Speaking Out On Norplant

Author(s): Daksha Hathi
Date Published: July 18, 2006
Source: (Political Environments #4, Summer/Fall 1996)

Twenty-five women in and around Belgaum have Norplant-6 inserted under their skins. "It is completely their own choice. There was no force and no pressure whatsoever. It is known as the 'cafeteria' method and they chose Norplant", says Dr. B.S. Kodkani, Officer-in-charge, and his team of research scientists, of the Civil Hospital, Belgaum, which is one of the 33 centres chosen by the Indian Council for Medical Research (ICMR) where Norplant-6 along with other contraceptives is being offered free to women.

Saira is the wife of an autorickshaw driver. She has three sons and wanted spacing. She chose Norplant because she had experienced problems with Copper T and also because the doctor had recommended it. When reminded that she was told about all the alternatives, she agrees. She has had Norplant for more than a year. "But when will the spotting stop, Doctor?" she asks, "My mother-in-law grumbles because I cannot do namaaz and I also get backache now and then". She has had no periods for the past three months and has low moods too, but the doctor is quick to remind her that she has low moods otherwise too, not just after the Norplant. She agrees readily, with the timidity and the deference of the uneducated and the ill-informed towards doctors.

Gita, a high school graduate in her early twenties, is also the wife of an autorickshaw driver. She opted for Norplant when the Copper T became troublesome. "Sometimes I get headaches & dark moods", she says, but admits that it could be due to household tensions too. She had had Copper T only for a month when continuous bleeding and dizziness forced her to remove it. She prefers Norplant which she has had for 15 months because she now has "less bleeding, irregular periods".

Vanitha, 20 plus, illiterate, has two children; Her husband works in a dairy. A sweeper at the district hospital had told her mother-in-law about Norplant. She has had it for 18 months and for the last three months has been having backache and irregular bleeding.

Madhuri, 25, conceived despite a Copper T. After a medical termination of the pregnancy, she opted for Norplant, She has had it only for a month, and prefers it to the pill which she might forget to take regularly.

Hasina, an autorickshaw driver's wife is in her late twenties and very stout. She has had Norplant for six months and has put on five kgs ever since, besides suffering severe headaches and dark moods. "I had enough and more problems with it", she said firmly and refused to budge from her stand even when the social worker asked her sarcastically whether she had lost any weight after removing it. She replaced Norplant with Copper T. Her problems have not ended. Even with Copper T she has severe backache. But she should have been advised against Norplant because it is not as effective for obese women.

Meena Nayak, 24, whose husband is a lorry driver, chose Norplant without telling her mother-in-law. Meena was very thin, obviously anaemic.

Ganguri an ayah in a school is an 'old case' who had Norplant implanted in an earlier trial and had it removed after a year because of very heavy bleeding. And yet, she advised her sister Mahadevi to opt for Norplant in the current trial. Why? "Because she is healthier and I thought she won't have problems". Mahadevi was out of town though it was time for her regular check up at the Civil Hospital.

Sreedevi Kaligowd has had Norplant for one year without any problems. Earlier she had a Copper T and suffered very heavy bleeding. She had opted for Norplant after being advised by the doctor who again reminds her that she had been told of all the other choices. She has had no problems with Norplant.

Suman Suvekar switched to Norplant after having heavy bleeding for four months with Copper T. She looked very weak, harassed, pale, thin and overburdened with housework (with two small children clinging to her), and had complained of severe pain around the insertion site barely a month later. The doctor at the hospital had prescribed painkillers but her husband never got them for her.

Lakshmi Gowde and her husband run a mobile tea stall near the bus stand. Both have studied up to Standard V. She opted for Norplant last February simply because she had no one to stay at home while she had a tubectomy which entails a day's stay in the hospital. She also had no one to run her business for her. She too had suffered excessive bleeding and weakness with Copper T. Lakshmi was worried that she had no periods for three months but the research doctor reminded her that she had been warned of this. She said she also had severe abdominal pain for one and a half months. A local doctor told her that this was due to the Norplant and had prescribed medicine for the abdominal pain but the hospital drug store did not stock it.

