- Email: [email protected]
Attitude of men in Nigeria to vasectomy
International Health (2009) 1, 169—172
available at www.sciencedirect.com
journal homepage: http://www.elsevier.com/locate/inhe
Attitude of men in Nigeria to vasectomy Hyginus Uzo Ezegwui ∗, Jamike Osondu Enwereji Sexual/Reproductive Health Unit, Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria Received 11 May 2009; received in revised form 18 June 2009; accepted 7 August 2009
KEYWORDS Vasectomy; Attitude; Knowledge; Men; Developing country; Nigeria
Summary The objective of this study was to assess the attitude of men in Nigeria towards vasectomy as a method of family planning. This was a cross-sectional study, using self-administered pre-tested questionnaires containing mainly close-ended questions. The questionnaires were given to 146 randomly selected men. The responses were analyzed with descriptive statistics. Ten (6.8%) may accept vasectomy with the knowledge they have while 130 (89.0%) will not. Eighty-eight (67.7%) believe sterilization procedures should be left for women only. Vasectomy was viewed as castration by 55 (40.7%). Forty-three (31.2%) may consider vasectomy if they understand that it is not associated with problems, 82 (59.4%) refused while 13 (9.4%) did not know if they would ever accept the procedure. There was a lack of knowledge of vasectomy and attitudes towards it were based on myths and misconceptions regarding the procedure; some may accept it if they understand the safety of it. Interestingly, level of education does not improve vasectomy uptake. A concerted effort to involve men in reproductive health is needed. Interpersonal communication and counseling will greatly improve vasectomy uptake in developing countries. © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
1. Introduction Vasectomy, or vas occlusion, is considered to be the most effective form of contraception and it remains very popular in many developed and developing countries.1 About 100 000 men in the UK, and 500 000 men in the USA, undergo the procedure each year.1,2 It is also common in New Zealand, South Korea, China and Nepal.3 In Nigeria, a developing country, the incidence is not known and the procedure is unpopular. In a retrospective review of vasectomies in Jos, Nigeria only 10 were done over a period of 16 years compared to
∗
Corresponding author. Tel.: +2348054040675. E-mail address: [email protected] (H.U. Ezegwui).
3675 tubal ligations performed over the same period. This gives an incidence rate of 0.3%.4 It has been found that some healthcare providers are prejudiced against vasectomies because of lingering misconceptions about the method’s effect on health and sexual function, and hence underestimate the demands of men for vasectomy.5 Research has shown that if men are to take a greater responsibility for family planning, they must be offered the means with which to regulate their fertility in a safe, effective, reversible/irreversible and acceptable way.6 For the man who wants no more children, vasectomy offers several benefits: effectiveness, a quick and simple procedure, permanent protection, convenience, a low risk of complications, no long-term effect on his own health or sexual performance and no health risks for his wife.3
1876-3413/$ — see front matter © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.inhe.2009.08.007
170 Despite these advantages, vasectomy remains unpopular in many developing countries, because in a male-dominant society men are not supposed to take an active part in fertility regulation. Vasectomy is confused with castration and wrongly associated with loss of libido, lack of erection, decreased sexual ability, loss of vitality, changes in physical characteristics such as hair loss and voice change and even changes in personality.7 Refusal of vasectomy has been attributed to religious reasons plus fear of chronic weight gain, abdominal pain, accumulation of semen in the body and infertility in the after-life.8 Fears concerning the safety of the procedure have also been expressed. This study was undertaken to assess the attitude of men to vasectomy in Nigeria.
2. Materials and methods 2.1. Study Population The study was conducted at the University of Nigeria Teaching Hospital, Enugu, Nigeria; a tertiary health institution that serves as a major referral centre for many states in eastern Nigeria. The study was conducted from January 2007 to June 2007 on 146 men who attended the General Outpatient Department and those that accompanied their wives to the family planning clinic and labour room. Informed consent was obtained from the participants.
2.2. Data Collection A table of random numbers was used in selecting the respondents who were sampled using simple random sampling. Data was collected through a self-administered questionnaire that contained 32 close-ended questions. The questions included socio-demographic characteristics such as income, number of children, number of male children and past use of contraceptive methods. Other factors enquired about included leaving permanent contraception for women only and whether they would like to have a vasectomy if they had completed their families. These were followed by questions on the meaning of vasectomy, general attitude to vasectomy including rumours, myths and misconceptions. They were then asked about the drawbacks of vasectomy. Finally, they were asked whether if they understood that their conceptions about vasectomy were wrong they would like to have the procedure and who they would like to take the decision.
