"The Challenge of Contraceptive Implant Removals in East Nusa"
COMMENTS The Challenge of Contraceptive Implant Removals in East Nusa Tenggara, Indonesia By Terence H. Hull I ndonesia has the largest contraceptive The recommended way of using the errors, and quite expensive to carry out. implant program in the world, with a method is to leave all six rods in place for Although well aware of these constraints, decade’s experience in promoting the five years and then remove them. If the a research team (of which the author was a mass acceptance of the method.1 Follow- woman desires continued contraceptive member) from Australian National Uni- ing ﬁve years of clinical trials, Indonesia protection, she can have another set of versity and the Indonesian Institute of Sci- approved the general use of implants in rods inserted immediately, or she can ence that was studying marriage and fam- January 1986, and in the following year, switch to any other method of birth con- ily planning decision-making in the more than 44,000 women nationwide ob- trol. A woman who does not have the rods province of Nusa Tenggara Timur in Jan- tained the method. In 1987–1988, the num- removed after five years and does not uary 1996 gathered information on implant ber of implant acceptors was 146,000; by adopt a supplementary form of contra- use recounted during interviews with two years later, the annual number of in- ception faces a growing risk of pregnan- providers, users and other community sertions reached 400,000. cy (including ectopic pregnancy).3 members in three communities on the is- This very rapid increase in insertions Both the rapid growth in use and the land of Timor. Spontaneous comments and clearly placed strains on the systems for plan to expand use in a major way (which discussions about implant acceptance and, training staff, providing client information has been halted by the economic crisis of in particular, problems associated with and monitoring users; consequently, after 1997) raise questions about the capacity timely removal led the team to look close- 1991–1992, the annual number of new ac- of the health and family planning system ly at information available from clinics to ceptors fell to less than 300,000. In 1994–1995, in Indonesia to guarantee the quality and assess whether standard medical records the number had again climbed to more than efﬁciency of implant services. A number were adequate to keep track of users over 400,000, and a year later, the program pro- of research efforts on this topic are being the ﬁve years following insertion. vided implants to half a million women. In carried out by the Indonesian National Three clear points emerged from these 1995, while exploring possible domestic pro- Family Planning Coordinating Board investigations that may have applications duction of implants using one or two rods, (BKKBN), with funding from the World locally, nationally and even internation- Indonesia considered increasing the capa- Bank and the U.S. Agency for Interna- ally. First, implants were very popular, de- bility of its health and family planning sys- tional Development, and with technical spite a few respondents’ serious concerns tem to serve two million new implant ac- assistance from the Population Council.4 about side effects and services. Second, ceptors a year in-country and to export Studies focusing on single communities providers and users alike lacked a full or implant kits to neighboring nations. or even single provinces in Indonesia are clear understanding of how the method The contraceptive implant is a method unlikely to yield adequate insights into the works and why it expires in five years. of continuously delivering sufﬁcient hor- dynamics of implant insertion and re- Third, many women do not obtain time- mones into a woman’s bloodstream to pro- moval services on a national level, because ly removals of their implants, but there is vide long-term protection from pregnan- practices vary widely. Studies of both qual- not enough information available to cor- cy. The hormone is packaged in six small ity of services and adequacy of follow-up rectly assess the nature or magnitude of plastic rods, which are inserted under the care are particularly difﬁcult to carry out, any problems these delays might produce. woman’s skin, usually on the upper left because women’s clinical records fre- arm. Its gradual release keeps the woman’s quently are lost or discarded during the Acceptance and Voluntarism total hormonal levels high enough to pre- ﬁve years after they obtain the method. At ﬁrst glance, a contraceptive method in- vent ovulation and implantation. As the Mass insertion campaigns are limited in volving puncturing skin on the upper arm, hormone in the rods is dissipated, the hor- geographic scope, and waves of training inserting a stainless steel tube and injecting mone levels in the bloodstream fall, and leave very heterogeneous legacies of a “fan” of small plastic rods that remain vis- ovulation resumes. With the rods in place, knowledge and practice among providers, the amount of time it takes for ovulation whose patterns of work rotation also dis- Terence H. Hull is senior lecturer in the Demography Pro- gram, Research School of Social Sciences, Australian Na- to resume depends on the woman’s body rupt efforts to trace the impact of special tional University, Canberra. Thanks are due to colleagues mass and normal hormone production, interventions. Thus, conclusive studies of from the Indonesian Institute of Science for assistance but tests have shown that pregnancy rates implant services must, almost by deﬁni- and advice, and to the Australian Agency for Interna- begin to rise slowly after ﬁve years, and tion, be national in scope and detailed, yet tional Development for funding through the project Pop- more quickly as time goes on.2 they will be subject to various biases and ulation and Development in Eastern Indonesia. 