Auditing the introduction of a new product to a family planning service

The audit aimed to develop a questionnaire to monitor how a new method od contraception is offered in service by identifying local demand and assessing levels of awareness of and interest in a new product (Mirena(R)) The audit also aimed to establish those suitable for Mirena and the numbers of Mirena fitted and characteristics of recipients.

Compliance and use behaviour, an issue in injectable as well as oral contraceptive use? A study of injectable and oral contraceptive use in Johannesburg

This study examines the compliance, use behaviour and knowledge of method of women using injectable and oral contraceptives in two clinic sites in the Johannesburg area, South Africa. An interviewer administered questionnaire was used to collect information in the clients' home language. A total of 400 women were interviewed in the clinics. The mean age of clients was 26.2 years (range 13 to 43 years). Of the clients not wanting to get pregnant, 30.4 per cent of injectable users and 18.4 per cent of oral contraceptive (OC) users had stopped using their method temporarily before returning to the same method (called the nonuse segment) and had not used any other form of contraception during this time. Almost one third of injectable users (31.2 per cent) had been late for their next injection at least once. Although nearly all women using injectables had experienced some menstrual disturbances, over one third (38.5 per cent) had not been informed by the providers about the possibility of these changes. Many women gave the disruption of their menstrual cycle as the reason for the nonuse segment. The majority of OC users lacked information on how to use their method correctly. Nearly all women expressed an interest in obtaining more information on their current method and other available methods. This study shows that compliance is an issue in injectable as well as OC users.

Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation

CONTEXT

Oral contraceptive users' risk of accidental pregnancy may be higher than it should be, because of inconsistent pill-taking. However, few reliable data are available on pill users' everyday experiences with their method, especially characteristics that may affect consistency of use.

METHODS

Two months after initiating or resuming oral contraceptive use, a nationwide sample of 943 women completed questionnaires examining their compliance with instructions for proper use, the quality of their interactions with their provider, their satisfaction with the method, and the frequency and costs of visits or calls to their providers because of pill-related side effects. Regression analyses were used to determine the factors associated with compliance difficulties and method dissatisfaction.

RESULTS

In all, 47% of users missed one or more pills per cycle, and 22% missed two or more. Women who lacked an established pill-taking routine, who did not read and understand all of the informational material accompanying the pill package, or who experienced spotting or heavy bleeding had increased odds of missing two or more pills per cycle. Method satisfaction was most likely among women who were aware of the pill's noncontraceptive benefits, were satisfied with their relationship with their provider, had used the pill in the past and experienced few side effects. Some 22% of users called their provider at least once about pill-related side effects, and 9% made at least one visit for this reason; these women spent $25 and $62, respectively, to treat side effects.

CONCLUSIONS

Improving pill use is a shared responsibility of the provider, the patient and, to a lesser degree, pill manufacturers. Awareness of potential difficulties such as inadequate counseling is a key step in helping women use oral contraceptives effectively.

Socio-demographic characteristics of family planning clients and their possible influence on contraception in Malawi

In a survey of family planning clients at the central Teaching Hospital, Blantyre, between July 1 and December 31, 1993, to determine their social, biological and reproductive profiles, contraceptive awareness and previous use, 766 new clients were recruited and interviewed by means of partially structured questionnaire. Their mean age was 27 years, with a range of 15-43 years. Adolescents formed 10.1% and those above 35 years of age were 17.1%. 91.3% were married. While 12.6% had no formal education, 29.7% had secondary school education and higher. Their mean parity and living children were 3.6 and 3.1 respectively. The mean desired fertility was 4.5. 93.3% of all clients had live births in their last pregnancies. Contraceptive awareness was quite high, about 98.0%. However, only 30.9% had ever-used contraceptives before then. When these are looked at against a background of the corresponding situations in the country, it appears that the individuals seeking, accepting and using contraceptives in Malawi, are better off in the various aspects of life, thus suggesting their possible influence on contraceptive use. There is need to review the national family planning programme, address the contraceptive needs of adolescents and women aged above 35 years, improve formal female education, change the prevailing socio-cultural and traditional beliefs and practices which affect women adversely, thus empowering them over affairs of their health.

