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:
- How widespread is sterilization in your country? How active
are sterilization services in your facility? Is female or male
sterilization more popular?
- Are you involved in sterilization services? What is your
role?
- 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?
- 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?
- 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:
- 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?
- Are there current efforts to improve/maintain the image of
sterilization (e.g., training, Behavior Change Communication campaigns,
increased funding
- 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:
- 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?
- 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?
- 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?
- 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:
- What are the most commonly asked questions that clients
have
about male sterilization? Female sterilization?
- What are the advantages of sterilization that appeal to
people in your country?
- 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