2.3. Data Analysis The answers were analyzed using frequency tables, percentages and cross-tabulations of demographic factors with rejection of vasectomy using different versions of 2 test. Analysis was done with SPSS software version 10.0 (SPSS, Chicago, IL, USA). In all statistical tests, the level of significance was P ≤ 0.05.
3. Results The respondents consisted of 35 artisans (24.0%), 30 civil servants (20.6%), 36 skilled workers (24.7%), 18 military men
H.U. Ezegwui, J.O. Enwereji Table 1
Socio-demographic characteristics of respondents
Characteristic
Frequency (%)
Age (years) ≤30 31—40 41—50
16 30 100
(11) (20) (69)
No. of living children 0 1—4 ≥5
5 85 56
(4) (58) (38)
No. of male children 0 1—4 ≥5
19 123 4
(13) (84) (3)
Level of education None Primary Secondary Post secondary
2 23 35 86
(1) (16) (24) (59)
Marital status Single Married Divorced/separated
9 133 4
(6) (91) (3)
Average monthly income (Naira) <20 000 28 20 000—49 999 46 50 000—99 999 39 ≥100 000 33
(19) (31) (27) (23)
Religion Christian Islam Pagan
(98) (1) (1)
142 2 2
(12.3%), 18 secretarial workers (12.3%), 7 farmers (4.7%), 1 health worker (0.7%) and 1 traditional ruler (0.7%). Table 1 shows the socio-demographic characteristics of the respondents. The majority were aged between 41 and 50 years, are married, have between one and four children and have post secondary education. The level of education does not significantly affect vasectomy uptake. One hundred and eighteen (80.8%) earn about $200 monthly and 142 (97.3%) are Christians. Sixty-four (43.8%) have difficulty maintaining their children and 87 (59.6%) had used some form of contraception in the past. Methods of contraception used are shown in Table 2. Only 3 (2.1%) of the respondents had wives who had undergone tubal ligation. When asked whether they would like to have vasectomy if they had completed their families only 10 (6.8%) answered in the affirmative while 130 (89.0%) declined. Forty-two (28.8%) of the respondents thought that sterilization procedures should be left for women since they were the ones that bear children. When cross-tabulations were done using all the sociodemographic factors against refusal of vasectomy, there were virtually no associations.
Attitude of men in Nigeria to vasectomy
171
Table 2 Current contraceptive methods used by respondents and their spouses Methoda
Current usage
Male condom Penile withdrawal Abstinence Bilateral tubal ligation Intrauterine contraceptive device Medroxy progesterone acetate injection Other (not specified)
59 49 54 3 15 10 6
a
Many of the respondents used more than one method.
Table 3 Cross-tabulation of educational status versus liking for vasectomy among respondents Level of education
None Primary Secondary Tertiary Total
Like vasectomy No
Yes
4 21 31 81 137
1 2 3 3 9
Total
5 23 34 84 186
Vasectomy was viewed as castration by 55 (37.7%) while 38 (26.0%) did not know what it meant. Fifty-eight (53.7%) of the 108 respondents who ‘knew’ what vasectomy meant associated it with a lot of risks like inability to urinate, change in personality, accumulation of semen in the body, loss of libido, loss of hair on the body, weight loss or weight gain. Other perceived problems included infertility after reincarnation and abdominal pain. Seventy-eight (53.4%) respondents believed that vasectomised men would regret it in the future. Reasons for regret included: unsatisfactory sex life, death of spouse and spouse promiscuity, unexpected childlessness and re-marriage. When asked whether they would like to undergo the procedure in future when they understood that vasectomy was not associated with their previously mentioned problems, 82 (56.2%) responded negatively, 43 (29.5%) said they may consider it and 21(14.38%) did not know if they would ever accept it. Of the 43 who may consider vasectomy, 30 (70%) of them would like to take the decision together with their wives, 10 (23%) would like the health worker to take the decision for them, while 3 (7%) would like to take the decision alone. Interestingly, increase in educational attainment does not lead to increase in vasectomy acceptance (Table 3).
