Set clear guidelines for Norplant removals
What is your clinic’s policy when it comes to Norplant removals upon patient request, particularly when it comes to costs? Be sure that you understand that policy and share it with your patient during the counseling session before selecting the method.
Why is it so important to have such a policy? A recently published study of Nor plant users found that although the majority of women perceived no provider or cost barriers to removal, one-third reported at least one factor. The most common barrier was the perception that cost would make it more difficult to remove Norplant.1
Norplant has high continuation rates in comparison with other methods, and the majority of users are satisfied with the implant contraceptive, says Deborah Kalmuss, PhD, associate professor in the Center for Population and Family Health at Columbia University in New York City and one of the investigators on the multicenter trial. Many women who have had implants in place for five years are returning to clinics for reinsertions, she notes.
Providers walk a fine line in counseling Norplant users, Kalmuss observes. They need to counsel women about the management and tolerance of side effects in a manner that communicates an openness to removal.
Perceptions of barriers
Kalmuss and colleagues examined the exper iences of 687 low-income women who chose Norplant implants. Researchers gathered information through interviews before insertion, six months after insertion, and two years after insertion or at the point of discontinuation.
Although 64% of women in the study perceived no barriers to Norplant removal, 20% of respondents said their health care provider tried to convince them to continue using Norplant, and 9% felt pressured to stay on the method. All participants were enrolled in clinics that offered free Norplant removal, but 11% still assumed they would incur the cost of the procedure, while 18% indicated the cost would make it more difficult to get the implant removed.
Did any of these perceived barriers block removal? None of the anticipated barriers stopped women from initiating a removal discussion with their providers, and only one of the four proposed barriers — cost — had an effect on the removal decision.
Cost no barrier
Removal of implants must be done regardless of a patient’s ability to pay, state the authors of Contraceptive Technology.2 This agreement must be honored, even if the implants were not originally inserted by the provider.
"Clinics must ensure that no woman using Norplant ever has a problem in having the implants removed, no matter where inserted," concurs Allan Rosenfield, MD, dean of the school of public health at Columbia University in New York City.
Although the removal procedure requires staff time and effort, ways must be found to provide the service, even to those who are not eligible for Medicaid or Title X reimbursement, notes Rosenfield, who chaired a committee on contraceptive research and development at the Institute of Medicine in Washington, DC. The committee convened a workshop to review the introduction and acceptance of Norplant implants.
Use Norplant resources
The Norplant Foundation provides financial assistance to women without insurance who cannot afford to pay for the Norplant system, its removal, or replacement. The Foundation is a nonprofit, independent organization, originally established with an unrestricted grant from Wyeth- Ayerst Laboratories of Philadelphia, manufacturer of the implant system. (For contact information and other Norplant resources, see box, below.)
The company also has established a provider network to link women who desire implants or removals with trained personnel, says Audrey Ashby, a Wyeth-Ayerst spokeswoman. "We as a company believe that a woman should be able to have Norplant system inserted or removed at any time," she explains. In keeping with that policy, the company has sponsored training for more than 28,000 professionals in hands-on removal and insertion techniques and donated more than 20,000 system kits to health care professionals for use in eligible patients.
Although the Norplant Foundation was set up to provide access to Norplant insertion, its role was expanded in 1995 to cover removal costs as well, says foundation chairman Louise Tyrer, MD, FACOG, of Incline Village, NV. Tyrer serves as medical director of the local Planned Parenthood and medical director for the Association of Reproductive Health Professionals in Washington, DC.
Providers must be trained in proper insertion and removal techniques before they are included in the national directory, Tyrer says. Nurse prac titioners also are eligible for reimbursement, provided they have received proper insertion/ removal training and are allowed through their state boards to receive such payment. The foundation recently enhanced its services for better data tracking and speedier provider reimbursement.
References
1. Kalmuss D, Davidson A, Cushman L, et al. Potential barriers to the removal of Norplant among family planning clinic patients. Am J Pub Health 1998; 88:1,846-1,850.
2. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th edition. New York: Ardent Media; 1998.
Resources
Here are Norplant resource toll-free phone numbers:
• (800) 934-5556. Patients should use this number to access the Norplant Health Care Professional Referral Network, a directory of providers trained in Norplant insertions and removals.
• (800) 922-0877. Providers should call this number to access the Norplant Provider Support Center. The center offers telephone assistance Monday through Friday from 8 a.m.-8 p.m. EST.
• (800) 760-9030. Patients can call this number to locate providers who are participating in the Norplant Foundation Supply and Removal Network. Information is available in English and Spanish.
To participate in the Norplant removal assistance network, or for more on reimbursement, contact:
• The Norplant Foundation, P.O. Box 29240, Phoenix, AZ 85038-9986. Telephone: (800) 760-9030. Fax: (877) 855-5777.
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