Voices of Mongolia.

PIP: Mongolia's rapid transformation in 1990 into a democratic, market economy republic, after 70 years of socialist rule, caused financial chaos from which the country is only recently recovering. Health care services deteriorated in the context of this economic crisis. The Mongolian Ministry of Health and Social Welfare and AVSC jointly sent teams of experts into four parts of the country in March 1998 to assess the quality and availability of reproductive health services. Three Mongolian doctors and the author visited Uvs aimag (province) as part of the assessment, where they interviewed potential reproductive health care clients and their providers about what they need and want from the health care system. Long distances and transportation problems reaching available health care providers, myths and traditional attitudes about contraceptives which limit their use, inadequate access to reproductive health services and information among men and women, the absence of anesthesia for use during abortions, inadequate STD prevention and control, and poor or lacking publicly provided reproductive health care for adolescents are among the major problems found to be currently plaguing the delivery of reproductive health care in Mongolia. The findings of this assessment will be used by the UN Population Fund to design and fund a program to improve services in Mongolia. That program will be implemented by the government and carried out by AVSC.^ieng

Family planning week in Ukraine.

PIP: More than 600 events, including disco dances, seminars, and training courses for health professionals, took place during National Family Planning Week, held throughout Ukraine this year from May 26 to June 1. The events were announced on the radio, television, and in newspapers in every region of the country. The following are among the events which took place during the week: physicians gave presents and contraceptives to mothers of newborn infants in maternity hospitals in Dnipropetrovsk; loudspeakers blared messages about family planning in the most crowded streets of Sevastopol, Crimea; family planning rooms and centers opened in 8 districts of Rivninska; and every region of the country held an official opening ceremony. Many of the events had a special focus upon youth, with more than 200 events for adolescents. For more than 6 months, a special multi-ministry coordinating committee worked closely with AVSC to make this first-time event a reality. Public awareness of family planning increased as a result of the Week. Ukraine's Ministry of Health is looking forward to holding the event again next year with or without the support of outside agencies.^ieng

Vasectomy in the United States, 1991.

OBJECTIVES: Recent conflicting findings on possible health risks related to vasectomy have underscored the need for reliable and representative estimates of numbers and rates of vasectomies in the United States. The purpose of this study was to estimate the annual US number, rate, and characteristics of vasectomies in 1991. METHODS: A national survey of urology, general surgery, and family practice physician practices was conducted with probability sampling methods (n = 1685 physicians). RESULTS: An estimated 493,487 (95% confidence interval = 450,480, 536,494) vasectomies were performed in 1991, for a rate of 10.3 procedures per 1000 men aged 25 through 49 years. Most vasectomies were performed by urologists, and most were done in physicians' offices with local anesthesia and ligation as the method of occlusion. The rate of vasectomies was highest in the Midwest. CONCLUSIONS: This survey provides the first national estimates of the number and rate of vasectomies in the United States, as well as the first estimates of occlusion method used. Results confirm previous findings that urologists perform most vasectomies and that most vasectomies are performed with local anesthesia. Recommendations include the monitoring of vasectomy numbers and rates as well as demographic studies of men obtaining vasectomies.

A patchwork of funding sources for Norplant users in the U.S.

PIP: Since the US Food and Drug Administration approved Norplant in December 1990, many family planning advocates are concerned about its high cost. The US manufacturer, Wyeth-Ayerst laboratories, charges $350/unit no matter if the unit goes to the public or private sector. Many medical, family planning, and public health organizations object to this action. So Wyeth-Ayerst has set up a foundation to distribute 10,000 units free of charge to physicians and nurses practitioners who will insert them in individual low income women. Yet this number is already lacking. So far overall demand for Norplant has been greater than expected. During the first 9 months, Wyeth-Ayerst had already distributed its projected 12-month supply to the private sector. In Colorado, the state preventive health block grant provides Norplant funds for the family planning program of the Department of Health. Individual clinics have been able to obtain units from the Norplant Foundation. The cost for women who can afford to pay full price is $400. 2 trained physicians provide free training sessions for all clinicians. A Norplant task force in Denver is examining ethical and legal issues to develop a policy statement. In Texas, low income women can receive implants because of funding from Medicaid or Title XX. Full costs are $450. Many teens ask for Norplant and, in Texas, they do not need parental consent. The family planning clinic at the Texas Southwestern Medical Center lacks trained physicians and nurse practitioners. Waiting lists for Norplant exist in California. The state office of family planning, Title X, and Medical pay for most Norplants in low income women. Full cost is $426. Teenagers tend not to ask for Norplant in California. As of July 1992, the Margaret Sanger Center in New York City has inserted 350 units. Full cost is $750. The high cost has not limited access overall.^ieng

The U.S.S.R. in transition: contraception and abortion.

