Int J Gynaecol Obstet 17: 11-14, 1979
A Follow-up of Vasectomy Clients in Rural Bangladesh Atiqur Rahman Khan, 1 Ingrid E. Swenson 2 and Azizur Rahman 3 1
Bangladesh Fertility Research Programme, Dacca, Bangladesh The Johns Hopkins University Fertility Research Project, Dacca, Bangladesh 3 Bangladesh Association for Voluntary Sterilization, Dacca, Bangladesh 2
ABSTRACT Khan AR, Swenson IE, Rahman A (Bangladesh Fertility Research Programme, The Johns Hopkins University Fertility Research Project and Bangladesh Association for Voluntary Sterilization, Dacca, Bangladesh). A follow-up of vasectomy clients in rural Bangladesh. Int J Gynaecol Obstet 17: 11-14, 1979 A one-year follow-up of 585 vasectomy clients sterilized at vasectomy camps in Shibpur and Shalna in rural Bangladesh showed that almost half of the clients were dissatisfied with their vasectomies. The majority of dissatisfied clients stated that their primary reasons for dissatisfaction were: (a) their ability to work had decreased and (b) they had not received all of the incentives they had been promised. However, 58% of the matched nonvasectomized controls also felt that their ability to work had decreased in the last year. Only 2%-7% of the dissatisfied clients cited decreased sexual performance as their primary reason for dissatisfaction. Satisfied vasectomy clients most frequently cited: (a) the permanence of this method of birth control and (b) the incentives they received as their reasons for satisfaction.
INTRODUCTION T h e objectives of this follow-up of clients from two vasectomy camps in Bangladesh were: (a) to assess the demographic characteristics of the vasectomy acceptors (ie, age, parity of wife, age of the youngest child, etc) in order to determine the demographic impact anticipated from the male sterilizations and (b) to assess the long-term results of vasectomy, such as client satisfaction or dissatisfaction, changes in sexual capacity and general health problems attributed to vasectomy. Such information will help to determine the appropriate role of vasectomy in the national family planning program in Bangladesh. Sterilization is being given increased priority in the Bangladesh family planning program. Vasec-
tomy is the only method of contraception that can be offered directly to the male (other than the condom). Traditionally, family planning programs have been aimed at the female, primarily because the majority of nonpermanent contraceptive methods are for the female. Several studies have suggested that programs for fertility control in developing countries should give as much attention to males as to females (2, 3). O n e of the major advantages of vasectomy is that it is a sure, irreversible method of contraception which requires only one-time motivation. This very advantage also necessitates that special discretion is exercised in the selection of the clients (1, 4, 5, 9, 10, 12).
BACKGROUND AND STUDY POPULATION T h e two largest vasectomy campaigns in Bangladesh were conducted at Shibpur a n d Shalna in J a n u a r y 1976. Recruitment of acceptors in Shibpur was organized by the general civil administration personnel assisted by local Family Planning Field Workers. Each client was given T a k a 17.50 (about U S $1.10) for transportation a n d one meal. An immediate postoperative follow-up of the vasectomy cases was conducted to treat surgical complications. Of a random sample of 346 clients selected from the 733 clients vasectomized at Shibpur, 304 were successfully interviewed. T h e Shalna Vasectomy C a m p was conducted by the Bangladesh Association for Voluntary Sterilization (BAVS) in J a n u a r y 1976 at Screpur T h a n a in Dacca district. A total of 304 clients were randomly sampled from the 1054 clients. T w o hundred eighty-one of these 304 clients were successfully interviewed. Of the 23 cases that were not interviewed, 21 could not be located because their addresses were incomplete or inaccurate. O n e patient died since his vasectomy.
Int J Gynaecol Obstet 17
12
Khan et al
Case control clients from each village were matched by age, wife's age, number of living children, n u m b e r of living male children, education, occupation a n d age of the youngest living child. They differed in landholdings. While only between 13% (Shibpur) a n d 18% (Shalna) of the vasectomy clients owned the land they farmed, 55% of the controls owned land.
