Evaluating contraceptive choice through the method-mix approach. An Indian Council of Medical Research (ICMR) task force study

The method-mix approach was used to evaluate informed contraceptive choices in the present study. A total of 8,077 potential clients were given a balanced presentation of all available contraceptive methods in the national program, ie, the CuT 200 intrauterine device (IUD), low-dose combined oral pills (OC), condom, and sterilization (female/male) along with a new method, Norplant(R).(1) The majority of women opted for spacing methods; among them, the IUD was preferred by about 60% of clients, followed by condoms (9%), OC (6%), and Norplant (5%). Sterilization, mainly female, was accepted by about 17% of the women making an informed choice.The economic status of couples did not influence the contraceptive choices, as all the methods were offered free of cost in the present study, which is the current practice in the national program. Illiterate women more often accepted sterilization (about 25%) than did literate women (15%). This is because illiterate women had more children; about 30% of illiterate women had three or more children, as opposed to 16.2% of literate women. However, literacy status did not influence the choice of any specific spacing method. The study also revealed that, by encouraging potential clients to make an informed choice, they could override the provider's bias while accepting a particular type of spacing method. This is evident from the observation that Norplant was the first choice of the provider for 35% of the women, whereas only 5% of women preferred and accepted Norplant. The present study stresses an urgent need to promote the practice of informed choices in the national program with a variety of contraceptive options-especially, spacing methods for improving contraceptive prevalence and reproductive health in the country.     

A five-year clinical evaluation of NORPLANT contraceptive subdermal implants in Bangladeshi acceptors

A non-comparative study of the Norplant contraceptive subdermal implant system was conducted in Dhaka, Bangladesh. The study was designed to evaluate the contraceptive efficacy, safety and overall acceptability of Norplant implants. Six hundred women were enrolled in the clinical trial, which began in 1985 at three study sites. Follow-up visits were scheduled at 1, 3, and 6 months after Norplant implant insertion, and every six months thereafter until removal or at the end of five years. There were no post-insertion pregnancies during Norplant implant use in this study. After five years of Norplant implant use, there was no clinically significant change in body weight, systolic or diastolic blood pressure. Less than 3% of the women ever reported having any significant medical problems such as migraine, respiratory or cardiac problems during the study. The gross cumulative continuation rate was 41.2 per 100 women at the end of five years. The two most frequently reported reasons for discontinuation during the study were menstrual problems and desired pregnancy. Of the women who completed the five-year user satisfaction questionnaire, the majority of the women (86.3%) planned to continue using contraception after study completion. Of these women, approximately one-third said they planned to use another Norplant set. The findings presented suggest that the Norplant system is a highly effective, safe and acceptable method among Bangladeshi women.     

Implantable contraceptives for women: effectiveness, discontinuation rates, return of fertility, and outcome of pregnancies

Progestogen-only contraceptive implants are highly effective. In most studies, 5-year cumulative pregnancy rates are less than 1.5/100 women for Norplant and Norplant II. No study has yet reported any failures with Implanon. Weight over 70 kg and age at insertion under 25 years both increase the failure rate of Norplant and Norplant II; however, data are as yet lacking for Implanon. The effectiveness of other progestogen-only implants for which there are as yet few data are unlikely to be any different. Continuation rates are high compared with other hormonal methods and with the intrauterine device. In most cohorts at least 35% of women, and often many more, are still using Norplant by the end of 5 years. Rates vary according to a number of factors, including population studied, age, and parity. Menstrual disturbance is by far the most common reason for discontinuation, with headache, acne, weight gain, and desire for pregnancy accounting for other common reasons for implant removal. Fertility returns rapidly following implant removal, and pregnancy rates (76-100% 1 year after removal) are usually no different from those following discontinuation of any other contraceptive method. There is no increase in the risk of ectopic pregnancy, fetal malformation, or impaired infant health in pregnancies conceived either during implant use or after removal.     