PIP: As a team from the Association for Voluntary Surgical Contraception (AVSC) observed on a recent visit to Soviet Georgia, change has begun to take place in the reproductive health care system of the USSR, a country where so far multiple abortions have remained a fact of life. Official statistics say that the average Soviet woman undergoes 8 abortions in her lifetime. As the AVSC team found out, contraception rarely plays a role in controlling fertility. Not only does the population know little about contraception, contraceptive supplies are scarce. Among those who do know about contraception, including doctors, the IUD is the favored method. The IUD that they like, however, is not the Soviet-made one, but the Western-made Copper T, which is often found only in the black market. The Soviet-made IUD, they say, if os poor quality. Both women and doctors remain suspicious of oral contraceptives, and doctors strongly disapprove of the use of hormonal contraceptives. Condom sales have increased in Georgian pharmacies, possibly because of fears over AIDS. But again, the men prefer foreign brand condoms over domestically produced condoms. Although preferences over contraceptive methods vary, doctors do see contraception as the way to bring down the unhealthy level of abortions. So far, sterilization has not been used for contraceptive reasons. And among Georgian men, vasectomy seems out of the question. However, changes in the way reproductive health is administered appear to have begun. AS the USSR's first deputy minister of health told the AVSC team, the government is committed to increasing and meeting the demand for contraception, including sterilization. AVSC has been invited to help introduce voluntary contraceptive sterilization in the USSR.^ieng

Female sterilizations in the United States, 1987.

A study by the Association for Voluntary Surgical Contraception and the Centers for Disease Control estimated that 640,000 tubal sterilizations were performed in the United States during 1987. The majority of these were inpatient procedures (66 percent) performed in civilian or military hospitals. Hospitals were also the site for the largest share of the 215,000 outpatient procedures. Overall, 33 percent of sterilizations were laparoscopies: 10 percent of the inpatient sterilizations and 79 percent of outpatient procedures. The region with the largest number of sterilizations was the South, which also had the smallest proportion done on an outpatient basis.

Old and new ways: family planning in Kenya.

PIP: Kenya has the highest fertility rate in the world. The average woman has 8 children. Further, urban areas attract people from rural areas leaving fewer people to farm the finite land or raise cattle. Therefore a reduced need for children to partake in agricultural activities exists. Nevertheless many barriers to family planning continue in Kenya. Family planning services are scarce especially in rural areas. Husbands must agree to their wives undergoing voluntary sterilization by going to the clinic to sign a consent form. Children are highly valued. Succession of the generations is important. The higher a woman's fertility the more valuable she is to husband. The continuance of legal polygamy fosters competition among a man's wives to have many sons with the 1 having the most being his most prized wife. In spite of these obstacles, the president of Kenya promotes family planning through his speeches and requires the Ministry of Health (MOH) to provide family planning services at all government hospitals. Moreover, church hospitals also provide family planning services. Additionally, articles that cover teenage pregnancy and family planning programs appear in daily newspapers. The MOH and the National Council on Population and Development are organizing a network of government and nongovernment organizations that provide family planning services to the public. A sample of these organizations include the Family Planning Association of Kenya, an influential women's organization (Mandeleo ya Wanawake), and several church organizations. The Association for Voluntary Surgical Contraception's regional office has promoted minilaparotomies under local anesthesia since 1986. They are now used in maternal and child health programs in government hospitals, mission hospitals, and in several family planning clinics.^ieng

Men and their worries about vasectomy: will a new surgical technique help?

PIP: Men in the US do not choose vasectomy over the women having voluntary sterilization even though the procedure is safer, simpler, and cheaper. Some men delay or avoid the operation because they think it will be painful or will harm their sexual performance. A new surgical technique for doing a vasectomy is introduced by the the Association for Voluntary Surgical Contraception. Called the no-scalpel vasectomy, this technique should reduce discomfort, swelling, and hematoma after surgery. In this vasectomy, the vas is grasped by special ring forceps and the skin and vas sheath are pierced by sharp-tipped dissecting forceps. Then, the forceps stretch an opening and lift out the vas. AVSC believes the new method will address some fears of men and make vasectomy more acceptable. Plans to introduce the new method effectively and responsibly include designing patient education materials, clearly explaining the term no-scalpel, collecting data for comparison from US doctors about use of and complications from the method, and training a "critical mass" of experienced vasectomists.^ieng