RESULTS Nineteen percent of the Shibpur clients and 34.1% of the Shalna clients were 40 years or younger. Their mean ages were 48.6 years a n d 46.3 years, respectively. However, more than 70% of the Shibpur a n d 74% of the Shalna clients' wives were 40 years or younger. T h e wives' mean ages were 39.5 years and 36.4 years, respectively. At vasectomy, the mean numbers of living children reported by the Shibpur and Shalna clients were 4.1 and 4.8, respectively. T h e mean numbers of living male children were 2.5 a n d 2.4, respectively. At follow-up a year later, 40% of the clients h a d five or more living children. Ten Shibpur clients a n d one Shalna client reported that they had no living children at follow-up, although they all reported at least one living child at vasectomy. At follow-up, the mean ages of the youngest child were 9.5 years for the Shibpur clients and 6.4 years for the Shalna clients. T h e majority of the clients in both Shibpur and Shalna h a d no formal education (mean years of education = 1.0 and 1.6, respectively). More than 60% worked as agricultural or unskilled laborers, a n d less than 10% were skilled laborers (9.7% and 5.3%, respectively) or employed in business or service (4.9% and 6.9%, respectively). About 10% of each group was unemployed. Between 3% (Shalna) a n d 7% (Shibpur) of the clients a n d / o r their wives used contraception before vasectomy. By comparison, 16% of the matched case controls or their wives had previously used contraception, although only 9% were using some type of contraception at follow-up. Oral contraceptives were the most frequently used method among previous and current users. Less than 10% of the clients indicated they felt coerced into having the vasectomy or were unaware that vasectomy was a permanent means of contraception. While 31.57o (Shalna) to 49.3% (Shibpur) of the vasectomy acceptors said they wanted a permanent contraceptive, 39.8% (Shibpur) to 59.6% (Shalna) said the financial incentive was their primary reason for selecting vasectomy rather than another method of contraception. While the major-
IntJ Gynaecol Obstet 17
ity of Shalna patients said they were self-motivated (50.2%), three quarters of the Shibpur clients were recruited by "agents," police or councilmen. T h e "agents" were motivators who recruited vasectomy acceptors for a share of the incentive money paid to clients. T h e frequency of dissatisfaction a m o n g the clients brought in by "agents" was 89%, while among the clients motivated by other individuals— councilmen, family planning workers, relatives a n d neighbors—the frequency of dissatisfaction varied from 30% to 50%. Although 86.5% (Shibpur) to 92.5% (Shalna) of the vasectomy clients said they did not want additional children, only 60.0% of the matched control clients did not want more children. Twenty-eight percent of the controls wanted at least 1-2 more children, although the mean number of living children for the controls was 4 (essentially the same as for the vasectomy acceptors). Forty-three percent of the Shibpur clients and 47% of the Shalna clients stated that they used the condoms given to them after surgery; 45% and 48%, respectively, took the condoms but did not use them (no specific reasons for nonuse were given). Less than 1% refused the condoms offered to them. T h e majority from both centers said that they experienced slight or moderate pain. Postoperative swelling was most frequently stated as the primary immediate postoperative complication. Only 5% of the Shibpur clients and 2% of the Shalna clients recalled having an infection after surgery. Almost half of the Shibpur and Shalna clients (45.4% and 49.1%, respectively) were dissatisfied about having the vasectomy. T h e most frequent primary reasons for client dissatisfaction in Shibpur were: (a) that vasectomy decreased ability to work (19.7%) and (b) that the clients did not get all of the incentives that they had expected (10.9%). More dissatisfied Shalna clients cited the second complaint (24.9%) than the first complaint (14.6%) as primary reasons for their dissatisfaction. T h e majority of satisfied Shibpur a n d Shalna clients said that they were satisfied with the vasectomy because they wanted effective birth control. A small proportion expressed a good opinion about vasectomy as a method of contraception. About three quarters of the Shibpur clients and 84% of the Shalna clients discussed the procedure with other men. Thirty percent of the Shibpur clients recommended vasectomy to at least one other man. Of these clients, 48% said that that person actually had the vasectomy done. Twenty-two percent of the Shalna clients recommended vasectomy to at least one other man. Of these, 5 1 % had a vasectomy. T h e majority of the clients had no child deaths
Follow-up of vasectomy clients
after vasectomy; however, of the 9% in Shibpur who had children die after vasectomy, 2% had lost two or more children. Three percent of the Shibpur clients' wives had a pregnancy termination after vasectomy compared to 2% in Shalna. In all cases, conception occurred before vasectomy or less than four months after surgery.
