Head of midwifery and MCH, Department of Nursing and Midwifery, An-Najah National University, Faculty of Medicine and Health Sciences, Nablus, Palestine
Received Date: July 20, 2019; Accepted Date: August 15, 2020; Published Date: August 31, 2020
DOI: 10.36648/206 9-54220.127.116.11
Norplant has recently been introduced in Palestinian Family Planning and Protection Association (PFPPA) services in the last 3 years. This study covered the experience of Norplant and ECPs in WB and GS, using survey questionnaires and interview method. The total number of responders in Norplant survey were 178 (34%) of total population that received Norplant services. The total number of ECPs responders were 75 (33.3%) of total population that received service. Four focus groups were conducted, two FGs with beneficiaries and others with health care providers, who are working in PFPPA clinics in WB. Telephone interview was done in women's Health Center, Al-Bureij in GS and other calls to policy makers, healthcare providers at UNRWA and MOH in WB to understand their experience.
Study findings emerged that satisfaction and advantages was greatest for both method of Norplant and ECPs. The percentage of occurrence of side eï¬ÂÂects and number of removed Norplant (29% in WB, 8.8% in Gaza) was acceptable rate compared with international studies. The most side eï¬ÂÂects were change in menstrual cycle after using implants, mood change, bleeding/ spotting other than period and weight gain and this is in line with previous studies. The most common barriers of using Norplant and ECPs were lack of awareness and information of this new method among women, unavailability of Norplant in FPS except in PFPPA, considered it as a luxury element and cultural reasons such as misperception about Norplant. It is crucial to understand community and women’s perceptions and incorporate these understandings into contraceptive consultations.
Study findings revealed that ECPs and Norplant are not available at UNRWA or MOH agenda. The main reasons for not using Norplant in MOH and withdraw it from Al-Bureij center in GS was the absent of capabilities for training and cultural issues. In recent study about “quality of FP services in Palestine”; highlighted the problem of having countless multi-modality in FP services that eï¬ÂÂects quality of service. Another point is SRHS in Palestine are designed to serve married women only. ECPs pills should be oï¬ÂÂered in essential drug list to ensure the availability for women in need. The PFPPA are Member Associate of IPPF. Running training sessions for insertion and removing Norplant, as well providing FP including Norplant and ECPs to beneficiaries is high quality service. The PFPPA has followed a practical guide and committed to increasing electiveness, evidence-based decision, and accountability.
Finally, Governments and policy makers should commit to ensure the implementation of a national FP strategy. The FP services should include modern contraceptive as Norplant and ECPs to meet women’s need.
Norplant; Emergency pills; Contraceptive; Inequity of health services
In all countries including Palestine, the fertility rates are lower today than they were 50 years ago . The use of Family Planning is not only connected to higher quality of life and health outcome but also a reduction in mortality and morbidity rate. The report of sexuality and reproductive health found that contraceptive prevalence rate was 40.8% for use of modern contraceptives . Taking into consideration the demand for contraception will increase, especially the total population in Palestine would double from 4.75 million in 2015 to 6.9 in 2030 and to 9.5 million in 2050 .
Recently in 2017, the Prevalence Rate of contraceptive in Palestine reached 59%. The annual increase rate of contraception use of all methods in the past 15 years is at 0.78%, 0.74% in WB while it is 1.2% in GS . According to international and regional rates standards, the rate of contraceptive use is considered low in Palestine, compared with rate in Turkey at 74.4%, Jordan 62.2%, Lebanon 62.3%, Israel 71.1%, Egypt 60.6% and Iran at 82% . According to the MICS survey of 2014, a quarter of women were used traditional method of contraception; while 43% reported not using any method at all.
Contraceptive implants were not accepted for insertion within the MOH system of care due to challenges related to training of staff, maintaining sufficient logistical preconditions and cultural factors. Norplant has recently been introduced in Palestinian Family Planning and Protection Association (PFPPA) services in the last 3 years.
