"The Shot" in Indian Country

Things have changed; now, they use Depo Provera instead.

Statistically, teenage pregnancy is far and away the highest among Native Americans than in any other ethnic group. And with the nearest clinic sometimes hundreds of miles distant, long-lasting contraceptives like Depo and Norplant may seem good alternatives.

But health problems common to Native American women also make Depo's side effects more dangerous. There is a much higher incidence of obesity, heart disease and adult-onset diabetes, making glucose intolerance and high lipid levels potentially lethal.

Management problems at IHS also make it questionable whether women have adequate counseling. Though IHS guidelines state that Depo Provera should only be prescribed when alternative methods cannot be used, interviews with users seem to indicate that the Indian Health Service is very eager to have women use Depo; about half claimed that Depo was recommended over other forms of contraception.

In a small study done in South Dakota by the Native American Women's Health Education Resource Center in cooperation with the National Women's Health Network, over 80 percent of the women were IHS clients, and all used Depo Provera.

Only one woman in the study reported signing a consent form; testimonies indicate that incomplete or incorrect information about the drug and its side effects was given in a majority of cases, and that a very high majority experienced some or many of the known side effects. Of the women who sought treatment for the effects, over 80 percent claimed that their problems were trivialized or ignored.

A "disturbingly low percentage" of these women, according to the study, were informed of the possible long-term effects of Depo Provera, especially the arguably unknown risks of fetal exposure in utero, and increased risk of certain kinds of cancer. In several instances, the IHS has dismissed the claims of women who felt they miscarried as a result of Depo. IHS has been slow to respond to these issues.

And despite the fact that Upjohn provides its guidelines with the product, 1993 Depo guidelines from an IHS clinic in Gallup, New Mexico, state that Depo is safe for breast feeding women, and that it is to be given within seven days of menstruation; if this is not possible, then the woman is to be tested for pregnancy. Upjohn recommends administering Depo in the first five days of menstruation, or not at all, and that breast feeding women should wait six weeks.

At the same time, sexual behavior is becoming more pronounced at an earlier age on reservations as it is elsewhere, but it is not traditional. These are still strong taboos associated with promiscuity, and also with discussion and use of birth control methods. This makes the privacy of Depo (more widely used than Norplant because it's cheaper) very attractive, but problematic when it comes to sexually promiscuous minors.

Add in the difficulty of obtaining health care in Indian Country, and statistics of Native women with STDs are particularly worrisome. A 1985 study covering eight states reported nearly double the gonorrhea rate of all other races combined, and almost four times the rate of syphilis. HIV infection is also higher than for Whites or Asians.

Besides treatment for STDs, the great distances to IHS clinics present special problems for Norplant users who want the implants removed. And in one study of Native Alaskan women, 1 out of 3 wanted Norplant taken out within the first 18 months because of side effects, one of the women removing the capsules herself. Discouraged by the high number of women who want the expensive Norplant taken out before the end of the five years, this IHS clinic has introduced a new policy: a manditory 3 to 6 months on Depo Provera, despite its different risks.