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.     

Blood-lipid fractions: the side-effects and continuation of Norplant use

Objectives: Norplant has been widely used in Indonesia, though a previous study conducted in Jakarta indicates that there is a significantly high cholesterol level in acceptors. Other international studies indicate different results. Accordingly, a study on the fraction of blood lipids of Norplant acceptors was considered necessary.Material and procedures: A prospective cohort comparative study was conducted in the Dr Kariadi General Hospital and Primary Health Center at Gunungpati. Clinical and laboratory observations were done by means of pre-post test design. Norplant acceptors were treated as the case group while IUD acceptors were the control group. Cholesterol level, triglyceride, HDL, LDL, and ratio of cholesterol:HDL, side-effects and continuation of use were evaluated.Results: The subjects were 91 Norplant and 89 IUD acceptors. Norplant acceptors showed the following study results: Total cholesterol showed a slight decrease (165.06-132.80 mg/dl), triglycerides were slightly increased (76.23-81.87), HDL showed a decrease (45.55-38.85), and so did LDL (105.75-78.55); the ratio of cholesterol:HDL remained constant (3.75-3.78) and all fraction levels of blood lipids were within the limit of tolerance and did not exceed the critical value. Normal menstrual blood flow remained constant, but heavy menstrual blood flow decreased. The cycle of normal menstruation was reduced and the inter-menstrual bleeding and the 2-3 month menstrual cycle were increased. Complaints of dizziness/headache, leucorrhea, and pain at insertion were all relatively few. There was no change of body weight and blood pressure. Continuation of use was 100%.Conclusions: The fraction of blood lipids found indicates varied results though blood lipids are still below critical values; it can be concluded that there is no risk of coronary heart disease.The continuation rate of Norplant use was high, due probably to side-effects counseling, and the social and cultural circumstances of acceptors.     

Factors affecting continuation rates of DMPA

A prospective study was conducted with 430 new depot medroxyprogesterone acetate (DMPA) acceptors to estimate continuation rates and investigate factors associated with length of use. Data were collected on services received and sociodemographic characteristics of participants. Women were enrolled over the course of 1 year and were followed for up to 13 months. Failure to return to the same clinic within 104 days of the last injection was the outcome of interest. The 3-, 6-, 9-, and 12-month continuation rates were 68%, 67%, 55%, and 51%, respectively. In the bivariate analysis, women who were told to return to the clinic for side effects were more likely to continue using DMPA than those who were not given such advice (p <0.05). Likewise, women who received information on DMPA efficacy, side effects, and amenorrhea were more likely to continue using DMPA compared to those who did not receive such information (p <0.05). A proportional hazards regression model was constructed to estimate the simultaneous effect of various factors on length of use. In results consistent with the bivariate analysis, women who were told to return to the clinic were 2.7 times more likely to continue using DMPA compared to women who did not receive that advice. Likewise, women who were told about the possibility of amenorrhea were 2.5 times more likely to continue using DMPA compared to those who did not receive that information. The regression model also identified new factors such as number of children, attitude toward menstruation, lactating at admission, and spousal input on method choice. The findings suggest that providers play an important role in ensuring the highest possible continuation rates for DMPA.     

Efficacy and side effects of Norplant use in Thai women above the age of 35 years.

A prospective study of Norplant implant use in women aged above 35 years was conducted in Bangkok, Thailand. The purposes of this study were to evaluate the efficacy, menstrual patterns, and side effects of Norplant use in these women. A total of 100 women were recruited in a 1-year clinical study. Their mean age was 39.7 years. Most acceptors had completed secondary school. No accidental pregnancy occurred throughout the 1 year of use in this study. The most common menstrual pattern in these acceptors was amenorrhea followed by irregular bleeding. The major side effect was irregular bleeding. There was no significant change in systolic and diastolic blood pressure during the 1 year follow-up period. Thus, Norplant implant use in older women is a safe and effective contraceptive method. This should become another choice for contraception in women aged above 35 years who have contraindications for oral contraceptive use.     

A comparison of program and contraceptive use continuation rates in a family planning clinic.