The current study aimed to highlight the current situation of using modern method of contraceptive as Implants & Emergency contraceptive pills in Palestine, to bring evidence to health policy makers on inclusion of implants and emergency contraceptives into use within the public sector.
Both quantitative and qualitative research methods were adopted in current study to answer the research question. A cross sectional design used questionnaire which was completed by face to face interview or telephone interview by interviewers. To ensure the representative of sample, it included all target populations, 523 women who used the services of implants contraceptive and 255 women have registered in record that received emergency pills services in PFPPA clinics. Implant survey consisted of 50 items while EPs have 38 items; both of them have built based on literature review and researcher experience. SPSS version 20 was used for analysis.
Four focus groups were conducted in this study. Two of FGs with women who are using a Norplant and other two FGs with health care provider’s team who are working in PFPPA clinics in WB that includes doctors, midwives, nurses and social worker. The FGs was consisted from 5-8 persons with average time of interview between 60-90 minutes. Audio recording was used after informed consent of participants in FGs. Data then transcribe ad verbatim and analyze using thematic analysis. Additional call individual interviews were done to policy makers / healthcare providers at UNRWA and MOH to cover the research question. Interview guild dialogue covered the following areas: The safety, acceptability and effectiveness of the emergency contraceptive and the implant; How to offer decision makers information necessary for inclusion of both methods as part of the national method mix for family planning; How to encourage other Palestinian health and medical associations and organizations in providing implants and emergency contraceptives into their service; and recommendation to improve the available usage of contraceptive services.
The total number of responders were 178 which composed of 34% of total population (523 women have registered in PFPPA database at receiving Norplant services). Almost 82.6% of participants still have Norplant and 17.4% removed it. Half of participants 51.1% have their implants for more than one year, 28.1% from 7-12 months, and 20.8% less than 6 months.
The most reasons for removal were 35.5% vaginal bleeding; followed by desire for Pregnancy 29%; 19.4% social reasons and acne, 12.9% change in the duration of menstrual cycle and 3.2% mentioned more than one reason.
One fifth 19.4% participants who removed Norplant reported they become pregnant, a half of them become pregnant directly. Emphasizing that Norplant did not affect their fertility, while 80.6% reported they did not become pregnant, because they had used another FP method. Most women 97.2% received information about Norplant before insertion while only 2.8% did not received information.
Study findings showed that most common side effect of Norplant that occurred to women (Figure 1) were change in menstrual cycle after using implants 50.6%, 32.6% mood changed, 28.7 bleeding other than period, 28.1% weight gain, 19.1% bleeding in another menstruation time, 17.4% increase vaginal secretion, 15.2% acne and 14% inflammation in insertion site. While less mentioned side effects were 12.4% change in sexual relationship, 10.7% anemia, 9.6% decreased weight, 7.3% change in lactation, 5.3% nausea and vomiting.
Generally, participants were satisfied using Norplant. 79.8% agreed to statement that Norplant is the best method to prevent pregnancy. 82% agreed that it is the effective method used to prevent pregnancy. 83.1% agreed it is the effective method used to prevent pregnancy. 83.1% agreed it has the fewer side effects from other method.81.5% agreed the side effect for this method can be treated; 87.6% agreed the use of implants is easier because it does not require calculation process (calendar to calculate ovulation time and unsafe period to avoid pregnancy) to be used;88.8% agreed using this method save time and effort; 82% agreed to advise their friends to use this method; 86% agreed that implant works more easily than other methods; 89.9% agreed that the person who is installing or the type of implant should be a doctor; less percentage 52.2% agreed that the person who is installing or the type of implant should be a nurse/midwives; 92.7% were satisfied with information provided and agreed that the information they provided when installing the plant was sufficient.
The total number of responders were 75 which composed of 33.3% of total population (225 women have registered in PFPPA record that received emergency pills services). Most of respondents 81.3% their age between 21-45 years, 13.3% between 18-20 years old, 2.7% below 18 and 2.7% above 45 years old. Most of responders have university degree 42.7%, 16% diploma, 16% have primary and 25.3% secondary degree. Obesity was a noticeable health problem among Palestinian women, half of them 45.3% are overweight, 45.3% are normal weight and 7.7% are obese.
