If Maternal and Child Health is Bad, Family Planning = Large Families

Would having a vasectomy make some men more likely to have unprotected sex? If they see contraception as just a protection against HIV (and perhaps other sexually transmitted infections), the vasectomy shouldn't, logically, result in a reduction in condom use. But I suspect it would be a good excuse for not using condoms.

If they see condom use and/or vasectomies as a means of reducing unplanned pregnancies, having a vactomy could well result in men having unprotected sex. They could see condoms having a dual purpose, but many HIV prevention and other types of health programs have made little effort to emphasize this dual purpose.

If male circumcision was also involved, how would that affect condom use? Of course, mass male circumcision campaigns do drone on about having to use condoms for circumcision to be effective. But I don't see many men getting circumcized if they don't think they can reduce their condom use, perhaps even dispense with them altogether.

If programs that aim at reducing heterosexual HIV transmission are combined with programs that aim at reducing a country's population, this could result in a very mixed message indeed. Who is going to undergo both circumcision and a vasectomy and still use condoms?

If circumcision in conjunction with condom use is intended to reduce sexual HIV transmission, this sort of program might best be kept separate from a program that aims purely at population control.

Besides, people who are not in a position to, or don't see themselves as being in a position to make family planning related choices that we in the Western world take for granted, may require a more subtle approach than 'offering' them vasectomies.

There must be a lot more to family planning than merely reducing the probability of conception in as many ways as possible. This smacks of the eugenicist subtext that seems to be hidden in much of the public health programs one hears about in developing countries.

Apparently Rwanda is combining its population growth program with its circumcision program, which is intended to reduce HIV transmission. Yet, the respective merits of each strategy, circumcision, condom use and vasectomies, are themselves matters for debate.

There is little doubt that correct and consistent use of condoms plays a large part in reducing unplanned pregnancy. But will people continue to use them if they think there is an alternative, or if they take care of unplanned pregnancy?

But it is far less clear that mass male circumcision has a significant impact on heterosexual HIV transmission outside of (relatively) carefully controlled trials. And even those trials only claim that circumcision reduces female to male transmission, which is a lot less common than male to female transmission, which it may even increase.

And a vasectomy may well reduce conception, perhaps even eliminate it completely. But the ethics of encouraging large numbers of people to have vasectomies, perhaps young men, should be considered carefully. And maybe those advocating the combination of all three should also look at the potential incompatibilities involved.

Programs designed to, or even programs that happen to reduce conception need to be accompanied by programs that aim to improve health services and even health education, nutrition, water and sanitation, working condititions, living conditions and everything else that make up the determinants of health.

Rwanda still has high infant, under five and maternal mortality. Life expectancy is low and most premature deaths are due to treatable and preventable conditions. Even HIV positive people tend to die of treatable and preventable conditions. Under such circumstances, the only viable form of family planning is to have big families.

Health programs that ignore the broader determinants of health will have little positive impact and may do a lot of damage. And the combined contraception/HIV reduction/vasectomy approach suggested for Rwanda sounds entirely unethical, as well as ineffective.