The first young woman smiles into the camera. "I love my Norplant," she says. "You don't have to worry about having a child for five years," the next says shyly. A third volunteers: "For me, I think Norplant is the ideal method."
Their inviting testimonials are part of a widely used educational video, made by the Emory University Summer Program in Family Planning and Human Sexuality, for women considering Norplant. The upbeat 18-minute presentation, distributed to sales representatives, doctors and family-planning clinics, notes accurately that Norplant is the most effective reversible contraceptive available and that it is brand new. A doctor explains some of the common side effects, but they're quickly counterbalanced by the young women, who say that the irregular bleeding and the weight gain didn't really bother them. The young women display their upper arms, where the six slim, inch-long rods containing synthetic hormones were implanted, and testify that the pain of the operation, if any, was easily diminished with Tylenol. They say their fathers and their boyfriends approve.
More girls come forward with the same cheerful message. "It doesn't hurt, there's nothing to worry about with it. It's simple, and it works real good," says a happy young woman. "A lot of teen-agers needed Norplant. I'm about the only girl in my neighborhood who doesn't have kids. . . . They need to get some (Norplant) so they can have fun and enjoy life while they be young. You got all your life to have kids."
As the tape is concluding, a white-haired doctor in a white coat pats the shoulder of a young African-American girl looking up at him from a chair. "So, what might you tell a young teen-age girl?" he asks her. "Get it!" she replies. He smiles to bystanders off camera.
The promise of Norplant as a foolproof, long-lasting contraceptive that requires little thought and works for almost everyone is so seductive, so longed-for, that the message has spread with amazing speed among young women and policy-makers since the Food and Drug Administration approved it for public use in December, 1990.
In less than two years, 13 state legislatures had proposed Norplant measures, nine of them requiring or inducing mothers on welfare or who abused drugs to be surgically implanted with the rods. Norplant's upfront costs are high--the distributor charges clinics and private physicians $365 to buy it, and paying patients can be charged more than $500. But within two years, despite the distributor's insistence that public agencies pay the same price as private physicians, despite a list of known and suspected health risks similar to those of birth-control pills and amid explosive charges of racism, all 50 states and the District of Columbia had approved Norplant as a birth-control method covered by Medicaid. In California, state officials say they plan to save more than $5 million in health and welfare costs by offering $5 million in Norplant subsidies to about 10,000 eligible women. Nationally, the independent, nonprofit Norplant Foundation has committed $2.8 million in 1994 (equal amounts were allotted in '92 and '93) to provide implants for low-income women not covered by Medicaid.
Now an estimated 780,000 women in the United States are assured they will not conceive because tubes continually pump synthetic hormones into their bodies, altering rhythms as ancient as the tides.
But along with the obvious relief expressed by many women, the new technology has brought complex and worrisome issues. Will the poorest of the poor feel forced or pressured into using a birth-control method they cannot then control? Is an implant appropriate for teen-agers? Will it make women less likely to protect themselves from sexually transmitted diseases? Is birth control an acceptable way for society to solve its seemingly intractable social problems?
SONDRA, A SECOND-GENERATION INNER-CITY WELFARE MOTHER, HAD her first baby at 15, her second a year later. Like her friends in the drug-ridden northeast Washington, D.C., neighborhood where she grew up, Sondra, now 17, can't really say why she didn't use birth control before. Now she sees how it is: Her boyfriend has departed, and she and her children are forced to live in an aging brick townhouse with her grandparents, two aunts and their four children. She cannot live with her own mother, who abuses both drugs and children.
"I don't want to be on welfare," she says. "I want to give my kids things. That's why kids go out and sell drugs. Because their parents can't afford to give them things."
She heard about the implants from a friend and, like most, was eager to try an alternative to the hassles of taking the Pill regularly, the dangers of the much maligned IUDs, the embarrassment of foams and diaphragms--something, in short, that wasn't a problem. She firmly believes that the rods of progestin, barely visible under the fatty tissue of her upper arm, promise her a new life. She plans to complete high school soon, then go on to training school, get a job and eventually get married. "I ain't going to have no more kids," she says. "Never."
