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Male and Female Sterilization

March 17–21, 2008
http://my.ibpinitiative.org/sterilization

This one-week forum reviewed the latest guidance on male and female sterilization featured in the Family Planning: A Global Handbook for Providers and provided a venue for participants to exchange information and expertise with colleagues who are working to provide good-quality female and male sterilization services.

Discussion Statistics


Number of participants: 69
Number of participants' countries: 27
Number of contributions: 22 contributions from 14 participants
% of contributions from developing countries: 95%
Number of countries contributing: 12 countries

Contributing countries: Brazil (1), Rwanda (1), Nepal (2), Ethiopia (2), and Democratic Republic of the Congo (2), Malawi (2), Uganda (2), Sri Lanka (4), Bangladesh (2), Peru (1), Pakistan (2), USA (1)

Purpose

Review the latest guidance on male and female sterilization featured in the Family Planning: A Global Handbook for Providers and exchange information and expertise with colleagues who are working to provide good-quality female and male sterilization services.                                  


Day 1.  Addressing programmatic issues related to sterilization. 

Questions:

  1. How widespread is sterilization in your country? How active are sterilization services in your facility? Is female or male sterilization more popular?
  2. Are you involved in sterilization services? What is your role?
  3. What are some of the barriers to female sterilization service delivery in your country? What are some of the barriers to male service delivery in your country?
  4. What questions would you like to ask your colleagues who have been experiencing success (or have not been experiencing success) in increasing sterilization service delivery?
  5. What strategies would you recommend to increase service delivery? Have you tried any of these strategies? How have these worked in your country and/or program?                                                                         

Day 2. Addressing the image of sterilization

Questions:

  1. What seems to be the image of sterilization among clients and service providers in your country? Do images of female sterilization differ from male sterilization?
  2. Are there current efforts to improve/maintain the image of sterilization (e.g., training, Behavior Change Communication campaigns, increased funding
  3. In some places where sterilization is common and accepted, some providers think that they do not need to do anything “special” or “extra” to ensure that everyone has access to sterilization. Is this true in your service program? If you have encountered this, have you done anything to address this?

Day 3. Addressing technical issues related to sterilization

Questions:

  1. Who is allowed to provide sterilizations in your country? Where are sterilization services offered (e.g. hospitals or clinics)? Are there mobile outreach services in your country and/or facility?
  2. Do you know which surgical techniques are used for female and male sterilizations in your country? If yes, what are they? What is the cost to the client?
  3. After vasectomy, many men do not return to the clinic to get a semen analysis to confirm vasectomy success, even in developed countries. For vasectomies done in your country or at your clinic, do you know what percentage of men get at least one semen analysis after vasectomy?
  4. A simple test for post-vasectomy semen analysis has recently been given a green light by the US Food & Drug Administration and should soon be available for post-vasectomy semen analysis in the US. It is designed for men to buy over the counter and use at home, similar to home pregnancy tests. Are pregnancy tests used in your clinic and/or purchased by your clients? Please describe the details of their use, such as what they cost, where they are available, and who pays for them? If a semen analysis test was of similar cost/availability, what percentage of men do you think would use it after a vasectomy?                                 

Day 4. Addressing commonly asked questions and advantages/disadvantages of sterilization

Questions:

  1. What are the most commonly asked questions that clients have
about male sterilization? Female sterilization?
  2. What are the advantages of sterilization that appeal to people in your country?
  3. In your experience, what are the most common reasons for men and/or women to accept or reject sterilization?

Emerging themes and issues: Days 1-4

Questions:

  • Image of sterilization. Female sterilization is more popular and widespread than male sterilization. Vasectomy is safer, simpler, and less expensive than female sterilization and is just as effective, yet in much of the world it remains one of the least known and least used methods.
  • Barriers to sterilization. Challenges occur at the client, community, provider, and system level. Barriers include:

