Norplant introductory programs have emphasized the need for provider training, adequate counseling and informed consent for users, and ready access to removal. These needs require a well-prepared service delivery infrastructure.
If counseling is not always available, then some users may not be informed adequately about a method's side effects or how to manage them. The need to return for follow-up services may not be clear to users, and providers may not have prepared adequately to give follow-up services. For example, a study of Norplant users in Bangladesh found that some women attempted to remove the implants themselves or to enlist the help of untrained people because some of the original providers did not offer adequate removal services, says FHI's Dr. Karen Hardee, who coordinated the study.1
Lack of planning in introducing intrauterine devices (IUDs) during the 1960s resulted in problems with supply management, infection control, access to removal, and fears among a poorly informed public. "People tried to learn from the mistakes of the 1960s," says Dr. Hardee, who has studied quality of care issues extensively. "The result was that a lot more planning went into the introduction of Norplant" when the implant was first introduced in developing countries during the 1980s.
Norplant provides up to five years of pregnancy prevention with little user or provider action needed after insertion. However, it needs to be removed after five years when its effectiveness begins to decline, or earlier if women wish. Also, Norplant's tendency to cause menstrual irregularities (as do all progestin-only methods) makes good counseling essential for high continuation rates.
The Population Council, which developed Norplant, and other agencies, including FHI, worked with the U.S. Agency for International Development (USAID) on its worldwide introduction strategy. The strategy sought to establish a consistent channel of supply between manufacturer and distributors, obtain national regulatory approvals, build local capacity to use Norplant by training providers and setting up pre-introductory studies, develop information and training materials, and ensure that it was offered as part of a range of choices to clients.
The pre-introductory studies were particularly important. They helped country officials assess the method's acceptance and programmatic implications, allowing potential difficulties to be addressed before Norplant was integrated into a family planning program.2 As contraceptive introduction models typically recommend, these studies examined how the method would actually work in a specific country or culture. A pre-introductory study among 694 women in Haiti, for example, found that 99 percent of them liked the method and 96 percent would recommend it to a friend.3 Consequently, expansion moved forward quickly, and by 1992, Haitian providers were inserting Norplant into nearly 10,000 women a year. The viewpoints of users, carefully evaluated ahead of time, indicated such acceptance would occur.
Greater demand, however, requires a corresponding increase in trained personnel to insert and remove the implant. To address this concern, a Haitian hospital has trained nurse auxiliaries to do insertions in rural clinics, and FHI is assessing whether insertions and removals by nurse assistants are as successful as those performed by physicians. The study could lead to a change in service delivery regulations. Preliminary findings indicate the nurse assistants perform as well as the doctors, says FHI's Betsy Tolley, who is coordinating the study. "The clients seem to be well-informed, while infections or complications from the insertions by nurse assistants are as rare as they have been when doctors made the insertions," says Tolley.
Vietnamese assessment
An important question is whether a new method should be introduced at all. In Vietnam, a needs assessment suggested that Norplant should not be introduced.
In 1994, the Vietnam Ministry of Health, Vietnam Women's Union, United Nations Population Fund (UNFPA) and WHO gathered information on provider skill levels, program needs, cultural and political restrictions, and women's concerns regarding all contraceptive methods in the Asian country. The team analyzed contraceptive prevalence surveys, interviewed 100 actual and potential family planning users, and talked to providers in 12 community health centers and two large clinics.
Following this needs assessment, the government changed its strategy on Norplant, explains Dr. Ruth Simmons, a member of the team and co-chair of a WHO task force on contraceptive introduction. Due to Norplant's heavy service demands, the team recommended delaying the introduction of Norplant until the service delivery system is stronger. A systematic introduction of DMPA, the three-month injectable, was initiated instead.
"Previous efforts have assumed that service delivery capabilities would be adequate to provide the new technology or could be improved where necessary," stated the team's report. "It is increasingly recognized that introducing new contraceptive methods adds burdens and complexities to the service delivery, training and administrative/operational systems which may act to reduce rather than improve quality of care."4
-- William R. Finger and Sarah Keller
Footnotes
Hardee K, Khuda BF, Kamal GM, et al. Contraceptive implant users and their access to removal services in Bangladesh. Int Fam Plann Perspect 1994; 20(2):59-65.
Beattie KJ, Brown GF. Expanding contraceptive choice: The Norplant experience. Eds, Van Look P, Perez-Palacios G. Contraceptive Research and Development 1984 to 1994. (Geneva: World Health Organization, 1994) 263-76.
Balogh S. Haiti private sector family planning project: Norplant strategy. Unpublished paper. Durham: Family Health International, 1992.
Vietnam Ministry of Health. Assessment of the need for contraceptive introduction in Vietnam. Unpublished paper. Dec. 19, 1994.
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