Sondra is precisely what policy-makers have in mind when they propose offering Norplant at school-linked clinics or conditioning welfare payments to its use: a young woman who just needs information, a little technology, a little push to get herself together and off the welfare rolls. A dream solution. A magic bullet.
But in their desire for a simple solution, policy-makers may not see the risks. Sondra, for instance, weighed 180 pounds and had high blood pressure when she obtained the inserts. Now she has gained 20 pounds. She has no regular health care and has not been back to the clinic for four months.
Nor do policy-makers often consider Norplant's implications for women like Sondra's friend Sara. Sara lives in a housing project with her mother and brother. She hangs out with an assortment of men, often disappearing for weeks at a time. She says she has sex with as many as half a dozen men a month, many of them drug dealers. At 20, her eyes look nearly dead, suggesting she long ago gave up seeking a better life. Like many women her age, she could not keep up with taking the Pill, even though "the boys I know ain't worth having babies for." She had had two abortions by the time she obtained Norplant last summer.
For Sara, Norplant may hasten the slide into an already lethal lifestyle. Since obtaining the implants, she has slept with at least one HIV-infected man. She says no one at the clinic she visited counseled her about the importance of also using a condom to protect herself against sexually transmitted diseases.
In another era, Norplant might be considered just another birth-control option. But having appeared at a time of economic cutbacks and welfare resentment, into a society riven by deprivation and overdue for contraceptive innovation, Norplant seems to have an exaggerated appeal, leading some to wonder whether its very success signals deeper trouble for the women who use it. Not only are the health risks of poor young women a matter of concern, but also, as politicians continue to push long-acting contraceptives, the expectation seems to have vanished that these women might learn to manage their sexuality and be responsible for their own reproduction.
Asks Gabriel Bialy, a reproductive biologist at the National Institutes of Health: "Is it so impossible to teach these kids responsibility that we have to say, 'We're going to pump this implant in you, and you can act like a bunny for five years'? I don't accept this business that they are totally irresponsible."
The entire Norplant phenomenon "brings together issues of social control, sexuality, money, politics, the whole class and racial tensions we have," says Jacqueline Darroch Forrest, vice president for research for the nonprofit D.C.-based Alan Guttmacher Institute, which is monitoring the introduction of Norplant.
There are questions of balancing the ease and effectiveness of the new technology with the increased dependence on health providers. And of soothing the tension within a tax-supported system that aims to offer contraceptives to all, but can afford to provide for only a few. Forrest cites the real desperation to find a new method to avoid accidental pregnancies, which compose more than half of all pregnancies in the United States, and the desire on the part of some lawmakers to control the reproductive behavior of poor people in order to save tax dollars.
Ultimately, she says, the issue is much larger than the development of a new technology. "The real question is how we treat each other in our society."
FROM THE BEGINNING, NORPLANT WAS RECEIVED AS A NEAR-PERFECT solution to some troubling problems. A 1990 press release from Norplant's sole U.S. distributor, Wyeth-Ayerst Laboratories, called the contraceptive an "eagerly awaited medical advance (that) is the most innovative contraceptive in 30 years. It not only provides a long-term contraceptive option for many women of reproductive age, but also may provide an alternative to sterilization."
The first implants were sold to middle-class women through private physicians, but when marketing began in 1991, and as news spread, the public-sector market took off. "As soon as word came out, we were deluged with phone calls," says Thomas Kring, former CEO for the Los Angeles Regional Family Planning Council. Women clearly understood they did not have to remember to take a pill but could still receive the Pill's benefits: They did not have to obtain their partner's cooperation or interrupt sex to use birth control. What sparked the widespread public interest was that, like an IUD, "It's a method that requires the patient do nothing once it's in," Kring says. "It's just there."
Norplant uses levonorgestrel, one of the synthetic forms of the natural hormone progesterone. Developed 20 years ago, it is widely used in oral contraceptives and the progestin-only mini-pill. It prevents conception by decreasing the number of eggs a woman produces and at the same time thickening her cervical mucus, making it more difficult for sperm to reach the egg. Because it works on a time-release basis, it is more effective at lower doses than the Pill, which requires doses as much as five times higher to compensate for women's fluctuating hormone levels.