DISCUSSION T h e high mean ages of the clients and their wives limit the effectiveness in averting births expected from vasectomy. T h e total fertility rate in Bangladesh is 6.0, while the mean numbers of living children were 4.1 and 4.8 for Shibpur and Shalna, respectively. Thus, one could project at best that 12 births were averted per couple when the husband was vasectomized. This is, however, an optimistic projection considering the high mean ages of the wives (40 years in Shibpur and 36 years in Shalna). Thirty-three percent of the men in the study had been married more than once. Thirty percent of the matched controls interviewed had also been married more than once. T h e effects of vasectomy on births averted may be greater than anticipated given this frequency of remarriage and the likelihood of remarriage to a younger woman. T h e use of incentives may attract clients who are really not ready to terminate childbearing. Financial incentives may also attract some of the most destitute members of society to have a vasectomy. Such individuals may have more general health problems, problems with sexual performance and marital difficulties. Studies which evaluated the psychological responses related to vasectomy have shown a higher incidence of adverse effects among men with some underlying pathology before the procedure (3, 6, 7, 11). T h e small percentage (18%) of clients who said that they considered themselves the most influential in their decision to have the vasectomy may indicate that coercion was used to recruit them. This response may also be influenced by the negative peer pressure experienced by the clients. Although 75%-84% of the clients discussed their vasectomies with other men, the majority of the clients said that few men approved of the vasectomy. Since so little positive reinforcement was given by the clients' peers, the likelihood of the clients regretting the procedure would increase. Furthermore, the clients may also be less willing to admit that they made the decision themselves. In addition, some of the complaints such as "decreased sexual capacity," "weakness" and "decreased ability to work," which have no physiologic basis, may also be greater with negative peer
13
pressure. Only 5%-8% of the clients considered vasectomy a good method of contraception, a n d only 22%-30% of the clients suggested vasectomy to another man. T h e majority h a d not recommended vasectomy to anyone. T h e negative consequences of the improper use of incentives is apparent from the following two cases. O n e unmarried 18 year old said that he was 26 and had three children when he heard that "money was given for getting an injection at the c a m p . " Another married 24 year old with no children stated that he had two children "to get money for an injection." T h e second most frequent reason for client dissatisfaction was that clients did not receive the incentives promised them. This does not indicate that the "incentive" is detrimental. T h e incentive was intended to compensate the patients for their travel to the clinic and time lost from their work activities. However, problems arose in cases where misinformation about incentives was given to the clients by the recruiters. T h e most frequent complaints a m o n g the Shibpur clients, " a decreased ability to work" a n d sexual "weakness," were not very well specified; 58% of the matched case control clients also said that their ability to work had decreased over the past year a n d 55% of these controls said that they h a d become sexually weaker in the last year (4% had no sexual relations within the last 1-3 years). Forty-seven percent of the control clients had not heard of any adverse effects associated with vasectomy; however, 44.1% had heard vasectomy decreased one's ability to work. Although 7%-9% of the clients h a d one or more of their children die after vasectomy, none of the clients gave this as a reason for dissatisfaction with vasectomy. This finding is quite different from the results in our follow-up studies of tubectomy clients in Bangladesh. Although less than 5% of the tubectomy clients said that they regretted having the procedure, almost all who regretted the tubectomy did so because one or more of their children h a d died after tubectomy (8). Most of the satisfied clients wanted a method of birth control. Approximately equal percentages of clients gave such varied reasons as simply being indifferent, being thankful there h a d been no complications after surgery or attributing their recovery from an illness to the vasectomy.
ACKNOWLEDGMENT A special thanks is given to the Statistics Branch of the Cholera Research Laboratory in Dacca, especially the programming services of M r S. R a h -
IntJ Gynaecol Obstet 17
14
Khan et al
m a n . T h e conscientious interviewing a n d coding of the following field staff is acknowledged: Sunil C h a n d r a Saha, N u r M o h a m m a d Bhuyan, Narayan Bhowmick, J a h a r Lai Barua a n d Yusuf Chowdhury. T h i s work was supported in part by t h e International Fertility Research Program a n d the Office of Population, U n i t e d States Agency for International Development (AID/pha-C-1172).
