Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy
RHL practical aspects by Bahamondes L
FIRST CONTACT (PRIMARY CARE) LEVEL
The delivery of implants requires very well-trained health-care providers to perform insertions and removals and good follow-up skills to resolve any problems, principally bleeding irregularities. This challenge is particularly significant at the first level of care, especially in developing countries.
Once a decision is taken to include implants in the method mix, all health-care professionals in the family planning programme should be trained in the delivery of these methods. However, initially, insertions and removals of implants could be offered only at selected centres that specialize in the provision these methods. Such centres could be those that also offer insertions and removals of IUDs. Then, once demand for implants expands, additional centres could begin to offer these services. This step-by-step approach can help ensure that high-quality services are delivered. The purpose of training all health-care professionals at the outset is to ensure that when problems associated with implants arise women are able to go to the nearest centre for help. Centres at the primary level selected to offer services related to implants must create a mechanism for notifying users when their implant has reached the end of its life and needs to be replaced or removed (1).
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
For purposes of delivery of implants, the second level of referral care need not necessarily be a hospital, but could be a referral health-care clinic. The main challenge with implants at this level too is the establishment of a service for the insertion and removal of the implants. Habitually, hospitals are run by doctors who are busy dealing with patients and emergencies. They may see provision of family planning methods as a primary-level activity that is not specific to hospitals. Consequently, in many cases trained doctors often fail to provide implant services to women. The solution to this problem may be to train different cadres of professionals (physicians, midwives and nurses) who would be able to insert and remove implants after adequate training and after being able to demonstrate that they are capable of managing all aspects of implant service delivery (1).
In addition, although the incidence of infection or expulsion after insertion is very low, health-care providers must be trained in the removal of implants that are embedded deep under the skin. Also, at the second level, providers must be aware of the need for counselling and management of bleeding irregularities to avoid early discontinuations. Providers should also be aware that despite bleeding irregularity haemoglobin levels remain unchanged. On the other hand, amenorrhoea may not be acceptable to all women in all cultures. In some developing countries women rely on menstrual bleeding to reassure them that they are not pregnant; they view monthly bleeding as a "free" pregnancy test (2, 3).
AT HOME OR IN THE COMMUNITY
Implants should be promoted in the community as long-term, highly effective, safe and easy-to-use methods of contraception. As to the initial high cost of implants, and if the full or partial cost is to be charged to the clients, it should be explained to the community that implants are cost-effective when they are used over their full life span. Thus, women seeking effective long-term contraception are ideal candidates for their use.
References
- Estanislau do Amaral MC, Hardy E, Hebling EM, Faúndes A. Menstruation and amenorrhea: opinion of Brazilian women. Contraception 2005;72:157-61.
- Snow R, Hardy E, Kneuper E, Hebling EM, Hall G. Women's responses to menses and nonbleeding intervals in the USA, Brazil and Germany. Contraception 2007;76:23-9.)
- Brache V, Faundes A, Alvarez F. Risk-benefit effects of implantable contraceptives in women. Expert Opinion on Drug Safety 2003;2:321-32.
This document should be cited as: Bahamondes L. Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy: RHL practical aspects (last revised: 1 December 2008). The WHO Reproductive Health Library; Geneva: World Health Organization.