First-time use of newer oral contraceptives and the risk of venous thromboembolism

Recent epidemiologic studies reported that the risk of venous thromboembolism (VTE) was higher with the use of the newer third generation oral contraceptives than with second generation agents. Although the overall findings of these studies are similar, the results, as they relate to patterns and duration of oral contraceptive use particularly among first-time users, are inconsistent. We reanalyzed data from the Transnational case-control study to assess the risk of VTE associated with first-time use of oral contraceptives as a function of its duration of use. Over the period 1993 to 1995, 471 cases of venous thromboembolism were identified in Germany and the United Kingdom. For each case, up to four controls were obtained, for a total of 1772 controls. Data on oral contraceptive use and confounding variables, including data on sociodemographic, lifestyle, medical history, and family history of disease, were obtained by interview. Data analysis was based on the 105 cases and 422 controls who were first-time users of second or third generation agents, or never users of oral contraception. Rate ratios, adjusted for confounders and approximated by odds ratios, were estimated as a continuous function of duration of oral contraceptive use by logistic regression and quadratic spline models. We found, for first-time users, that the adjusted rate ratio of VTE as a function of the duration of oral contraceptive use is essentially identical for second and third generation pills relative to never users. This rate ratio increases to around 10 in the first year of use and decreases to around two after 2 years of use, remaining at this risk level thereafter for both second and third generation agents. We conclude that second and third generation agents are associated with identical risks of venous thromboembolism when they are prescribed to women who are using oral contraceptives for the first time ever.

Teaching about the female condom

Reality female condoms became available for over-the-counter purchase in the fall of 1994. Because the female condom is a new sexual barrier device, women need to learn how to use it correctly. Health care providers must also be knowledgeable about the correct use of the female condom so that they can teach women how to use it as a barrier method. To facilitate learning about the female condom, a curriculum was developed that included a quiz on knowledge about the female condom. Content validity was established through a content validity index completed by six content experts. This quiz was used to evaluate educational sessions offered to 42 persons in an urban college setting and 18 women in a community setting. The article describes the female condom along with the curriculum that was developed to teach its correct use and the reactions of potential users of the female condom.

Patient satisfaction with a levonorgestrel-releasing contraceptive implant. Reasons for and patterns of removal

OBJECTIVE

To investigate the experience of the users of a levonorgestrel-releasing contraceptive implant (Nor-plant) and reasons for early removal.

STUDY DESIGN

Two hundred fifty-one women who had Norplant placed through the Ohio State University Department of Obstetrics and Gynecology were sent a questionnaire that included general demographic questions and questions regarding preplacement education; reasons for choosing Norplant; problems experienced due to Norplant; reasons for removal, if applicable; and overall satisfaction.

RESULTS

One hundred eleven questionnaires (44%) were completed and analyzed. Twenty-four (21.6%) of patients had Norplant removed, 32 (28.8%) planned on early removal, and 55 (49.5%) desired continued use. Ninety-eight percent of women who planned continued use of Norplant had received reading material as part of their preplacement counseling and 95% felt adequately counseled. This is significantly higher than women who had Norplant removed or planned on early removal. Convenience, problems with other contraceptive methods and effectiveness were the most important reasons why patients chose Norplant. Menstrual changes were the most common side effect, experienced by 80% of all women in the study. Weight gain, headache, mood changes, mastalgia and acne were also frequently reported. Women who had Norplant removed were significantly more likely to have experienced dizziness when compared to women desiring continued use. Women planning early removal were also more likely to have experienced dizziness in addition to acne, headache, hair loss and other side effects. Menstrual irregularities, followed by mood changes and headaches, were the most important side effects associated with early Norplant removal. Overall, 68% of users were at least somewhat satisfied with Norplant.

CONCLUSION

Norplant contraception was a satisfactory form of birth control for the majority of patients in the study despite the frequent occurrence of side effects. Reading material regarding benefits and side effects of Norplant is an important aspect of patient counseling and may improve long-term use of Norplant.

Using situation analysis data to assess the functioning of family planning clinics in Nigeria, Tanzania, and Zimbabwe

Situation analyses conducted in Nigeria. Tanzania, and Zimbabwe have revealed problems in the functioning of many of the subsystems of family planning service delivery, namely in supplies of commodities; in facilities and equipment; in staffing and training; in information, education, and communication; and in record keeping. Although a clear pattern of clinic use exists, in that only a few service-delivery points provide contraceptive services to the majority of new family planning acceptors in the three countries, an attempt to explain how clinics with more clients differ from those that are visited less frequently revealed only a weak association between subsystem functioning and use.