  • Access. Lack of trained personnel is a major barrier in many countries. However, some countries allow trained “lesser cadres” to provide clinical services, including sterilization, which enables higher rates of sterilization. Where to provide/obtain services can also be a barrier and some countries are using both mobile and fixed sites to solve this problem.
  • Acceptability. Some cultures believe that sterilization goes against God’s wishes. Others believe that female sterilization causes menstrual irregularities. Misperceptions about male sterilization flourish, including that vasectomy is equal to castration and makes one prone to testicular cancer.
  • Quality. It is essential to have trained staff provide sterilization services. Also, vasectomy follow-up is essential to ensure success.
  • Making vasectomy programming friendly to men. Vasectomy programs need to be “friendly” and inviting to men. Options include male-only settings or making family planning programs for women friendlier to men as well.
  • Creating demand for vasectomy. Evidence tells us that it is best to use several channels to deliver consistent messages. The messages need to be relevant to men’s actual concerns—and to those of their wives.
  • Ethical issues around sterilization. Programs must remain vigilant to ensure that abuses do not occur and that free, informed and voluntary choice is maintained. U.S.-supported programs must follow the Tiahrt Amendment, which is meant to ensure that clients are able to exercise free, voluntary and informed choice. No incentives or financial rewards can be given to individuals in exchange for becoming a family planning acceptor. No numerical targets or quotas—either for overall FP or for specific methods such as female sterilization—can be used.
  • Islamic teachings and family planning. Different Islamic authorities have issued different opinions on various types of family planning methods, including vasectomy and female sterilization. In keeping with predominate Islamic attitudes toward birth control, the legal status of contraception in Muslim countries (derived primarily from European civil codes) is overwhelmingly permissive. The exception to this rule is sterilization, which is illegal in some countries and remains the subject of ongoing debate within Muslim communities.

Program Examples

Questions:

  • Malawi. Female sterilization is an upcoming method of contraception for those who have completed their families. However coverage of service is a problem because there are not many service providers in the country. Sterilization has to be done by specially trained clinicians and there is generally a tendency to prioritize other emergency services and put aside routine services like sterilization. Changing policy at the international or national level to train lesser cadres (e.g. nurses) to offer this service would help. Male sterilization is very rarely is done due to the fact that very few people are trained. Another problem with male sterilization is sensitization. 
  • Ethiopia. The knowledge and skills of many service providers regarding sterilization is not optimal as there have not been many efforts in this area in the past. However, EngenderHealth-Ethiopia and partners are expanding long acting and permanent methods by building the capacity of service providers in counseling skills, clinical skills, and availing the necessary equipment and supplies. More specifically, EngenderHealth, partners, and the Ministry of Health are trying to create a pool of providers, identify the operational and policy barriers that contribute to the poor image of sterilization, increase funding for sterilization, and integrate family planning services to increase access. 
  • Bangladesh. Female sterilization and vasectomy are underutilized methods in Bangladesh. While nearly half of married women of reproductive age do not want any more children, only two out of five are using any family planning method, and among these women using a method, sterilization only accounts for 14% of the users (one in seven women). The Bangladesh government recently launched a vasectomy promotion campaign— “My husband is the Best”— targeted to men 25-45 with two or more children. The goal of the campaign is to provide Bangladeshi couples more balanced information about family planning options available to them. Incorrect perceptions of vasectomy is one of the biggest reasons why couples do not consider vasectomy more often as a method of family planning. The campaign approach specifically focuses on myths and misperceptions by addressing the barriers and promoting the benefits. Both mass media and interpersonal activities were employed to support the intervention.

Post-forum survey results

N of surveys completed - 5

% who have passed content to others - 25%

% who have or will use in their work - 25%

% very satisfied with forum content - 25%

Suggestions for improvement:


  • Because the forum seems largely to be question and answer, I felt at times the "evidence" of the questions themselves was not always representative. To some extent this could be mitigated, and was, by the way the questions were answered. But I would have not minded having some questions which themselves were 'expert' in providing a broader, international statement as to what some of the current issues are and then asking for further opinions from the forum experts.
  • I was not satisfied with the questions raised and the expert opinions; there should have been more experience sharing and information on new and latest developments in sterilization. More experts should have been invited across the globe. I feel this was a good start and we can further improve on this in the future. Though the sterilization techniques are the same globally, the quality of care component is very weak and varies from country to country, and needs to be discussed in length.                                                  
                                                              
References and resources

Click here to see community library/list of references

Click here for additional male sterilization resources in library

Click here for additional female sterilization resources in library

Click here for Family Planning: A Global Handbook for Providers: Chapter on Vasectomy and Chapter on Female Sterilization

Organizing groups

The ACQUIRE Project/EngenderHealth, Family Health International, and the INFO Project based at the Johns Hopkins Bloomberg School of Public Health's Center for Communication Programs (JHU/CCP) with support from partners of the Implementing Best Practices (IBP) Initiative

Contributing experts/facilitators 

Dr. Carmela Cordero, The ACQUIRE Project/EngenderHealth

Mr. John Pile, The ACQUIRE Project/EngenderHealth)

Dr. Roy Jacobstein, The ACQUIRE Project/EngenderHealth

Dr. David Sokal, Family Health International (FHI)

Steering committee

The ACQUIRE Project/EngenderHealth, Family Health International (FHI), and the INFO Project (JHU/CCP)

Moderators

Megan O’Brien, JHU/CCP