176 International Family Planning Perspectives ible under the surface of the skin seems a the weight loss. Nothing that the woman “implant.” They also refer to the device as very intrusive and discomforting thought. and her friends had heard from the service a “susuk,” a word that the BKKBN has ap- One might expect that many women would provider contradicted their interpretation. propriated from Javanese, which originally be afraid of the procedure and apprehen- By making removals difﬁcult to obtain, the referred to a piece of metal placed under sive about potential problems. provider had undermined their confi- the skin to magically enhance beauty or at- Yet the women we interviewed in house- dence that the health system was con- tractiveness. They know that something holds and clinics expressed more interest cerned about their welfare. is put in the arm and that after ﬁve years and enthusiasm than fear, even when they Many respondents noted that while the it should be removed. They are less clear had misgivings about the conduct of the midwives’ efforts in the clinics are aimed about why it should be removed. national family planning program—the at ensuring that rods are retained, the As a result, many providers and users major supplier of implants in the province. same midwives may be willing to perform have little motivation to ensure that re- Women ﬁnd the implant attractive because removals without question at their private movals are carried out in accordance with of its long-term effectiveness. In addition, practices. This does not surprise clients, the established procedures. Without a sys- the method appeals to them more than ster- since one of the major reasons for going tematic and clear implementation of such ilization because it is reversible, more than to an afternoon clinic in a rural area is to procedures, it is easy to see how the pro- the IUD because it does not require vagi- get better service, as implied by the high- gram could be confused about the magni- nal examinations and more than the pill be- er price and measured in terms of con- tude and causes of the problem of overdue cause it does not require constant vigilance. formity with clients’ wishes. removals, and why the simple repetition Women also like that the implant is Another dimension of voluntarism is of rules will not overcome the difﬁculties. under their control—i.e., that they can more difficult to study. When implants The most common misconception is that have it removed, and have their fertility were ﬁrst introduced into the Nusa Teng- the number of rods is linked to the duration restored, at will. However, the device is gara Timur program in the late 1980s, they of effective protection. Many people believe expensive to produce and insert, and in were provided through regular special that each rod is good for one year, and thus Nusa Tenggara Timur, these costs are drives (also called safaris), which involved incorrectly report that they have ﬁve (rather borne by the government; thus, providers gathering women in groups to obtain ser- than six) rods for ﬁve years’ protection.* For try to prevent frivolous or temporary con- vices on one day. This approach econo- example, one woman in Kupang noted: siderations from precipitating requests for mized on the time of the limited number “Around here, people say that if you put removal. As a result, economic factors of providers who were trained to insert in three needles [rods], it means three years; often undermine voluntarism in the use implants, and it allowed more intensive if ﬁve, it means ﬁve years. If that’s the case, or termination of the method. supervision by senior BKKBN ﬁeld staff then I have ﬁve years, at which point they Some respondents told of difﬁculties get- who attended the event. can be removed. That’s what they say.” ting the devices removed, especially if they However, according to the accounts of Most people we interviewed, users and requested removal before ﬁve years were clients and providers, the women received nonusers alike, know that the rods should up. (The stories are similar for IUDs.) If a only limited information about the method, be removed after ﬁve years, but they are client goes to the health center for a re- and many participated more out of a sense not sure why. Because the concept of a de- moval, she is discouraged in a variety of of duty to their community than out of spe- clining amount of