Norplant was tested in clinical trials around the world and in the United States by 55,000 women before being approved in this country.
Some of the known risks associated with Norplant are also associated with the Pill. Guidelines from the World Health Organization warn that women who use Norplant should receive regular medical checkups if they have diabetes, anemia or high blood pressure. Women who have given birth within six weeks are warned against it.
Norplant is currently approved for use in 23 countries and has been used by 1.8 million women worldwide since it first became available from the Finnish manufacturer, Leiras Oy Co., in 1983. Their experiences vary widely, with more problems reported in developing countries aiming to control population growth, according to the Dutch Women's Health Action Foundation. The most frequently reported side effects involve altered menstrual bleeding patterns: either prolonged bleeding in the first several months after the implant, spotting between periods or no periods at all. There might also be headaches, acne, weight gain or depression.
As with IUDs, users must depend on providers to insert the device and, most significant, remove it. According to Forrest, removal is "something people have not thought much about yet. It makes it a method you can't control yourself."
In Washington, one 16-year-old says she had severe pain, heavy bleeding and clotting after her implant. She returned to her clinic to get the rods removed. She says she was told to work with the health providers to find another solution. Determined, she went to a hospital, where they were eventually removed.
Clinic workers in Los Angeles say women who want their Norplant removed are encouraged to try it a little longer, particularly when their complaint is the most common one: irregular bleeding. "It's because of the cost," says Pam Garcia, education director of Planned Parenthood of Pasadena. "We don't want her to have it (out) after spending all that money," she says. "It's not like we're sitting them down and threatening them to keep it in. There's nothing we can do if she wants it removed; obviously, we'll remove it."
Claudia Thomas, a health educator at the East Valley Community Health Center, says if the problem was something they had discussed, like irregular bleeding, "We would say, 'We told you this was going to happen. This will probably stop within nine months.' If they don't want to wait, we ask, 'Are you sure?' If they don't, no problem."
CAROL IS ONE OF MANY YOUNG WOMEN EAGER--DESPERATE, even--to try Norplant. At 25, she has had five abortions. The wide-eyed redhead can barely believe it herself and weeps at the memory as she sits on the clinic table waiting for a nurse practitioner to insert the rods into her upper arm.
She tried a year earlier to get Norplant, but then it was not subsidized and, earning $6.50 an hour as a member of an itinerant performing troupe, she could not afford it. Without subsidy, the implants can cost as much as $1,000 at a private physician's office. Carol tried again some months later, but the clinic wanted her to attend a monthlong information seminar on the implants. She didn't have time.
Now, after one visit to Santa Monica's Planned Parenthood clinic, which offers Norplant on a sliding-scale fee, Carol, who qualified for a subsidy, has brought $52 and some change borrowed from her boyfriend to help pay for the inserts. She signed the consent forms, initialing the paragraph that reads: "I understand that some rare, but serious problems or complications have occurred with the use of birth control pills. I understand that it is not known whether these problems and complications can also occur with the use of Norplant. . . . I understand that I may also be at risk for the following: blood clots, heart attacks or strokes, especially in women who smoke, disease of the gallbladder, growths in the liver." A smoker, she also initialed the sentence reading, "I have been advised not to smoke." She says she will probably not give up smoking.
Nervous as she lies down on the table, she asks nurse practitioner Jo Ann Woodward, "How does it work?" Woodward answers quickly, repeating information already given Carol in a brochure, at the same time swabbing her upper arm and preparing the local anesthetic. She shows her the soft Silastic tubes that will be placed under her skin. "I thought it was one piece," Carol says.
Woodward, who has done about 100 implants, places a fan-shaped stencil over Carol's arm and marks where the rods will go. Then she makes a nearly bloodless incision about one-eighth of an inch wide. With gloved fingers, she drops one of the tubes into a metal straw, uses it to tent up the skin and injects the tube into place. Working quickly, she repeats the process until all six rods are in place. The procedure takes five minutes and, starting within 24 hours, will prevent Carol from becoming pregnant until she is 30.
