Birth Controlling the Third World

To fully appreciate the ancedote below, consider yourself a woman in rural Bangladesh. You spend about four hours a day gathering material for fire, often dried dung or the residue from crops. You are 29 years old with three children, and don't want more.

And you have six sticks under the skin that you're certain are making you ill.

One client, who had used the implant for 12 months, experienced irregular bleeding and weakness throughout that time. Twice, she was prescribed treatment and was advised to keep the implant. On her third visit, the client told the counselor that she would go to another doctor for removal, if necessary. The counselor accused her of being "daring" and did not allow her to see the doctor. She was also told that the implant was very costly and could not be removed according to her "sweet will."

"Providers are sometimes reluctant to remove it if there's just a minor bleeding problem," says Dr. Douglas Huber, Medical Director of Pathfinder, an international family planning organization. "And other providers might be reluctant to do the removal, if they didn't insert [the Norplant capsules] originally.

"There are questions whether health care workers are adequately trained for removal; the skills required are fairly substantial. Norplant removal is not simple, and lends itself to problems," Huber says. Also, "if women move around, there may not be an accessible clinic that can do a removal."

These concerns are greatest in Indonesia, Huber noted, because about 500,000 women are soon due for removal of Norplant. The government is now intensifying efforts to provide removal services.

But Pathfinder and other organizations assume many of those women won't be able to have Norplant removed, and are now writing guidelines on how to use a second contraceptive while the "six sticks" -- as the implants are called in Africa -- remain embedded in the woman's arm.

"But all kinds of corruption of the message is possible," he says. While Paxman feels that in theory the women are told of possible normal and abnormal side-effects, "It's my impression is that there's probably lots of errors -- that the counselling is not what it should be."

Sandra Waldmen, spokesperson for the Population Council, agrees that counselling is as important as receiving the implant. But, she adds, "I think you should apply the same criteria to instructions for users of oral contraceptives, IUDs, and barrier methods. Are pill users told what to do if they forget to take a pill? Or that they have to take their pills at the same time of day for maximum effectiveness? Are they told of side effects with the pill, [such as] spotting, headaches, acne, weight gain?"

Side effects from Norplant, however, can be more serious than that. Capsules planted too deeply in the arm may require an operation under general anesthesia. And the 2 percent of women who become pregnant while using Norplant are much more likely to have life-threatening ecotopic pregnancies, which also require a surgeon's knife -- if such an operation is available in that part of the world.

And besides not explaining risks clearly, Paxman and others worry that women are sometimes intentionally misled. Norplant is an interesting new medical procedure for many providers, and health care workers may be more concerned about selling women on the contraceptive than explaining side-effects, which could discourage them.

"The medical community gets fascinated by things like this," says Paxman. "Do women have to be 'persuaded' so [the provider] can have experience doing the insertion?"

Another woman from Bangladesh commented on the different treatment she received when Norplant was implanted, and when she visited the clinic for complications:

Oral contraceptive pills were prescribed for her to control heavy bleeding. During her second visit the doctor told her, "Did we insert the capsules by force that you repeatedly come and annoy us? Go away, it can't be removed now." The client was again given pills... She went back to the center two more times. The client said, "At the time of insertion, they were so affectionate, it was as if I was one of their nearest and dearest ones. But for removal, I had to go such a long distance with so much hazard, where, far from giving a penny [for transportation expenses] or medicine, they didn't care a damn about me." She finally had the implant removed elsewhere.

But in practice, Norplant especially takes control from women and gives it to her doctor -- or maybe her government. As in Bangladesh, a woman can find herself with an illness-causing foreign body buried in her flesh, and no one willing to take it out. Or at least, before the five year lifetime of the drug expires. Norplant can bring entrapment as well as empowerment.

These problems lead activists to call it yet another form of cultural imperialism. It is ultimately a Western drug that is being peddled in societies with very different standards, both medically (where a doctor can't always be found nearby) and socially.

One report filed by a USAID worker in Africa is revealing. Her experiences there, she said, gave her "...an appreciation of the complexities involved and difficulty a provider may have in providing counseling without making decisions for a client, especially in a context where independent decision-making (especially by women) is not a dominant cultural value."

For the great majority of women for which Norplant works, it is undoubtedly wonderful. And probably most of those women will have no trouble with removal, nor arguments from their doctor.

But there are also those who remain, like that woman in Bangladesh spending her four hours daily, searching for anything that will fuel her fires. Maybe every so often she rests and her fingers unconciously rub the six lumps in her arm, hoping that it someday, somehow, her strength will return.