hormone is not clear, ways—instructed to keep trying, given pal- ciﬁc interest in adopting the method. Some they think this might be an arbitrary rule liative medicines to treat bothersome side of these women (including the wife of one with little health consequence. Thus, the effects or told that removal is not immedi- ofﬁcial) explained that they were “model notion emerges that the rods themselves ately available. If she is persistent, she can users,” who encouraged other women to prevent pregnancy and can be maintained achieve her goal by going to the midwife’s adopt the method but had the rods removed after the five-year limit as long as the afternoon (private) practice, where the ser- after one or two years because of “dizziness” woman has no medical symptoms. vice will be provided, but for a higher fee or other vaguely deﬁned health problems. Because the family planning program than is charged at government facilities. Thus, the safaris backﬁred because the relies heavily on volunteer and commu- One woman in Kupang, the provincial “models” were not strongly motivated to nity workers to spread the message and capital, related the difﬁculties experienced use implants over the long term, but were maintain the motivation to practice con- by a neighbor and a cousin when they felt people of influence, whose experiences traception, many women discuss removal unhappy with the implant. Both lost weight with “medical problems” and private re- of the implant ﬁrst with their local volun- while using the method; the respondent de- movals were discussed widely in their teer. In discussions with neighbors, one scribed them as looking like skin and bones, neighborhoods. Safaris also suffered from volunteer said he found that women often even though previously they had been “ro- problems of recordkeeping, since the ser- delayed coming forward for removal be- bust” and had experienced no problems vices were provided outside the clinic, by cause they were afraid to disturb a method sleeping or eating. The problem was at- staff brought in from city hospitals. All in that had effectively controlled their fertil- tributed to “tidak cocok,” a mismatch, and all, the special implant drives of the late ity for a very long time: “They seem to say: the women had to force the midwife to re- 1980s are remembered as times of ques- ‘Don’t tell me that if the rods are removed, move the rods. As the woman expressed it: tionable service quality. there will be another pregnancy. Hell, who “Yes, we fought with her tooth and nail, wants to carry around another kid? I’m until ﬁnally she did the removal.” Understanding of the Method tired of that.’ That’s the attitude now.” Immediately afterward, she reported, As part of the ofﬁcial family planning pro- Though long a volunteer, and the veter- they regained their lost weight. In the re- gram in Nusa Tenggara Timur, the implant spondent’s mind, the association was is introduced and discussed in a variety of *None of the women reported that they had received clear: Because the removal was followed meeting conducted by ﬁeldworkers; both fewer than six rods, but only that they assumed they had by weight gain, the implant had caused women and men seem to know the term ﬁve rods in their arms. Volume 24, Number 4, December 1998 177 The Challenge of Contraceptive Implant Removals an of many training sessions, this worker in the same or the other arm. they did not, however, commonly believe could not explain why the rods had to be In Nusa Tenggara Timur, practitioners that rural women are somehow less capa- removed. A Community Health Center discourage insertion of a second set of ble of managing their affairs than their city (Puskesmas) paramedic whose wife had rods, arguing that women need a “rest” cousins. One doctor in Kupang who had been using implants for two years made it after using implants for ﬁve years. Gen- worked in both rural and urban areas de- clear that there was a general interest in erally, they recommend use of an in- scribed the differences between the two: stretching the period of use beyond ﬁve jectable or IUD instead. Sometimes the “In the city, it is rare for the removal to years. While the medical staff may under- reason they give for discouraging follow- be delayed. But around 70 kilometers out- stand that the device has declining poten- on use is the need to have the wound heal side of Kupang, there are lots of cases. For cy, they are quite sanguine about deter- after the removal, as one man related: instance, in Takari, there was a mass pro- mining the timing of removals and believe “Actually, [my wife and I] wanted to gram of insertions [years ago], but now we removals have become a problem because have a reinsertion, but because the removal don’t know where the women go for re- “village women” are uncertain about time. wound was not healed, it was decided to movals or whether [their implants] have One worker, for example, recounted that have the injection ﬁrst. I encouraged my been removed.” wife to have an- One type of problem commonly en- other implant, but countered in the ﬁeld was found in the re- “Ultimately,…the difﬁculties of implants in she was afraid to gency of