Our SUV bounced along the dirt road through the Rwandan mountains, which are noted for roads complicated by switchbacks and steep descents but dotted with stunning sites. On one side of the car, tea farmers pruned the lush green bushes atop raised beds of rich, black soil. We were destined for the Kinihira Health Facility, and our goal was to provide vasectomies. We looked forward to hearing more from our clients, usually husbands and wives who want to provide better lives for their children, about what led them there.
After two decades of experience in East Africa, I could not imagine that we would have many clients. Worldwide, less than 2.4 percent of men of reproductive age have had a vasectomy.1 In Africa, the prevalence of vasectomy is negligible, less than one percent. Studies on vasectomy in Africa have found that men and women have limited knowledge of the method and many misconceptions, including equating vasectomy with castration and attributing the procedure to a reduction in sexual performance or desire, weight gain and laziness.
In reality, vasectomy is safe, effective and the least expensive long-acting or permanent contraceptive method.
Since 2010, FHI 360 has been providing technical assistance to the Rwandan Ministry of Health to scale up the delivery of enhanced vasectomy procedures, such as no-scalpel vasectomies (NSV). NSV has significant advantages, including a very low failure rate (0.15 percent) and a decreased risk of surgical complications like bleeding. To increase demand for vasectomy, Rwanda’s Vasectomy Scale-up Program — one of the first national vasectomy scale-up efforts in sub-Saharan Africa — has strived to provide reliable access along with facts to dispel common myths about the procedure.
Progress in Kinihira and beyond
Kinihira was the second stop on a week-long tour in which physicians received hands-on training in providing NSV. I traveled with Dr. Michel Labrecque, a master vasectomy trainer and one of the top researchers on vasectomy procedures, to help facilitate this training of trainers.
Our clients in Kinihira spend their days in the plantation below the health center. Their exposure to weather and hard work shows on their faces and hands. My colleague, Theophile, asked our clients and their partners, “Why did you decide to have a vasectomy?” Many couples reported having large families, often more than five children. A significant number of women mentioned that they had tried to use hormonal methods, but the side effects were too significant. Almost all shared their struggles with feeding and educating their children on the small incomes generated through their fixed plots of land and the tea plantation collective. They communicated their desire to limit their family size but retain their ability to be intimate while free from the worry of pregnancy.
During the training week, 67 men received vasectomies. The participating physicians learned quickly, reducing the time it took them to perform the procedure from about 20 minutes to just at 10 minutes. Since the training in February 2010 and through December 2012, a total of 64 doctors and 103 nurses from 42 hospitals across all 30 districts in Rwanda have been trained in NSV, and 2,523 vasectomies were performed. The mean age of the clients was 45; they were in stable relationships (with a mean length of 19 years) and had many children (with a mean of 5.5 children).
Lessons learned
We experienced success with this program because we were able to meet our clients’ needs for family planning and provide access to vasectomy services in an environment supportive of family planning. In Rwanda, there is broad-based political support and, in turn, high levels of societal acceptance for family planning. This has contributed to men’s greater acceptance of vasectomy. Importantly, vasectomy is offered as part of the standard package of family planning services, and physicians from district hospitals travel regularly to rural health facilities to perform the procedure.
The goal of World Vasectomy Day is to increase awareness of this highly effective and underutilized contraceptive method. On October 18, physicians from around the world, in nearly 25 countries, have agreed to deliver 1,000 vasectomies. In Rwanda, there are clients and physicians who are now prepared to contribute to this goal.
How do you think other countries can benefit from Rwanda’s experience?
A longer version of this blog is available here.
1 United Nations Department of Economic and Social Affairs, Population Division. World contraceptive use 2011. http://www.un.org/esa/population/publications/contraceptive2011/wallchart_front.pdf.
2 Darroch JE, Singh S. Estimating unintended pregnancies averted from couple-years of protection (CYP). Guttmacher Institute. 2011.
3 Central Statistical Agency [Ethiopia] and ICF International. Ethiopia demographic and health survey 2011. Addis Ababa, Ethiopia, and Calverton, Maryland: Central Statistical Agency and ICF International; 2012.
4 Kenya National Bureau of Statistics (KNBS) and ICF Macro. Kenya demographic and health survey 2008–09. Calverton, Maryland: KNBS and ICF Macro; 2010.
5 National Statistical Office (NSO) and ICF Macro. Malawi demographic and health survey 2010. Zomba, Malawi, and Calverton, Maryland: NSO and ICF Macro; 2011.
6 Ministerio da Saude (MISAU), Instituto Nacional de Estatística (INE) e ICF International (ICFI). Moçambique inquérito demográfico e de saúde 2011. Calverton, Maryland: MISAU, INE e ICFI.
7 National Population Commission (NPC) [Nigeria] and ICF Macro. Nigeria demographic and health survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro; 2009.
8 National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], and ICF International. Rwanda demographic and health survey 2010. Calverton, Maryland: NISR, MOH, and ICF International; 2012.
9 Agence Nationale de la Statistique et de la Démographie (ANSD) [Sénégal], et ICF International. Enquête démographique et de santé à indicateurs multiples au Sénégal (EDS-MICS) 2010-2011. Calverton, Maryland: ANSD et ICF International; 2012.