REFERENCES 1. Burnight RG: Male sterilization in Thailand: a follow-up study. J Biosoc Sci 7:377, 1975. 2. Chowdhury AD: Demographic and socio-economic study of mass vasectomy. J Indian Med Assoc 64(4):\06, 1975. 3. Goldberg R, Goldsmith A, Echeverría G: Vasectomy as a contraceptive choice in Latin America. Adv Plann Parent 9(1):49, 1974. 4. Leader AJ, Axelrad SD, Mumford SD: Modern eligibility criteria for vasectomy in the United States. J Urol 115:689, 1976. 5. Leavesley J H : Psychological effects and pre-operative counseling. Aust Fam Physician 5(2): 142, 1976.
IntJ Gynaecol Obstet 17
6. Sharma BP: Observation upon patients following vasectomy in Nepal. South Med J 63:771, 1970. 7. Squires JW, Barb MW, Pinch LW: The morbidity of vasectomy. Surg Gynecol Obstet 143:231, 1976. 8. Swenson IE, Khan AR, Jahan FA: A follow-up of tubectomy clients in Kaliakair, Dacca and Kustia, Bangladesh. Report No 11. The Johns Hopkins Fertility Research Project, Dacca, Bangladesh, June 1977. 9. Wiest WM, Janke LD: A methodological critique of research on psychological effects of vasectomy. Psychosom Med 36(5)A38, 1974. 10. Wolfers D, Wolfers H: Vasectomy and Vasectomania, p 82. Mayflower Books Ltd. Frogmore, St Albans, Herts, AL2 2NF, 1974. 11. Wolfers H: Psychological aspects of vasectomy. Br Med J ¿•297, 1970. 12. Wortman J: Vasectomy—what are the problems? Population Reports Series D, No 2, January 1975.
Address for reprints: Ingrid Swenson 4604 Blanchard Dr Durham, NC 27709 USA
A Follow-up of Vasectomy Clients in Rural Bangladesh Atiqur Rahman Khan, 1 Ingrid E. Swenson 2 and Azizur Rahman 3 1
Bangladesh Fertility Research Programme, Dacca, Bangladesh The Johns Hopkins University Fertility Research Project, Dacca, Bangladesh 3 Bangladesh Association for Voluntary Sterilization, Dacca, Bangladesh 2
ABSTRACT Khan AR, Swenson IE, Rahman A (Bangladesh Fertility Research Programme, The Johns Hopkins University Fertility Research Project and Bangladesh Association for Voluntary Sterilization, Dacca, Bangladesh). A follow-up of vasectomy clients in rural Bangladesh. Int J Gynaecol Obstet 17: 11-14, 1979 A one-year follow-up of 585 vasectomy clients sterilized at vasectomy camps in Shibpur and Shalna in rural Bangladesh showed that almost half of the clients were dissatisfied with their vasectomies. The majority of dissatisfied clients stated that their primary reasons for dissatisfaction were: (a) their ability to work had decreased and (b) they had not received all of the incentives they had been promised. However, 58% of the matched nonvasectomized controls also felt that their ability to work had decreased in the last year. Only 2%-7% of the dissatisfied clients cited decreased sexual performance as their primary reason for dissatisfaction. Satisfied vasectomy clients most frequently cited: (a) the permanence of this method of birth control and (b) the incentives they received as their reasons for satisfaction.
INTRODUCTION T h e objectives of this follow-up of clients from two vasectomy camps in Bangladesh were: (a) to assess the demographic characteristics of the vasectomy acceptors (ie, age, parity of wife, age of the youngest child, etc) in order to determine the demographic impact anticipated from the male sterilizations and (b) to assess the long-term results of vasectomy, such as client satisfaction or dissatisfaction, changes in sexual capacity and general health problems attributed to vasectomy. Such information will help to determine the appropriate role of vasectomy in the national family planning program in Bangladesh. Sterilization is being given increased priority in the Bangladesh family planning program. Vasec-
tomy is the only method of contraception that can be offered directly to the male (other than the condom). Traditionally, family planning programs have been aimed at the female, primarily because the majority of nonpermanent contraceptive methods are for the female. Several studies have suggested that programs for fertility control in developing countries should give as much attention to males as to females (2, 3). O n e of the major advantages of vasectomy is that it is a sure, irreversible method of contraception which requires only one-time motivation. This very advantage also necessitates that special discretion is exercised in the selection of the clients (1, 4, 5, 9, 10, 12).