Most patients are instructed to come back in two weeks, then two months to talk over side effects, then annually for regular checkups and Pap smears. Because Carol will be headed east soon, Woodward advises her on items not listed on the form. "If you want to get it out, ask the person, 'How many times have you done this?' Make sure they have done it at least once," she says. She knows Carol smokes but says smoking is not a contraindication, in spite of the consent form's warning.
After almost three years of public use, Norplant has experienced high removal rates. According to Forrest, the single most important strategy to mitigate Norplant's shortcomings--and keep the implants in place--is sensitive counseling and provider conduct.
Not long after Norplant came to the Rosebud reservation in South Dakota, for instance, "Rumors were spreading," says Charon Asetoyer, director of the Native American Women's Health Education Resource Center in Lake Andes, S.D. "Some women thought it would cause cancer or make them sterile. Maybe they were put in too readily." Large numbers of the women demanded to have the rods removed. In the distributor's opinion, the women had not been thoroughly counseled.
In Los Angeles, more than 300 counselors trained through the Los Angeles Regional Family Planning Council have received thick Norplant notebooks detailing "appropriate counseling skills, establishing rapport and trust, using open-ended questions, clearing up misinformation that clients might have and providing complete and accurate information about the method," says Lisa Fries Anderson, Norplant projects coordinator.
Counselors are also trained to recognize their own biases in sessions where they are asked to write down their honest reactions to statements such as: "All drug-abusing women should have Norplant" or "All sexually active teens should have Norplant." If they can recognize their own biases before they are faced with a drug abuser or a teen-ager with multiple partners, Anderson says, counselors are better prepared to say, "Look, this person is pushing my buttons. This is a person I might have trouble counseling. Either I need to step out or recognize it and put it aside."
Counselors are told to make sure the client can repeat back to them four elements of the counseling: Norplant does not protect against sexually transmitted diseases, there are side effects, they can come back at any time for any reason to have it removed, and they need to return for annual Pap smears. "We do the best we can to deal with it beforehand," Anderson says. "There's only so much we can do."
Most implant providers like to say that their birth-control counseling is as complete as time allows and is accomplished in a value-free and neutral manner. But all counselors have their own opinions, says Margaret L. Frank, an assistant professor at Baylor College of Medicine. Her unpublished study of 100 Texas family-planning providers found they harbored strong--and divided--opinions about whether women at risk of HIV should use Norplant. Despite the increased personal risk to users, 81% of the providers said it would be a good method, reasoning, " 'At least we don't want a pregnancy in addition to everything else,' " Frank says. "The rest said, 'Absolutely not.' "
One study shows that some teen-age implant users find it hard to believe they need to use additional protection to guard against disease. Preliminary results from a study of 100 inner-city Norplant users in San Francisco showed that 37% had decreased their condom use since getting the implants, but 54% had not altered their condom use.
This year, addressing the sense of false security, the Food and Drug Administration required Wyeth-Ayerst to adopt a warning label on Norplant, stating that it does not protect women against sexually transmitted diseases.
IN DECEMBER, 1990, THE PHILADELPHIA INQUIRER published an editorial suggesting Norplant would help solve the problem of poverty among blacks and called for incentives for welfare mothers to receive it. Charged with racism by its own staff, the paper later published an apology. But proposals encouraging Norplant use among poor women have continued to surface. In Washington, state Sen. Shirley Winsley sponsored three Norplant bills, including a defunct proposal that would have mandated Norplant for women who give birth to babies with fetal alcohol syndrome or who are drug addicted, and another that would offer a $500 incentive to welfare mothers for a Norplant insertion and $50 each month they do not remove it.
"This is not welfare bashing," she says. "In my case, I'm using it as a means of stopping a cycle of behavior that has negative results." In Washington each year, she says, 8,000 to 12,000 babies (10% to 15% of all births) are born to substance-abusing women.
A self-described "progressive Republican," Winsley says she became convinced policy-makers must focus their efforts on prevention after years of hearing testimony from experts describing the suffering of children born to drug-addicted mothers and the costs of caring for them. Despite treatment and counseling, she says, the problem is getting worse. "We have 10-year-olds having babies. Girls are having their period earlier. I think teen-agers need another choice. That is birth control. Whatever reason, they don't remember to take the Pill. If they're a drug addict, they don't remember much either. I can hardly believe a 14-year-old mother wouldn't want to have Norplant if it was offered to her."
