1. Motivation and barriers to vasectomy in low and middle income countries, a review of the literature. Emily Jane Sullivan, MSc. London School of Hygiene & Tropical Medicine Submitted Thesis 2014

2. Did you know? Q: Most children born to one women? A: 69 children by Russian women, Feodor Vassilyev 16 pairs of twins, 7 triplets, & 4 quadruplets Q: Most children fathered by one man? A: 1,042 children by Moroccan Sultan Moulay Ismail 4 wives and 500+ partners *LSTHM Lecture September 2014. Photo Credit: Wikipedia

3. Value of Male vs. Female Sterilization Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013. Smith GL, Taylor GP, Smith KF. Comparative risks and costs of male and female sterilization. American Journal of Public Health. 1985;75(4):370-4 Marie Stopes. What is a couple year of protection? Access: https://mariestopes.org/sites/default/files/MSI-CYP-Infographic.pdf

4. Value of Male vs. Female Sterilization Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013.

5. Value of Male vs. Female Sterilization Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013.

6. Value of Male vs. Female Sterilization Population Reference Bureau. Family Planning Worldwide 2013 Datasheet. Washington, DC, USA: Population Reference Bureau, USAID, 2013.

7. Aim To understand the low prevalence of vasectomy in LMIC: by identifying the profile of vasectomy users or acceptors, including their motivations and barriers.

8. Methods: Inclusion Criteria Type: Primary studies, peer-reviewed or grey literature Publication date: 1980 to 2014 Language: English Setting: LMIC Findings: Quantitative, qualitative, and mixed-methods Topic: Focus on describing acceptors or users of vasectomy Availability: Full text

9. Methods: Search, Quality, Analysis Systematic Literature Search: – Screen abstracts & full articles: 1,365 studies. – Final inclusion: 18 studies. Quality Appraisal: – 8 strong, 8 moderate, 2 poor. Data Analysis: Integrated Narrative Approach – Qualitative, Quantitative & Mixed studies.

10. Results: Study Characteristics Study Locations: – Bangladesh, Costa Rica, Ghana (2), Guatemala, India (4), Iran, Kenya, Mexico, Nepal (2), Nigeria, Philippines, Rwanda, Sri Lanka, Tanzania, Turkey. Study Participants: – 12,744 men, 1,322 women, 29 healthcare providers. Study Designs: – Qual (8) Quant (6), Mixed Methods (4).

11. Results: Strong Motivations Limit number of children, exceeded desired, multiples Economic Stability Feeling of responsibility Informed Difference between male & female Misinformation corrected PH Nurse Talk with a sterilized man or couple Spouse Approval Aware of man’s other partners Misinformation Corrected Man initiate conversation Diagnosis or illness Side effects from other methods (IUDs) Women’s Health Near miss mortality or frequent pregnancy Improve Love Life Confidently avoid pregnancy with wife Or with other partners Religious Views Only have children can care for Education & Services provided at faith- center

12. Results: Strong Barriers Concerned if she gets pregnant Spouse Disapproves Misinformation Man will seek out other partners Keep vasectomy a secret Community Perception Loss on control within family Loss of authority in community Religious Views Heightened when confused with castration Similar to other forms of family planning Can’t remarry if wife changes her mind Future Uncertainty Maternal or child mortality Improved economic circumstances Lack of Access Delayed, have unintended children No designated provider Discouraged or humiliated by providers Misinformation Side effects & Operation Procedure is castration Local language General poor health, gain or loose weight Sexual desire or dysfunction

13. Summary of Results Frames sterilized men as: – Economically stable, in good health, able to work, and with normal sexual function. Educational resources include: – Procedure details; – Difference between male and female sterilization; – Testimonials from sterilized men or couples; – Endorsement statements from faith leaders.

14. Recommendations: Improve access to services: – Mobile clinics & accepting providers; Targeted education: – Adverse health event or FP side effects; Continually assess motivations and barriers: – Vasectomy camp users (not static clinics); – Apply nuanced findings to educational materials and counseling.

15. Looking Forward: Global Commitments & Local Actions Commitment: To not make assumptions. Men may be interested and willing undergo vasectomy. Action: To incorporate thoughtful and ethical vasectomy awareness, education, and services into in all family planning programming. Vasectomy has the potential to alleviate burden from women and healthcare systems.

16. Thank you! Questions? Acknowledgements: Joelle Mak, London School of Hygiene & Tropical Medicine; Susannah Mayhew, PhD, London School of Hygiene & Tropical Medicine; Lynda Clarke, PhD, London School of Hygiene & Tropical Medicine; Johns Hopkins Bloomberg School of Public Health. Emily J. Sullivan, MSc. E-mail: emsully71@gmail.com Photo Credit: International Conference on Family Planning 2015 website