Factors associated with oral contraceptive discontinuation in rural Bangladesh

Oral contraceptives (OCs) account for half of all modern contraceptive methods used in Bangladesh, however, discontinuation remains fairly high in OC use. This paper identifies factors associated with discontinuation of OC use, where discontinuation refers to cessation of OC use in the 6 months prior to the survey. The data for this study were drawn from a survey on OC compliance in rural Bangladesh. A total of 1600 OC users, current or past, aged 15 to 49 years were interviewed; of these, 36% discontinued OC use. Of the women who discontinued, 47% reported the experience of side-effects as the main reason for OC discontinuation. Multivariate analysis identified lack of fieldworker's visit as the strongest predictor of OC discontinuation; women who were not visited by fieldworkers had a four-fold risk of discontinuing OC use. Discontinuation of OC use decreased with increased duration of use and number of living children. OC discontinuation was associated with side-effect experiences, lack of husband's support in OC use and failure to purchase OCs. Of great concern is that about 70% of the women who were at risk of unintended pregnancy were not using any method of contraception following OC discontinuation. Husband's education was positively associated with the substitution of OCs with another contraceptive method. Effective OC use should be advocated through adequate counselling about how to take it correctly, the possibility of side-effects and their proper management and, more importantly, the possible alternative contraceptive method should OCs prove unsatisfactory or unsuitable. Better provider-client interactions along with improved access to the newly established community clinics could be instrumental in the continued and effective use of OCs.     

Contraceptive discontinuation attributed to method dissatisfaction in the United States

BACKGROUND: This study examines contraceptive discontinuation due to method dissatisfaction among women in the United States. STUDY DESIGN: The study population, drawn from the 2002 National Survey of Family Growth, consisted of 6724 women (15-44 years of age) who had ever used a reversible contraceptive method. We first estimated the overall proportion of women who had ever discontinued their contraceptive due to dissatisfaction. We then calculated method-specific discontinuation risks due to dissatisfaction and analyzed the reasons for dissatisfaction given by women who had ever stopped using Norplant, Depo-Provera, oral contraceptives or condoms. RESULTS: Overall, 46% of women had ever discontinued at least one method because they were unsatisfied with it. Dissatisfaction-related discontinuation risks varied widely by method: the diaphragm and cervical cap showed the highest proportions of such discontinuation (52%), followed by long-acting hormonal methods (42%). Oral contraceptives were associated with an intermediate risk of dissatisfaction-related discontinuation (29%), while condoms had the lowest risk (12%). CONCLUSION: A broader understanding of women's concerns and experiences using contraception could help health care providers redesign counseling strategies to improve contraceptive continuation.     

The user perspective in northern Thailand: a series of case studies

Comprehensive case histories were obtained from 37 rural Thai women to gain a deeper understanding of the factors that influence the behavior, perceptions, and attitudes of long term contraceptive users. As a group, the women had experimented with a wide range of contraceptive methods, and while many experienced side effects, there was a very high level of motivation to use and continue contraception. The government family planning delivery network appeared successful in making family planning services accessible, and health workers were often consulted. A potential health problem for some women stems from their continuous use of certain temporary family planning methods, such as the pill; they had been using them for more than 10 years and indicated their desire to continue until menopause. The subjects all live in Lampang province in varying levels of prosperity and accessibility to family planning and health centers. All but 1 woman began contraception with the pill with 58% continuing. 41% had changed their initial method. Reasons for using family planning included wanting no more children (39%), poverty (36%), desire for spacing children (20%), and not ready to have a family (5%). A majority discussed their decision with friends before going to obtain contraceptive methods, and went to government sources for this service. Place of service, cost of services, and attitudes toward childbirth, abortion, menstruation are also detailed. All feared abortion more than childbirth; 21 out of 37 respondents expressed no concerns with menstruation although for some work and religious attendance was affected by beliefs associated with menstruation.     

Norplant as a Contraceptive Device in Enugu, Eastern Nigeria

This paper is an evaluation of acceptability and use-experience with the contraceptive device Norplant at the University of Nigeria Teaching Hospital, Enugu, Eastern Nigeria. Over a period of 36 months, 173 women (8% of the clinic population) accepted the implant. Use of Norplant was concentrated among high-parity women, and the proportion of Norplant users was highest among women aged 30–34 years. Comparing Norplant and IUD users, we found Norplant users to be significantly less highly educated with <1% of Norplant users having tertiary education compared to 25% of new IUD users. The continuation rate with Norplant was 89% at three years, suggesting this method has the potential for improving the low contraceptive prevalence in this region.     

