Kenyan a Birth Control Pioneer : 10-Minute Operation Aids Family Planning in Africa

The first time Dr. Joseph Kanyi performed the operation, his nurses fled.

“I thought they were going for tea,” he recalled in his whitewashed office one day recently, 13 years later. “But they never returned.”

It was not tea, but the unfamiliarity of Kanyi’s procedure that drove the nurses away: It was the first time that they had seen abdominal surgery performed using only local anesthesia.

“They disapproved of doing the operation while the patient was awake,” Kanyi said. His staff gone, Kanyi glumly canceled the three other operations he had scheduled for that day. Racked by frustration and embarrassment, he spent a sleepless night.

That was the inauspicious beginning of Kanyi’s pioneering work in birth control, or “family planning,” in the preferred terminology of Africa. The woman on the table was Kanyi’s first patient for a procedure known as a minilaparotomy, a simple and convenient method of performing tubal ligations, or surgical sterilizations.

After years of searching for a simple way to provide his rural patients with the permanent contraception they desired, Kanyi had learned the technique abroad and brought it to his tiny clinic here in the shadow of majestic Mt. Kenya. With a three-inch incision and an hour’s surgery, since reduced to 10 minutes, he could surgically sterilize a woman and have her out of his clinic and on her way home that day.

Within a year of that first operation, with a new staff of nurses, Kanyi was performing hundreds of the voluntary procedures annually. Since that discouraging day in 1975, he has done 3,500. In Kenya, the leader in Africa in the procedure, the 300 doctors and nurses he has trained perform 9,000 every year.

It is on women’s shoulders that the burden of Africa’s population explosion falls disproportionately. Often bearing as many as eight or 10 children, they are frequently left to support the children on their own. By a wide margin, it is women who have the greatest incentive for birth control and who suffer its myriad inconveniences.

Thus, to thousands of women, and perhaps to the continent as well, the minilaparotomy has been a godsend, for in few other places on Earth is birth control more urgent than in Africa.

In population growth, as in so many other fields, the continent seems forever out of step with the rest of the world. In the 19th Century, for example, it was the only continent, Antarctica aside, to suffer a declining population.

Then the European colonists arrived with their own ideals of medical care and disease eradication. Africa’s infant mortality rate dropped, and life expectancy increased.

Since 1950, education and medicine have cut Kenya’s infant mortality rate from 163 deaths per 1,000 births to about 70 today. Life expectancy at birth in the same period has risen to 53 years from 39.

High Fertility Rate

Conventional wisdom dictates that, high mortality rates being the leading inspiration for high fertility, African birthrates should be falling. Yet in Kenya, to take one example, the fertility rate--the average number of children born per woman--has scarcely budged: It was 8.2 in 1950, and it is 8.12 today.

One reason may be that the drop in the infant mortality rate is not so clearly visible to rural villagers.

“Even though the rate is down, as many children die as in the past because there are so many more children,” said Dr. Eric Krystall, head of the Family Planning Private Sector program, a privately financed group operating in Kenya. “In Kenya, there are still 70,000 child funerals a year, so we still have a job convincing people.”

Although Kenya has the world’s highest natural growth rate, its problem is mirrored by many other nations in sub-Saharan Africa. With mathematical inevitability, the continent’s human population has begun to outstrip the land’s ability to support it.

In 1950, the region supported about one-fifth as many people as all of the developed world; by 1985, it had closed the gap to about a third. United Nations statistics indicate that in the year 2025, even assuming Africa’s growth rate falls to 0.72% annually from today’s 1.84%, the continent will have 1.1 billion people, equal to all the people in the developed world.

Bride Price

The population impact already cuts across all economic categories in Africa. In Rwanda, the tiny central African nation with the continent’s heaviest density, population growth has so reduced the size of most families’ cattle herds that the traditional price of a bride, a cow, has become hard to meet. On the alternative cash market, brides fetch as much as $1,350. This spring, the government responded to this inflation by fixing the price of a bride at three hoes.

Africa’s fragile ecology suffers as well. In Niger, where the growth rate will double that destitute West African country’s population to 13.6 million in 23 years, the U.S. Agency for International Development blames the population explosion for contributing to extensive deforestation and desertification, as people strip the country’s forests for wood to burn.

Even if Africa were to sharply cut back its fertility and growth rates today, the continent’s future is etched in stone for decades to come. Half its population is below the age of 15; in many countries, this youthfulness might presage an explosion of industry and economic vitality. In the straitened lands of Africa, it portends a geometric increase in population and an overwhelming strain on inadequately developed resources.

More and more, African governments have come to recognize population growth as their paramount economic curse. Even some Muslim countries, with traditional censures against birth control, have instituted official programs.

