Norplant: an unmet contraceptive need in Enugu, Nigeria
Dr Ibekwe, Perpetus Chudi - FWACS
Department Of Obstetrics & Gynaecology, Ebonyi State University Teaching Hospital - Abakaliki, Nigeria.
(Formerly -Department Of Obstetrics/Gynaecology University Of Nigeria Teaching Hospital Enugu, Nigeria)
Nigeria has one of the highest maternal mortality rates in the world[1] and ranks lowest in terms of contraceptive prevalence rates in Africa[2]. The contraceptive prevalence in Nigeria ranges between 7-14.8%[3-5]. This high maternal mortality rate coupled with the very high total fertility rate (above 6.0 in the area of study)[6] has led to a renewed vigour in effecting solutions through a pervasive family planning programme, not only in Nigeria but in other developing countries. It has been opined that if family planning services were more widely available, up to 42% of maternal deaths could be averted in developing countries[7]. This same survey revealed that approximately 300 million couples in the reproductive age range did not want more children, but were not using any method of contraception.
One of the factors that have contributed to this low contraceptive prevalence and high birth rate is that a large percentage of the population lives in rural areas, where family planning services may not be available. In addition, the low socio-economic status of the people combined with high rate of infant and child mortality, religious and cultural factors and changing pattern of social organization may all negatively influence motivation[8-10]. In another study, male opposition, low availability and accessibility were reported as commonest reasons for non-use of contraception[11].
It has been accepted that reproductive health of women can only be enhanced if they are provided with an opportunity to plan their reproductive lives through provision of various contraceptive methods that are relatively safe, available, accessible and affordable[7-11]. Norplant, as a family planning method, became available for use at the University of Nigeria Teaching Hospital (UNTH), Enugu in 1992[12]. Hitherto, clients had relied on intrauterine contraceptive device (IUCD), depots of norethistherone enanthate and medroxyprogestrone acetate (Depo-Provera), oral contraceptives, tubal ligations and other non-prescriptive methods like condoms and foams.
At the family planning clinic of the UNTH, clients receive group counseling on all methods of contraception from the health nurses. Private counseling is thereafter provided by the doctors before a decision on the most appropriate method is reached. Norplant acceptors are informed about the benefits and side effects of the implant. They are physically examined to rule out medical contraindications before insertion. Norplant implant, consisting of six silastic capsules of levonorgestrel, is inserted by doctors in the upper non-dominant arm, about four- finger breath above elbow.
An eight-year review of Norplant use at the Family planning clinic of the UNTH, Enugu (January 1996 - December 2003) showed that Norplant was in sporadic supply throughout 1997 and major parts of 1998, and totally out of stock for eleven months in 2000. From 2001, high financial commitment was requested from clients desiring Norplant, thus creating problem of affordability. Also, the product was in short supply between 2001 and 2003. All other products mentioned above were available throughout the review period.
In spite of these problems of availability and affordability, Norplant enjoyed an acceptance rate of 8.5%. Were the products more readily available, it would have compared favorably with an acceptance rate of 12.4% recorded in Lagos, Nigeria[13]. Experience from other parts of the World has also demonstrated a high acceptance rate of norplant[14, 15]. This method of family planning may therefore be fulfilling an unmet need for a long term, efficient, reversible form of hormonal contraception for women who have achieved their desired family size, but for fear of the unknown, do not want the permanence of sterilization[16].
With the, continuation rate of 95% at one year and 89% at three years, lowest observed failure rate of 0.04%[17], effective life of five years[18], Norplant is one of the most effective reversible contraceptive methods. It is also a suitable option for lactating women when effective non-hormonal methods are contraindicated or not acceptable[19]. Sexually transmitted diseases are prevalent in Nigeria[20] and in many sub-Saharan African countries and this may make Norplant a more appropriate contraceptive method than IUCD for clients with high risk of acquiring sexually transmitted diseases such as teenagers and sex workers.
There is a great need therefore for strong advocacy for regular and efficient supply of Norplant, all year round in all family planning units. It is known that successful implementation of any family planning programme depends on the ease of access of contraceptive services and the availability and affordability of the products[21]. Thus, availability and accessibility of Norplant are very important as it was observed, very obviously, that the sporadic nature of the availability of Norplant and the cost constraint imposed on the product at a time, adversely affected it as a contraceptive method and its acceptance rate. Government and donor agencies are called upon to formulate appropriate strategies to meet this very important contraceptive need of women.
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