The majority 89.3% has no concerns about using these pills. When asking about previous methods of contraception before using emergency pills, 18.7% of women used IUD, 8% condom, 6.7% pills, 20% nothing and 41.3% used more than one method of these mentioned before. The reason for stop using these methods 56.9% vaginal infection, 13.7% back pain, 5.9% bleeding, 19.6 % become pregnant and 20% have multi reasons of mentioned above.
In this study the most common reasons for using emergency pills were the lack of contraception which agreed by 49.3%, followed by the ineffective method of contraception 44%, while 6.7% the reason was sexual abuse. This is considered an indicator of SGBV. Participants were satisfied regards their used of emergency pills. The questions that examined side effects of ECPs, most of participants were satisfied and reported not have the following; 89.7% general fatigue; 86.6% dizziness; 78.7% headache; 85.3% breast tenderness; 70.7% Nausea or vomiting; 89.3% bleeding between periods or heavier menstrual bleeding; 82.7% diarrhea and 61.3% lower abdominal pain or cramps.
Most 84% agreed that the price of emergency contraception is appropriate; 86.7% considered it effective and safe; and 66.7% disagreed that the use of emergency contraception provides prevention of sexually transmitted infections.
The question that examine actual usage of emergency pills; 66.7% have used emergency contraception just once; 76% have used emergency contraception less than 5 times a year; 24% have used emergency contraception more than 5 times a year. Most of participants 88% need to have emergency contraception pills before they needed it (just in case); 73.3% think they might use emergency pills again; 90.7% have recommend other women to use emergency contraception pills; and 93.3% agreed the information they have received about emergency pills was sufficient.
Thematic analysis was used to analyze the focus group data, six themes emerged from data analysis that consisted of 191 codes.
Theme 1: New methods
Norplant implant was considered as a new method of modern contraceptive methods in Palestine in the last 3 years, until now it still not well known compared to other contraceptive and people are afraid to use it. This is due to many reasons as lack of knowledge of Norplant, its unwanted complication like irregular menses and cultural issues or factors. One of participant from FG # 2 said: “Norplant is not well known among Palestinian community, regarding effectiveness it has super effective 99% prevent pregnancy and it is safe. A few side effects may occur in first 6 months of insertion as problem in irregular menstruation but women who have it say that they are so happy and reported less discomfort”
Theme 2: Advantages and disadvantages
The women from focus groups as well as health care providers from West Bank and Gaza strip agreed that the Norplant implant has many advantages. It is a super effective and convenient way to prevent pregnancy; implants gives women’s great, long – term protection against pregnancy; it's more than 99% effective; implants are one of the most effective methods women can attain because there is almost no way she can make a mistake; she cannot forget to take it or use it incorrectly; the implant is convenient and private; implant prevent many unwanted pregnancy; and is suited for many women.