Timor Tengah Utara, where it had have the rods put been reported that many women were given the future, as now, will be less matters of tech- in again.” implants during mass mobilization and nology than problems of ﬁeld service organiza- discussed man As this his demonstration campaigns in 1988–1991. A review of the records made available in the tion and client and provider education.” wife’s experience clinic revealed that many apparent users with the implant, were clustered in a hamlet that was now another issue— under the administration of a new clinic, and his wife preferred to get an implant rather closely related to misinformation about these women’s record cards were no longer than having him obtain a vasectomy, be- the potential for follow-on use, but in held in the facility that performed their in- cause she had heard of women who had some ways more important—emerged. sertions. (Even when records were available, retained implants for six or seven years The service provider and counselor had however, they were of little use for epi- without becoming pregnant. He explained: failed to reassure a successful user about demiologic study, since they provided only “The people who are most often that the rods’ mechanism of action and stabil- the user’s name and hamlet. They offered late have themselves failed to calculate the ity; as a result, even after ﬁve years of use, no information on follow-up checks, med- correct removal time. They are village she was fearful of rumored side effects ical indications, removal or method failure. women, in isolated places, far from health discussed in the community: Such information would need to be collect- facilities, and when they check their ac- “Right from the start there were six rods ed by a special survey, which would be ex- ceptor cards, they see that they are late in put in the one place, and there they stayed pensive to conduct.) getting the removal.” until they were removed. But according to The midwife in charge of the district su- Another element of knowledge that the experience of the health workers doing pervised both clinics and had records of should be widespread but is not is the ap- the removal, only my wife among the fam- the number of implants inserted. In many propriate steps for a woman to take once ily planning users had no problem, while cases, she could remember the events in the implant has been removed. Practi- the others had rods move around. Others 1988–1991, but she found it difﬁcult to lo- tioners and health agencies around the had the rods in place but had difﬁculty in cate any records of removals. By her mem- world are quite open to the possibility of the removals. So that made my wife—well, ory, though, she and the doctor had car- inserting another set of rods for a second she was scared to have new rods inserted.” ried out only a few removals. Given the period of ﬁve years. Trainers note that the Literature stressing the need for inten- dates of insertions and numbers of ac- second set can be inserted at the same time sive communications to educate clients, ceptors, more than 25 women would have that the first set is removed, using the providers and managers about the nature been due for removal. same incision, unless difﬁculty in removal of the contraceptive implant has warned When asked about the removals already causes swelling or excessive bleeding. Al- against allowing rumors and misinfor- carried out, she told of her own informal ternatively, a second incision can be made mation to multiply and create uncertain- training in insertions and the dilemma she ties among actual and potential users.5 faced when a couple of the women came *The international experience on this is still clouded with a year or so after acceptance, asking for disagreement. A 1992 report on the implant stated: “All women should have the capsules removed after ﬁve years Achieving Timely Removals removal. The ﬁrst of these women was re- in any case because little is known about the effects of im- If women do not understand the need to re- ferred to the nearest hospital, 32 kilome- plants left in place longer.” (Source: McCauley AP and Geller move the rods,* and if some women do not ters away. When the second woman came JS, Decisions for Norplant programs, Population Reports, request timely removals, the question for forward, the midwife decided to accom- 1992, Series K, No. 4, p. 5.) In contrast, recent work by Fam- the program is how to identify women who pany her to the hospital, to watch the re- ily Health International looks at implants as a form of vol- have had implants in place for ﬁve or more moval. On her return to the clinic, she untary sterilization, in which further childbearing could be years and persuade them that they need im- asked the doctor’s permission to try a re- prevented by simply continuing to add active rods over mediate assistance. Respondents who were moval, and when the next client came for- time. Spent rods would be left in place, on the assumption that they pose no danger, because leaving them avoids the familiar with health care delivery in both ward, she repeated the procedure she had potential trauma and added costs associated with removal. rural and urban areas contended that dif- seen in the hospital; in about 30 minutes, (Source: Fortney J, Family Health International, Research ferences in service delivery style in the two she had successfully removed all of the Triangle Park, NC, USA, personal communication, 1997.) settings contribute to the removal problem; rods, with a minimum of trauma. 