Vasectomy: A Long, Slow Haul to Successful Takeoff

"Robust demand generation should include messaging specific to vasectomy, but should also draw on broader social and behavior change communication efforts increasingly aimed at engaging men in family planning."

Published in the journal Global Health: Science and Practice, this editorial examines what its authors characterise as the fundamental underlying constraint to vasectomy uptake: low demand for the method among men in low- and middle-income countries. They outline various reasons for this low demand, including the fact that men and women typically see contraception as women's responsibility; thus, it is a gender-equality issue. In unpacking the overriding issue of weak demand, Shelton and Jacobstein critique a literature review by Shattuck and colleagues in this same journal issue (see Related Summaries, below). They are concerned, for one thing, that focusing on supply-side issues like training, as the Shattuck literature review did in part, can "foster the misapprehension that if only we could make vasectomy more accessible, its use would rise substantially." They also question the article's proposal of active integration of vasectomy with current male circumcision programming, although they do see value in trying to reach these boys and young men with messages on contraception and reproductive health in general and on positive gender norms.

Shelton and Jacobstein respond to the question of how much investment in vasectomy, with its "compelling advantages", makes sense, outlining reasons including: "Supporting wider individual and couple choice promotes better client satisfaction and use of contraception, as well as individual rights." They stress the need to harmonise vasectomy demand generation with broader family communication planning designed to reach men. (Men are increasingly the intended audience of social and behaviour change communication (SBCC) efforts for family planning more generally.) Examples of this broader messaging include: promoting a positive image for family planning; increasing couple communication; advancing the advantages of healthy timing and spacing of pregnancies, including limiting fertility for those who have reached desired family size; promoting an active role for men in pregnancy planning; projecting images such as the ACQUIRE Project's "permanent smile" of vasectomy users; and projecting the potential better sexual satisfaction when the couple is freed from the worry of unwanted pregnancy. "Moreover, broader development efforts to advance gender equality should, in turn, promote the appropriate role for men in family planning as a client, supportive partner, and advocate."

The authors conclude by reiterating their belief that "serious, increased, and sustained support to vasectomy is warranted." However, they say that the reality is that vasectomy programming has generally been carried out through modestly resourced pilot programmes of short duration; "fulfilling the potential for vasectomy will require long-term and substantial investment."