In many parts of the world, family planning is still considered a woman's responsibility. This has prevented men from being more involved in family decisions about fertility. But it has also limited their access to family planning services targeted at them.
A vasectomy, or male sterilisation, is considered one of the few fertility control methods that allows men to take personal responsibility for contraception.
Global contraceptive patterns for 2013 show that only 2.2% of the world's men have had vasectomies. This is compared to female sterilisation which sits at 18.9%.
Countries with the highest vasectomy rates include Canada where 22% of men of reproductive age have had a vasectomy. This compares to the UK with 21%, New Zealand with 19.5% and the US with 11%. In Africa 0.1% of men have undergone vasectomies.
But on the continent, vasectomies could be one of the most effective male birth control methods. They are inexpensive and could therefore have a major impact on sustainable development and population growth. But the procedure is misunderstood and as a result poorly used.
There is a knowledge gap about the vasectomy procedure as a family planning method in several African countries. Only 38% of women and 48% of men in Kenya knew of a vasectomy for family planning. In Nigeria this figure dropped to only 16% of married women and 27% of men identified. In Liberia, this figure stood at 20% for both married women and men.
For family planning to be effective emerging evidence increasingly shows that men must both support women's use of contraceptives and use male fertility control methods if necessary.
A risk free procedure
A vasectomy is an effective (and increasingly reversible) method of birth control. It involves clamping, cutting, or sealing the duct that conveys sperm from the testicle to the urethra.
It is a fairly quick, simple and straightforward procedure which lasts barely 30 minutes. It can be done in a doctor's practice or clinic on an outpatient basis, and under local anaesthesia. There are also very few risks or complications.
Very few vasectomies fail or go wrong. In very rare cases, the duct spontaneously reconnects. But only about 1 in every 500 women have an unintended pregnancy in the year after their partner has undergone a vasectomy.
A low uptake
Despite all of this, the uptake of vasectomies in Africa remains consistently low.
In Kenya only one of the 24 125 married women who were surveyed said her husband had undergone a vasectomy. In Senegal and Nigeria none of the married women surveyed said their husbands had undergone vasectomies. And only 0.01% of the men interviewed in Zimbabwe admitted having a vasectomy.
The low uptake derives from a number of factors. Our field research suggests that a major reason for this is the cultural belief that a man's fertility belongs to the community as a whole. As a result, men who go for vasectomies risk stigma and contempt. There are several myths and misconceptions surrounding the procedure. These include:
Local beliefs associating vasectomy with de-masculinisation, framing it in terms of castration
notions that vasectomy causes painful sex, weight gain and obesity among men, and makes men develop female features, such as breasts
fears that it would reduce their sex drive and sexual satisfaction
In addition, another challenge is that few health and family planning providers on the continent offer vasectomy services or discuss it in family planning counselling sessions. One study in Nigeria reflects that only 5.8% of doctors discussed vasectomies during counselling sessions.
In our project in western Kenya, we wanted to increase the knowledge and uptake of family planning services, including vasectomies.
When the project began there were no recorded cases of vasectomies. By the end of 2014, 118 vasectomies had been done.
Community health workers were meticulously trained to help local communities understand vasectomies, family planning and men's role in reproductive and family health. The consistent and careful engagement using clear and accurate messages and information helped people accept the practice.
Changing the mentality
Our work promoting the uptake of family planning in western Kenya has raised critical lessons about vasectomies and male involvement in family planning in Africa.
The first lesson is that men can become more involved in fertility planning and childbearing decisions. It happens when they are supported to make a strong personal connection to the issue of family and reproductive health and well-being.
The second is that vasectomies will be accepted as a method of family planning when the myths and misconceptions surrounding it are systematically dispelled.
A third lesson is in the value of getting community male champions to popularise vasectomies. The few men who undergo vasectomies often do so secretly and are rarely willing to speak out in support of the practice. Locally respected and authoritative men must be identified and recruited to act as ambassadors of change challenging myths and misunderstandings and highlighting the benefits of the procedure.
It is also important that health care providers who can offer vasectomy counselling and procedures are available. When we started our project, few providers had the necessary skills to perform the procedure. By mid-2015, the project had trained over 100 health providers.
Efforts to improve the uptake of vasectomy in Africa will fail without the accompanying training of health professionals.
What is urgently needed is a bold and innovative plan to address misconceptions and change perceptions around the process, communicate its benefits and ensure there are adequate numbers of well trained providers to offer it.
Chimaraoke Izugbara works for the African Population and Health Research Center. He receives funding from the Packard Foundation, Hewlett Foundation, Sida, MacArthur Foundation, and the Wellcome Trust.
Michael Mutua receives funding from the David and Lucile Packard Foundation for the data collection and staff time at African Population and Health Research Center.