rounding vasectomy, especially castration. Many may reject the procedure even after completing their families. Some believed sterilization procedures are for women only. Lack of reversibility of the procedure further drives them away from vasectomy. Since 29.5% of the respondents may choose vasectomy if they understood the procedure to be safe, this calls for co-ordinated programmes to educate the public and to provide information on vasectomy. This will aim to refute the myths and misconceptions of vasectomy, explain the side effects properly and show the advantages of vasectomy over tubal ligation. Vasectomy services should be made available in all family planning clinics. Dissatisfaction with previously used methods, spousal influence, vasectomised men and economic hardship may facilitate acceptance of the procedure. Most of the problems have been overcome in the Philipines, Tanzania and Ghana through the ACQUIRE project by USAID. Vasectomy is now increasingly accepted by men in these countries.9,10 In these areas, a sustainable strategy is being developed to increase awareness and availability of vasectomy services to clients. Male healthcare providers are mainly used. It has been suggested that vasectomy is unacceptable to most Africans and will probably remain so,11 however, similar predictions were made in 1980s concerning tubal ligation, yet today the reverse is the case.12 Attitudes towards vasectomy will likely follow the same way. This is being seen in the gradual success achieved in Tanzania and Ghana by the ACQUIRE Project/Engender Health. It is concluded that acceptance of vasectomy by men in developing countries will rise if more attention is paid to interpersonal communications and counseling. Interestingly education does not enhance vasectomy uptake. Clinical service providers in developing countries should be trained on the vasectomy procedure. Vasectomy must be included in counseling clients that attend family planning clinics. Authors’ contributions: EHU conceived the study; EJO administered the questionnaire and collated the data; EHU and EHO designed the study; analysed and interpreted the data, drafted and revised the paper and read and approved the final manuscript. EHU is guarantor of the paper. Funding: None. Conflict of interest: None declared. Ethical approval: Ethical Committee of the University of Nigeria Teaching Hospital, Enugu, Nigeria.
References 4. Discussion Despite the fact that most respondents had a relatively good level of education, had male and female children, an acceptable monthly income, knew about vasectomy, had used one form of contraception in the past and had problems maintaining their family there appears to be poor knowledge of the true meaning of vasectomy, hence its rejection. Many of the respondents believed the myths and misconceptions sur-
1. Boardman A. The Puerperium. In: Ling FW, Duff P, editors. Obstetrics and Gynaecology—Principles for Practice. New York: McGraw Hill Medical Publishing Division; 2000. p. 545—71. 2. Kevin T, Simon W, Lewis JDI, Kingsland CR. Surgical options in the treatment of male infertility. In: Studd J, editor. Progress in Obstetrics and Gynaecology, 15. London: Churchill Livingstone; 2005. p. 354—7. 3. Shaista J, Shabana A, Muhammed AR, Haroon RC. Psychological factors and male sterilization. Pak J Med Sci 2006;22:277—81.
172 4. Mutihir J, Ujah IAO, Ekwempu C, Daru PH, Aisien OA. Acceptability of vasectomy in Jos, Northern Nigeria. Trop J Obstet Gynaecol 2004;21:56—7. 5. Were EO, Karanja JK. Attitudes of males to contraception in Kenya rural population. East Afr Med J 1994;71:106—9. 6. Liskin L, Pile JM, Quillan WF. Vasectomy—Safe and Simple. Population Reports Series D. No. 4. Baltimore: Johns Hopkins University, Population Information Programme; 1983. 7. Aguilar EJ. Voluntary vasectomy: rethinking Pagkalalaki among married Capuano. Cebu City: Sociology and Anthropology Research Group (SOAR Group). University of San Carlos; 2005. 8. Otolorin EO, Falase EA, Olayinka IA, Oladipo OA. Attitudes of Nigerians to voluntary sterilization—a survey of an urban population. Trop J Obset Gynaecol 1990;(Special edition):18—21.
H.U. Ezegwui, J.O. Enwereji 9. The ACQUIRE Project. ‘Get a Permanent Smile’—Increasing awareness of, access to, and utilization of vasectomy services in Ghana. New York: The ACQUIRE Project and EngenderHealth; 2005. 10. Frajzyngier V, Bunce A, Searing H, Riwa P, Guest G, Pile J. Factors affecting vasectomy acceptability in the Kigoma region of Tanzania. New York. The ACQUIRE Project/EngenderHealth 2006;5:1—28. E & R Study. 11. Caldwell JC, Caldwell P. The cultural context of high fertility in sub-Saharan Africa. Popul Dev Rev 1987;13: 409—37. 12. Dwyer JC, Haws JM. Is permanent contraception acceptable in Sub-Saharan Africa? Stud Fam Plann 1990;21: 322—6.