Programs and contraceptive use continuation rates were obtained for a rural Georgia family planning clinic. Program continuation is a measurement of maintenance of clinic attendance, while use continuation is related to actual use of effective contraceptives regardless of clinic activity status. Program continuation rates ranged from 0.77 at 12 months to 0.48 at 36 months. Contraceptive use continuation rates were 0.78 at 12 months and 0.58 at 36 months. Women who moved or were otherwise lost to follow-up formed the largest category of discontinuation. The highest rate of discontinuation from clinic attendance occurred after the first visit with secondary peaks around the time of scheduled annual checkups. Women who were younger and had fewer living children had a greater likelihood of discontinuing clinic attendance and contraceptive use. The reasons for and timing of discontinuation from clinic attendance suggest that clinic personnel should place special emphasis on the first visits, arrange referral for women who might have plans to leave the service area before the scheduled return visit, send reminders before first revisits, and follow up patients soon after missed visits. Priority might be assigned to the younger women of low parity who have been shown to be at higher risk of discontinuation. Other factors which might influence continuation include method of contraception, marital status, and race. Program continuation can be determined by analysis of clinic records alone while contraceptive use continuation often requires follow-up of patients. Although the two continuation rates were not equivalent, program and use continuation were roughly parallel through much of the study period. This suggests that a simple review of records in the clinic or on computer tape, when available, to determine program continuation may give an estimate of actual contraceptive use in the population.     

Singapore: a study of clinic continuation rates

The continuation rates of oral contraception in the Singapore National Program based on clinic record cards of women who were first seen between July 1, 1967 and December 31, 1968 are reported. 2969 cases were studied. 39% of the pill users were still continuing with the method on December 31, 1969, 17-30 months after original acceptance. The women 30 years old and over were more persistent pill users. It was also determined that Malay women were more likely to return to the clinic than Chinese or Indians and Pakistanis. The Indians and Pakistanis showed the smallest proportion of women continuing pills. The mean number of living children was 4.1 for continuing program users and 3.2 for dropouts. Of the women who terminated the use of pills due to pregnancy, planned or unplanned, 72% had 0-1 children. Medical reasons, 25%, were the main type given for termination. Nausea, vomiting, and giddiness were the most common medical reasons. Planned and unplanned pregnancy accounted for 9%. Of pregnancies occurring, 83% were planned. As to breaks in use, 59% had no breaks and 29% had 1 break. 28% of discontinuers returned to the clinic for pills. Of the discontinuers, 44% were known to have abandoned contraception after having discontinued the pill. The condom was the most popular method of alternative protection. 31% of the women who dropped out did so after 1 cycle. The cumulative discontinuation rates after cycles 24 and 30 were 628 and 668, respectively.     

Norplant selection and satisfaction among low-income women.

OBJECTIVES: This study examined correlates of Norplant selection and satisfaction among low-income women. METHODS: Interviews were completed in family planning clinics in 4 Florida counties with 1152 Norplant users and 1268 nonusers, with follow-up interviews with a subsample up to 1 year later. Logistic regression models estimated the associations of socio-demographic and medical characteristics with Norplant selection and method satisfaction. RESULTS: Odds ratios for Norplant selection were significantly greater among women who planned to have children in 5 or more years, those who were "offered" Norplant, those who lived in Palm Beach County, those who were using drugs, and those who were Medicaid clients. Women younger than 17 and those who learned about Norplant from a friend were twice as likely as others to select Norplant. Ninety-two percent of Norplant users were satisfied with the method; women with side effects and those who felt pressure to select a method were significantly less likely than others to be satisfied. CONCLUSIONS: Norplant provides an acceptable and satisfying method of birth control for many low-income women. Proper counseling about all methods of birth control and about Norplant's side effects remains critical to the appropriate delivery of this method.     

Carbohydrate metabolism before and after Norplant removal.

