourage women to bring their partner in for counseling and services. Clinics should furthermore extend hours and locations so that the services are readily available to men. Separate hours or a separate clinic for men might encourage more men to come for testing, counseling and perhaps a vasectomy because it provides increased privacy and a supportive environment.
In most areas of the world, vasectomies are a highly underutilized form of contraception. Overall, the number of female sterilizations performed is five times higher than the number of vasectomies performed. The rates of vasectomies are higher than the rates of female sterilization in only five countries. The rates are relatively high in Oceania and North America, and very low in parts of Asia and nearly all of Africa. There are currently many barriers to vasectomy that stem from inadequate service delivery of vasectomy and from cultural and community beliefs. Strategies aimed to overcome these barriers must be introduced so that the vasectomy prevalence can continue to increase throughout the world.
1 Jacobstein, Roy, and John Pile. “Vasectomy: The Unfinished Agenda.” ACQUIRE Project Working Paper. Aug. 2007. Web. 21 Nov. 2009. http://http://www.acquireproject.org/fileadmin/user_upload/ACQUIRE/Publications/Vasectomy_Unfinished-Agenda-FINAL_updated.pdf.
2 Barone, Mark and John Pile. “Demographics of Vasectomy- USA and International.” EngenderHealth. 2009. Web. 21 Nov. 2009. http://http://www.mdconsult.com/das/article/body/173083966-2/jorg=clinics&source=&sp=22378320&sid=0/N/706390/s0094014309000470.pdf?issn=0094-0143.
3 Pile, John. “Vasectoy Advocacy Package: Safe, Cost-Effective and Underutilized.” The ACQUIRE Project. USAID, 2008. Web. 21 Nov. 2009. http://http://www.acquireproject.org/archive/files/2.0_invest_in_fp_and_lapms/2.2_resources/2.2.2_advocacy_briefs/Advocacy-Brief-5-final.pdf.
4“World Contraceptive Use 2007.” United Nations, Department of Economic and Social Affairs, Population Division. 2007. Web. 21 Nov. 2009. http://http://www.un.org/esa/population/publications/contraceptive2007/contraceptive2007.htm.
5 Ringheim, Karin. “Factors that Determine Prevalence of Use of Contraceptive Methods for Men.” Studies in Family Planning 24.2 (1993): 87-99.
6 Ringheim, Karin. “Reversing the Downward Trend in Men’s Share of Contraceptive Use.” Reproductive Health Matters 7.14 (1999): 83-96.