Preparing to Offer New Implants
Good implant services require a competent and wellprepared staff that can perform insertion and removal procedures and can help clients make an informed choice about implants. Programs can prepare providers to insert and remove implants through competency-based training. Providers can help clients interested in implants by: counseling them about side effects with an emphasis on bleeding changes; screening clients using the World Health Organization (WHO) Medical Eligibility Criteria; describing and answering questions about insertion and removal; and determining whether the client can have implants inserted immediately. Programs should also make sure they can assure women’s access to removal services.
Who Can Provide Implants?
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Good implant services require staff competent to insert and remove implants and to counsel clients.
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Many different cadres of health care professionals can safely provide implants if they are thoroughly trained. These include nurses, nurse-midwives, nurse-practitioners, midwives, physicians, and, depending on educational and professional standards in each country, physician’s assistants and associates (16, 60, 124). Training a wide variety of health care professionals spreads awareness of implants and increases access to services (23, 30, 52, 79, 84, 103).
Where only physicians can insert and remove implants, access to implants is unnecessarily limited. For example, when implant services were first introduced in Ghana, only doctors had been trained to provide implants. As a result, women seeking implants often encountered long waiting times or found that the doctor was unavailable. EngenderHealth and the Ghana Ministry of Health collaborated to train a large group of nurses in implant insertion and removal and in related counseling. This effort contributed to a tenfold increase in the number of women using implants in Ghana (see Spotlight: Training Nurses Increases Implant Use in Ghana).
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Providers in Indonesia practice inserting Norplant implants in a model arm. Providers later go on to perform actual insertions under supervision until they demonstrate competence.
(© 1992 Gary Bergthold/JHPIEGO, Courtesy of Photoshare)
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Competency-Based Training Helps Providers Learn By Doing
Competency-based training develops the skills, knowledge, and attitudes required to meet standards of competence. Training continues until each trainee is competent to provide implant services, and satisfactory completion of training is based on the achievement of all the specified competencies (108). Competence is defined as the point at which the trainee knows the steps in their sequence and can perform the required skill or activity (8). The approach focuses on the success of each trainee, recognizing that different providers need different amounts of practice to reach competence (16, 108). Although insertions and removals of implants are minor surgical procedures, experience in Norplant programs has shown that a formal competency-based training program, using model arms and supervised practice, leads to proficient and confident providers (9, 13, 38).
Information and communication technology (ICT) tools can deliver some aspects of competency-based training. Computer-based training offers a new means of selfeducation (7). Computers enable participants to control the pace and flow of their learning. Organon, the maker of Implanon, has developed a number of computer-based ICT training tools. For example, a CD-ROM on insertion and removal techniques not only includes slides presenting relevant technical information, but also offers videos of actual insertions and removals (see Box: Information and Communication Technology Supports Implant Programs).
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Many different cadres of health care professionals can safely provide implants if they are thoroughly trained.
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Training to insert Jadelle, Sino-Implant (II), and Implanon. Training for insertion requires attention to infection prevention procedures under sterile conditions, correct placement of implants, and care to minimize tissue damage. The rods are inserted just under the skin of the inner side of the upper arm. With Jadelle, the rods are loaded in a reusable hollow needle, called a trocar. Preloaded disposable inserters are available in a few countries. The clinician injects a local anesthetic into the woman’s arm and makes a small incision—about 3 mm long—using a scalpel or the tip of the trocar. The rods are placed, one at a time, to form the shape of a V opening toward the shoulder. Alternatively, the trocar is used to puncture the skin and insert the rods, without the need for an incision. The procedure should take only a few minutes. Usually, the incision or puncture does not require stitches. A small adhesive bandage and protective gauze bandage are all that are necessary (99). Sino- Implant (II) is inserted in the same way as Jadelle.
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An Implanon rod is inserted just below the skin of the upper arm. If implants are placed properly, removal usually is not difficult.
(© 2005 Dr. Philippe Faucher/Paris)
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Implanon comes packaged in a specially designed applicator. The provider identifies the location for insertion on the inner side of the upper arm. After injecting local anesthetic, the provider uses the pre-loaded applicator to puncture the skin and place the single implant under the skin (67, 69) (see companion INFO Reports, “Implants: Tools for Providers,” Insertion and Removal of the New Implants). Gauze or a pressure bandage minimizes bruising.