BACKGROUND AND STUDY POPULATION T h e two largest vasectomy campaigns in Bangladesh were conducted at Shibpur a n d Shalna in J a n u a r y 1976. Recruitment of acceptors in Shibpur was organized by the general civil administration personnel assisted by local Family Planning Field Workers. Each client was given T a k a 17.50 (about U S $1.10) for transportation a n d one meal. An immediate postoperative follow-up of the vasectomy cases was conducted to treat surgical complications. Of a random sample of 346 clients selected from the 733 clients vasectomized at Shibpur, 304 were successfully interviewed. T h e Shalna Vasectomy C a m p was conducted by the Bangladesh Association for Voluntary Sterilization (BAVS) in J a n u a r y 1976 at Screpur T h a n a in Dacca district. A total of 304 clients were randomly sampled from the 1054 clients. T w o hundred eighty-one of these 304 clients were successfully interviewed. Of the 23 cases that were not interviewed, 21 could not be located because their addresses were incomplete or inaccurate. O n e patient died since his vasectomy.
Int J Gynaecol Obstet 17
12
Khan et al
Case control clients from each village were matched by age, wife's age, number of living children, n u m b e r of living male children, education, occupation a n d age of the youngest living child. They differed in landholdings. While only between 13% (Shibpur) a n d 18% (Shalna) of the vasectomy clients owned the land they farmed, 55% of the controls owned land.
RESULTS Nineteen percent of the Shibpur clients and 34.1% of the Shalna clients were 40 years or younger. Their mean ages were 48.6 years a n d 46.3 years, respectively. However, more than 70% of the Shibpur a n d 74% of the Shalna clients' wives were 40 years or younger. T h e wives' mean ages were 39.5 years and 36.4 years, respectively. At vasectomy, the mean numbers of living children reported by the Shibpur and Shalna clients were 4.1 and 4.8, respectively. T h e mean numbers of living male children were 2.5 a n d 2.4, respectively. At follow-up a year later, 40% of the clients h a d five or more living children. Ten Shibpur clients a n d one Shalna client reported that they had no living children at follow-up, although they all reported at least one living child at vasectomy. At follow-up, the mean ages of the youngest child were 9.5 years for the Shibpur clients and 6.4 years for the Shalna clients. T h e majority of the clients in both Shibpur and Shalna h a d no formal education (mean years of education = 1.0 and 1.6, respectively). More than 60% worked as agricultural or unskilled laborers, a n d less than 10% were skilled laborers (9.7% and 5.3%, respectively) or employed in business or service (4.9% and 6.9%, respectively). About 10% of each group was unemployed. Between 3% (Shalna) a n d 7% (Shibpur) of the clients a n d / o r their wives used contraception before vasectomy. By comparison, 16% of the matched case controls or their wives had previously used contraception, although only 9% were using some type of contraception at follow-up. Oral contraceptives were the most frequently used method among previous and current users. Less than 10% of the clients indicated they felt coerced into having the vasectomy or were unaware that vasectomy was a permanent means of contraception. While 31.57o (Shalna) to 49.3% (Shibpur) of the vasectomy acceptors said they wanted a permanent contraceptive, 39.8% (Shibpur) to 59.6% (Shalna) said the financial incentive was their primary reason for selecting vasectomy rather than another method of contraception. While the major-
IntJ Gynaecol Obstet 17
ity of Shalna patients said they were self-motivated (50.2%), three quarters of the Shibpur clients were recruited by "agents," police or councilmen. T h e "agents" were motivators who recruited vasectomy acceptors for a share of the incentive money paid to clients. T h e frequency of dissatisfaction a m o n g the clients brought in by "agents" was 89%, while among the clients motivated by other individuals— councilmen, family planning workers, relatives a n d neighbors—the frequency of dissatisfaction varied from 30% to 50%. Although 86.5% (Shibpur) to 92.5% (Shalna) of the vasectomy clients said they did not want additional children, only 60.0% of the matched control clients did not want more children. Twenty-eight percent of the controls wanted at least 1-2 more children, although the mean number of living children