Norplant contraceptive implants are now available in more than 50 countries, including more than 30 in the developing world. While the method has been found to be safe and effective, concerns have been raised about the issue of removal: Can a woman get the implants removed when she wants? Do providers have the skills they need to remove the implants with minimal risk of complications?

These concerns are heightened in developing countries, where factors such as long distances and scarcity of providers can make it difficult for a woman to have the implants removed.

A recent study conducted by AVSC International in collaboration with the Kenyan Ministry of Health (MOH) provides some insight into these questions.

Nationwide Services

Norplant implants were made part of Kenya's national family planning program in 1992. Since that time, the MOH, the Family Planning Association of Kenya (FPAK), and the Christian Health Association of Kenya (CHAK) have conducted a carefully planned training program, placing an emphasis on counseling and the clinical skills of insertion and removal. By the end of 1995, the method was available at 72 public and private sites throughout the country.

In 1996, researchers reviewed the records of 225 women who had obtained removal services at six health facilities in Kenya. They also interviewed 35 of those clients to learn more about why they sought removal and the quality of the services they received.

Reasons for Removal

Over half of the 225 clients reported that the main reason for requesting removal was side effects, primarily heavy bleeding or irregular bleeding. This finding is consistent with other studies on implant removal.

About one-fourth of the women wanted to have the implants removed because they wanted to become pregnant. Because the method is still relatively new in Kenya, only three women requested removal because of the five-year expiration date for the implants.

Finding a Provider

Women reported having a relatively easy time finding a provider to remove the implants. Thirty of the 35 women interviewed obtained the service from the first health facility they approached, usually the site where they had had the implants inserted. Fifteen of the women received removal on the same day that they first asked for it; most of the other women had the procedure done within eight weeks of their decision for removal.

The procedure went well for the women interviewed; none reported complications. Two-thirds said the procedure was not painful; one-third said it was slightly painful. This finding suggests that providers offering removal services were skillful and well trained.

Although side effects were an important concern for women who had the implants removed, 33 of the 35 women interviewed said they would recommend the method to a friend. This finding suggests that women recognize the method as a viable option for some, even though they might personally choose not to use it.

Counseling Improvements

One concern of the Kenyan national program is the quality of counseling received by clients. The study identified areas for improvement.

Researchers interviewed 131 women just after they had the implants inserted. A large majority of the women--over 90%--knew that the implants were effective against pregnancy for five years. However, 31% could not name a side effect of the method.

Considering that side effects were the primary reason for requesting removal, this finding suggests that providers need to pay more attention to ensuring that clients receive and understand information about side effects during counseling.

Removals to Rise

The number of requests for removal is expected to rise in the next few years, as many women reach the five-year expiration date. AVSC estimates that about 12,500 women in Kenya will request removals in the year 2000.

The Kenyan program is taking this emerging demand for services into account as it trains new providers and provides continuing education for those already trained. The public and private sectors plan to continue monitoring the services closely, learning as the program develops, and improving the services as they learn.

This article is based on a report prepared by Janet Bradley, former evaluation and research coordinator, Nairobi, and now a consultant to AVSC; John Githiari, senior medical advisor, Nairobi; and Joseph Dwyer, regional director for East and Southern Africa, Nairobi.