Judges in several states have ordered women to be implanted with Norplant as a condition of probation. In July, a Florida woman who pleaded guilty to child abuse agreed to have Norplant inserted in addition to going to jail and receiving counseling. In February, a mildly retarded Illinois woman, who also pleaded guilty to child abuse, was ordered to have Norplant implanted and to obtain a court order before ever having it removed. The judge denied an objection by the American Civil Liberties Union, saying, "How many children should a parent be allowed to abuse before the state has the right to say, 'You can't have any more children until you can show you are not likely to abuse another child'? And how many children of a parent should the taxpayers of this state have to support in foster homes or alternate care before the state has the right to say, 'You can't have any more children until you take care of the ones you already have'? "
Child-abusing mothers in California, Texas and Nebraska have also been ordered to be implanted with Norplant.
Meanwhile, in the 1991-92 legislative term, about 20 Norplant-related bills, amendments and welfare-reform proposals were introduced in 13 legislatures. So far this year, 17 measures have been introduced in 10 states: Arizona, Arkansas, Colorado, Florida, Illinois, North Carolina, Ohio, South Carolina, Tennessee and Washington. Only two have been enacted. Among those still pending: In Florida, welfare mothers would receive an extra $142 a month for having the implant. The North Carolina bill would mandate that all women who obtain a state-funded abortion receive free implants unless it is unwise medically. But proposals such as Winsley's were quickly and strongly opposed by civil- and reproductive-rights groups. Even the American Medical Assn. has said that such proposals "raise serious questions about a person's fundamental rights to refuse medical treatment, to be free of cruel and unusual punishment and to procreate. . . . There is not sufficient evidence to demonstrate that long-acting contraceptives are an effective social response to the problem of child abuse."
As the proposals start to move beyond outright mandates to friendlier persuasion, however, the ethics quickly become grayer. According to Charles Murray, senior fellow at the American Enterprise Institute, a conservative Washington, D.C., think tank, "The question is, can young women who are not emotionally, intellectually or financially prepared to have babies be good mothers? The answer is usually no. The data is clear and very depressing. (The issue is not that) we're running up the welfare bill, but what is happening to the kids."
In Murray's view, the ethical way to handle Norplant is to broadcast the new option to all young women and even offer government financing. But he says he draws the line at government coercion of private behavior. "I am generally against all kinds of policies that use money as a club. With welfare, it would be used as a club, and that bothers me."
But society must also address human suffering. This society's problem is that alternative solutions to the misery of poverty, drug and child abuse are maddeningly elusive. While many programs are experimenting with close supervision of parents, substance-abuse treatment and counseling, Murray says, "We know very damn little about how to orchestrate human behavior."
IN HER OFFICE IN DOWNTOWN WASHINGTON, JULIA R. SCOTT REACHES across her desk, picks up a small fan and holds it to her face. A hot flash, she explains, and then chuckles as she recounts how shocked some people are at her candid descriptions of her experience with menopause. Scott, director of the public education and policy office at the National Black Women's Health Project, believes in frank and open discussion about women's health issues, and she's convinced there's not enough of that when it comes to Norplant. "Our experience is that people are mainly talking about the benefits" and not the risks, she says.
"We don't think that Norplant is necessarily a bad method," she says. "We are very much in favor of alternatives, but the operative words are safety and choice."
Scott says poor women have specific health conditions, such as obesity, high blood pressure or diabetes, which could make Norplant use disproportionately risky. Lacking regular, quality care, some poor women of color may not know if Norplant is safe for them or not. African-American women in particular are prone to cervical cancer, whose warning sign, irregular bleeding, may be masked by Norplant side effects (similar side effects are also caused by IUDs and the Pill). In addition, some African-American women develop keloid scarring after surgical incisions, which would make removal more difficult.