The most common disadvantages revealed from study were the weight gain, edema, irregular menses, amenorrhea, bleeding between menses, ecchymosis around Norplant and cultural stigma. One of women from FGs #3who has the Norplant for two and half years said “After insertion of Norplant I went to my home. My sister in law has touched my shoulder and palpated it. She asked me how you tolerate to do surgery and suture to your hands… are you crazy. For me I prefer to get a kid every year but not to do surgery. Then my mother in law come to see my hand and yell at my face. In the first 6 months I have spotting and irregular bleeding then after first year I am used to it and no problem at all”
However, other participants mentioned that they are happy for the following reasons. First, physiological one that includes the following: no bleeding or infection as in using IUD, no need to remember pills, less cost compared with other modern contraceptive methods and no back pain as what happen when using IUD. Second, psychologically one: no worries to mess up any pills, they have self-confidence because there is no risk to become pregnant (99% no pregnancy); it is a guarantee method from their point of view and no need for follow up for 5 years. Third item was the feeling of hygienic and freshness all the time because of no infection and no secretion from vagina compared to before. Some women highlighted the feeling of sex desire increase and they feel Comfortable during sexual intercourse. One of participant FG#1 said “After using Norplant I have started to enjoy my sexual life, previously I used IUD it has annoyed me and my husband. Now, I feel myself clean and free from secretions I can pray, walk and do what I want freely without any worries”
Theme 3: Barriers and facilitators
The study revealed that common barriers for using Norplant in Palestine can be categories into three reasons. First, lack of awareness and information of this new method among couples especially women and among health care providers as doctors in private clinics. Many participants from FGs emphasized that during their visit to their doctors and during discussion with them they got negative feedback regards the Norplant. Some of the doctors said this is the first time they heard about Norplant others considered the complication of using Norplant is greater than its advantages and advise women to remove it. One of women in FG#3 mentioned that the nutritionist advises her to remove the Norplant in order to help her to reduce weight. “During my consultation visit to nutritionist and after taken a full history from me, she said: you have to remove this toxic from your body before you think to come back to my clinic to help you control or reduce your weight, I am so happy with Norplant and I do not want to remove it, just what I need is to Keep my weight ideal, actually they relate any problem to Norplant and this is not true”
Second, cultural reason was considered as a barrier while religious issues considered as a helping factor in using Norplant. Religion supports women doing the best for her body.
Many participants claimed that husbands’ family and mother in laws play a big role in preventing women using this method. While other emphases that their husband supported their usage of Norplant. One of health care providers in FG#4 said: “Ah, it is nice story, one lady came to our clinics and asked for using Norplant and she was so happy for this method, just a few days later she came to our clinics with her husband and mother in law and asked to remove it. We asked her if there is any complication the answer was no complication. Actually, her mother in law consider the Norplant as a way of spy (card spy) and they accuse the lady for using it, we tried to explain to them everything about Norplant, but they insist to remove it, yes this what happened”
Third, Unavailability of Norplant and consider it as a luxury: The participants mentioned in order to trust people to use this method the major health care providers should provide it, otherwise people considered it unsafe methods. Ministry of Health considered is a main health care provider in Palestine and providing the Norplant through its clinic will encourage the people to use it. The cost was not considered as a barrier, all participants from FGs agreed that the cost was appropriate and cheaper than any other methods.
Two phone interviews were conducted with MOH and UNRWA in order to understand their position regards the Norplant, barrier for providing it and how we can instruct them in using it. One of health care providers in MOH said. “The main barrier for not introducing Norplant in our services is lack of trained staff/ team, cultural factors of Palestinian people and inability of us to maintain this service. Already we received many years ago 600 pieces of Norplant and we sent it to PFPPA”.
One of health policy maker at MOH said “Before 5 years we received 600 pieces of Norplant from PFPPA and we form a committee consisted of 5 specialized doctors in obstetrics and gynecology, most of them retired now. Then they decided and considered that Norplant was not appropriate for Palestinian women. This method was designed and used in developing countries as Africa, not for developed countries. Bleeding is the serious side effect of Norplant. We have many choices of contraceptive, why to use Norplant”.
As for UNRWA, the policy maker makes it clear when he said that “Norplant contraception is not present in UNRWA policies and services. Why to use it … we have many methods of contraception and women are happy using them, I think the problem with Norplant is not the insertion, the problem is in removing it. It is not easy procedure and need to train doctors. For PFPPA still too early, we have to wait 5 years and follow up complication rates of removed Norplant for women who have inserted it. The insertion project of Norplant started 3 years ago, and we should see if there are complications after removal”
One of health care providers in UNRWA said “UNRWA facing a lot of financial problem, sometimes we cannot offer essential drugs medication to patients. Norplant is luxury element. It is very hard to insert anything not essential. If we think to insert Norplant into our FPS we have to get acceptance from UNRWA director in Jordan. Another point that we work in collaboration with MOH, if it not used in MOH, how we can use it”.
Another health care provider at MOH said “For me as a midwife and manager, Norplant is a luxury thing, I prefer to spend money to bring essential drug as prostaglandin and other essential medication in labor. Sometimes we do not have them and ask the patient to buy them. That health care profession has considered Norplant as a luxury element. This might be influenced by working in health care system facing a lot of critical financial situation forced them to think in this way.
