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Annals of African Medicine, Vol. 5, No. 1, 2006, pp. 20-23 Norplant® Acceptors in Jos, Nigeria J. T. Mutihir, F. Guful and I. A. O. Ujah Department of Obstetrics and Gynaecology, JosUniversity Teaching Hospital, Jos, Nigeria Reprint requests to: Dr. J. T. Mutihir, Department of Obstetrics and Gynaecology, JosUniversity Teaching Hospital, Jos, Plateau State, Nigeria. E-mail: jtmutihir01@yahoo.co.uk Code Number: am06005 Abstract Background:The Norplant contraceptive
implant has since been an accepted long-term steroidal method of contraception
in Jos. It is now competing favorably with the older methods in our center. Key words:Norplant, acceptors, contraceptive, Jos–Nigeria Résumé Fond:
L'implant contraceptif de Norplant a été depuis longtemps accepté comme une
méthode stéroïdale de contraception à long à Jos. Il concurrence
maintenant favorablement avec les méthodes plus anciennes à notre centre. Mots clés: Norplant, accepteurs, contraceptif, Jos- Nigéria Introduction Norplant® implant development began in 1966 with the pioneering research work of Segal and Croxatto, made possible by the introduction of silicone rubber in the late 1940s. 1, 2 The goal of this development was to develop a contraceptive that would allow women to make a single decision resulting in effective contraception for many years. 3 Norplant is the trademark of the Population Council for levo-norgestrel subdermal implants. 4 Norplant became registered for use in Nigeria with National Agency for Food and Drug Administration and Control (NAFDAC), in 1998, with the registration number of 04-110. 5 A local clinical trial was conducted on the product before its registration by NAFDAC; and to date, no adverse reports have been received following its use. Women of any age and parity, with or without children can use the implants for contraception. A set of Norplant capsules can prevent pregnancy for at least 5 years, and may prove to be effective for a longer period of time. Norplant contraceptive implants though a safe, effective, convenient, and cost-effective family planning method; yet the use remains low in most African countries. This long term subcutaneous implant offers an alternative for child spacing, and is used as a long-term reversible method of contraception. 6 The level of utilization of modern contraceptives in Nigeria is still low. Despite the high level of contraceptive awareness in Nigeria, only 9% of women of reproductive age (15-49 years) and 16% of men (15-64 years) are using modern contraceptives. 7 Contraceptive use in Sub-Saharan Africa and Nigeria is low, below 10%, and this is also true in Nigeria where Norplant users constitute less than one per cent of all family planning users. 8 Jos University Teaching Hospital, a tertiary health center, provides all the types/methods of contraception. It commenced Norplant services to desiring clients in 1985, along with other methods of contraception. The acceptance rate, its utilization and continuation rates have apparently been on the increase over the years. We therefore decided to review the records to evaluate the socio-demographic characteristics of clients accepting Norplant at the centre. Materials and Methods This is a retrospective study of the socio-demographic characteristics, previous contraceptive behaviour, and sources of referral. From May 2002 to July 2004, all records of women attending the family planning clinic of the Jos University Teaching Hospital were studied and their number noted. Those that accepted the Norplant implant method of contraception were further analyzed for their previous use of contraceptive method, marital status, age distribution, parity, weight at insertion and the source of information about the method. The data was analyzed using the Epi-Info 2002 software. Results A total of 3,793 women accepted contraceptive methods within the period of study. Two hundred and sixty had Norplant insertion after due counseling, constituting 6.8% of all contraceptive methods in the center (Table 1). All clients were married, and 85.4% of them had used other methods of contraception before switching over to Norplant implants. Most of the clients had used multiple methods of contraception before switching over to the Norplant implants. The injectables had been used by 22.7% of the clients. About 20.8% had used the pills, 10.8% the intrauterine contraceptive device and only 1.9% had used the natural method of contraception (Table 2). The ages of the clients accepting Norplant implants ranged from 18-48 years with a mean of 33.1 ± 5.33 years and majority (80.8%) was within the age range of 25-39 years (Table 3). The women were of parity 0-8 and a mean of 3.57 ± 1.58. Women that had not been pregnant or delivered (nulliparae) were also using the method. The women of parity 3 used the method in 27.3% of the cases (table 4). The weight of the women ranged from 32-95 kg and a mean of 65.78 ± 11.74 kg, and 33.5% were of weight of above 70 kg (Table 5). Majority (94.5%) of them were literate women. The commonest source of information about the method was the family planning clinic (50%), followed by the antenatal clinic 32.4%. Husbands and the mass media were the sources of information in 4.2% and 3.5% respectively (Table 6). Table 1: Acceptors of contraceptive methods in Jos University Teaching Hospital, Nigeria
Table 2: Previous contraceptive methods used by 222 clients accepting Norplant
