Jacobstein, Roy

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The kindest cut: global need to increase vasectomy availability
Famil y planning programmes in low-resource countries 
have notably expanded access to modern contraception. 
The modern method contraceptive prevalence rate 
(MCPR) is now 56% in UN-designated least developing 
regions (61% in developed regions).1 In least developed 
countries, the rate has risen from negligible proportions 
in the 1970s to 30% in 2011. A bedrock principle of 
family planning programmes is to ensure individuals 
and couples seeking contraception are able to make a 
voluntary and informed choice from a wide range of 
methods to meet their reproductive goals. This principle 
was endorsed by 179 countries in the Programme of 
Action of the 1994 Cairo International Conference on 
Population and Development, and has been reiterated 
often.2 There is also longstanding international 
consensus on the importance of gender equity. From 
the standpoint of vasectomy (male sterilisation), 
however, there has been a disconnect between stated 
commitments to choice and equity and programme 
realities. 
Almost all men are eligible to have a vasectomy.3 It 
is highly eﬀ ective, convenient, and easy to provide, 
and is also, along with female sterilisation, one of only 
two permanent methods of contraception. For these 
reasons, and to share contraceptive responsibilities, 
vasectomy is widely chosen in regions and countries 
with high socioeconomic development and gender 
equality. Vasectomy prevalence is 12% in Northern 
America and 11% in Oceania and Northern Europe.1 
In Canada it is the most widely used method: 22% of 
women rely on vasectomy, accounting for 31% of all 
modern method use. The UK, New Zealand, and South 
Korea have similar proﬁ les, with vasectomy prevalence 
ranging from 17% to 21%, comprising 24% to 27% of 
modern method use. Australia, Belgium, Denmark, 
Spain, Switzerland, and the USA also have substantial 
vasectomy use, with prevalence ranging from 8% to 
11%. In the USA, 175 000 to 350 000 vasectomies are 
done every year.4 
The situation diﬀ ers markedly in the world’s 69 least 
developed countries: only 0·7% of women are able to rely 
on a partner’s vasectomy. Vasectomy prevalence in Africa 
is 0·0%, with fewer than 100 000 men having accessed 
it.5 Of 54 African countries, only ten report measurable 
vasectomy use and only Swaziland (0·3%), Botswana 
(0·4%), and South Africa (0·7%) exceed 0·1% prevalence. 
Vasectomy is the least known modern method in most 
low-resource countries.6 Furthermore, the knowledge 
(or, more accurately, awareness) that does exist, among 
women and men alike, is often burdened by erroneous 
understandings that equate vasectomy with castration, 
impotence, and weakness (inability to work).7 When 
a man does desire vasectomy, skilled providers are 
generally unavailable to provide services. Although 
vasectomy is simpler to perform, less invasive, safer, and 
more cost eﬀ ective than female sterilisation, less than 
one in 11 users of permanent methods in developing 
regions relies on vasectomy.
However, all is not bleak. As greater education and 
participation of women, rapid urbanisation, and the 
spread of global communication continue to drive 
smaller desired family size in almost all countries, 
demand to limit future childbearing among married 
women continues to rise and now exceeds demand 
to space births in all regions except western Africa 
and middle Africa. The average age at which this 
occurs can be surprisingly low—eg, 29 years in Malawi, 
28 years in Namibia, 24 years in Lesotho, and 23 years in 
Swaziland.8 Female sterilisation is the most widely used 
method worldwide, with 223 million women relying 
on it; another 28 million women rely on their partner’s 
vasectomy.5 Malawi, one of the world’s ten poorest 
countries, has achieved 9·7% female sterilisation 
prevalence; more than 170 000 procedures were 
provided there from 2008 to 2011 via public–private 
partnerships, free mobile services, and family planning-
dedicated, non-physician providers.9 Thoughtful, male-
centred programming has resulted in greater vasectomy 
use in Nepal (7·8% prevalence), Brazil (5·1%), and 
Colombia (3·4%). In Rwanda, pilot programmes have 
provided more than 1000 vasectomies annually.10
What, then, needs to be done for vasectomy to 
become a routinely available, readily accessible method 
option in low-income countries? First, policymakers, 
donors, and programme leaders and implementers 
must appreciate the current and likely future extent of 
demand for preventing future pregnancies. Second, 
they need to understand that quality vasectomy services 
can feasibly be introduced, scaled up, and, ultimately, 
sustained. This will require adequate time and resource 
Published Online
November 3, 2015
http://dx.doi.org/10.1016/
S2214-109X(15)00168-0
This online publication 
has been corrected. The 
corrected version first 
appeared at thelancet.
com on Jan 26, 2016
Comment
e734 www.thelancet.com/lancetgh   Vol 3   December 2015
commitment to address provider, client, and health-
system factors. Third, they need to appreciate that 
vasectomy unavailability is a gender issue as well as 
a programme issue. Perhaps we can emulate Bhutan, 
known for its index—and achievement—of Gross 
National Happiness, and with a vasectomy prevalence of 
13%, 19% of its overall MMCR of 65%. From a woman’s 
perspective in low-income countries, after having borne 
her desired number of children, and, typically, the lion’s 
share of contraceptive responsibility, vasectomy can 
indeed be the kindest cut.
Roy Jacobstein
Senior Medical Advisor, IntraHealth International, Chapel Hill, 
NC 27517, USA
rjacobstein@intrahealth.org
I declare no competing interests. 
Copyright © Jacobstein. Open Access article distributed under the terms of CC BY.
1 UN Department of Economic and Social Aﬀ airs, Population Division. 2014. 
World contraceptive patterns wall chart 2013. http://www.un.org/en/
development/desa/population/publications/pdf/family/
worldContraceptivePatternsWallChart2013.pdf (accessed July 24, 2015). 
2 UNFPA. UN Population Fund Programme of Action of the International 
Conference on Population and Development, 20th Anniversary Edition, 
2014. Isbn 978-0-89714-022-5. http://www.unfpa.org/sites/default/ﬁ les/
pub-pdf/programme_of_action_Web%20ENGLISH.pdf (accessed 
July 24, 2015).
3 WHO. Medical eligibility criteria for contraceptive use, 5th edn. Geneva: 
WHO, 2015.
4 Eisenberg ML, Lipshultz LI. Estimating the number of vasectomies 
performed annually in the United States: data from the National Survey of 
Family Growth. J Urol 2010 184: 2068–72.
5 UN Department of Economic and Social Aﬀ airs, Population Division, 2012. 
World Contraceptive Use 2011. http://www.un.org/esa/population/
publications/contraceptive2011/contraceptive2011.htm. (accessed 
July 24, 2015).
6 Measure DHS, 2015. STATcompiler. Calverton, MD. http://www.statcompiler.
com (accessed July 24, 2015).
7  The RESPOND Project. A matter of fact, a matter of choice: The case for 
investing in permanent contraceptive methods. EngenderHealth White 
Paper. New York: EngenderHealth, 2014. 
8 Van Lith LM, Yahner M, Bakamjian L. Women’s growing desire to limit further 
births in sub-Saharan Africa: meeting the challenge. Glob Health Sci Pract 
2013; 1: 97–107. 
9 Jacobstein R. Lessons from the recent rise in use of female sterilization in 
Malawi. Stud Fam Plann 2013; 44: 85–95.  
10 Shattuck D, Wesson J, Nsengiyumva T, Kagabo L, Bristow H. Who chooses 
vasectomy in Rwanda? Survey data from couples who chose vasectomy, 
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The kindest cut: global need to increase vasectomy availability

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