Nawal and Omar, both in their 20s, are a typical couple in Amman, the capital of Jordan. They share a small house that has no indoor plumbing with their four children, Omar's parents, and his many brothers.

Last year, the couple decided they wanted to wait before having any more children. Nawal visited the local clinic and began taking oral contraceptive pills. Though her family is poor, they have good health insurance and access to high-quality health care services, thanks to the country's well-developed health care system.

Nawal became unhappy about the weight she gained as a side effect of the pill, and she had trouble remembering to take it every day. So she went back to the clinic and had an IUD inserted. But after experiencing some unpleasant side effects, she had it removed. Now the couple is not using any form of contraception, and they worry that Nawal will become pregnant.

Nawal and Omar are fictional characters, but their situation is representative of that of many couples in Jordan. Though many contraceptive methods are available, public awareness is limited to only a few of them, and misinformation is common. With the average woman bearing between four and five children in her lifetime, Jordan's population is growing at a fast rate.

Study Examines Method Expansion

To increase the choice, knowledge, availability, and use of contraceptive methods, the government of Jordan initiated a study to determine the feasibility of introducing two long-acting contraceptive methods--Norplant implants and Depo-Provera.

The study, which was sponsored by AVSC and Family Health International (FHI), followed over 300 clients who received Norplant implant or Depo-Provera services at three health care facilities in Amman. Its goals were to determine why these clients chose to use one of the two methods, assess the quality of family planning counseling services they received before choosing a method, and evaluate their satisfaction with the chosen method six months later.

Counseling and Client Choice

"Before I had the capsules, I wanted to have a tubal ligation," said a 37-year-old mother of seven. "But when they told me about the [Norplant] implants, I felt at rest because they are inserted in the arm and remain there for five years. What made me feel more comfortable is that I can remove them anytime...."

Counseling quality varied among the three facilities. Overall, most of the clients reported receiving counseling only about one or both of the new methods. Most also reported being very well counseled on the method they chose, but wide variations were seen in counseling about removal.

Client Satisfaction

At the end of the six-month period, about 80% of the Norplant implant users and about one-third of the Depo-Provera users reported being very satisfied with the method and said they planned to continue using it.

Side effects were cited as the main reason for discontinuing use of both methods. Most of the clients experienced at least one side effect during the first six months of use; however, those who discontinued using a method were significantly more likely to have experienced problems with it than were those who continued use.

Though the number of clients who stopped using Depo-Provera seems high, several factors other than client satisfaction contributed to the decision to discontinue use of either method. Often, decisions about their contraceptive use were made for them or influenced by health care providers, counselors, husbands, or other family members. Popular attitudes about family planning in general, and hormonal contraceptive methods specifically--though often based on false or incomplete information--appeared to influence their decisions.

"When my husband heard [about Norplant implants leading to 'slow death'], he said, 'You must remove them,'" reported one client. "I didn't want to say no to him, and if I became ill later on, he would say it was due to the implants. So ... I removed [them]."

Study Results

To present the results of the study to the public and the health care community, a workshop was held in Amman last fall. Sponsored by AVSC under the patronage of the Minister of Health and Health Care of Jordan, the workshop had 87 participants, representing many national and international health care organizations. Eight members of the media also attended.

Along with the study results, experiences delivering Norplant implant and Depo-Provera services in other countries were presented. Overall, the study findings were consistent with the international studies in regard to the two methods' acceptability, side effects, safety, effectiveness, and user satisfaction and continuation rates. As a result, the workshop participants recommended official endorsement of the two methods.

Improving Services

During the course of the workshop, the participants made recommendations and guidelines for providing affordable and high-quality Norplant implant and Depo-Provera services.

To make the services accessible throughout the country, they recommended their gradual introduction and expansion into private- and public-sector institutions. This expansion would coincide with the introduction of a comprehensive, nationwide program to raise public awareness of and lower misconceptions about the two methods.

Several methods were suggested to ensure service quality. The participants recommended routine training of physicians in Norplant implant insertion and removal, as well as management of side effects and complications of both methods. Keeping health care providers informed about new contraceptive techniques and maintaining an awareness of clients' rights were also suggested.

Developing method-specific counseling standards was suggested to inform clients of the unique benefits and side effects of each method. Also discussed was the need to inform clients about all the methods available, provide the necessary counseling materials, develop the capability to train trainers in counseling, and involve male partners in counseling.

To provide for long-term implementation and sustainability of the services, the participants recommended developing criteria for selecting service sites and service-delivery protocols. To facilitate research and evaluation of the methods in Jordan, they proposed creating a centralized referral system for data collection and problem solving.

AVSC plans to work with members of Jordan's public- and private-sector health care communities to provide training, counseling, and quality-assurance measures to ensure that these recommendations and guidelines are implemented. It is hoped that, over time, couples like Nawal and Omar will have access to a range of safe and effective family planning methods, as well as the information needed to make choices that are right for them.

Melinda Gallagher is the program officer for AVSC's programs in Jordan and Yemen.