A multicenter comparative study on the efficacy, safety, and acceptability of the contraceptive subdermal implants Norplant and Norplant-II

In order to assess efficacy, safety, and acceptability of the contraceptive subdermal implants Norplant^® and Norplant^®-II in Mexican women, a comparative phase III clinical trial was undertaken in eight clinics across the country. The study involved 1052 women who were followed-up trimonthly for three years. Cumulative pregnancy rates were 0.29% and 0.34% for Norplant and Norplant-II implants, respectively. Similar overall cumulative discontinuation rates were observed at three years: 50.38% for Norplant capsules, and 50.44% for Norplant-II rods. The main method-related reason for termination was endometrial bleeding irregularity which led to discontinuation rates of 11.94% and 11.62% for Norplant and Norplant-II contraceptive systems, respectively. In 15,279 woman-months of experience accumulated with Norplant implants and 14,092 with Norplant-II implants, there were few adverse events reported. No difference was found between the two groups in either difficulty for implants placement and removal or women's discomfort, even though the time required for insertion and removal of Norplant capsules was longer than for Norplant-II rods. It is concluded that during the first three years of use, both implants systems are equally effective, safe, and acceptable.     

Norplant: users' perspective in Pakistan

Five hundred and eighteen Norplant acceptors (260 ever-users and 258 current users) were interviewed to assess their perceptions about Norplant. The mean age of the acceptors was 32.6±5.7 years (mean±SD). The mean parity was 4.3 and many of the users (40.2%) were illiterate.The most common reason to choose Norplant was its long duration of action (70.1%) followed by doctor's advice (10.4%) and use by other women (10.1%). Norplant was recommended by family planning workers in 35.3% cases, doctors in 29.2% cases and friends in 17.4% cases. Advertisement did not play any role in the women's choice of Norplant.In 77.3% cases, the decision to use Norplant was a joint decision. Only 15% of the users had fears/anxieties before insertion. Most of these women (44%) were concerned about possible ill-effects of Norplant on their health rather than efficacy. The social acceptance of Norplant was very high (76%) and more than half of the users (52.5%) were satisfied with the method.Among current users, 83.9% wanted to continue Norplant for 5 years. Only 39 users (15.1%) intended to discontinue. The main reason for discontinuation was menstrual disturbance (69.2%), followed by weight gain (12.7%).The study suggests that long duration of effective action and high social acceptance are likely to make Norplant a popular method among Pakistani women.     

Side effects and oral contraceptive discontinuation in rural Bangladesh.

Using data from a survey on oral contraceptive (OC) compliance in rural Bangladesh, this study examines the role of side effects on OC discontinuation along with other potential predictors. A total of 1403 currently married women aged 15-49 years were interviewed; of these 43% discontinued OCs. Of the women who discontinued, 53% did so because of side effects, which was the main self-reported reason for OC discontinuation. Multivariate analysis revealed that after adjusting for duration of OC use, women who experienced side effects were 1.4 times more likely to discontinue OC use than their counterparts without such experience. Discontinued OC use was also associated with being Muslim, not being visited by field-workers, OC use as first method of contraception, lack of husband's support, and was inversely associated with duration of OC use. Adequate counseling about OC use, emphasizing the possibility of side effects, and better management of them, coupled with improved client-provider interaction and husband's supportive role could help in reducing OC discontinuation in rural Bangladesh.     

Korean experience of abortion

Dr Sung-bong-Hong, of the department of obstetrics and gynaecology, Woo Sok University, Seoul, has studied the effect of induced abortion (which is illegal) in Korea. It has markedly reduced the birth rate, and in the women he studied is used mainly by those in the higher scio-economic strata. In Seoul Cith, 33% of pregnancies in married women end in induced abortion. Nearly 80% of all induced abortions in Korea are of fourth or later pregnancies--family limitation being the main motive. Although both Buddhism and Catholicism prohibit destruction of life, about a quarter of the women belonging to both these religious groups have induced abortions. Dr Sung-bong-Hong concludes that until contraceptive practice becomes established women will resort to induced abortion, especially those with large families. The women pay moderate fees for this operation and most receive good medical care. Many husbands are just as interested in family limitation as their wives once there are several living children. This motivation towards limitation of families may help to popularize contraceptive methods once the women have been educated towards them.     

