Population Matters-USA – working for a sustainable world

**BRAZIL–**From: Policies for expanding family planning coverage: Lessons from five successful countries. Hellwig et al., 2024.

The Cairo Conference “Programme of Action” includes a statement that all people should have the right to decide freely and responsibly the number and spacing of their children. Unhappily, many people have been forced to follow the old adage “the rich get richer and the poor get children”.

Fortunately, this adage has been disproven in at least 5 countries where voluntary Family Planning (FP) has been made accessible to all, with little regard to income. Brazil, Ecuador, Egypt, Ethiopia and Rwanda were chosen for study because they represent different societies on different continents. 196 policies affecting the availability of FP services were identified in these countries from 1961 to the present, and the effect was described in a 2024 analysis. The progress in the availability of high-quality FP is amazing in all five of these countries!

The genocide in Rwanda was 30 years ago. Hunger was a factor that led to neighbors killing neighbors. People in many places in this largely agrarian society were not able to produce enough food to keep away hunger. Contributing factors included land degradation and rapid population growth; there was no violence in areas where people had at least 1500 calories of food per day. The average American eats almost twice that amount!

Back in the year 2000, few low-income people in Rwanda had access to modern FP. The country was largely Roman Catholic, which forbad modern FP and relied heavily on unreliable rhythm for birth spacing. Then, in 2005, the government started supporting a more effective method of natural FP, the Standard Days Method (SDM). The Church approved of SDM and it became popular. It is simple and is up to 95% effective—if used properly. Only 5 years after its introduction, the proportion of the poorest couples using effective contraception had risen to half!

The year 2005 also marked a presentation that changed attitudes in the Rwandan Parliament. The RAPID Model is a computer-based tool that stakeholders can use to demonstrate the effect of rapid population growth on different sectors, and the benefits of FP programs. The model demonstrated how FP can reduce mortality, improve health and increase the availability of women in the workforce. Rwanda has taken advantage of that benefit: almost 2/3 of members of parliament are women—the highest percentage of any country! RAPID also showed the economic benefits of FP—for every dollar spent on contraception, the government would save four. To quote a minister of health, “family planning is a tool of development.”

Since the five countries have different conditions and customs, each approached the need to slow population growth with different policies. For instance, the literacy rate is low in rural Egypt, so they used TV to get across FP messages. Ethiopia established primary health care for all—including contraception. Brazil focused on preventing adolescent pregnancies by improving sexuality education and facilitating access to FP for teens. In 2008 a change in Ecuador’s constitution named health care as a right, and ensured that women could make their own decisions about FP. Rwandan policies have already been discussed. It is remarkable that all 5 countries established policies that increased use of effective FP—and in 3 of the countries, there is equity between rich and poor in their use of FP.

Although each of these countries has its own policies and areas of focus, they all received help from the US government and from other rich countries. Nongovernmental agencies, such as the Gates Foundation, also provided expertise and resources. It is wonderful that all 5 of these countries did what they could to make family planning services available to all.

I was walking down the street in Mountain View, California when I noticed a man coming toward me wearing a white T-shirt with small black lettering: “SEEDLESS”. I wonder if he was advertising his vasectomy?

Vasectomy motivators in Northern Sumatra use humor in their presentations to men about vasectomy. Perhaps they should wear shirts with “KESIP” (Indonesian for “seedless”) on them! From what I can tell, these motivators need all the help they can get, since very few men get vasectomies in Indonesia. However, Indonesian husbands tend to be quite supportive of their wives’ contraceptive choices, even if very few men actually use a male method of birth control.

Indonesia is a mixture of more than a thousand ethnic groups speaking over 700 languages, living on over 6000 large and small islands. Fortunately, they are united by a single official language, although most Indonesians are multilingual. The motto of their National Family Planning Program is: “Realizing Quality Families”.

The country has supported family planning for decades. When we visited Bali (another Indonesian island) in 1996, we learned about banjars—the community organizations for a small village or neighborhood. The banjar serves perhaps 1,000 people, and helps its members through thick and thin. Banjar members organize religious ceremonies, dances, weddings and funerals. I was surprised to learn that each banjar also keeps track of every family’s fertility plan; the husband registers if his wife is trying to conceive, is pregnant or if they are using contraception. Although this would be considered an invasion of privacy in the USA, Balinese society does not have a problem with this openness.

The fertility rate in Bali is a bit above replacement, but is similar to the average for Indonesia. Sumatrans, on the other hand, tend to have larger families, averaging 2.5 children per woman. This is where vasectomy could really be helpful!

Only a tiny number of men in Indonesia have had vasectomies—just 3 per 1000 men. The vasectomy peak in that country was 30 years ago, with double that number. Unfortunately, this is true globally; the number of vasectomies has declined rather than increased. I am proud that the USA is one of two countries bucking that trend; the other is South Korea.

I know of two heroes who are working to change this trend—in addition to the vasectomy motivators in Sumatra. One is Dr. Charles Ochieng, whom I met at an international family planning meeting. He performs vasectomies, using the latest techniques, in his native Kenya. Another hero is Dr. Doug Stein, one of the co-founders of World Vasectomy Day (WVD). Trained as a urologist, Stein has limited his practice to male sterilization procedures. Each year he travels to a different country to train doctors there, and together they do a bunch of procedures—on WVD. This year it will be Zambia, November 24^th. WVD is not just a day—in fact, they have 9 events scheduled in Zambia, all relating to vasectomy!

When I was practicing and a patient expressed an interest in being sterilized, I would suggest that vasectomy for her partner was safer and less expensive. I just read another, unfortunate statistic: 1 in 12 women will become pregnant within a decade after tubal ligation. To make things worse, many of these pregnancies will be in a Fallopian tube. A tubal pregnancy can cause serious—even fatal—bleeding.

I am happy that WVD, Dr. Ochieng and the vasectomy motivators in Sumatra are all promoting vasectomy. They are helping put the responsibility for family planning where more of it belongs—with men.