Female sterilization in Thailand: past, present and future

Female sterilization is the most effective contraception and has a very high demographic effectiveness. In the past, there have been developments in technological aspects. At present, the minilaparotomy and laparoscopic sterilization have been well developed and widely used, but the number of new acceptors is declining, and there is still a large number of unmet demands. Social action rather than technological action is needed. In the future, steps to increase the number of acceptors, are, proper management of the sterilization services, including adequate monitoring and a good surveillance system.

A comparison of the performance of male and female CBD distributors in Peru

This report presents the results of an operations research project to increase male involvement in family planning in Peru. Two community-based distribution (CBD) programs, PROFAMILIA of Lima and CENPROF of Trujillo, Peru, recruited male contraceptive distributors and compared their performance to that of female distributors recruited at the same time. Both programs found it harder to recruit men than women as distributors. Program supervisors, who were women, were less comfortable with men than with other women, even though there were no differences in distributor compliance with program norms. Male distributors were more likely to serve male clients and sell male methods (condoms), while female distributors were more likely to serve female clients and sell female methods (pills). Men sold as much or more total couple-years of protection than did women, and they recruited as many or more new acceptors. Gender was found to exert an impact on method mix independent of other distributor characteristics, such as age, education, marital status, and number of living children. The study suggests that family planning programs can influence method mix and client characteristics by recruiting men as CBD distributors.

Factors related to autonomy and discontinuation of use of natural family planning for women in Liberia and Zambia

From 1983 to 1988, natural family planning programs were conducted in Liberia and Zambia. In Liberia 1055 and in Zambia 2709 women used natural family planning to avoid pregnancy. These users could become pregnant, discontinue use of the method, or become autonomous users. Women who changed intention did not stop use of natural family planning and were not treated as discontinuations. In a multivariate analysis, client's age, breastfeeding status, employment, urban/rural residence, time of registration in the program, and visit intensity were significantly associated with the outcomes. The most consistent association was that women who entered the programs in the later time periods were more likely to become autonomous users and less likely to discontinue use of the method or to experience an accidental pregnancy.

Further analysis of contraceptive failure of the ovulation method

Reanalysis of data on the ovulation method of natural family planning collected by the World Health Organization yields the following conclusions. The method is effective during perfect (correct and consistent) use, with a first-year probability of failure of 3.4%. However, it is extremely unforgiving of imperfect use, with a first-year probability of failure of 84.2% if the method is not used correctly. During the initial year, 87% of the cycles were characterized by perfect use. Nevertheless, the 13% of cycles characterized by imperfect use had a tremendous impact on the overall failure rate. During the first year of typical use 22.5% of the women in the clinical trial became accidentally pregnant.

The modified mucus method in India

The modified mucus method-Prajanan Jagriti (fertility awakening) is intended to serve the cultural needs of illiterate and semilliterate women. Over 10 months, 3003 women in northern India were taught the modified mucus method. There were a total of 42 pregnancies in 24,702 cycles for a Pearl index of 2.04. High effectiveness is attributed to the support that was provided to clients by the instructor.

Long-term effects of depot-medroxyprogesterone acetate on lipoprotein metabolism

To assess the effects of depot-medroxyprogesterone acetate (DMPA) upon serum lipids and lipoproteins, a comparative study in chronic users and new acceptors was undertaken. Two groups of women of reproductive age were included in the study; group I (n = 8) was formed by new acceptors whereas, group II (n = 14) constituted DMPA users of more than five continuous years (7.0 + 2.1 years). Blood samples were taken on the day of injection and 15, 29, 57 and 92 days after the i.m. administration of 150 mg of DMPA for the measurement of total triglycerides (TG), cholesterol (CHOL) and phospholipids (PHL). In addition, the TG and CHOL content in the very low density (VLDL), low density (LDL) and high density (HDL) lipoprotein fractions obtained by ultracentrifugation were also determined. The results demonstrated a moderate increase in the serum total TG concentrations at the expense of the VLDL fraction in the group of chronic DMPA users. In both groups, the administration of DMPA induced a moderate, though not significant, decrease in total CHOL and HDL-chol, an effect that was noticed at the end of the treatment interval; the serum LDL-chol content remained unchanged. In addition, a decrease in the total serum phospholipids content was noticed after DMPA injection in both groups, which resembled the fluctuations observed in the luteal phase of normal ovulating women. The overall data indicate that acute and/or chronic DMPA administration at the dose currently employed for contraception does not induce major abnormalities in lipoproteins in serum.