Theme 4: Decision for contraception
In order to help couples or women to decide the appropriate methods of contraception, the responsibilities of health care providers in Palestine such as ministry of health, UNRWA and non-governmental organizations to make modern contraceptive availability, accepted cost (or even free) and spread knowledge to motivate people to use it. The evidence shows the availability of a broad range of methods has been shown to increase contraceptive use [5,6].
Participants mentioned that women have the right to know all kinds of family planning and then decide which type of family planning method she should use. Every individual is unique and some women are satisfied with specific type of contraceptive and others are not. Some of them agreed that her husband should know and agreed to any kind of contraceptive as implants. They consider him as their partner in everything in life, so it is important to get his permission. They considered that Norplant is 5 years method of family planning is a long time and he should be informed. However, others mentioned that women should have a freedom to do the best for her body with or without husband or mother in law agreement. From the participants’ point of view, the economic situation plays a big role in any decision between couple to have future pregnancies.
One of participants said “we have 4 kids and I think nowadays it is common to have a family with 3-4 kids not like in the past the family size was bigger than this 12 at least as my husband’s family. The life is so expensive not like before, we decided in the beginning to have from 3-4 kids not more. If he wants more kids, he has to think first to get more money. We agreed in principle no more kids and it is my body I can use appropriate contraceptive for me, after Norplant was inserted to my hand two years ago, I have informed my husband he said if you are happy that’s fine, really I am so happy and relax it is guarantee method 99%”
Theme 5: Increase usage of Norplant
This study showed that the encouraging Norplant usage relies on three partners; health care providers, MOH and PFPPA.
• Participants emphasized the important roles of UNFPA to support FPS. To facilitate the access to Norplant and ECPs through providing PFPPA and MOH with them.
• The participants considered post-natal period and at time of baby immunization as a golden time to recruit women and explain to her about different methods of family planning especially the Norplant.
• The health care provider should use different techniques to increase awareness about various contraception methods and remove any misperception.
• Presentation of success stories of couples using Norplant and build ideal case using social media and web site.
• Increase team Training about FPS to educate women about Norplant. Training should involve identifying the implant and how to install it theoretically and practically. PFPPA had done many training courses about apply and removed implant.
Theme 6: Emergency pills
Participants mentioned that emergency pill should be taken within 72 hours of unsafe sexual intercourse or when women switched between one methods of contraceptive to another. It is suitable for all women and no complications at all. They considered it as a brilliant super pill if used in proper time by women. The study highlighted the lack of knowledge regarding the availability of emergency pills as a method of contraceptive. Although, it is clear from health providers that emergency pills are sometimes taken by men to their partner or wife. The health providers in their field visit for community education regarding the contraception provided many women with information about emergency pills. The policy of PFPPA is to make registration for beneficiaries for their names and contact information and other essential material. One of health care providers in FG#4 said “Sometimes the women come and asked for morning pills after un protecting sex. Many husbands work in Israel or outside country and they have their sexual intercourse without any plan. Many men came to our clinic asking about emergency pills for their wives, we are the only organization providing it with accepted price for people. It not available in MOH services or UNRWA services”
The emergency pills are the basic need and right of women. The major health provider sectors in Palestine do not provide them regularly and there is strict procedure for prescription. It is apparent that emergency pills not available at UNRWA or MOH agenda. Regarding using emergency pills in UNRWA one policy maker said “we started to introduce the emergency pills for 7 years into our clinic. Actually, it is not present in our policies; there is no system for emergency pills at UNRWA not only in Palestine but in any UNRWA clinics. The source of these pills present at our clinics was donation from PFPPA or another source. We used it mainly in case of gender-based violence or similar cases. In my point of view, it is not easy to introduce emergency pills especially for unmarried women”
One of health care provider at ministry of health said “The number of emergency pills distributed last year was 129 pills from west bank. Generally, the emergency pills are not available in our service. For many months the stock is zero, the emergency pills are not available. The doctor has to prescribe them to patients, it is not allowed for midwife or nurse to give them to any women in need”.