The last woman we met was a young Muslim woman who had also chosen Norplant after suffering with Copper T. She has had it for six months with no problems, that is, discounting the absence of periods for three months. "Those who are well nourished and with a good family background generally do not complain of side effects", says the research scientist.

Another unsettling aspect is that all the project doctors are incredulous about the side effects, their perceptions totally warring with those of women and women's groups. One male doctor stated that there were no side effects at all! However, Dr. Kodkani admitted that two women had 'slight' problems with the removal of Norplant and two others had gained weight. However, none of the women had complained of depression, migraine heavy bleeding etc. "Most of them have less or no bleeding."

We met three more women in a poorer part of Belgaum City who had recommended Norplant to each other and this won smiles from the social worker and the research scientist. It was not possible to meet all the women who had opted for Norplant as the social worker who keeps in touch with them was unwell and no one else knew their addresses. This made Dr. Bagi remark, "We must ensure a better way of contacting these women, otherwise follow up will be a problem". These women were told to come for periodic check ups after insertion so that Norplant could be removed if they had problems.

The follow up by this team appears to be fairly efficient in spite of the fact that only the social worker knew the whereabouts of the recipients. Would this work in a larger, more chaotic setting such as PHCs and Government hospitals? In an earlier trial with Norplant-2, 1.21 percent of the women were untraceable.

According to Dr. Daisy Dharmaraj who presented a review of Norplant in a Women and Health Report recently, "Deep vein thrombosis and subendocardial infarctions have been reported in women, five women out of 907 showed dysplastic changes with Norplant-2. (Contraception Vol.38 No.6) which prove very serious for women in remote villages".

She says even in Finland, the removal rate is very high. A study in one clinic in 1989 showed that 51 of 202 Norplant recipients removed it within two years because of side effects. In another clinic 26 out of 195 women removed the implants during the same period. In Finland, doctors do not consider it to be a contraceptive of first choice. They also tend to treat irregular bleeding due to Norplant, with a completely irrational estrogen therapy. Norplant is said to cause an increase in blood pressure, heart rate problems, myocarditis and varicose veins. It disturbs the clotting mechanism of the blood and can lead to thrombophlebitis, deep vein thrombosis and myocardial infarction. Fall in brinogen and most other coagulation factors have been documented during two years of use.

The post marketing surveillance studies show that side effects were reported by 97 percent of the users in Sri Lanka, 33 percent in Thailand, 73 percent in Chile and 74 percent in China. The overall complaints among Norplant users is 64.7 percent as against 44 percent of IUD users. Thus, according to Daisy Dharmaraj, "It is clear that this hormonal contraceptive's relevance and safety cannot be blindly accepted".

Among the present Norplant users, many have had bad experiences with Copper T and seemed to welcome the amenorrhoea that Norplant induces. Also none of them had been told of the side effects listed by women's groups. They were only told about bleeding disturbances and that too scanty periods and spotting.

Norplant's plus points are that it is long-acting and has a high success rate. But a specially trained medical professional is required for insertion and removal. Dr. Kodkani admits that this would require training on a massive scale to provide proper medical care before and after insertion. Problems in removal can occur when the rods have not been properly inserted. The device should be removed after the prescribed five years as otherwise it could cause ectopic pregnancy.

There have been cases in other Third World countries where donor agencies have suddenly stopped free supply of Norplant because of its high cost. The concerned government has also been unable to continue with it. The cost of the device has also made doctors reluctant to remove it before the end of five years.

In 1994, 235 lawsuits were filed against Norplant, including 50 class action suits in the US, causing a dramatic slump in sales. The lawsuits and horror stories about Norplant are mostly related to faulty insertion, which in India, will become a significant factor

Daksha Hathi, who writes on consumer issues, is a senior sub-editor with the Deccan Herald, Bangalore. This article is an abridged version of a feature printed in the paper in September 1995.