Population Matters-USA – working for a sustainable world

Dr. Charles Ochieng at the International Conference on Family Planning

Sixteen years ago the Durango Herald published my column “Do your Partner’s Vasectomy”; it got lots of laughs on April Fool’s Day! Unfortunately, the latest news on male sterilization is not so funny.

There is some recent good news, fortunately. In some states, men are rushing to get permanently sterilized because of the recent Supreme Court decision about abortion. My experience, however, is that they will be moving a little more slowly after this minor procedure. I was sore for a couple days after my vasectomy, many years ago.

Remember that vasectomy is much safer and easier than a tubal ligation, the female sterilization procedure. Male sterilization is done with local anesthesia and is finished in just 10 or 15 minutes. There are only two drawbacks to vasectomy. While female sterilization is effective immediately, it takes a couple of months after the procedure before a man starts shooting blanks. The other drawback is that many men are frightened to have it done.

It is interesting to note the countries where vasectomy is most popular. The top five are: South Korea, Australia, Bhutan, the USA and New Zealand. Bhutan? Yes! Perhaps it is because that little country’s government has promoted this simple surgery. Bhutan has had mobile vasectomy camps which bring the service to villagers. Furthermore, men tend to take responsibility for family planning in this enlightened country.

The bad news is that we seem to have reached “peak vasectomy”. Worldwide, the maximum number of couples who use vasectomy for protection from unintended pregnancy was reached in 2001. That year, 44 million couples worldwide were safeguarded by this simple procedure. The latest figures show a sad decline to just 17 million couples who are dependent on vasectomy.

What can be done to bring back vasectomy? One group is doing its best to spread the good word all over the world. World Vasectomy Day, www.wvd.org, has worked in several countries to introduce people—especially men—to this simple surgery. They claim: “World Vasectomy Day is the largest male focused family planning movement ever”. WVD was started by a New York film producer, Jonathan Stack, and urologist Doug Stein. Together, they have built an amazing crusade to not only to do the surgery, but also to train doctors to perform the procedure.

Stein is a master of the No Scalpel Vasectomy technique. It uses a couple of special instruments that make it possible to perform this delicate procedure with tiny incisions. Because it involves less cutting, NSV has fewer complications than older methods.

Vasectomy would be ideal for couples in developing countries who want to stop childbearing, since it doesn’t require a fancy facility. Dr. Charles Ochieng of Nairobi, Kenya has become an evangelist for vasectomy. He had his own vasectomy years ago, and has done hundreds since then. An award-winning family practice doctor, he is devoted to providing vasectomies and teaching other physicians the NSV technique. He learned the NSV technique while spending time in Florida with Dr. Stein.

I met Ochieng at an international family planning convention in Kigali, Rwanda. He told me that he even offered to do his father’s vasectomy! His dad has 3 wives (polygamy is legal in Kenya) and many children. He was sad that his father turned down the gift. For some cultures, a large family is a status symbol, especially for men.

Now, as restrictions on women’s reproductive health increase in the USA, I hope more men will take this small, but important, step to prevent unintended pregnancies.

In the early 1990s I read about women who were using a medication to cause abortions without visiting a doctor. Brazilian women had found that misoprostol (CytotecÒ) was available without a prescription, and would cause strong uterine contractions that could expel an early pregnancy.

Since then, this knowledge has spread to all corners of the globe. Misoprostol is now approved by the US Food and Drug Administration for use in conjunction with mifepristone to be prescribed for legal abortions. This combination has been found to be both very effective and very safe. Recognizing the safety of this combination, the FDA has decreased restrictions on mifepristone. The combination can also now be prescribed by telemedicine. However, misoprostol is almost as effective when used alone.

The original indication for misoprostol had nothing to do with abortion. Instead, it was found to protect the stomach lining in people who had irritation from NSAIDs, such as ibuprofen. It has other uses, including induction of labor (in a teeny dose) and is a lifesaver for treating postpartum hemorrhage.

A Honduran friend sent me the transcript of a BBC News Program, “Inside Honduras’s abortion pill black market.” Abortion is illegal under all circumstances in this Central American country—the most restrictive law in the world. Having an abortion is punishable by 6 years in prison. Although “back ally” surgical abortions may still occur, this excellent piece of investigative journalism is about medication abortion. Only misoprostol is available in Honduras, not mifepristone. Unfortunately, this article doesn’t give any follow up on women who use the medicine. There are risks, and some women end up in the hospital.

One of the risks is that the pregnancy will continue; misoprostol alone is only about 90% effective. Follow up is needed to detect the one in 10 women who doesn’t abort. If the first dose doesn’t work, she should use a second dose or she may go to term. Sadly, a fetus exposed to miso early in pregnancy may be affected with serious congenital anomalies—one of the risks of unsafe abortion.

Back to Honduras. The reporter, Laura, first spoke with a young woman who didn’t use protection during a one-night-stand and was 2 months pregnant. She bought 4 tablets of misoprostol on the black market. José, the black-market supplier, charges on a sliding scale. He gets from $70 to $270—depending on what he thinks the woman can pay. In this country they might cost $10, with a prescription. José has to pay off his ex-girlfriend who works in a hospital and supplies the prescription. He may also keep the police happy with bribes.

Honduras’s largest public hospital is in the capital, Tegucigalpa. It treats around 60 women each week for bleeding during pregnancy, either from miscarriage or induced abortion. The UN estimates that there are about 70,000 unsafe abortions in Honduras each year. Making abortion illegal doesn’t prevent desperate women from having unsafe abortions. Without sexual education teens don’t know how to prevent pregnancies; Honduras has the highest rate of adolescent pregnancies in Central America. Could these facts reflect the unrealistic religious teachings in a country where 48% of people are evangelical Christian and 34% are Roman Catholic?

What lessons does Honduras have for the USA? Outlawing abortion doesn’t prevent women from obtaining abortions, but they may be unsafe, expensive and exploitive. Similarly, US states that have acted to restrict or outlaw abortion are among those with the highest teen pregnancy rates, the least sex ed and the poorest support for mothers and children. Many also have high maternal mortality rates, which will probably rise as desperate women take abortion into their own hands.