IUD: Intrauterine contraceptive device Table 3: Age distribution of 260 clients accepting Norplant
Range 18-48 years (mean 33.1 years) Table 4 Parity of 260 clients accepting Norplant
Range 0-8 (mean 3.57) Table 5: Weight at insertion of 260 clients accepting Norplant
Range 32-95kg (mean 65.78 ± 11.74 kg) Table 6: Source of information about Norplant implants among 260 clients
Discussion This study reveals that Norplant acceptors constituted about 7% of all contraceptive methods in Jos. The cost of the contraceptive though subsidized to a large extent still makes it the most costly contraceptive method in the center. This may be the reason for the acceptance being relatively low among our clients, as mainly the literate who can afford the cost patronize it. Though available and accessible to clients, it is not affordable to many potential users. The utilization of contraceptive methods depends to a large extent on accessibility, availability, and affordability to potential users. 9 Long active methods of contraception have been developed and refined over the last 20 years. 6 Norplant contraceptive implants have been available in Nigeria for almost 20 years. 8 With an increase in available methods of contraception (method mix), there is usually an attendant increase in contraceptive acceptance. Another phenomenon observed was method switch from other methods to the newly introduced method. Method switch was observed in about 85% of the clients. About 10% were continuing with the method after a five-year period of use in the first instance and about 5% of the clients were totally new clients to contraception and had never used any method of contraception before this time. All our clients were married women. A client whose husband died 10 months after the insertion had the capsules removed within 12 months of insertion. Ladipo in a study in Ibadan had married women constituting 92.7% of the clients, single women 4.5%, and widows 2.8%. 10 The reason for this difference is that single women in this part of the country shy away from obtaining contraceptive advice or a method from public health institutions for fear of being labeled as promiscuous. The mean age (33 years) of Norplant acceptors appeared younger than those accepting bilateral tubal ligation (36.4 years) at the same center, 11 but higher than the mean age of 29.6 years in Norplant acceptors in Ibadan. 10 About 0.8 percent of the clients were of parity 0, as they were married but still in school and did not want to start child bearing until they had competed the school. This contrasts with the intrauterine device (IUD) where because of the slight increase in the risk of pelvic inflammatory disease in users, nulliparity or women of low parity are advised to consider more suitable contraceptive methods for fear of infection with subsequent tubal damage and infertility. 12 The mean number of living children at the time of Norplant insertion in the clients was 2.8, and lower than the finding of 4.4 in Ibadan. 10 Our clients appear to use this contraceptive more for child spacing or postponement of childbirth. The mean weight of the clients accepting the method in the study was about 66 kg. This was higher that that the reported figure of 55 kg, from Ibadan. 10 Norplant has a higher rate of pregnancy among heavy women, and clients weighing 70 kg and above have been known to be associated with an increased failure rate. 13 This group of women constituted about 34% of the acceptors despite appropriate counseling about the increased failure rate in women above 70 kg. No failure has been recorded in the series so far in any group of the clients. The commonest source of information about Norplant in the clients was the family planning clinic of the hospital. This is expected as the clients come for contraception and are informed about all contraceptive methods including Norplant, its mechanism of action, duration of action, common side effects, other untoward effects amongst others. This was the source of information in 50% of the acceptors. About a third of the clients also heard of the Norplant contraceptive in the antenatal clinic where health talks including contraception and the methods are discussed. Not surprisingly, husbands, concerned about the number of children, were also the source of information to their wives in about 4% of cases. Other studies in Ibadan had a similar finding in the source of information and source of referral. 10 During the period of study, continuation rate was about 99%, as only two clients discontinued the method, that is, one each for infection and the loss of a spouse. This was higher than another study where approximately 88% of women continued to use the implants at one year, and about 50% in the third year. 13 A wide range of clients in seeking for contraception to limit or space their births have benefited from the Norplant contraceptive method. Younger women of lower parity appear to prefer this method to older clients. Weight of over 70 kg is no more deterrent to intending clients from accepting and using this method of contraception. Method switch from other contraceptive methods to Norplant was observed in the study. Women now have another safe and effective long-term method to rely upon for contraception. The acceptance of the method entails that sustainability measures be put in place to ensure the continuous supply of the method of contraception at affordable prices for desiring clients. References
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