Public Health Magazine: Spring 1996, Vol.4, No.1
Issues & Answers-- Norplant: Reality Check

A Long-lasting Contraceptive Raises Many Questions

Even before it was approved by the Food and Drug Administration (FDA) in 1990, Norplant-a long-acting contraceptive-was hailed as a major breakthrough in family planning circles. As the first truly new method in 30 years, it greatly enhanced contraceptive options. Norplant has special attributes that, with the exception of the IUD, really do not exist in other methods. It offers greater effectiveness, longer duration, and requires no effort by the user. The fact that 57 percent of U.S. pregnancies are unintended and half of these end in abortion, points to the need for new contraceptive methods.

Despite its promise, the method has raised many questions and, in fact, has declined in popularity in the past two years. Columbia Public Health invited two researchers who have studied patient satisfaction with this contraceptive for four years to open the discussion.

This conversation took place at Columbia School of Public Health in New York City with the co-principal investigators of the largest federally funded study of Norplant use in the United States.

Debra Kalmuss, Ph.D., is an associate professor of clinical public health in the Division of Population and Family Health. She is an expert in contraceptive methods, pregnancy resolution and fertility decision making, and adolescent childbearing.

Andrew R. Davidson, Ph.D., is an associate professor of public health in the Division of Population and Family Health and associate dean of academic affairs. He is an expert in contraceptive methods, family planning and fertility issues.

Jean Llewellyn is director of public relations for Columbia School of Public Health.

How does Norplant work?

Norplant uses the same hormone (the progestin levonogestrel) that has been used in a number of oral contraceptives for years. A safe and effective method, according to a recent reevaluation by the FDA, Norplant consists of six hormone-releasing rods, match stick size, that are implanted in the upper arm for five years of pregnancy prevention. The rods must be inserted and removed by a physician or nurse trained in the technique. After a counseling session and making the decision to have the Norplant surgical procedure, a woman does not have to do anything until she decides to see her physician to have it removed. She cannot simply discontinue its use; it requires a minor surgical removal procedure. So while "you can't start it on your own and you can't end it on your own," says Kalmuss, "it's still the most effective way to retain your fertility but be assured that you won't have a child."

What accounts for the decline in popularity of Norplant?

"Norplant has suffered a one-two punch," says Davidson. "First, it was branded a method of social control. Second, it has been the victim of exaggerated media attention." The root problem is the labeling of Norplant as an instrument of coercion. Within two days of the FDA approval, an editorial in the Philadelphia Inquirer suggested that Norplant should be used as a tool in the fight against black poverty. The effect was immediate. Norplant was cast as a method of social control. As the columnist Ellen Goodman noted, "It took 24 years to develop, test, and approve an implantable device...it took less than two weeks for Norplant to be billed as a new method of coercion." Adds Davidson, "Twenty-five years of research and development and the fact that tens of thousands of women were in the trials are ignored."

Davidson

Why did Norplant become branded as an instrument of coercion of minority groups?

Fears about the coercive use of Norplant initially focused on public action targeted at poor and minority women. Legislators in 13 states have proposed nearly two dozen bills to use Norplant for social engineering purposes-making the use of Norplant a condition of receiving welfare payments or enticing women on welfare to use Norplant through financial incentives. A small number of women convicted of child abuse have had Norplant inserted as a condition of probation. Poor single mothers, who are frequently women of color, were singled out for fertility control. Because these policy makers specified Norplant as the agent of control, it is seen as an instrument of coercion. These concerns were particularly charged because of the involuntary sterilization of poor and minority women as recently as the 1970s.

"In fact," says Kalmuss, "the reality of public coercion has been far less dramatic than its threat." No state legislature has enacted into law any of the proposals linking Norplant to welfare payment. And forced use of Norplant by the judicial system is abating: it is illegal in Illinois; in California, a judge is facing formal disciplinary charges for making Norplant insertion a requirement of probation.

Do the women who use Norplant think they have been coerced?

"Not according to our findings," says Davidson emphatically, referring to the NIH study he and Kalmuss are conducting. When 2000 women in large urban health care systems, where most poor and minority women receive their family planning services, were asked if they had felt any pressure from a health care provider to use Norplant, only three said yes. One of these chose sterilization-suggesting she was feeling pressure to avoid a permanent method of contraception. The other two returned to the clinic a number of times, suggesting that pressure was not associated with a rush to insert Norplant. Kalmuss points out, "The women rated the process of obtaining Norplant as significantly more difficult than that for obtaining the pill-which they take with them when they leave the building after counseling." Adds Davidson, "Remember, our Norplant counseling sessions last an average of 40 minutes."

Kalmuss

What do the women have to say about Norplant?

"Overwhelmingly, women pointed to Norplant's pluses-convenience, effectiveness and duration-as the reasons for their choice," says Kalmuss. "Let the data speak for the women's satisfaction: 87.3 percent of the women surveyed would make the decision to use Norplant again; 91.5 percent would recommend it to a friend; 81.8 percent plan to use Norplant for the full five years. Only seven percent regretted using the method." She adds, "The removal rate after six months is about seven percent; this is a lower discontinuation rate than any of the other reversible methods."

Why have the media focused on Norplant? "In the spring and summer of 1994," says Davidson, " class action suits were initiated against the U.S. distributor of Norplant. The suits focus on the adequacy of information provided on potential side effects of the method, as well as the adequacy of health care providers' training to remove the implant. Newspapers, magazines and television and radio news programs carried stories-some of which were considered sensational-about the potential risks associated with Norplant. "We know that the numbers of women requesting Norplant have diminished dramatically since the July '94 media blitz. In addition, women's satisfaction with the method declined, although-as you can see from the chart (far left)-it remained at a high level," adds Davidson.

What are the implications of the Norplant experience?

"Media and court cases have silenced the voices of many women and health care professionals who support Norplant," says Davidson. "The method has been stigmatized by overstated concern about coercion. This has made it difficult for women and providers alike to impartially evaluate Norplant. The pervasive shroud of controversy surrounding the method is troubling." And according to Kalmuss, "If Norplant is pulled from the market, it is a nail in the coffin of contraceptive development in this country."