Most agree that the short-term solution to preventing potential Norplant abuse is intensive counseling that stresses Norplant's drawbacks as well as its benefits. But instead, Scott says, poor women's fertility became "fair game" when the Reagan and Bush administrations exploited the public's fear that low-income women cause the bulk of social problems by having too many babies. "It's been a battle to get full information from the medical community for women. You add on to that poor women and women of color. We do have stereotypes and an attitude that information will only scare them. There's a lack of trust in our ability to take in information and make the choice. We're comfortable with middle-class women choosing not to use the Pill, but we don't have that same kind of sense with poor people.
"We have a frightening history of coercion and lack of information," Scott says. She observes that the proposed incentives are being offered only for one contraceptive--Norplant-- and only to one class of women: "poor, single mothers on welfare, who are more than likely women of color."
Haunted by the memory of mass compulsory sterilizations in this country at the beginning of the century, some minority leaders suspect that attempts to promote long-acting contraceptives are really eugenics in disguise. One African-American minister in Baltimore has said that promoting Norplant to inner-city teen-agers is a form of genocide. The Tennessee legislator who sponsored Norplant incentive bills says a colleague compared him to Hitler.
"In minority neighborhoods," says Linda Gordon, professor of history at the University of Wisconsin at Madison and author of "Woman's Body, Woman's Right: Birth Control in America," "we're dealing with people who have good historical reason to be suspicious."
From the 1890s until the Holocaust of World War II, it was fashionable in the United States to believe that society needed to control population among "inferior" groups. "People assumed many qualities were hereditary which we now know not to be hereditary, such as criminality and insanity," Gordon says. "In the first third of this century, 27 states passed laws involving forcible sterilization of people labeled feeble-minded or criminally insane." Using these laws against minorities, immigrants and culturally deprived people as well, health providers sterilized more than 12,000 people.
Even in the 1970s, when attitudes had changed, several disturbing cases came to light of poor or minority women sterilized without their knowledge or consent. Gordon says it was common practice to threaten to take away a woman's welfare payments or to ask women on welfare to sign a sterilization consent form when they were in labor.
In 1978, federal guidelines were passed prohibiting consent during childbirth or an abortion and requiring informed consent, extensive counseling, a 30-day waiting period between consent and procedure and a ban on sterilization for those under 21.
Some health professionals argue that guidelines are needed to prevent abuse of Norplant. In California, the state Office of Family Planning has sent a sample Norplant consent form to all its clinics. While such guidelines do not prevent legislative and judicial actions, they help decrease the possibility of coercion if coupled with effective training of health-care personnel.
WHETHER NORPLANT WILL remain popular is unclear, but it is certain that Norplant is only the beginning of a new era in reproductive control. The FDA has already approved a second long-acting contraceptive, Depo Provera, a progestin injection that lasts three to six months. It may be more popular than Norplant because of its lower upfront costs, but it has a serious drawback: No matter what side effects occur, it cannot be reversed; it must wear off.
A two-rod version of Norplant is also on the drawing board, as are biodegradable implants and vaginal rings (the latter already available in other countries), also with time-release hormones. Several morning-after methods are also being developed. One already available is Ovral; two tablets of high-dose estrogens are taken within 72 hours after sex, then again 12 hours later. The controversial French product, RU-486, which sloughs off eggs from the lining of the uterus, has been approved in China, France and Germany but is unlikely to be available in the United States soon because some consider it an abortifacient.
Further down the road, a non-hormonal anti-fertility vaccine will likely become available. And at least four new methods are being developed for men, including ultrasound treatment to prevent the growth of sperm and polymer injections that slow sperm motility for more than a year.
With widening choices, perhaps young women--and men--of the '90s will start to hear the "drums of prevention," says Rosetta Stith, principal of Laurence Paquin School for expectant or parenting adolescents in Baltimore. She believes that if we teach morality and self-esteem to toddlers, giving children character-building experiences, when they reach puberty they will understand the importance of delayed childbearing and the value of abstinence.
"A lot of young people don't have anything in their lives," says Julia Scott of the National Black Women's Health Project. "They need places to go for emotional support. They need a place to feel safe. In very depressed areas like the projects, they feel frightened every moment. They're trying to find some place to feel protected and loved--even if it's in a moment of sexual intimacy.
"There's not a pill or an implant that's going to solve the teen-age pregnancy problem," Rosetta Stith says. "That's going to come when this country decides to be committed to children."