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[Unpublished] . 9 p.IPPF relies on its International Medical Advisory Panel (IMAP), formed in 1979, for advice on safety and acceptability of contraceptive methods; service delivery; training of service delivery staff; and scientific aspects of the manufacture of contraceptives. The specializations of IMAP members include contraceptive technology, gynecology endocrinology, public health, and family planning program management. Whereas there was a relatively high demand in the first couple of years after IPPF issued its statement approving Norplant in 1985, and Norplant was added to the commodities list, after 1989 the requests by FPAs for Norplant have diminished, as it is now (1991) considered to be too expensive. The cost of training doctors to insert and remove Norplant is also high and many FPAs are reluctant to train doctors because of the expense. In Pakistan the nearly 100% effectiveness of this method makes it an ideal contraceptive and it can be compared with the IUD, which has 2-4% failure rate. The FPA of Bangladesh Annual Report 1990 stated that 304 cases had been recruited in Rangpur and 308 cases in Dhaka, of which 549 were continuing for 1-3 years. The Thai government is aware that Norplant is expensive and is limiting its use to the rural hilly areas. On an optimistic note, PROFAMILIA, Colombia, plans to expand access to Norplant services at its clinics, which will require additional trained personnel and Norplant implants. The plan is to start this project in January 1992. In Eastern Europe, the Bulgarian FPA expressed an interest in introducing Norplant into its programs. Although the trials concluded that it is an acceptable, long-acting and effective method of contraception, IPPF has only had requests from three countries in 1991 for the supply of Norplant (Indonesia, Bahamas and Kenya). The major constraints on the use of Norplant are its cost, lack of trained personnel, and difficulties in licensing.
PHNFLASH: ELECTRONIC NEWSLETTER ON POPULATION, HEALTH, AND NUTRITION. 1995 Oct 25; (93):1.Many contraceptive implant specialists provided an overview of current contraceptive implant technology and practice to the staff of the World Bank on July 18, 1995. The Director of the UNDP/UNFPA/World Health Organization/World Bank Special Program of Research, Development, and Research Training in Human Reproduction informed the audience about the history of implant technology. The chief investigator of many clinical trials of contraceptive implants in Chile discussed the mechanisms of action of implants and the benefits and disadvantages of the various types of implants that are available or under development. The only contraceptive implant on the market is Norplant, which more than 3 million women currently use. Most Norplant users live in Indonesia, followed by users in the US. Providers insert the 6 progestin-releasing rods in the upper arm, which provides protection from pregnancy for 5 years. Norplant acceptors may request removal of rods at any time. Many people are concerned that Norplant users may not have timely access to removal of the implants when they want them to be removed. Another concern is the potential for coercion since Norplant requires assistance of a medical provider to start and end use. Many women's groups in developing countries share these concerns and have protested against Norplant. As a result, developers of contraceptive implants and representatives of women's groups have met to discuss these concerns. More discussions will be needed to make sure that developers adequately address these concerns.
In: Issues in reproductive technology I: an anthology, edited by Helen Bequaert Holmes. New York, New York, Garland Publishing, 1992. 11-30. (Garland Reference Library of Social Science Vol. 729)The progestin, levonorgestrel, suppresses ovulation and thickens the cervical mucus. The 1-year pregnancy rate is 0.2/100 users and the 5-year rate is 3.9/100 users. Contraindications of Norplant include abnormal bleeding, cardiovascular conditions, liver tumors, and breast cancer. The most frequent side effect is changes in bleeding patterns. A main concern of women's health advocates is that women are dependent on the medical establishment for insertion and removal of Norplant which affects the provider-client relationship. Family planning programs that do not recognize a woman's right to free choice of existing contraceptives and her right to have Norplant removed at any time may abuse Norplant. Health workers still do not know the long term effects of Norplant and Norplant's effect on the fetus in case of method failure or insertion while pregnant. Most acceptability studies occurred at university-based health clinics or at clinics in urban areas. The clinic environment may affect women's answers. These studies should occur in the community and home of users and nonusers. Another bias of these studies was clinic staff chose women who would tend to continue using Norplant. Thus subjects were not representative of the population. Researchers did not attempt to understand the women's perception of reproduction physiology and mode of action, the women's cost benefit analysis used to determine what method to use, or the consequences of menstruation changes. They also did not report on the information women received about contraceptive choices. The issue of abuse has arisen in Kansas where a state legislator proposed paying any mother on welfare US$500 if she uses Norplant. In California, a judge ordered a woman convicted of child abuse to use Norplant after release from jail and throughout her probation period.
OUTLOOK. 1990 Jun; 8(2):7-9.This article summarizes the most recent data on WHO's multicenter clinical trial test of the low dose progestin-releasing vaginal ring as an effective contraceptive for women. The study involved 1005 women aged 19-34 and was carried out from 1980-86 at 19 centers in 13 countries, including 9 developing countries. The overall findings on vaginal ring use included: the ring's effectiveness was comparable to oral contraceptive (OC) effectiveness, pregnancy rates increased with increasing body weight, about 1/2 of the users had discontinued the ring by 1 year, the ring disrupted menstrual bleeding patterns in about 1/2 of all users, and about 1/4 of all users expelled the ring at least once but most continued to use it. The irregular bleeding pattern was the main reason for discontinuation. Part of the reason for having different ring contraceptive effectiveness in different countries could be due to differing average weights of the women. Increasing risk of expulsion was directly related to increasing age by approximately 3% with each year of age. For effective use of 90-day low-dose levonorgestrel-releasing vaginal ring, appropriate clients should have the following: a dislike for inserting and removing vaginal devices, low weight, counselling on potentially irregular bleeding, and counseling on how to deal with an expulsion. (author's modified)
Effective interception with the levonorgestrel-20-IUD contrarily to WHO advocated Lng-2-microdose IUD. Reply to letter to the editor [letter]
CONTRACEPTION. 1988 Jun; 37(6):644-6.This letter is a response to Professor Haspels' letter criticizing the World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction's clinical study of a 20 mcg microdose levonorgestrel IUD for Contraception (Contraception 1987;35: 363-79). The Population Council's International Committee for Contraceptive Research was provided with the results of the study prior to publication. The feasibility of an IUD that released a dose of progestational steroid that was pharmacologically active only on the endometrium was confirmed in a study conducted between 1980-1982 in 7 centers, only 3 of which were in developing countries. There was no evidence of effects on ovulation and no ectopic pregnancies in this study. The study itself resulted in only 8 ectopic pregnancies (6 with the levonorgestrel device and 2 with copper devices) out of 17,064 woman-years of experience. Nevertheless, the study was terminated and the results published. The polymeric delivery system used in the 2 mcg levonorgestrel IUD had undergone extensive animal toxicological studies in the US and the UK before human use. Moreover, the ethical acceptability of the study was approved by the World Health Organization as well as by local institutional ethic committees and appropriate national authorities.