available at www.sciencedirect.com
journal homepage: http://www.elsevier.com/locate/inhe
Attitude of men in Nigeria to vasectomy Hyginus Uzo Ezegwui ∗, Jamike Osondu Enwereji Sexual/Reproductive Health Unit, Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria Received 11 May 2009; received in revised form 18 June 2009; accepted 7 August 2009
KEYWORDS Vasectomy; Attitude; Knowledge; Men; Developing country; Nigeria
Summary The objective of this study was to assess the attitude of men in Nigeria towards vasectomy as a method of family planning. This was a cross-sectional study, using self-administered pre-tested questionnaires containing mainly close-ended questions. The questionnaires were given to 146 randomly selected men. The responses were analyzed with descriptive statistics. Ten (6.8%) may accept vasectomy with the knowledge they have while 130 (89.0%) will not. Eighty-eight (67.7%) believe sterilization procedures should be left for women only. Vasectomy was viewed as castration by 55 (40.7%). Forty-three (31.2%) may consider vasectomy if they understand that it is not associated with problems, 82 (59.4%) refused while 13 (9.4%) did not know if they would ever accept the procedure. There was a lack of knowledge of vasectomy and attitudes towards it were based on myths and misconceptions regarding the procedure; some may accept it if they understand the safety of it. Interestingly, level of education does not improve vasectomy uptake. A concerted effort to involve men in reproductive health is needed. Interpersonal communication and counseling will greatly improve vasectomy uptake in developing countries. © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
1. Introduction Vasectomy, or vas occlusion, is considered to be the most effective form of contraception and it remains very popular in many developed and developing countries.1 About 100 000 men in the UK, and 500 000 men in the USA, undergo the procedure each year.1,2 It is also common in New Zealand, South Korea, China and Nepal.3 In Nigeria, a developing country, the incidence is not known and the procedure is unpopular. In a retrospective review of vasectomies in Jos, Nigeria only 10 were done over a period of 16 years compared to
∗
Corresponding author. Tel.: +2348054040675. E-mail address: [email protected] (H.U. Ezegwui).
3675 tubal ligations performed over the same period. This gives an incidence rate of 0.3%.4 It has been found that some healthcare providers are prejudiced against vasectomies because of lingering misconceptions about the method’s effect on health and sexual function, and hence underestimate the demands of men for vasectomy.5 Research has shown that if men are to take a greater responsibility for family planning, they must be offered the means with which to regulate their fertility in a safe, effective, reversible/irreversible and acceptable way.6 For the man who wants no more children, vasectomy offers several benefits: effectiveness, a quick and simple procedure, permanent protection, convenience, a low risk of complications, no long-term effect on his own health or sexual performance and no health risks for his wife.3
1876-3413/$ — see front matter © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.inhe.2009.08.007
170 Despite these advantages, vasectomy remains unpopular in many developing countries, because in a male-dominant society men are not supposed to take an active part in fertility regulation. Vasectomy is confused with castration and wrongly associated with loss of libido, lack of erection, decreased sexual ability, loss of vitality, changes in physical characteristics such as hair loss and voice change and even changes in personality.7 Refusal of vasectomy has been attributed to religious reasons plus fear of chronic weight gain, abdominal pain, accumulation of semen in the body and infertility in the after-life.8 Fears concerning the safety of the procedure have also been expressed. This study was undertaken to assess the attitude of men to vasectomy in Nigeria.
2. Materials and methods 2.1. Study Population The study was conducted at the University of Nigeria Teaching Hospital, Enugu, Nigeria; a tertiary health institution that serves as a major referral centre for many states in eastern Nigeria. The study was conducted from January 2007 to June 2007 on 146 men who attended the General Outpatient Department and those that accompanied their wives to the family planning clinic and labour room. Informed consent was obtained from the participants.
2.2. Data Collection A table of random numbers was used in selecting the respondents who were sampled using simple random sampling. Data was collected through a self-administered questionnaire that contained 32 close-ended questions. The questions included socio-demographic characteristics such as income, number of children, number of male children and past use of contraceptive methods. Other factors enquired about included leaving permanent contraception for women only and whether they would like to have a vasectomy if they had completed their families. These were followed by questions on the meaning of vasectomy, general attitude to vasectomy including rumours, myths and misconceptions. They were then asked about the drawbacks of vasectomy. Finally, they were asked whether if they understood that their conceptions about vasectomy were wrong they would like to have the procedure and who they would like to take the decision.