Changes in carbohydrate metabolism, measured by oral glucose tolerance test, were studied in Norplant users before and after removal. The mean area under the glucose curve rose from 24.7 min mmol/L before Norplant insertion to 35.1 min mmol/L before removal and decreased to 26.1 min mmol/L four weeks after Norplant removal. The areas before insertion and after removal were not statistically different (95% confidence interval -3.3 to 0.56, P = 0.16). The mean areas under the insulin curves before insertion (53.14 min uU/L) and after removal (59.46 min uU/L), however, were significantly different (95% confidence interval -7.64 to -5.0, P less than 0.0001). We conclude that changes in carbohydrate metabolism induced by Norplant are reversible once the implants are removed. While the changes in glucose induced by Norplant returned to pre-insertion levels within 4 weeks after removal, insulin changes were slower to return to pre-insertion values.     

WHO 86925 Norplant上市后监测(中国部分)

本课题研究目的是对Norplant皮下埋植剂潜在副作用进行监测,以进一步证实其安全性。对使用Norplant和IUD或绝育术的妇女进行比较随访研究。每半年随访一次,详细记录所有健康情况,共随访5年。随访率达99.9％。结果:Norplant组及对照组IUD和绝育术的5年继续使用率分别为76.25、80.89、98.10/100使用者。Norplant的5年累计妊娠率为0.6/100使用者,远低于IUD的8.11/100使用者,宫外孕发生率为0.46/1000妇女年,低于IUD的1.24/1000妇女年,但宫外孕和妊娠之比在Norplant组为31.6:100,远高于IUD的6.7:100,如发生妊娠,要警惕宫外孕的可能。月经问题是Norplant的主要终止使用原因,但使用5年者,其血红蛋白均值上升,和接收时相比P<0.001,而IUD使用5年者,其血红蛋白均值下降,和接收时相比P<0.01。在观察5年中胆囊炎胆石症、纤维囊性乳腺病在Norplant使用者中的发病率高于对照组,P<0.05～0.001,但未发现重大健康问题。Norplant使用5年是安全的。     

Norplant in The Netherlands

An 18-year old patient bearing a subcutaneous Norplant implant in the left upper arm for 2 years visited a gynecological clinic. The implant rods were removed under local anesthesia because of the increasing pigmentation of the skin, and she switched to oral contraceptive use. Norplant contains a total of 216 mg of levonorgestrel (LNG) in 6 silastic rods, each 3.4 cm long. Norplant-2 consists of 3 rods with a length of 4.4 cm providing a total of 140 mg of LNG. It has been in use since 1974 in Chile, and subsequently in Brazil, Indonesia, Thailand, Africa, and to a lesser extent in Scandinavia. It works via the continuous release of 30-50 mcg doses of progesterone daily that induces cervical mucous changes whereby sperm penetration is thwarted; nidation does not occur, and ovulation is also often inhibited. The Pearl-Index reaches .1-1.1 in the first 5 years of use. The most important side effects are menstruation changes (oligo- and amenorrhea), weight gain, and headache. The continuation rate is similar to that of the IUD: 95% through the 1st year of use, and 75% through 3 years reported from Chile and China. Reversibility is a major advantage: 50% of women become pregnant within 3 months after removal, 86% within 1 year, and 93% within 2 years. In the Netherlands sits acceptance is clearly distinct from prevalence in Chile and China, and it has only a minor role in applicability when other contraceptives fail.     

Initiation and continuation rates seen in 2-year experience with Same Day injections of DMPA

BACKGROUND: Women often need prompt initiation of effective contraception. Quick Start/Same Day Start protocols for combined hormonal contraceptive methods have been extensively studied. Experience with Same Day injections of longer-acting progestins is less well reported. The Same Day injection protocol is comprehensive and includes emergency contraception, backup methods for 7 days and repeat pregnancy testing within 2-3 weeks. STUDY DESIGN: This is a historical cohort study based on review of the charts of all women who received injections of depot medroxyprogesterone acetate (DMPA) at the Women's Health Care Clinic at the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center between January 1, 2003, and December 31, 2004. RESULTS: The study population included 1056 women who had a total of 3185 DMPA injections. More than 81% of the initial injections were given Same Day--outside the first 5 days of menses. At each reinjection, 14-27% of women were late and also benefited from rapid access to DMPA. Continuation rates were low in both groups but were not lower among those who utilized Same Day injections compared with On Time starters. Six pregnancies were diagnosed, all in the Same Day Start group. CONCLUSIONS: The introduction of DMPA as a Same Day injection policy is a safe and efficient way of providing women needed effective contraception within 7 days of the office visit.     

Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices

ObjectiveStudies show immediate postpartum (PP) insertion increases use of contraceptive implants and intrauterine devices (IUDs). Our objective was to compare the satisfaction and continuation rates of the two types of devices at 6 months and 1 year following PP insertion.Study DesignWe enrolled 133 women in a prospective cohort study following immediate PP insertion of an implant or IUD at two academic hospitals during 8 months of 2011. Subjects completed an enrollment survey during hospital admission and a follow-up phone survey 6 months and 1 year PP.ResultsAt 6 months PP, 72% of subjects provided follow-up information. Implant users were more likely to be using the originally-placed device (40/41, 98% vs. 45/55, 82%, p=0.02); nine women reported IUD expulsions. When accounting for replacement of expelled IUDs, IUD continuation at 6 months was 89% yielding similar continuation rates between groups (p=0.12). At 1 year PP, 51% provided follow-up. Of those, 82% still had a LARC method in place with similar continuation by device type (84% for implants, 81% for IUDs, p=0.96). Overall, satisfaction was similarly high in both groups.ConclusionDue to IUD expulsion, implants had a higher continuation rate than IUDs six months following immediate PP insertion. After replacement of expelled IUDs, continuation and satisfaction were similar for both devices at 6 months and 1 year.ImplicationsPlacement of implants and IUDs immediately PP can lead to high satisfaction. Despite early IUD expulsions, continuation rates were similar to those placed outside of the immediate PP period.     

Norplant皮下埋植剂使用七年效果

对Norplant皮下埋植剂继续使用7年以上的效果作了多中心研究。3600余妇女使用满6年,2400余妇女使用满7年。第6、第7年的年妊娠率均为0.4/100妇女年。妊娠率随体重增加而增加(P<0.05),随年龄的增长而降低,第6、7年合并计算任何年龄组或体重组其年妊娠平均未超过1/100妇女年。     

Acceptability of Norplant implants for fertility regulation in Singapore.

The continuation rate at the end of this five-year clinical study was 60% with no accidental pregnancy occurring throughout the five years. The post-removal conception rate in women desiring pregnancy was 92% at the end of two years. The majority of acceptors described the overall experience with the implants as favourable. In fact, 75% of the women planning to use contraception after removal of the implants were going to use implants again.     

Natural family planning in New Zealand: a study of continuation rates and characteristics of users

This study has determined long-term continuation rates of clients who attended clinics of the New Zealand Association of Natural Family Planning and became autonomous users. It has also identified factors which might influence the continuation of NFP use.A total of 509 female subjects, 452 of them with their male partners, were enrolled in the study at the beginning of clinic teaching. Once autonomous they were sent questionnaires at 6-monthly intervals for a period of 24 months. Time out was allowed for pregnancy. The number of female subjects entering the 2-year follow-up phase of the study was 406 (79.8%). Of these 164 completed 2 years of use with 102 (20% of study entrants) using NFP and 62 (12.2%) using fertility awareness in combination with a barrier method.Subjects for whom NFP was their first family planning method, who were Catholic or who gave religion as their reason for choosing NFP were more likely to continue long-term use.The majority of subject (> 90%) were highly satisfied with NFP use, with the most common reasons for satisfaction being self-awareness, freedom from drugs, naturalness and effectiveness. The difficulties reported related to abstinence and cycle interpretation.     

Skin damage associated with the Norplant contraceptive.

Three cases of localized skin reaction in the first month after implantation of the Norplant contraceptive resulted in a partial implant expulsion and removal in one patient, and implant removal in another. Clinical evidence of infection was absent in all patients. While lidocaine with epinephrine was used in all three patients, the cause for these skin reactions remains unclear. Physicians should be alerted to the possibility of significant skin reactions associated with this procedure.