Few Use Birth Control

But all falter in the face of logistical, educational and cultural obstacles. In Kenya, where family planning is a national policy aggressively supported by every government minister, a 1980 international study showed that only 29% of women had ever used any form of birth control, including 18% who used such traditional methods as rhythm and abstention.

In other countries, the rate is much lower--6% to 10% use modern methods in Niger, 4% to 6% in the destitute West African nation of Burkina Faso and 3% in sub-Saharan Africa’s most populous nation, Nigeria.

Few subjects are as charged with contention and emotion as family planning in Africa. National programs have collapsed after confronting unexpected tribal sensitivities. In semi-literate societies, the mine field of misunderstanding can be catastrophic.

For example, the male equivalent of the minilaparotomy, the vasectomy, is rare to the vanishing point throughout Africa. Men and women alike equate it with castration and fear it causes impotence.

Rumors, Misconceptions

“Rumors and misconceptions are bad even in the United States,” says one family planning expert active in Kenya. “In Africa, they spread like wildfire. If a contraceptive user in some village becomes ill, a rumor spreads identifying the method with the illness, even if it’s unrelated.”

Kanyi himself recalls hours of sessions with his patients disabusing them of common fallacies. Some women believed that if they conceived while using an IUD, “it would go through the baby’s heart, or the baby would come out holding it.” Others feared that contraceptives would make them frigid, or cause birth deformities.

Even as birth control officials struggle to gain acceptance for their methods, the efficacy of traditional methods has been declining. African women, for example, have traditionally breast fed their children for their first two years or even longer. Breast-feeding diminishes a woman’s fertility, and in many African tribes it is also taboo to have sex with a breast-feeding woman, so that helped to space children naturally.

Social Taboos

In many traditional societies it was also taboo for a woman to have any more children once her oldest daughter became pregnant--another social limit on fertility.

But as Africa becomes more urbanized, population experts say, traditional restrictions disappear.

“In cities there are fewer taboos,” said one population official in Nairobi. “Breast feeding is no longer a child’s sole nourishment, for example. Women are productive well into their 40s.”

With modern contraceptive methods, one problem is the continual difficulty of getting devices to the users.

“There are problems both on the supply and the demand side,” remarked one foreign aid official in Africa involved in population matters. In the past, some countries have been afflicted with erratic supplies of such contraceptives as Depo-Provera, an injectable contraceptive popular in Africa but not yet approved for use by women in the United States.

Users of most contraceptives also are inconvenienced by the need to travel to remote clinics to renew their supplies--every three months in the case of Depo-Provera. For this and other reasons, many older African women have long sought a permanent birth-control technique to substitute for the need to use temporary methods for what might be as much as 20 years between the birth of their last wanted child and the end of their period of fertility.

“They would ask why I couldn’t give them a method to get them out of the queue,” Kanyi recalled. “It became rather a challenge to me.”

Not Uncommon Method

Of course, a method did exist: tubal ligation, or the cutting of a woman’s Fallopian tubes to block the movement of the ovum into the uterus. Not uncommon in the developed world, this method of surgical sterilization created huge problems for doctors and patients in Africa.

The conventional procedure required the patient to check into a hospital for more than a week, go under the knife for hours and subject herself to general anesthesia. Any of those factors alone would be enough to discourage most of Kanyi’s potential patients.

In the cash economy that prevails in most of Africa, that much time out of pocket was insupportably costly. Such a long sojourn away from home, as well as the long scar, also made it impossible for a woman to keep her operation confidential--more than an inconvenience in societies where she might feel the sting of disapproval or even ostracism for taking such a permanent step. General anesthesia also frightened potential patients.

So tubal ligations tended to be performed in sub-Saharan Africa only on “women who were most desperate,” said one leading expert in surgical contraception in East Africa. “They were those with a ruptured uterus, or 13, 14 kids, or several Caesarean sections.”

New Set of Concerns

The advent of the minilaparotomy has changed that, although the availability of such an easy and permanent method of birth control has brought its own array of problems. The Family Planning Assn. of Kenya and other family planning agencies here have financed an extensive program of counseling to screen patients, rejecting those for whom permanent contraception might be a grave mistake. In Kenya’s polygamous tribes, out-of-favor wives might be pressured by their husbands to undergo sterilization.

Counselors in Kenya generally recommend the procedure only to women who have had six children or more.

“If a woman comes in at the age of 24 and with one child, it’s very questionable,” said one family-planning worker. “What if the child dies, or the woman is divorced and remarries? There would be very heavy pressure on her in that case to produce children in the subsequent marriage.”

But counselors find that among appropriate patients, acceptance of the procedure runs very high.

“When we tell clients it just takes 10 to 15 minutes,” said Jennifer Mukolwe, executive director of the Family Planning Assn., “they say, ‘My goodness, it’s just like going to the market--and no one even has to know.’ ”