NEW EVIDENCE ON VASECTOMY AND MALE INVOLVEMENT IN FAMILY PLANNING IN RWANDA

Joshua Davis, MSPH

Overview



Context and program background



Data and Methods



Research objective



Methods



Results



Conclusions

Background – Rwanda

 Population: 10,473,282  Pop. Growth: 2.7 (17 th Worldwide)  TFR: 5.5 children/woman (22 nd worldwide)  Most densely populated country in Africa (similar in density to Netherlands) • 48% of women want no more children • 38% of women have unmet need for FP (want to limit or space births but weren’t using contraception)  Government of Rwanda has made family planning a national priority

Background – No-scalpel vasectomy

Safe, effective, underused

Percentage of women of reproductive age who rely on vasectomy for contraception

Worldwide 2.7%

Africa 0.0%

Asia Latin America/Caribbean 3% 1.3% Europe North America Oceania 2.9% 10.3% 7.4%

Background – IntraHealth’s Pilot Program

 Funding from USAID’s Office of Population  NSV initially introduced in two districts  Created supply of trained providers  Generated demand for services in population  Introduced data collection system for clients

Data – Program Evaluation

 Conducted in Summer of 2009  Goal was to evaluate aspects of the pilot program that were successful and develop recommendations for a country wide scale up

Data – NSV client records

 Parallel to standard HMIS to gather additional information on male acceptors  Additional questions were integrated into the patient screening form:  Demographic information on clients  Qualitative responses on use and attitudes towards family planning  Service outcomes and statistics

Objective

 To assess the profile of vasectomy acceptors and to identify key aspects of the program that led to relatively high uptake rates compared to similar efforts in Sub-Saharan Africa

Methods – Program Evaluation

 IntraHealth M&E staff conducted evaluation in Summer 2009  Focus groups and individual interviews with 50 stakeholders  Process evaluation of pilot implementation

Methods – Records Review

 IntraHealth staff visited 10 sites where NSVs were preformed by project-trained staff  Records were entered into a database  Qualitative responses were categorized by in country staff

Results

Socio-demographic characteristic of the males in the Rwandan NSV pilot program Mean n Std. Dev.

Client's Age Spouse's Age Number of Children Number of Sons Number of Daughters 44.8

38.3

5.7

2.9

2.8

450 440 453 453 453 9.6

7.4

2.1

1.5

1.6

% n Education Level None Primary Secondary Occupation Farmer Unemployed Skilled Manual Prof., Tech., Manag. Sales, Services Unskilled manual HIV Status No Answer Negative Positive 25.8% 63.5% 10.7% 91.3% 0.2% 2.7% 3.3% 2.0% 0.4% 62.3% 26.8% 10.9% 113 278 47 411 1 12 15 9 2 286 123 50 Min.

24 24 0 0 0 Max.

85 65 14 7 9

NSV clients compared to DHS sample Age NSV clients under 25 - 59 compared to DHS married sample NSV Clients 25 -59 DHS married n 412 Mean 43.2

n 1583 Mean 39.9

Number of Children 412 n 5.6

% 1583 n 4.5

% Education Level None Primary Secondary Occupation 95 256 47 23.9% 64.3% 11.8% 339 1002 252 20.7% 63.3% 15.9% Farmer Prof., Tech., Manag. Skilled Manual Sales Unskilled manual Not working Other 371 15 12 9 2 1 0 90.5% 3.6% 2.9% 2.2% 0.5% 0.2% 650 116 127 56 73 555 6 41.1% 7.3% 8.0% 3.5% 4.6% 35.1% 0.4%

NSV clients compared to sample

Mean children by age of client, NSV and DHS

10 7 6 9 8 1 0 3 2 5 4 25 30 35 40

Age

45 50 55 60 DHS NSV

Reason for wishing to cease having children 30% 20% 10% 0% 70% 60% 50% 40% 32% 60% n = 455 8% 1% Enough children Financial concerns Health Other

Reasons for choosing vasectomy 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 43% 25% 12% 5% n =448 10% 4% Concern about wife's health Convienence/ease/eff ectiveness of NSV Enough children Financial concerns Side effects of other methods Other

Rumors heard about FP and vasectomy 30% 25% 20% 15% 10% 5% 0% 26% 20% 26% 13% 15% Castration Decreased libido Impotence None Other n =196

Previous contraceptive use 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 40% 21% 15% 14% n = 461 10% Injectables Pill Condom None Other

Results – Program evaluation

• • • • • Sustainable Approach 10 doctors and 25 nurses trained in NSV • Service expanded to 8 other (10 total) districts Community Health Worker outreach • 252 men (54%) reported speaking to a CHW before deciding to have a NSV Service Extension Model • 59% of NSVs were done as part of extension service Engagement of Political Stakeholders

Conclusions

 Given access and information, men in Rwanda are willing to accept sterilization as a from of family planning  Supply creation and demand generation need to be coordinated  IEC materials can be delivered at a community level in the absence of a mass media strategy

Thank you