Norplant: Overcoming barriers to method use
Post-marketing research shows its safety and efficacy, and women who have used the method for five years are choosing reinsertion - so why does the Norplant implant contraceptive lag in the list of family planning choices?
Two-thirds of Contraceptive Technology Update's readers who participated in the 1998 pill survey report no Norplant insertions in the last year. For the 18% who inserted one to five implants, almost 12% removed the same number. The number of removals outrank the insertions in the subsequent three numerical ranges. (See above chart.)
Norplant is not a popular choice for patients at Women's Hospital of Greensboro (NC), says Charles Harper, MD, coordinator of ambulatory care/OB/GYN. Many younger patients report headaches or irregular bleeding, he notes.
"Some of them don't stay on it long enough before they really get the amenorrheic type of benefit," Harper says. "The majority of our users choose not to have it reinserted."
However, not all Norplant removals are due to side effects. As Mary Anne Baker, CNM, a clinician at Health Quarters Reproductive Health Care Services in Beverly, MA, reports, the last two removals at her facility were from women who had used them for five years. Both of them had Norplants reinserted.
"There are a variety of reasons for those who have asked to have them removed: side effects like bleeding, didn't need birth control now, or it was the end of five years," Baker observes. "Some changed to the pill, some to DMPA."
The majority of Norplant removals for the family planning program in the San Antonio Metro pol itan Health District are after five years of use, says Janet Realini, MD, MPH, medical director. About 25% to 33% of these patients desire to continue with the method and request reinsertion, she states.
Counseling key factor
Alfred Poindexter III, MD, professor of obstetrics and gynecology at the Houston-based Baylor College of Medicine and director of its division of contraceptive research and development, says counseling is a key factor in satisfaction with the method. Poindexter is tracking a long-term database of Norplant users and has conducted focus groups to learn more about why women continue to choose the method.
He says the key factors for staying the course with Norplant include a mature patient who does the following:
· has a long-term interest in contraception;
· knows what side effects to anticipate with the method;
· is able to accept those side effects.
Such patients do not mind experiencing some bleeding between periods, somewhat longer periods, or even no periods, he comments. Their driving desire is to obtain a convenient, highly effective method of birth control.
"This is all about counseling," he says. "It is sitting down, taking time to have an appreciation for a person's life circumstances, and then discussing with them, not only Norplant, but all the methods of birth control and side effects, and making sure as you explain those side effects, that you discuss how it will affect their menstrual period."
What does partner say?
Don't gauge only the patient's fertility desires, but those of her partner as well, says Deborah Kalmuss, PhD, associate professor in the Center for Population and Family Health at Columbia University in New York City. Kalmuss and associates at Columbia have conducted several studies of Norplant users and have found that women whose partners wanted a child within the next two years following Norplant insertion were significantly more likely than others to have an early removal.1
During contraceptive counseling, Kalmuss recommends asking patients such questions as, "Have you told your partner that you're thinking about getting a Norplant?" and "How does he feel about that?" In addition, the same questions asked to further ascertain candidacy for an implant - such as "Do you want to have any more children?" and "In how many months or years do you want to have your next pregnancies?" - should be asked again in terms of what the woman thinks her partner wants as well.
Squeamish providers
In today's litigious society, many providers may shy away from methods that may prove problematic. Such is the case with Steven Eisinger, MD, professor of family medicine and associate professor of obstetrics and gynecology at the University of Rochester (NY)/Jacob W. Holler Family Medicine Center. Due to medical and legal considerations, he is no longer inserting Norplants, and he offers his patients alternative methods.
Many Norplant patients in the San Antonio Metropolitan Health District report being approached by lawyers who encourage them to sue for money if they have had side effects, says Realini.
Norplant definitely has its place in the list of contraceptive choices, especially for those women who, for one reason or another, are unable to successfully use reversible methods, Kalmuss explains.
"I strongly recommend it still as a contraceptive," Poindexter states. "It is very good and has proven to be exactly what we thought it should be. It has a place in the contraceptive armamentarium."
Reference
1. Kalmuss D, Davidson AR, Cushman LF, et al. Determinants of early implant discontinuation among low-income women. Fam Plann Perspect 1996; 28:256- 260.
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