We conducted a retrospective descriptive audit, analysing the data captured via patient record reviews at three district health facilities offering a vasectomy service in the western half of the Cape Town Metropole, Western Cape.

The three facilities included were Wesfleur District Hospital, Mitchell’s Plain Community Health Centre (CHC) and Heideveld CHC. These facilities have a day theatre for minor surgical procedures, where vasectomies are performed by different cadres of skilled doctors, including medical officers, registrars and family physicians. University of Cape Town (UCT)-affiliated family medicine registrars and family physicians perform the procedures at these facilities as part of their outreach service. The location of the facilities is depicted in Figure 1.⁹ The 2011 Census description of the local communities is provided in the next section, as the accessible 2022 Census findings describe the data only at the level of the overall Cape Town metropolitan municipal population, which showed an overall population growth of 1 032 815 (27.6%) from 2011 (3 740 031) to 2022 (4 772 846).¹⁰

The study population included all the men who underwent vasectomies at these facilities from 2016 to 2021. This timeframe was used as two of the three study facilities introduced the vasectomy service in 2016. We used 2021 as our cut-off time to collect as much data as possible. We included all the available records in this timeframe and no sampling was performed. Like other local public sector hospitals, all three facilities were affected by the coronavirus disease 2019 (COVID-19) pandemic and had to suspend surgical services early in March 2020.¹⁴ The vasectomy service recommenced around March 2021 when lockdown restrictions were eased.

The first author (M.L.l.R.) collected the data at the three facilities. Given the different modes and practices of record-keeping, the three facilities had different data sources for patient information:

The information-gathering process consisted of reviewing patient records and, in the case of Mitchell’s Plain CHC, theatre notes kept by the theatre staff. We developed and piloted a data-collection tool with demographic and procedural variables. The demographic data we gathered at the three facilities were retrieved from electronic databases and patient folders. These demographic variables included age, marital status, employment status and the number of children of these patients. Procedural data variables were informed by the guidelines described in the literature review.⁶ The information from the patient folders was captured in a Microsoft Excel spreadsheet.¹⁵

This quantitative data were analysed using the Statistical Package for the Social Sciences (SPSS).¹⁶ The percentages of the different variables and the association between the success of the procedure and the performing surgeon were calculated.

Ethics approval was obtained by the University of Cape Town’s Human Research Ethics Committee (Ref 196/2022). The Western Cape Provincial Health Research Committee (WC_202204_012) approved facility access.

Table 2 presents the sociodemographic data. Most patients were between 30 years and 50 years (78.5%). The age of the patients was unknown in 10.7% of the records. Around half of the patients (53%) were married, and in many patients, the marital status was unknown (45.2%). Thirty-six per cent of the population had three to four children. There was a substantial number of folders in which the number of children was not recorded (36.7%). The folder review also found that all the patients whose employment status was recorded (62.2%) were employed.

Table 3 represents the results of the PVSA performed. The results were obtained from the RMU at GSH, where the semen analyses were performed. The results for two facilities were collected: Heideveld Community Day Centre (HCDC) and Mitchells Plain Community Health Centre (MPCHC).

The HCDC theatre records showed 82 vasectomies that were conducted; however, the folder review revealed that only 49 (59.7%) PVSA results were known. This was found to be because of factors such as patient folders that were not retrieved or patients who did not go for their PVSA. The PVSA results revealed that 27 out of 33 known results were successful (81.8%), and six were unsuccessful (18.2%).

The MPCHC facility’s PVSA results were retrieved from the RMU at GSH. An electronic database at the RMU contained 89 PVSA results. These showed that 88 procedures were successful (98.9%) and only one was unsuccessful (1.1%).

The WFH results were unavailable as it was not standard protocol to refer patients for PVSA at the RMU. Ninety-nine vasectomies were recorded at WFH, and upon the folder review, none of the PVSA results were captured in the clinical records.

Thus, only 122 patients (45.1%) had documented adherence to the post-procedure follow-up plan. Of these 122 patients whose PVSA results were known, 115 procedures were successful (94.2%).

Table 4 demonstrates that of the 270 vasectomies, family physicians performed almost half (n = 123, 45.6%), urologists performed a third (n = 98, 36.3%), whereas family medicine registrars (n = 24, 8.9%) and medical officers (n = 5, 1.9%) contributed a lower number. The missing data from the source documents severely impacted our ability to describe the success percentages obtained by the different surgeon categories, as the surgeon category was unknown in 20 (7.4%) procedures. According to the limited accessible results, urologists had a higher success rate of 97.2% (n = 72 out of 74 known results). Family physicians had a lower success rate of 85.7% (n = 24 out of 28 known results); however, this success rate was impacted considerably by the high percentage, 77.2% (n = 95 out of 123), of unknown data for this surgeon category. The missing data from the patient records review made it very difficult for us to accurately determine the association between the success of the procedure and the performing surgeon.

The study revealed that this contraceptive method is available at all three facilities included in the audit. However, our description of procedural success was limited by the incompleteness of the source documents included in this baseline audit. Where data were available, we could show fair procedural success rates. A considerable number of patients did not follow-up for PVSA. Health service strengthening activities have been implemented to address these issues identified in the baseline audit.

This audit showed that vasectomies are utilised in our local setting, which is refreshing given that it is an underutilised method.⁴ This uptake may be ascribed to several factors, such as ineffective information sharing at the community level, uncertainty about the procedure’s effectiveness, operation and potential complications and a lack of knowledge on accessing and navigating the care pathway. Our study did not collect data to confirm this hypothesis. All three facilities have health promoters who are responsible for the distribution of information about the procedure. They offer counselling for males who show an interest in undergoing vasectomies.

