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Published in the Quinacrine Newsletter 2000 |
QS in Indonesia
Tina Agoestina, MD
Department of Obstetrics and Gynecology
Dr. Hasan Sadikin Hospital
Padjadjaran University
Bandung, Indonesia
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Indonesia has a generally recognized successful family planning program of which we are proud. Policies for our program are established at the highest echelons of government, with the final responsibility for their implementation in the hands of the National Family Planning Coordinating Board (BKKBN). The program has grown from an initial 40,000 acceptors in 1970 to over 18 million today, and includes more than 50% of all married couples. As would be expected from such a contraceptive prevalence increase, fertility has declined from 5.6 births per woman in the period 1967-1970 to 2.9 births in 1991-1994. Midwives are the most popular public and private dispensers of modern contraceptives, about 50% of which are supplied through government facilities. A high proportion of users pay for their method, including two-thirds who paid for services obtained from the government.
Despite this success, there remain significant health problems that are in part related to unmet need for some family planning services. Indonesia has a high maternal mortality ratio of 390 per 100,000 live births. Over 50% of married women want no more children, but the prevalence of sterilization is a low 3.1% and for men, only 0.7%. Further, declines in fertility in recent years have slowed. IUD prevalence is 17.1% and provided mostly by midwives in peripheral centers. It was in this context that quinacrine sterilization (QS) appeared to have potential to satisfy an unmet need of so many of our women who want no more children; it was a method that could be delivered with minimal additional training by midwives.
Our first QS experience was a clinical trial, conducted in Bandung at Hasan Sadikin Hospital and the Health Center Astana Anyar with support by the International Development Research Centre of Canada through the International Federation for Family Health. The trial was initiated in July 1985 and recruitment included 100 healthy women who desired no more children. They received 3 monthly insertions of 252 mg quinacrine, except for two who did not return. The remaining 98 women returned to the clinic for follow-up at 1 month, 97 at 3 months, 96 at 6 months and 86 at one year. Side effects were modest and transient. The gross life-table pregnancy rate for 98 women who completed 3 insertions was 3.1 at 12 months. In 1993 the BKKBN organized a multicenter trial in clinical research facilities in Bandung, Dempasar, Jakarta, Semorang, Surabaya and Yogyakarta. A comparison of single and 2 insertions of quinacrine was made in a randomized study with each center recruiting 70 subjects for single insertion and 30 for 2 insertions of 252 mg quinacrine. There were no serious complications and side effects were again moderate and transient. The cumulative life-table failure rates per 100 women at 1 year were 4.7 for single insertion and 1.1 for 2 insertions. Eleven of 31 failures for single insertion and all 3 failures for 2 insertions occurred in one center. A third trial was conducted in Central Java Province where 200 women were recruited from August 1992 through October 1993. All subjects received 2 monthly insertions of 252 mg quinacrine. There were no serious complications and life-table pregnancy failures per 100 women was 2.0 at 2 years (1).
With these successful experiences, we believe that the next needed steps are to conduct trials in the hands of health officers and midwives in peripheral centers where surgical sterilization is not presently available.
Reference
1. Suhadi A, Soejoenoes A.Quinacrine pellet nonsurgical female sterilization in Wonosobo, Indonesia. Fertil Steril 1997; 67(5):966-8.
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