Learning proper placement and removal requires practical, hands-on training. If an implant is not placed properly, removal may be difficult. Providers train for insertion on an artificial arm and later perform actual insertions under supervision until they can demonstrate competency (73). A study in Indonesia found that providers who were trained to practice on a model arm before performing supervised procedures with clients were more competent at insertions and removals than those who went directly from the classroom to performing actual insertions (10). Providers who are familiar with inserting and removing Norplant adapt quickly to the new implants (12). Providers who are new to providing implants need more training.
Training to remove Jadelle, Sino-Implant (II), and Implanon. Most removals are not difficult, but removal usually takes longer than insertion. Because the new implants have fewer rods, removing Jadelle, Sino-Implant (II), or Implanon implants takes considerably less time than removing Norplant.
There are two most commonly used techniques for removing new implants. With the “pop-out” technique, the provider first feels the site to be sure she can locate the implant(s) underneath the skin. The provider then makes a small incision at the lower (distal) end of the implant, pushes the implant gently towards the incision until the tip is visible, and then removes it with forceps (54, 69, 99). The “U” technique (named after its developer Dr. Untung Praptohardjo) was developed for use when Norplant proved difficult to remove and also to make routine removals easier. The technique involves the use of an oval-ring-tipped forceps with an internal diameter of 2.2 mm to reach through a 4-mm incision to firmly grasp and remove each of the Norplant capsules. This technique is recommended for removing Jadelle as well (54, 58, 83).
Ongoing removal training is essential. Every user of implants should be able to have the implants removed whenever she wishes, including when the end of their recommended lifespan has been reached. To make this possible, there must be sufficient numbers and broad geographical distribution of providers trained in implant removal. As with training in insertion, training in removal starts with using the model arm, followed by closely supervised practice with actual clients. It can take time to gain clinical experience in removals, however. Early in a program, at least, many more women are having implants inserted than are asking to have them removed (84). Thus, over the years, ongoing training in removal, with refresher courses, is important. Providers can practice removals on anatomical models and watch videos of live removals. If it is not practical to keep up all providers’ skills for implant removal, an alternative is training a core group of providers, giving them continued support and guidance, and referring clients to these providers for removals.
Helping Clients Make an Informed Choice
Counseling users of implants on what to expect can be as important to the client’s satisfaction as proper insertion and removal techniques (16, 99, 112). If the client is interested in implants, the provider should:
- Counsel the client about possible side effects, particularly bleeding changes,
- Screen the client, using the WHO Medical Eligibility Criteria,
- Describe and answer questions about the insertion and removal procedures (see What Clients Should Know About Insertion and Removal), and
- Determine whether she can have the implants inserted immediately.
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In Madagascar a woman considers choosing Implanon with the help of a family planning provider. Good counseling includes helping the client decide whether implants are right for her, discussing possible changes in menstrual bleeding, and describing the insertion and removal procedures.
(© 2005 Dr. Philippe Faucher/Paris)
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Counseling clients about side effects. Like some users of all other hormonal contraceptives, some users of implants report side effects such as weight gain, headaches, acne, and mood changes, but bleeding changes are the most common reason that women cite for discontinuing implants (28, 40, 53, 95, 96, 99, 100, 102, 125). A client who knows about possible side effects beforehand is more likely to keep using a method even if side effects occur (36, 118). In Indonesia users of Norplant implants who were more knowledgeable about the method and about potential bleeding changes were more satisfied with the method than those who had less knowledge. In the province with the greatest differences in levels of satisfaction, 98% of women with a high level of knowledge about the method were satisfied overall compared with 33% of women with a low level of knowledge (109). Similarly, in a Norplant study in Senegal, women who perceived their counseling to be “thorough”—that is, counseling included discussion of side effects and of other contraceptive options—were less likely than other women to discontinue use of implants when bleeding changes did occur (112).
Among the various side effects associated with implant use, bleeding changes can be particularly upsetting, especially if providers do not tell women about them and explain them in advance (11, 112). Providers should tell clients that, especially in the first year of using levonorgestrel implants, changes in bleeding patterns can include lighter bleeding and fewer days of bleeding, frequent irregular bleeding, prolonged bleeding or spotting that lasts more than eight days, infrequent bleeding, or no monthly bleeding. After about a year of use, bleeding changes typically include lighter bleeding and fewer days of bleeding, irregular bleeding, and infrequent bleeding. Users of etonogestrel implants are more likely than levonorgestrel users to experience infrequent or no monthly bleeding (28, 40, 53, 95, 96, 99, 100, 102, 124, 125).