178 International Family Planning Perspectives Since then, the midwife has performed had the device removed already; in some vices, the problem of delayed removals a number of other removals, usually in the cases, these same individuals were also could undermine public conﬁdence in the government clinic, but occasionally in the recorded as using injectables or other method. Three issues are essential to the Catholic clinic down the road. She is con- methods adopted after the removals. continuing success of the six-rod implant ﬁdent in offering services, although she Interviews with a number of BKKBN among women in Nusa Tenggara Timur. is not certified in either inserting or re- and health center staff indicated that this First, they need better information about moving implants. A number of other para- was less an indicator of purposeful mis- how the method works so they under- medical providers in the district handle reporting than of a lack of motivation to stand the ﬁve-year method life and the es- implants, and none of them have formal work through and correct the complex sential stability and safety of properly in- training or certiﬁcation. patterns of inconsistent information found serted rods. Second, health and family Deciding that we could not rely on the in subdistrict, Puskesmas, private clinic, planning programs need more effective clinic records and memories of staff to de- fieldworker and family welfare survey methods of monitoring women for the full termine the number of overdue removals, records. There is no single accurate, au- ﬁve years of use and providing them with we visited a hamlet where 16 women who thoritative record of the insertion, moni- adequate health care and advice on side had obtained implants in 1988–1989 toring and removal of implant rods.† To effects. Third, clearer and more rigorous- resided. The 17 kilometers of gravel road even work toward such a goal would in- ly implemented guidelines are needed to separating them from the main road is reg- volve deﬂating current user numbers and determine whether removal at ﬁve years ularly traversed by minibuses and vans, dismantling professional domains of ad- is required, and to clarify the feasibility of but getting to the clinic is still difﬁcult and ministrative authority. From the view- continued implant use into a second or expensive. A village midwife had once point of local workers, these are not de- even third ﬁve-year period. been assigned to set up a practice in the sirable challenges to tackle. While these are difﬁcult challenges for the hamlet, but she stayed only a few nights When we asked the acceptors and ofﬁ- Indonesian program, changes in technolo- before returning to the city. cials what they thought about the delayed gy may be even more important in setting Two acceptors and a number of local removal and loss of contraceptive effec- the direction of future implant use. One- leaders gathered to discuss the experience tiveness of rods, they indicated that they and two-rod implants will be easier to in- with implants. Following about an hour knew little about how the implant worked sert, but will initially offer only three years of making, checking and rechecking lists, or about the impact of removal delays. of protection. Given the emphasis women those assembled agreed that the 16 Some ofﬁcials said they had heard that the place on having ﬁve or even more years of women had all had removals, and that rods could be good for seven or eight protection, the idea of reduced periods of most of the procedures had been done by years, and others spoke of the need for re- effectiveness may not be appealing. a government midwife, the local mantri moval to allow the woman to “rest” and Moreover, if the clinical guidelines for (paramedic) or the doctor. Nobody could change methods. Nobody interviewed in the three-year method require removal say for sure, but it appeared that many of Nusa Tenggara Timur had heard of the po- and switching to another method, and if, the removals were carried out as part of tential link between implant effectiveness as now, the institutional provisions for re- the private practices of these government and body mass, or the potential increased moval are weak and often expensive, con- employees. After their implants were re- risk of ectopic pregnancy among women traceptive implants might be regarded by moved, most of the women were advised long overdue for implant removal.6 women and programs alike as simply too to use an injectable or IUD, and a few de- troublesome to consider. A number of op- cided to have a second or third child. The Method’s Future tions might be considered to overcome When asked how they had remembered Clearly, there is no systematic effort to mon- these difﬁculties, including the regular ad- to have the removals, the