Counseling key in Norplant satisfaction
How can you help women who choose the Norplant implant system to achieve satisfaction with the long-term method? Proper counseling about all methods of birth control, as well as Norplant’s side effects, is key to appropriate delivery, according to findings from women in four Florida counties.1
Florida was the first state in the nation to introduce the Norplant system in its publicly funded family planning clinics. Researchers interviewed 1,152 Norplant users and 1,268 non-users who attended public clinics in Duval, Hillsborough, Lee, and Palm Beach counties, then conducted follow-up interviews with a subsample of women up to one year later. Logistic regression models were used to compare the associations of sociodemographic and medical characteristics with Norplant selection and method satisfaction.
More than 90% of Norplant users were satisfied with the method, according to the results. Women with side effects and those who felt pressure to select a method were significantly less likely than others to be satisfied.
Florida public family planners made extens -ive preparations prior to the introduction of Norplant, says Leslie Clarke, PhD, research associate professor in the department of health policy and epidemiology at the University of Florida in Gainesville. The state produced its own educational videos and coordinated training sessions for clinicians throughout the state, notes Karla Schmitt, ARNP, MPH, who headed the training sessions and is now a nursing consultant with the bureau of sexually transmitted diseases at the Florida Department of Health in Tallahassee.
The BRAIDED (Benefits, Risks, opportunity to Ask questions, Inquiry, Discussion, Education, Documentation) method of educating patients on risks and benefits of Norplant was distributed to health care providers for use in counseling on the method. In addition, the state developed systems to track Norplant use and encourage clinical follow-up.
Prepared for side effects
Researchers found that women’s tolerance of side effects was higher if they were prepared to anticipate such events, notes Schmitt. Questions included in counseling sessions covered several issues, such as the following:
• How do you feel about spotting for one full year and having to have sex when you are spotting?
• How would you respond if a spouse, boy friend, or parent asked you about those "bumps" in your arm?
• What will you use to protect yourself against sexually transmitted diseases if you select this contraceptive method?
• Why do you think this method will be the right choice for your sexual health/child bearing plans at this time?
"This kind of candid questioning and dialogue gets out into the open issues that often were behind the desire for a removal at three to six months," notes Schmitt. "The reality is that candid sexual behavior questioning is not a part of many contraceptive option counseling sessions or interactions between providers and clients."
Clarke agrees that education played a key part in Norplant satisfaction. The amount of preparation spent in developing good patient and provider educational material paid off in the level of understanding evidenced in the selection of Norplant as a contraceptive choice, she notes.
In introducing Norplant, Florida state family planners set a clear policy stating that under no circumstances would removal be denied, regardless of where it was inserted, according to Schmitt. During the survey follow-up, a system of checks and balances went into place when women reported pressure to keep the implant system.
Officials found that in many cases, women either had to wait for an appointment with a provider trained in removals, or they were asked to try a trial run of supplemental estrogen to help with spotting side effects. Women who chose supplemental estrogen often went on with no subsequent problems, she says.
Diminished Norplant use
The use of Norplant has diminished in Florida during the past few years, Schmitt reports. Factors affecting the decline include the media coverage and litigation surrounding the method, as well as the advent of DMPA (depot medroxyprogesterone acetate) injections as an alternate progestin-only method, say Clarke and Schmitt.
However, many women who were satisfied with the Norplant method have asked for a new set to be inserted, Schmitt notes, while others have sought removal at the five-year timeline, fulfilling their need for "spacing" their family.
"I firmly believe good counseling is the key to success with this method," she explains, "and that it only will be retained when women are fully informed, are reassured removal is always a cost-free option available to them, and that they themselves selected this method and it was not strongly urged on them by the providers under an illusion that it had minimal side effects."
1. Clarke LL, Schmitt K, Bono CA, et al. Norplant selection and satisfaction among low-income women. Am J Public Health 1998; 88:1,175-1,181.