Providers can explain that bleeding changes are usually harmless and not likely to indicate a serious underlying condition. Usually, the bleeding changes gradually diminish. Every client should understand that she is welcome to come back to consult with the provider at any time. If the bleeding changes are not acceptable to the client, she should always have the option of switching to another, more appropriate method (124) (see companion INFO Reports, “Implants: Tools for Providers,” Counseling About Changes in Monthly Bleeding).
Screening clients with the Medical Eligibility Criteria. Before a client can begin using implants, WHO recommends that a provider ask a client about medical conditions that could affect implant use (121). Using a checklist, a provider can ask a woman if she knows she has certain medical conditions— conditions that would make another method preferable (see companion INFO Reports, “Implants: Tools for Providers,” Medical Eligibility Criteria Checklist for Implants). A pelvic exam, blood tests, breast examination, and cervical cancer screening are not needed to decide whether a woman can use implants, although they may be helpful for other reasons. They should never be required for implant use.
Can a client start implants immediately? A woman can start using implants any day of the menstrual cycle if it is reasonably certain that she is not pregnant. For example, a client who has regular menstrual cycles can begin implants within seven days after the start of her monthly bleeding (five days for Implanon). If it is more than seven days after the start of her monthly bleeding (more than five days for Implanon), she can have implants inserted if it is reasonably certain for other reasons that she is not pregnant—for example, if she has not had intercourse since her last monthly bleeding. She will need to abstain from sex or use a backup method for the first seven days after insertion. Also, if a woman is fully breastfeeding and her monthly bleeding has not returned, she can have levonorgestrel implants inserted any time between six weeks and six months after giving birth (124). Organon specifies that Implanon can be inserted 21 to 28 days after delivery without need for backup. If it is inserted later, a woman should use a backup method for the first seven days after insertion (69). (For more information on when to start implants and a checklist to help assess whether it is reasonably certain a woman is not pregnant, see Family Planning: A Global Handbook for Providers at http://www.fphandbook.org.)
Access to Removal Services Is Necessary to Good Quality of Care
Access to services for implant removal could strongly influence public perceptions of implants. Providers could be considered coercive if women cannot have implants removed when they want (43, 112). While the majority of Norplant users have had no problems getting their implants removed, some women have faced barriers. For example, clients have reported high prices charged for removal. One woman in Ghana who could not afford the cost said, “I have been here three times, and the nurse told me to bring 50,000 Cedis” (about US$5.75) (30)—a fee that was over five times the minimum daily wage in Ghana in 2003 (116).
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Every user of implants should be able to have the implants removed whenever she wishes.
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In an Indonesian study of 3,000 Norplant users in the 1990s, 8% still had their implants beyond their prescribed lifespan of five years. One-fourth of this 8% said that they never had the implants removed because the cost was too great. Among the women who had their implants removed, 9% reported having to make two or more requests (27). In Bangladesh 52% of Norplant users studied in the 1990s had to request removal two or more times. Some women were told that the doctor was too busy or that the implant could not be removed until at least five years of use. In a few cases clients removed the implants by themselves (37).
Clinics that offer implants should develop and communicate a clear policy on removal that states the following:
- When a woman wants her implants removed, she should be able to have them removed promptly and free of charge, without undue waiting, regardless of where or when the implants were inserted.
- A woman should not feel pressured to keep her implants. They should be removed whatever her reason, whether it is personal or medical.
All staff must understand and agree that women must not be pressured or forced to continue using implants. Clinics that do not have staff trained to remove implants should arrange to refer women to convenient services elsewhere. Providers can explain the policies to clients during counseling before they decide on implants.
Reminders. Many clients need help to remember when their implants should be removed. In the study of Norplant removals in Indonesia, about 38% of women remembered on their own when the time came to have them removed. Some 13% were reminded by a family member or another user, and 49% were reminded by a family planning worker (27).
Clinics can develop systems for notifying users when to have their implants removed or replaced. Follow-up in many situations can be extremely difficult, but most programs give clients reminder cards to keep with other important documents. A notation on a client’s records is important, too. Seeing the notation, a provider can remind the client of the date when she visits the clinic for other services (62, 88). If a woman realizes that she has missed the removal date and she is worried, but she has not become pregnant, a provider can reassure her that leaving the implants in place has caused no harm.
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