2.3. Data Analysis The answers were analyzed using frequency tables, percentages and cross-tabulations of demographic factors with rejection of vasectomy using different versions of 2 test. Analysis was done with SPSS software version 10.0 (SPSS, Chicago, IL, USA). In all statistical tests, the level of significance was P ≤ 0.05.
3. Results The respondents consisted of 35 artisans (24.0%), 30 civil servants (20.6%), 36 skilled workers (24.7%), 18 military men
H.U. Ezegwui, J.O. Enwereji Table 1
Socio-demographic characteristics of respondents
Characteristic
Frequency (%)
Age (years) ≤30 31—40 41—50
16 30 100
(11) (20) (69)
No. of living children 0 1—4 ≥5
5 85 56
(4) (58) (38)
No. of male children 0 1—4 ≥5
19 123 4
(13) (84) (3)
Level of education None Primary Secondary Post secondary
2 23 35 86
(1) (16) (24) (59)
Marital status Single Married Divorced/separated
9 133 4
(6) (91) (3)
Average monthly income (Naira) <20 000 28 20 000—49 999 46 50 000—99 999 39 ≥100 000 33
(19) (31) (27) (23)
Religion Christian Islam Pagan
(98) (1) (1)
142 2 2
(12.3%), 18 secretarial workers (12.3%), 7 farmers (4.7%), 1 health worker (0.7%) and 1 traditional ruler (0.7%). Table 1 shows the socio-demographic characteristics of the respondents. The majority were aged between 41 and 50 years, are married, have between one and four children and have post secondary education. The level of education does not significantly affect vasectomy uptake. One hundred and eighteen (80.8%) earn about $200 monthly and 142 (97.3%) are Christians. Sixty-four (43.8%) have difficulty maintaining their children and 87 (59.6%) had used some form of contraception in the past. Methods of contraception used are shown in Table 2. Only 3 (2.1%) of the respondents had wives who had undergone tubal ligation. When asked whether they would like to have vasectomy if they had completed their families only 10 (6.8%) answered in the affirmative while 130 (89.0%) declined. Forty-two (28.8%) of the respondents thought that sterilization procedures should be left for women since they were the ones that bear children. When cross-tabulations were done using all the sociodemographic factors against refusal of vasectomy, there were virtually no associations.
Attitude of men in Nigeria to vasectomy
171
Table 2 Current contraceptive methods used by respondents and their spouses Methoda
Current usage
Male condom Penile withdrawal Abstinence Bilateral tubal ligation Intrauterine contraceptive device Medroxy progesterone acetate injection Other (not specified)
59 49 54 3 15 10 6
a
Many of the respondents used more than one method.
Table 3 Cross-tabulation of educational status versus liking for vasectomy among respondents Level of education
None Primary Secondary Tertiary Total
Like vasectomy No
Yes
4 21 31 81 137
1 2 3 3 9
Total
5 23 34 84 186
Vasectomy was viewed as castration by 55 (37.7%) while 38 (26.0%) did not know what it meant. Fifty-eight (53.7%) of the 108 respondents who ‘knew’ what vasectomy meant associated it with a lot of risks like inability to urinate, change in personality, accumulation of semen in the body, loss of libido, loss of hair on the body, weight loss or weight gain. Other perceived problems included infertility after reincarnation and abdominal pain. Seventy-eight (53.4%) respondents believed that vasectomised men would regret it in the future. Reasons for regret included: unsatisfactory sex life, death of spouse and spouse promiscuity, unexpected childlessness and re-marriage. When asked whether they would like to undergo the procedure in future when they understood that vasectomy was not associated with their previously mentioned problems, 82 (56.2%) responded negatively, 43 (29.5%) said they may consider it and 21(14.38%) did not know if they would ever accept it. Of the 43 who may consider vasectomy, 30 (70%) of them would like to take the decision together with their wives, 10 (23%) would like the health worker to take the decision for them, while 3 (7%) would like to take the decision alone. Interestingly, increase in educational attainment does not lead to increase in vasectomy acceptance (Table 3).