Oral contraceptive pill use after an initial visit to a family planning clinic

A retrospective study of 1,311 women making initial family planning visits to metropolitan-area health department clinics found that many women switch methods or discontinue use in the first year following the clinic visits. Among a subgroup of women, most of whom selected the pill as their primary method and who used the pill for at least one of the months in the study period, almost half either changed methods or used no method at some point during a follow-up period averaging eight months. This includes 13 percent of women who made two or more changes. In addition, only 42 percent said they took a pill every day, and only half of these said they always took their pill at about the same time every day. Despite such irregularities, pill users were approximately one-third as likely to get pregnant during the study period as women making an initial family planning visit to a health department clinic who did not use the pill at all.

Return for follow-up care and contraceptive continuation among adolescents

Family planning service providers have noted a greater than 50% nonreturn rate among adolescent clients. Those who fail to return to the clinic are likely to discontinue their use of contraceptives and be at riskfor an unintendedpregnancy. Case record reviews of a random sample of adolescent oral contraceptive users were used to investigate variables correlated with nonreturn for follow-up care. Compared to adolescents who returned to the clinic, those least likely to return had a sexually transmitted disease, had irregular menstrual periods, had a pap smear over a year prior to the initial clinic visit, reported more general health problems, were referred for additional tests, and had waited longer since first coitus to obtain birth control. Implications for the development of a method to screen adolescents for risk of contraceptive discontinuation are drawn.

Contraceptive social marketing in Nepal: consumer and retailer knowledge, needs and experience

In 1986, a survey was conducted to assess knowledge, health concerns and experience with marketing (retailers) and use (consumers) of Gulaf and Nilocon pills and Kamal vaginal tablets distributed by the Nepal Contraceptive Retail Sales Company (CRS). A sample of 763 consumers of Gulaf, Nilocon and Indian pills and Kamal vaginal tablets, and 361 retailers from a stratified sample of urban medical shops were interviewed. The CRS marketing programme is reaching people who have previously never used family planning; most of the users were practising contraception to limit, not space, births; a high proportion of pill users over 35 smoked; only about a third of CRS pill users had prescriptions or consulted a physician prior to use; CRS training of retailers was found to have increased their knowledge. Recommendations are made for improving communication, education and marketing of CRS contraceptives to ensure their safe and effective use and increase the acceptability of this mode of service delivery.

Characteristics of ovulation method acceptors: a cross-cultural assessment

Five programs of instruction in the ovulation method (OM) in diverse geographic and cultural settings are described, and characteristics of approximately 200 consecutive OM acceptors in each program are examined. Major findings include: the religious background and family size of acceptors are variable, as is the level of previous contraceptive use. Acceptors are drawn from a wide range of socioeconomic and religious backgrounds; however, family planning intention was similarly distributed in all five countries. In sum, the ovulation method is accepted by persons from a variety of backgrounds within and between cultural setting.

[Young girls and contraception. A survey conducted in the MFPF family planning center, Strasbourg, in 1985]

The results of a survey on contraception among 513 adolescent women attending a family planning clinic in Strasbourg, France, in 1985 are presented. "Eighty percent of them were attending school. In over half the cases, this was their first consultation for contraceptive advice. 33% of the subjects did not return after this initial consultation. The age at which sexual intercourse first occurred was between 14 and 17, with a peak at 15-16 years of age. Most of the girls attending this Family Planning Center were told about it by friends or a sister (78%) and they rarely told their parents what they were doing (76%). Most of them (63%) preferred a woman doctor for a contraceptive consultation." (SUMMARY IN ENG)

Satisfied IUD acceptors as family planning motivators in Sri Lanka

In this study, government midwives were teamed with currently satisfied IUD acceptors to strengthen field motivational and recruitment efforts. The objective was to increase the number of new IUD acceptors. In the experimental study areas, a total of 3,019 new IUD acceptors were recruited. Time series regression analysis revealed a significant difference between the experimental and comparison areas that was over and above what might be expected on the basis of the past history of differences between these two areas. These and other findings suggest that teaming currently satisfied acceptors with government field-workers can have a substantial impact on the recruitment of new family planning users.