iPill, uChill | The male approach to birth control

Since we have never heard of her partner, Mother Nature evidently is a single mom. And like most mothers, she clearly bears the brunt of her brood. Anupama Rohidekar, consultant, obstetrics and gynaecology, Columbia Asia hospital, Bangalore, however, is considerably luckier.

“We were clear that we wanted only one child. So after our daughter was born I underwent a vasectomy,” says Deepak Rohidekar, 48, laparoscopic surgeon, Manipal Northside Hospital, Bangalore. “My wife had been through the whole stress of pregnancy and labour, and I felt I should take on the responsibility of birth control.”

Don’t start celebrating this as a coming of age of the 21st century Indian male—Dr Deepak Rohidekar bucks the larger trend. Mumbai-based gynaecologist Rishma Dhillon Pai, who works at the Lilavati Hospital and Research Centre, says most Indian men regard birth control as a “woman’s business”.

The curious case of fewer options

Not that there are too many options available to men. When it comes to contraceptive products, women are spoilt for choice, be it pills, gels, injections or implants. And condoms too. Men, on the other hand, have just two, vasectomy or condoms.

Vasectomies, though reversible, are generally rejected as drastic. National Family Health Survey (NFHS) figures for 2010-11 show that a little over 4% of the Indian male population opted for it compared to 95.6% women, who underwent tubectomies despite state governments offering various incentives. Tubectomy is an invasive, irreversible sterilization procedure, done under anaesthesia. There is a risk of damage to the internal organs.

And when it comes to condoms the accounts are not too encouraging either. “A lot of men virtuously tell me they use a condom but not every time,” says Vijaya Sherbet, a gynaecologist at the Columbia Asia hospital. “There is no realistic way to decide when you need protection. Most married couples I know in my practice seem to prefer the natural or withdrawal method which has a high failure rate. There is probably sheer mental and physical laziness (certainly not sexual though) at work here.”

The fallout, doctors say, is that many women end up using the i-pill to prevent a pregnancy. “I see women who have messed up their period cycles by using the i-pill as much as four-six times a month,” says gynaecologist Duru Shah, who consults at some of Mumbai’s top hospitals. “Or the i-pill fails and they come to me for a medical termination of pregnancy (MTP).”

Dr Sherbet adds: “The number of married couples who use the option of MTP to plan their family never ceases to amaze me. We have a very liberal MTP under which a woman can have her pregnancy terminated if a condom fails. In urban India, termination is used as a contraceptive, which puts women at huge risk!” Both Mumbai and Delhi reported over 20,000 MTPs each in 2010-11, according to official figures.

A 42-year-old upper-middle-class homemaker, who has been married for 12 years and has never used a contraceptive, says, “I have a hormonal issue so I cannot take pills.” The former advertising executive says: “Insertions caused infections. It was incredibly frustrating as I wanted the men to take responsibility and use the rubber but they always refused because it took away from the pleasure. Now, I am happier not to have sex!’’

The onus of contraception falls mainly on women. NFHS figures for 2010-11 show there were 16 million users of male condoms compared to over 83 million women using oral pills. “Once the family is complete, it’s always the woman who opts for permanent methods,” says Dr Dhillon Pai. “Vasectomy today is down to very low numbers. There is huge expertise available but I find men are too scared.”

“The biggest fear is loss of potency,” adds Dr Rohidekar. “Even educated men think they will become weak, and not just sexually. They feel they have to earn for the family and this will affect their overall strength.” Mumbai-based sex educator and counsellor Mahinder Watsa, who has a popular newspaper column, “Ask the Sexpert”, agrees.

“‘Will it stop my discharge?’ ‘Will I be able to perform?’ These are the commonest misconceptions about vasectomy that I hear,” says Dr Watsa. “Birth control is regarded by most men as a women’s issue because they do not like the other option available, and that is the condom. And women prefer to undergo tubectomy because they fear that if something goes wrong (with the operation), the (family’s) breadwinner is lost to them.”

The Brihanmumbai Municipal Corporation’s figures for Mumbai for 2011-12 are telling. In that period, 1,584 men opted for vasectomies, while 18,651 women underwent tubectomies even though vasectomy is less invasive than a tubectomy, requires no anaesthesia and can be reversed. It also has fewer risks of complications. Infections are rare.

Involving the other sex

But why is male involvement in birth control such a big deal, some may ask. “In more conservative families where reproduction is keenly anticipated by everybody other than the potential mother, who might have education or career goals, her partner’s support and participation would help ward off the pressure,” says Dr Sherbet.

Over the years, countries in Africa have shifted the focus of family planning programmes to men. In African society, much like in India, decisions that affect family and political life are made by men. Male involvement in birth control, it is believed, would not only take the load off women, it would also promote more quickly the need for family planning.

Apart from encouraging condoms and vasectomies, government programmes rely on mass media, all-male clinics and workplace interventions to encourage male participation. In Côte d’Ivoire, for example, a joint government-UN Family Planning Association (UNFPA) programme is working to promote condom use among soldiers. In Niger, the Schools for Husbands project, also supported by the UNFPA, encourages married men to discuss family planning.

Part of the blame for the indifference back home, Dr Rohidekar believes, lies with the medical community. “The general trend is that since the woman is here anyway, make her undergo a tubectomy. We need to involve men aggressively. When a couple comes in for a pregnancy termination, there is almost always no one to counsel them on family planning. No one is telling them what methods are available.”

A gap that PRACHAR, a community-based intervention project in Bihar, is trying to fill. The project reached out to young couples to change reproductive behaviour.

“Men don’t opt for vasectomy because no one has explained to them the right time to do it,” says Rema Nanda, the former country representative of Pathfinder International, a non-profit family planning organization working in developing countries, which launched PRACHAR in 2001. “Through community meetings, male workers provide contraceptive information and counselling to young married men and adolescents. When you have male workers reaching out, rates of contraceptive adoption rise dramatically. In the first phase of the project between 2001-2004, interventions led to an increase in contraceptive use among young couples from 4.3% at baseline to 20.7% at end line,” she adds.

This is an approach Dr Rohidekar believes in as well. At his hospital in Bangalore, he strongly advocates vasectomies. “I give them my example. I tell them ‘Look at me. I am fine. I have suffered no loss of strength, so you should consider it.’”

But most men don’t. And fatherhood is small beer compared to becoming a mother.

Shai Venkatraman is a journalist, teacher and blogger with a special interest in issues related to health and gender rights.