In the world more than 60 countries have been licensed with contraceptive implants . It is effective, safe and evidence suggesting that women do not experience serious health events [7,8]. Their ease of use, long duration of action, noninterference with intercourse, little ongoing attention, feeling well and immediate return to fertility after removal are main benefit in current study, in line with previous results [9-12]. While, disruption of the menstrual bleeding pattern is their major drawback, accounting for the greatest number of early discontinuations these results are in line with previous study findings as well [13-17].
This study covered beneficiaries besides health care provider of Norplant and emergency pills in WB and GS. It emerged that satisfaction and advantages was greatest for both method of Norplant and emergency pills contraception. The percentage of occurrence of side effect and number of removed Norplant 29% in WB 8.8% in Gaza were accepted compared with other studies as illustrated in literature review, in UK and Australia reached 50% rate of removal of Norplant. The most common side effects were change in menstrual cycle after using implants, mood change, bleeding/spotting other than period and weight gain, this in line with previous study [14,18-23]. This study emphasis the cultural issues influencing the usage of Norplant among Palestinian women and this emphasized in Wigginton et al. study  who founded that 40% of women changed contraceptive for noncontraceptive reasons. Therefore, in a review paper of Norplant complication, the authors recommended to educate women about side effects and the important to weigh the risks and benefits ratio of contraception .
The most common barriers of using Norplant were the lack of awareness and information of this new method among couples especially women and among health care providers, unavailability of Norplant in health services except PFPPA and cultural reasons such as misperception. Therefore, it is crucial to understand community and women’s perceptions about the implant and incorporate these understandings into contraceptive consultations. The total number removed were fifteen (8.8%). The most common side effect is irregular bleeding (spotting), especially in the first 6-12 months. Sometimes the implant causes long-term spotting, or periods get longer and heavier. But for most women, the implant makes their periods lighter - some women with implants stop getting their period’s l after a year. Jadelle implants were removed from (fifteen) women as a result of: five women plan to get pregnancy; one woman had significant weight gain and one woman complain of benign tumor at thyroid gland and according to her doctors’ advice removed the implant.
It is important here to emphasis that FP services in Palestine are designed to serve married couples only . The current study highlighted that current FP services do not include single woman and men. The comprehensive ICPD Beyond 2014 Review emphasized the foundation of sustainable development is the investing in individual human rights [26-28]. Therefore, the recommendation is to involve these vulnerable groups in future study and contraception services as emergency pills should involve them. Although, it is crucial to present and consider ECPs pills under essential drug list to ensure the availability for women in need.
Governments and policy makers should commit to ensure the implementation of a national FP strategy, different types of family planning should be available, accessible and affordable (free). The services should be comprehensive and include modern contraceptive like Norplant and ECPs. This study is evidence for inequity of health services for married women and unmarried as well.
• Strength and limitations of the study: The use of the triangulation methods to answer research questions was the most powerful tool of this study. In addition to that it is considered the first study that investigates the experience in Contraceptive Implants & Emergency contraceptive pills in Palestine. However, the main constraints that appeared in this study were lack of local and regional studies, and small sample size, which considered as a main limitation.
• Ethics approval and consent to participate: The study was followed Declaration of Helsinki in all study steps. The participants gave their written consent to participate in the study. Permission was obtained from PFPPA before conducting of this study.
• Consent for publication: Not applicable.
• Availability of data and materials: Additional data and material are available from the corresponding author on request.
• Competing interests: The authors declare that they have no competing interests.
• Funding: This project was funded by UNFPA and run through Palestinian Family Planning and Protection Association
• Authors’ contributions: The author was make the study design, coordinated the data collection, data analysis and writing up.
• Acknowledgments: Researcher would like to thank UNFPA for their fund and concern about Palestinian women health and express gratitudeto the Palestinian Family Planning and Protection Association (PFPPA)who helped in distributing and collection of survey as well in participate in interviews.