two acceptors itor acceptors’ implant use, and users and dition of rods without the removal of ﬁrst said that they knew their ﬁve years providers alike misunderstand the reasons spent ones‡ and the development of sin- of use had expired. But later they men- for removing rods after ﬁve years and are tioned that the paramedic had visited the confused about what to do after the ﬁve- *Respondents in some regions had acceptor cards read- ily available, but in other places they could not remem- hamlet in 1993 and read their names from year period of use ends. Nonetheless, the ber ever receiving a card. Observations at clinics conﬁrm a list he had compiled. He had done their implant remains a widely popular form of that staff are usually careful to ﬁll in and hand out cards. removals free of charge. They said that contraception, valued for its long-term, †Because insertion and removal are likely to be carried they had never been given acceptor cards* high level of effectiveness and its re- out by different service points (public and private), it is and had no written record of either the in- versibility. One village volunteer summed difﬁcult to match these records. The annual family wel- fare survey promises to collect data on current implant sertion or the removal of the rods. up the issue neatly in the following way: use, including the date of insertion. This would be an ex- Part of the difﬁculty of monitoring re- “If you use the injection, you have to cellent source for identifying removal needs annually, movals is that administrative pressures in come back every three months, but with but examination of the completed survey forms indicates that the year of insertion is often missing or incorrect. The the family planning program are aimed the implant, one procedure gives ﬁve or survey is carried out by local volunteers with minimal at increasing acceptance and discourag- six years’ protection. Sometimes [in- training. BKKBN supervisors complain that they have ing reductions in the numbers of users. jectable users] who are forgetful or busy great difﬁculty achieving validity and reliability in the data collection. Adding to the difﬁculty of the enumer- Thus, the BKKBN and Puskesmas work- have to think of that date of the injection— ation, the survey is conducted in January and February, ers have no incentive to discover and say it’s the 16th—and three months later the height of the rainy season, when some areas are hard record instances in which women have on the 16th, maybe they are working, or to reach, and toward the end of the ﬁnancial year, when acceptor targets must be reached. had the rods removed privately. As a re- they are busy, or they just forget the date. sult, the number of women recorded as Obviously, having a method good for ﬁve ‡The additive system of continuing implant use needs to consider how to keep track of the sequence of rods, so being current implant users in all three years is easier.” that a minimal number of active rods would need to be study sites was inﬂated by the number of Nonetheless, without more effective removed in case of a desire to return to fecundity. reported current users who had actually counseling and better monitoring of ser- (continued on page 205) Volume 24, Number 4, December 1998 179 Challenge of Implant Removal... donesia, Reproductive Health Matters, 1994, 3: No. 3 pp. 20–29. Corrections (continued from page 179) 2. Hatcher RA, Depo-Provera, Norplant, and progestin- In “The Challenge of Contraceptive Im- only pills (minipills), in: Hatcher RA et al., eeds., Con- plant Removals in East Nusa Tenggara, In- gle- or dual-rod systems with longer pe- traceptive Technology, 17th ed., New York: Ardent Media, donesia,” by Terence H. Hull [1998, riods of effectiveness. Ultimately, though, 1998, ch. 20, p. 471. 24(4):176–179 & 205], the references num- the difﬁculties of implants in the future, 3. Fisher AA et al., Norplant® removal in Indonesia, Stud- bered 2–5 should be numbered 3–6, and as now, will be less matters of technology ies in Family Planning, 1997, 28(4):308-316. reference 2 should read as follows: than problems of ﬁeld service organiza- 4. Fisher AA et al., Report on Norplant® Implants in In- “Hatcher RA, Depo-Provera, Norplant, tion and client and provider education. donesia, Jakarta, Indonesia: Population Council, 1995. and progestin-only pills (minipills), in: Luckily, as the Nusa Tenggara Timur in- 5 Spicehandler J, Norplant® introduction: a management Hatcher RA et al., eds., Contraceptive terviews revealed, clients and ﬁeld-level perspective, in: Segal SJ, Tsui AO and Rogers SM, eds., Technology, 17th ed., New York: Ardent providers are interested in the issues, and Demographic and Programmatic Consequences of Contra- Media, 1998, ch. 20, p. 471.” health workers are motivated to provide ceptive Innovations, New York: Plenum, 1989, pp. 199–225. better services. 6. Prihartono J, Norplant Removal Study: Factors Associ- ated with Due and Overdue 5 Year Removal, Jakarta, In- References donesia: Yayasan Kusuma Buana for The Population 1. Widyantoro N, The story of Norplant® implants in In- Council, 1990. 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