The global success of vasectomies is currently estimated to be 99%.¹⁷ Based on the available source data, our findings report that the success at these facilities is below this target (94.2%). The need for a repeat vasectomy globally is less than 1%,¹⁷ which currently leaves the results from our audit below the target. These results could be because of surgical technique, surgeon experience and unconfirmed vas deferens occlusion (no available histology to confirm the occlusion). The current international and local guidelines do not require histological evidence of vas deferens occlusion.⁶ However, given the available local information, our protocols were updated to include sending specimens (left and right vas deferens) for histological confirmation. This will indicate whether the procedure was successful and whether failure (risk of falling pregnant, which was 1 in 2000) was because of not being 100% reliable.⁶

There have been some international studies that showed that the follow-up after having a vasectomy is generally low, and non-adherence was found to be greater than 30%.⁷ The reasons for the low follow-up percentage have been explored on an international level and include patients feeling too busy to follow-up, patients feeling confident that the procedure was correctly performed and patients describing that the procedure process was too inconvenient.⁷ The reasons for non-adherence have yet to be explored on a local level. Our findings revealed that 45.2% of patients adhered to the recommended follow-up appointment for the PVSA. This puts the non-adherence percentage at 54.8%, keeping with internationally described follow-up rates. However, the percentage of adherence to PVSA may be higher than reported in the WFH group as these patients were encouraged to access a private facility for their PVSA. Another plausible reason for the poor follow-up rate may be that some patients were not well-informed or motivated to adhere to the follow-up protocols. Our facilities are also known to be very busy and full daily. This often leads to long patient waiting times, which may impact adherence. Health promotors at some facilities aim to stay in contact with patients following the procedure via telephone or messaging service and thus ensure they keep to the appointments to have their PVSA performed. This process involves the staff (nurses and health promotors) making appointments at GSH RMU for patients’ follow-up tests. Reports from counsellors at the facilities reveal that the implementation of the appointment system has been beneficial in assuring patient adherence.

The nature of the relationship between the cadre of surgeons who performed the vasectomies and the procedure’s outcome could not be described accurately. It is, however, evident from our findings that the urologists had a relatively larger percentage of success and this could have been because of the implementation and maintenance of the PVSA pathway that was set in place by them and their local teams (theatre staff) in the initial phase of implementing the service. From anecdotal testimony from staff, we found that the theatre nurse’s role in referring patients to GSH RMU ensured that they followed up for their PVSA. At present, family physicians are the only cadre performing vasectomies at these primary care facilities. The available results revealed a suboptimal success rate of 85.7%; however, the unknown PVSA results largely impacted it. These results likely underestimate the success rate as anecdotal reports from facility staff revealed very few failed procedures.

The WHO primary health care measurement conceptual framework describes how clinical governance, policies, healthcare workforce and health information systems contribute to quality service delivery and continuity of care.¹⁸ Figure 2 illustrates a suggested framework based on this WHO framework, which could assist in improving the vasectomy service from a health systems perspective.¹⁸ The recent call for collaboration between urologists and primary care providers is manifested in the processes domain, given the support of the GSH urology department for care coordination.¹⁹

A revised clinical care pathway to inform the delivery of an evidence-informed vasectomy service emerged during the audit and was developed in partnership with the local teams (Box 1). Capturing information on an electronic platform can strengthen access to a well-coordinated service through the continuity of clinical records. It would ensure follow-up in cases where patients disengage from the services. Standardised stationery for the vasectomy process is already being used at MPCHC and HCDC. This has since been introduced at WFH to ensure a uniform approach to vasectomies.

Our study represents a baseline audit to illuminate a poorly described family planning service and inform future research. The audit process enabled us to identify gaps in the care pathway process, from recruiting patients for vasectomies to documenting the pre- and post-procedure process. Active engagement with the local role-players facilitated the implementation of enhanced systems and record-keeping, including electronic data-collection tools that we developed and standardised stationery to ensure an efficient process.

Our study is limited by its retrospective cross-sectional observational design, which does not allow for the description of causation between variables. Two major limiting factors in our research were the loss of the MPCHC theatre records because of fire and incomplete record-keeping encountered in the available records. Because of the missing data, we could not accurately describe the possible association between the vasectomies’ success and the surgeons’ cadre.

Following this audit, record-keeping has now been standardised at all three facilities as part of a clinical care pathway. The adherence to the care pathway should be monitored and evaluated continuously to ensure efficiency. Health promoters should continue to play a significant role in recruiting and counselling patients for vasectomies. They could be allocated as the central person to arrange appointments for PVSA as they represent the ideal nucleus of the vasectomy service, given their role in supporting the patient on their journey, from pre-procedural counselling to post-procedural care. Stronger linkages with community networks and non-profit organisations such as Families South Africa (FAMSA) should be built to assist with counselling for families about the option as a family planning method.

The family physicians at these primary care facilities are currently the main surgical cadre performing the procedure. They are ideally placed to access and review the PVSA results as part of the post-procedural care pathway.

Further research may include an audit of record-keeping, determining the procedural success of the procedure using the PVSA findings, an association between the surgeon and the outcome of the vasectomy and adherence to the follow-up protocol in keeping with international guidelines. Qualitative research is also needed to identify factors that play a role in non-adherence to follow-up and explore perceived barriers to accessing the service.