for the controls was 4 (essentially the same as for the vasectomy acceptors). Forty-three percent of the Shibpur clients and 47% of the Shalna clients stated that they used the condoms given to them after surgery; 45% and 48%, respectively, took the condoms but did not use them (no specific reasons for nonuse were given). Less than 1% refused the condoms offered to them. T h e majority from both centers said that they experienced slight or moderate pain. Postoperative swelling was most frequently stated as the primary immediate postoperative complication. Only 5% of the Shibpur clients and 2% of the Shalna clients recalled having an infection after surgery. Almost half of the Shibpur and Shalna clients (45.4% and 49.1%, respectively) were dissatisfied about having the vasectomy. T h e most frequent primary reasons for client dissatisfaction in Shibpur were: (a) that vasectomy decreased ability to work (19.7%) and (b) that the clients did not get all of the incentives that they had expected (10.9%). More dissatisfied Shalna clients cited the second complaint (24.9%) than the first complaint (14.6%) as primary reasons for their dissatisfaction. T h e majority of satisfied Shibpur a n d Shalna clients said that they were satisfied with the vasectomy because they wanted effective birth control. A small proportion expressed a good opinion about vasectomy as a method of contraception. About three quarters of the Shibpur clients and 84% of the Shalna clients discussed the procedure with other men. Thirty percent of the Shibpur clients recommended vasectomy to at least one other man. Of these clients, 48% said that that person actually had the vasectomy done. Twenty-two percent of the Shalna clients recommended vasectomy to at least one other man. Of these, 5 1 % had a vasectomy. T h e majority of the clients had no child deaths
Follow-up of vasectomy clients
after vasectomy; however, of the 9% in Shibpur who had children die after vasectomy, 2% had lost two or more children. Three percent of the Shibpur clients' wives had a pregnancy termination after vasectomy compared to 2% in Shalna. In all cases, conception occurred before vasectomy or less than four months after surgery.
DISCUSSION T h e high mean ages of the clients and their wives limit the effectiveness in averting births expected from vasectomy. T h e total fertility rate in Bangladesh is 6.0, while the mean numbers of living children were 4.1 and 4.8 for Shibpur and Shalna, respectively. Thus, one could project at best that 12 births were averted per couple when the husband was vasectomized. This is, however, an optimistic projection considering the high mean ages of the wives (40 years in Shibpur and 36 years in Shalna). Thirty-three percent of the men in the study had been married more than once. Thirty percent of the matched controls interviewed had also been married more than once. T h e effects of vasectomy on births averted may be greater than anticipated given this frequency of remarriage and the likelihood of remarriage to a younger woman. T h e use of incentives may attract clients who are really not ready to terminate childbearing. Financial incentives may also attract some of the most destitute members of society to have a vasectomy. Such individuals may have more general health problems, problems with sexual performance and marital difficulties. Studies which evaluated the psychological responses related to vasectomy have shown a higher incidence of adverse effects among men with some underlying pathology before the procedure (3, 6, 7, 11). T h e small percentage (18%) of clients who said that they considered themselves the most influential in their decision to have the vasectomy may indicate that coercion was used to recruit them. This response may also be influenced by the negative peer pressure experienced by the clients. Although 75%-84% of the clients discussed their vasectomies with other men, the majority of the clients said that few men approved of the vasectomy. Since so little positive reinforcement was given by the clients' peers, the likelihood of the clients regretting the procedure would increase. Furthermore, the clients may also be less willing to admit that they made the decision themselves. In addition, some of the complaints such as "decreased sexual capacity," "weakness" and "decreased ability to work," which have no physiologic basis, may also be greater with negative peer
13