‘Marriage means having children and forming your family,so what is the need of discussion?’ Communication and negotiation of childbearing preferences among Bangladeshi couples

This paper explores communication and negotiation regarding contraception and childbearing based on multiple semi‐structured interviews with 19 married couples in southwestern Bangladesh. The narratives of three couples are presented to describe how sociocultural context and gender‐based norms influence interactions between husbands and wives and their fertility decision‐making. Despite national‐level declines in fertility, the couples' stories illustrate the ongoing struggles to balance their desired number of male and female children with their financial and social well‐being. The stories also indicate that the nature of the interactions between spouses evolves throughout the course of their marital and reproductive lifespans, resulting in a shift in fertility decision‐making power. Both wives and husbands described the relative powerlessness of new wives in negotiating fertility with husbands and extended family; however, wives' preferences appeared to dominate as they became more established in their households. Many wives acted independently and often contrary to their husbands' desires, through their covert use or non‐use of contraception and pregnancy termination. These findings illustrate that, despite efforts to increase contraceptive availability within Bangladesh, without concurrent changes in the opportunities available for women beyond their reproductive capacities, the demand for children, and particularly for male children, is not likely to change.     

Contraceptive use in Matlab, Bangladesh: the role of gender preference.

Research in several Asian societies has suggested that sons are generally preferred over daughters. The implications of gender preferences for actual fertility behavior have not been adequately investigated, however. This analysis examines the effect of the sex composition of surviving children on the acceptance and discontinuation of contraception in a sample of 3,145 women in Matlab, Bangladesh, who were observed for 60 months. Hazards regression analyses are employed in the analysis. Strong and highly significant effects of gender preference on contraceptive use are observed. The preference is not monotonically son-biased but is moderated toward a balanced composition, because parents desire to have several sons and at least one daughter. These findings suggest that gender preferences, particularly a preference for sons, represent a significant barrier to fertility regulation in rural Bangladesh.     

Norplant: what health educators need to know

The US Food and Drug Administration approved the contraceptive implant Norplant in December 1990. Many US physicians and nurse practitioners have received training in inserting the implant, but few health educators know enough about Norplant and potential users to provide adequate education and counseling. The 6-capsule system steadily releases 50-80 mg levonorgestrel into the bloodstream for five years for a contraceptive effectiveness rate greater than 99%. Levonorgestrel keeps the pituitary gland from releasing two hormones needed for ovulation, thickens the cervical mucus, and suppresses endometrial development. Irregular bleeding is the most common side effect. Contraindications for Norplant include liver tumors, active liver disease, breast cancer, active thrombophlebitis, unexplained uterine bleeding, pregnancy, blood clots in the eyes or lungs, diabetes, hypertension, and cigarette smoking. Advantages are its 5-year effectiveness period, that it is easy and convenient to use, does not require compliance, and is reversible. Disadvantages are that it offers no protection against sexually transmitted diseases, especially HIV/AIDS; it requires a surgical procedure; and its cost ($500-$750/patient). Few studies present a profile of US women using Norplant. Potential users are adolescents, vulnerable women, low income women with children, and women who do not want to become pregnant for a long time but do not consider the pill or sterilization viable options. Extensive research indicates that Norplant is safe in the short and intermediate term. More research is needed to identify the demographic profile of a typical user, why she chooses Norplant, how well she understands it, or whether she was well informed about it; to learn about satisfaction with Norplant; and to find out who discontinues Norplant before the end of 5 years. This information would help health educators in their counseling and education strategies.     

国产18甲基炔诺酮皮下埋植剂的临床研究

666例40岁以下健康育龄妇女所参加的前瞻性多中心研究,经过一年观察,国产组333例中无妊娠,对照的Norplant-1组发生1例妊娠,妊娠率0.3/100妇女,二组的续用率同为94/100妇女。     