rounding vasectomy, especially castration. Many may reject the procedure even after completing their families. Some believed sterilization procedures are for women only. Lack of reversibility of the procedure further drives them away from vasectomy. Since 29.5% of the respondents may choose vasectomy if they understood the procedure to be safe, this calls for co-ordinated programmes to educate the public and to provide information on vasectomy. This will aim to refute the myths and misconceptions of vasectomy, explain the side effects properly and show the advantages of vasectomy over tubal ligation. Vasectomy services should be made available in all family planning clinics. Dissatisfaction with previously used methods, spousal influence, vasectomised men and economic hardship may facilitate acceptance of the procedure. Most of the problems have been overcome in the Philipines, Tanzania and Ghana through the ACQUIRE project by USAID. Vasectomy is now increasingly accepted by men in these countries.9,10 In these areas, a sustainable strategy is being developed to increase awareness and availability of vasectomy services to clients. Male healthcare providers are mainly used. It has been suggested that vasectomy is unacceptable to most Africans and will probably remain so,11 however, similar predictions were made in 1980s concerning tubal ligation, yet today the reverse is the case.12 Attitudes towards vasectomy will likely follow the same way. This is being seen in the gradual success achieved in Tanzania and Ghana by the ACQUIRE Project/Engender Health. It is concluded that acceptance of vasectomy by men in developing countries will rise if more attention is paid to interpersonal communications and counseling. Interestingly education does not enhance vasectomy uptake. Clinical service providers in developing countries should be trained on the vasectomy procedure. Vasectomy must be included in counseling clients that attend family planning clinics. Authors’ contributions: EHU conceived the study; EJO administered the questionnaire and collated the data; EHU and EHO designed the study; analysed and interpreted the data, drafted and revised the paper and read and approved the final manuscript. EHU is guarantor of the paper. Funding: None. Conflict of interest: None declared. Ethical approval: Ethical Committee of the University of Nigeria Teaching Hospital, Enugu, Nigeria.
References 4. Discussion Despite the fact that most respondents had a relatively good level of education, had male and female children, an acceptable monthly income, knew about vasectomy, had used one form of contraception in the past and had problems maintaining their family there appears to be poor knowledge of the true meaning of vasectomy, hence its rejection. Many of the respondents believed the myths and misconceptions sur-
1. Boardman A. The Puerperium. In: Ling FW, Duff P, editors. Obstetrics and Gynaecology—Principles for Practice. New York: McGraw Hill Medical Publishing Division; 2000. p. 545—71. 2. Kevin T, Simon W, Lewis JDI, Kingsland CR. Surgical options in the treatment of male infertility. In: Studd J, editor. Progress in Obstetrics and Gynaecology, 15. London: Churchill Livingstone; 2005. p. 354—7. 3. Shaista J, Shabana A, Muhammed AR, Haroon RC. Psychological factors and male sterilization. Pak J Med Sci 2006;22:277—81.
172 4. Mutihir J, Ujah IAO, Ekwempu C, Daru PH, Aisien OA. Acceptability of vasectomy in Jos, Northern Nigeria. Trop J Obstet Gynaecol 2004;21:56—7. 5. Were EO, Karanja JK. Attitudes of males to contraception in Kenya rural population. East Afr Med J 1994;71:106—9. 6. Liskin L, Pile JM, Quillan WF. Vasectomy—Safe and Simple. Population Reports Series D. No. 4. Baltimore: Johns Hopkins University, Population Information Programme; 1983. 7. Aguilar EJ. Voluntary vasectomy: rethinking Pagkalalaki among married Capuano. Cebu City: Sociology and Anthropology Research Group (SOAR Group). University of San Carlos; 2005. 8. Otolorin EO, Falase EA, Olayinka IA, Oladipo OA. Attitudes of Nigerians to voluntary sterilization—a survey of an urban population. Trop J Obset Gynaecol 1990;(Special edition):18—21.
H.U. Ezegwui, J.O. Enwereji 9. The ACQUIRE Project. ‘Get a Permanent Smile’—Increasing awareness of, access to, and utilization of vasectomy services in Ghana. New York: The ACQUIRE Project and EngenderHealth; 2005. 10. Frajzyngier V, Bunce A, Searing H, Riwa P, Guest G, Pile J. Factors affecting vasectomy acceptability in the Kigoma region of Tanzania. New York. The ACQUIRE Project/EngenderHealth 2006;5:1—28. E & R Study. 11. Caldwell JC, Caldwell P. The cultural context of high fertility in sub-Saharan Africa. Popul Dev Rev 1987;13: 409—37. 12. Dwyer JC, Haws JM. Is permanent contraception acceptable in Sub-Saharan Africa? Stud Fam Plann 1990;21: 322—6.