pressure. Only 5%-8% of the clients considered vasectomy a good method of contraception, a n d only 22%-30% of the clients suggested vasectomy to another man. T h e majority h a d not recommended vasectomy to anyone. T h e negative consequences of the improper use of incentives is apparent from the following two cases. O n e unmarried 18 year old said that he was 26 and had three children when he heard that "money was given for getting an injection at the c a m p . " Another married 24 year old with no children stated that he had two children "to get money for an injection." T h e second most frequent reason for client dissatisfaction was that clients did not receive the incentives promised them. This does not indicate that the "incentive" is detrimental. T h e incentive was intended to compensate the patients for their travel to the clinic and time lost from their work activities. However, problems arose in cases where misinformation about incentives was given to the clients by the recruiters. T h e most frequent complaints a m o n g the Shibpur clients, " a decreased ability to work" a n d sexual "weakness," were not very well specified; 58% of the matched case control clients also said that their ability to work had decreased over the past year a n d 55% of these controls said that they h a d become sexually weaker in the last year (4% had no sexual relations within the last 1-3 years). Forty-seven percent of the control clients had not heard of any adverse effects associated with vasectomy; however, 44.1% had heard vasectomy decreased one's ability to work. Although 7%-9% of the clients h a d one or more of their children die after vasectomy, none of the clients gave this as a reason for dissatisfaction with vasectomy. This finding is quite different from the results in our follow-up studies of tubectomy clients in Bangladesh. Although less than 5% of the tubectomy clients said that they regretted having the procedure, almost all who regretted the tubectomy did so because one or more of their children h a d died after tubectomy (8). Most of the satisfied clients wanted a method of birth control. Approximately equal percentages of clients gave such varied reasons as simply being indifferent, being thankful there h a d been no complications after surgery or attributing their recovery from an illness to the vasectomy.
ACKNOWLEDGMENT A special thanks is given to the Statistics Branch of the Cholera Research Laboratory in Dacca, especially the programming services of M r S. R a h -
IntJ Gynaecol Obstet 17
14
Khan et al
m a n . T h e conscientious interviewing a n d coding of the following field staff is acknowledged: Sunil C h a n d r a Saha, N u r M o h a m m a d Bhuyan, Narayan Bhowmick, J a h a r Lai Barua a n d Yusuf Chowdhury. T h i s work was supported in part by t h e International Fertility Research Program a n d the Office of Population, U n i t e d States Agency for International Development (AID/pha-C-1172).
REFERENCES 1. Burnight RG: Male sterilization in Thailand: a follow-up study. J Biosoc Sci 7:377, 1975. 2. Chowdhury AD: Demographic and socio-economic study of mass vasectomy. J Indian Med Assoc 64(4):\06, 1975. 3. Goldberg R, Goldsmith A, Echeverría G: Vasectomy as a contraceptive choice in Latin America. Adv Plann Parent 9(1):49, 1974. 4. Leader AJ, Axelrad SD, Mumford SD: Modern eligibility criteria for vasectomy in the United States. J Urol 115:689, 1976. 5. Leavesley J H : Psychological effects and pre-operative counseling. Aust Fam Physician 5(2): 142, 1976.
IntJ Gynaecol Obstet 17
6. Sharma BP: Observation upon patients following vasectomy in Nepal. South Med J 63:771, 1970. 7. Squires JW, Barb MW, Pinch LW: The morbidity of vasectomy. Surg Gynecol Obstet 143:231, 1976. 8. Swenson IE, Khan AR, Jahan FA: A follow-up of tubectomy clients in Kaliakair, Dacca and Kustia, Bangladesh. Report No 11. The Johns Hopkins Fertility Research Project, Dacca, Bangladesh, June 1977. 9. Wiest WM, Janke LD: A methodological critique of research on psychological effects of vasectomy. Psychosom Med 36(5)A38, 1974. 10. Wolfers D, Wolfers H: Vasectomy and Vasectomania, p 82. Mayflower Books Ltd. Frogmore, St Albans, Herts, AL2 2NF, 1974. 11. Wolfers H: Psychological aspects of vasectomy. Br Med J ¿•297, 1970. 12. Wortman J: Vasectomy—what are the problems? Population Reports Series D, No 2, January 1975.
Address for reprints: Ingrid Swenson 4604 Blanchard Dr Durham, NC 27709 USA
