Family Planning Decision Making
Norplant and Depo Provera
Key Researchers: Linda Cushman, Andrew Davidson, Debra Kalmuss
Norplant suffered a one-two punch. First it was branded a method of social control; then it became the victim of exaggerated media attention. Yet what CPFH researchers have discovered is that around 90 percent of Norplant users surveyed would use it again or recommend it to a friend.
In a study published in the American Journal of Public Health, faculty reported that women pointed to the positive characteristics of Norplant -- convenience and effectiveness -- as the primary determinants of their choice and did not believe that they were coerced in their adoption of Norplant. A focus on potential barriers to Norplant removal, however, revealed a more complex picture. The majority of women perceived no provider or cost barriers to removal but one-third reported at least one factor. The most common barrier was the perception that cost would make it more difficult to remove Norplant.
These findings indicate that family planning clinics need to more effectively communicate their policies of Norplant removal upon demand, regardless of a woman's ability to pay.
Faculty have also addressed the question of condom use following the adoption of Norplant or Depo-Provera. In a study which will be published in 1998, they report that condom use dropped markedly after the initiation of long-term contraception, yet not evenly among all subgroups of women. Women with multiple sexual partners, and thus considered at high risk of contracting STDs, were less likely than others to reduce condom use. The study was the first to document the important impact of counseling on dual-method use: Women were less likely to decrease condom use after receiving the counseling message that condoms were still needed to protect against HIV/AIDS.
The following two research projects focus on the choice and continued use of Depo-Provera and Norplant, the two most significant advances in birth control since the advent of "the pill" 30 years ago.
Decision Making Concerning Depo-Provera Use and Discontinuation
This study examines various factors influencing the choice of this important new contraceptive method. Depo-Provera's potential utility is particularly significant for low-income women: their rate of unintended pregnancy is substantially higher than that for better-off women, and such pregnancies can have a worse effect on their lives.
Information gathered from this study will give a picture of women who choose and women who reject Depo-Provera, and the reasons for their decision. Some of these reasons could be: the relative influence of sociodemographic background variables; women's - and their partners' - attitudes towards the method; the side-effects they expect; their experience with other contraceptive methods; the influence of cost; the extent to which they feel health care providers steered them toward or away from this method; and their perception of how accessible and convenient the clinic was.
On the basis of interviews with women at the time they are choosing Depo-Provera and one year later, the study will look at the rates of discontinuation of this method and the reasons for this decision, such as dissatisfaction with the method, its side effects and changed fertility desires. It will also examine whether choosing to use Depo-Provera affects the use of condoms for HIV/STD prevention.
The study is based on interviews with 500 low-income women choosing Depo-Provera. These women are contrasted to 2,100 women choosing Norplant, the pill or sterilization. Interviewees are drawn from the University of Texas Southwestern Medical Center at Dallas and the Columbia Presbyterian Hospital in New York City, both serving low-income Hispanic, African-American and white patients in their areas.
Decision Making Concerning Norplant Use and Discontinuation
The purpose of this study is to understand why some women choose Norplant over other methods of contraception, and why some of these women become dissatisfied and discontinue its use. The study population consists of three groups: women who choose Norplant, women who choose another reversible method, and women who choose sterilization. Norplant users are re-interviewed three months after they get the implant inserted, and again two years later. Women who have the implant removed are interviewed within two weeks of removal.
The specific aims of the study are to describe the expectations and beliefs about Norplant held by women who choose this method and those who reject it; to test a model of the determinants of Norplant use; to describe the side-effects of Norplant use; to specify how women's experiences with Norplant relate to what they expected of it before its insertion; to test a model explaining why some women become dissatisfied with Norplant; and to identify the conditions under which women dissatisfied with the method decide to discontinue it.
This study represents the first systematic inquiry into Norplant decision making. It will also provide comprehensive information on the relationship between women's expectations of and experiences with a broad spectrum of outcomes related to Norplant use. Thirdly, it develops a framework that integrates more traditional social psychological determinants with structural and socio-demographic influences. And finally, it provides one of the first theoretically-driven studies looking at why women discontinue the use of a particular contraceptive.