According to 'Unwanted Fertility in South Africa', a recently published report from Statistics South Africa, "about 20% of all births in the five years preceding the 2016 Demographic and Health Survey (including pregnancies at the time), happened when women were not planning on having any more children". The report, based on demographic health data from 1998 and 2016, shows an increase in the percentage of unwanted births from 17.3% in 1998 to 20.4% in 2016.
Various forms of temporary contraception are already available in the public sector in South Africa - including condoms and birth control pills, intra-uterine devices and contraceptive implants for women - although availability of these various options varies between healthcare facilities. There are no registered contraceptive pills or implants for men - although research in this area is ongoing.
There are also more permanent birth control options such as female and male sterilisation - the latter in the form of vasectomy. According to this Lancet article, "vasectomy is simpler to perform, less invasive, safer, and more cost-effective than female sterilization".
Vasectomy is a surgical procedure where the sperm tubes (vas deferens) are tied off so that there is no longer sperm in a man's semen - thus rendering the man sterilised. A vasectomy does not have any impact on a man's sex drive and men who have had vasectomies still produce semen.
As some have argued, vasectomies offer men a means by which to help shoulder the burden of birth control. A man in a sexual relationship with a woman may, for example, get a vasectomy so that she can stop taking the birth control pill.
Low rates in South Africa
Popo Maja, spokesperson for the National Department of Health, does not try to hide the fact that vasectomy rates in South Africa are very low. According to Maja, only 639 vasectomies were performed in South Africa in 2020. This is close to half of the 2019 number of 1 391 and 2018's 1 205. In 2017, 689 vasectomies were performed and in 2016, the number stood at 564. Maja could not clarify whether these figures were for the public sector alone or for both the private and public sector combined (we suspect the prior) given how low these numbers are.
Though up-to-date figures are hard to find, what evidence there is indicates South Africa, like most African countries, has dramatically lower vasectomy rates than many other countries. (This UN Population Division report gathers much of the available data.) While fewer than 1% of men aged 15 to 49 in South Africa have had vasectomies, the rate in many wealthier countries is over 10%.
"We obviously are far below when it comes to our figures on vasectomies. I guess our citizens still want to expand," says Maja.
He points out that in South Africa the Sterilisation Act regulates sterilisation. Among others, the Act explicitly states that "a person capable of consenting may not be sterilised without his or her consent". Spotlight previously reported on instances where female sterilisations were allegedly performed without consent on women living with HIV.
How easy is it to get a vasectomy in SA?
The Department of Health's 2020 National Sexual and Reproductive Health and Rights Policy lists male sterilisation as one of several modern contraception services that should be available in public health facilities. Maja confirmed that the service is available in public sector facilities in all nine provinces, but could not confirm whether a target in the 2012 National Contraception Clinical Guidelines to make the service available at a minimum of one facility per district has been met.
The National Clinical Guidelines for Contraception 2019 states that: "Vasectomy is a permanent choice of contraception and, as such, requires serious consideration. It has fewer side effects and complications than most contraceptive choices for women. It is, therefore, suitable for men who definitely do not want to have any more (biological) children." It also says that vasectomy is the "preferred method of sterilisation" if a couple is sure that they do not wish to have any more children.
Having a vasectomy in the private sector typically costs a few thousand rands, with costs varying depending on factors like the type of sedation being used. Some medical aid schemes will cover the procedure, either partially or in full.
The Metro Men's Health Centre
While we have not been able to establish how easy or how difficult it is to get a vasectomy in the public sector in South Africa - it probably varies significantly from place to place - there are some initiatives that are trying to make the procedure more widely available. One such example is at a men's health centre in Cape Town.
"We are trying to focus on a holistic and comprehensive list of services which would include vasectomies," says Dr Abdul Sungay, director at the Metro Men's Health Centre at the Karl Bremer Hospital. "We saw a need as some of our clients have been asking for the service. We then approached the Tygerberg Urology team who have been running this service before the COVID-19 lockdown and they've agreed to perform the procedures at our facility," says Sungay.
"Clients asking for this service should call and make an appointment. When they arrive, they will be seen by a fertility counsellor before the procedure. They may need to go to Tygerberg Hospital for a follow-up test. Then, if all is well, the client's next visit will be the procedure. Boys aged 15-18 years can also access the facility for healthcare support, but they will need a guardian to accompany them," says Sungay.
Danelo Du Plessis is a lecturer from Stellenbosch University's Urology Department and has been offering his services at the Men's Health Centre. "We do vasectomies one morning per week, with five to six per list," he says. "I started at [the] Men's Clinic on 3 May 2021. Prior to COVID-19 lockdown, we have been performing six per list (once a week) at Karl Bremer Hospital, for many years (about 10 years)." He adds that the service is free and that extensive counselling is done by a dedicated nurse when the booking is made.
A safe procedure
On the risks involved during surgery, Du Plessis says the procedure is "very safe". "Having said that, it always carries inherited risks; in this case pain, infection, and bleeding would be most common."
The procedure, according to Du Plessis, is 99% effective and takes a minimum of 10-15minutes. "Only the local anaesthetic is felt, thereafter no pain. Full recovery by day five is the norm," he says, adding that men with chronic illnesses can also undergo it.
He explains that the procedure does not work immediately.
"The sperm remaining in the vas deferens and ejaculatory ducts needs to clear, which takes time. It is very important that men confirm that there is no sperm in ejaculation at three months post-procedure by means of a semen analysis," he says.
Du Plessis says that a vasectomy can be reversed, but that it should be regarded as a permanent form of contraception, "as the reversal is not widely available and very expensive without guarantee of success".
Spokesperson for the national men's organisation Takuwani Riime, Sipho Barnes strongly believes that vasectomies have a vital role to play in preventing unplanned pregnancies.
"We have made great strides in stressing the importance of condoms to men to avoid STIs and HIV and with vasectomies, we are encouraging men to use it to prevent unplanned pregnancies. But having said that, we are also stressing to men that condom use is still important, whether or not one has had a vasectomy."
"Over the past years, we have been engaging men about the importance of avoiding unplanned pregnancies," he says. "Many children are wandering the streets because of unplanned pregnancies. Hence, we are reaching out to communities to spread the message of vasectomy to men."