Women's autonomy and husbands' involvement in maternal health care in Nepal

Both increasing women's autonomy and increasing husbands' involvement in maternal health care are promising strategies to enhance maternal health care utilization. However, these two may be at odds with each other insofar as autonomous women may not seek their husband's involvement, and involved husbands may limit women's autonomy. This study assessed the relationship between women's autonomy and husbands' involvement in maternal health care. Field work for this study was carried out during September–November 2011 in the Kailali district of Nepal. In-depth interviews and focus group discussions were used to investigate the extent of husbands' involvement in maternal health care. A survey was carried out among 341 randomly selected women who delivered a live baby within one year prior to the survey. The results show that husbands were involved in giving advice, supporting to reduce the household work burden, and making financial and transportation arrangements for the delivery. After adjustment for other covariates, economic autonomy was associated with lower likelihood of discussion with husband during pregnancy, while domestic decision-making autonomy was associated with both lower likelihood of discussion with husband during pregnancy and the husband's presence at antenatal care (ANC) visits. Movement autonomy was associated with lower likelihood of the husband's presence at ANC visits. Intra-spousal communication was associated with higher likelihood of discussing health with the husband during pregnancy, birth preparedness, and the husbands' presence at the health facility delivery. The magnitude and direction of association varied per autonomy dimension. These findings suggest that programs to improve the women's autonomy and at the same time increase the husband's involvement should be carefully planned. Despite the traditional cultural beliefs that go against the involvement of husbands, Nepalese husbands are increasingly entering into the area of maternal health which was traditionally considered ‘women's business’.     

Acceptability of levonorgestrel subdermal implants versus tubal ligation for long-term contraception in a rural population of Zimbabwe

This prospective cohort study of 257 rural Zimbabwean women was designed to compare patient satisfaction with levonorgestrel subdermal implants (Norplant and reg;) versus tubal ligation (TL) as a method of long-term contraception. Women were equally satisfied with both methods. At 1 year, 96% of Norplant users and 97% of the TL group reported being “satisfied” or “very satisfied,” and 98% of Norplant users, and 99% of the TL cohort would recommend their chosen method to a friend or relative. Rating scores at both 6 months and 1 year were high and equal, with women in each cohort rating their method, on average, as 9 out of 10. Norplant users were significantly more likely to rate birth spacing as a reason for satisfaction with their method, whereas women in the TL cohort were more likely to select multiparity. The 1-year continuation rate with Norplant was 90%, with 4% discontinuing in order to have more children. Selecting the most appropriate method depends primarily on the potential desire of the woman to have more children.     

Gendered interests and poor spousal contraceptive communication in Islamic northern Nigeria

Relying on focus group discussions and in-depth individual interviews with men and women in Jigawa and Kano states in northern Nigeria, we investigated barriers to spousal contraceptive communication. While attitudes toward spousal contraceptive communication were generally positive, there was very little evidence that respondents engaged in it. Poor spousal contraceptive communication in northern Nigeria is, in many ways, driven by the ample incentives that husbands and wives have to keep having children. For wives, having many children stabilises their marriage. It prevents husbands from marrying additional wives and sustains their attention and investments even if they ultimately do. For husbands, having many children helps them to keep their wives from objecting to their taking other wives and to mollify them by showing their continued commitment to that relationship should they take other wives. Our findings clearly challenge conventional population, family planning and reproductive health programmes that view high fertility as disempowering for women, and contraceptive use as capable of redressing gender inequality. New norms of gender relations are key to promoting contraceptive uptake and smaller families in northern Nigeria.     

Enhanced metabolism of levonorgestrel during phenytoin treatment in a woman with Norplant implants

A 26-year-old woman, treated with phenytoin for 10 years because of epilepsy, had Norplant subdermal implants inserted after a legal abortion. She became pregnant again after nine months of Norplant use. Her plasma levonorgestrel (LNG) levels were followed during one month during phenytoin treatment and then later during one month after discontinuation of phenytoin. During phenytoin treatment, plasma LNG levels were markedly below the levels found in healthy women with Norplant. There was a pronounced, statistically significant increase in plasma LNG levels after discontinuation of phenytoin. The plasma levels of sex hormone binding globulin were markedly above those found in normal healthy women during treatment with phenytoin and decreased significantly after cessation of phenytoin. The effects on the pharmacokinetics of LNG were reflected by effects on the menstrual cycle. During phenytoin treatment, the woman had regular ovulatory menstrual cycles. After cessation of phenytoin, her cycles became irregular and during the study period of one month, no signs of ovulation were found. It is concluded that treatment with phenytoin during use of Norplant subdermal implants enhances the metabolism of LNG to an extent where the contraceptive efficacy is endangered.