Contraceptive implants: providing better choice to meet growing family planning demand

Contraceptive implants are extremely effective, long acting, and suitable for nearly all women—to delay, space, or limit pregnancies—and they are increasingly popular. Now, markedly reduced prices and innovative service delivery models using dedicated non-physician service providers offer a historic opportunity to help satisfy women's growing need for family planning.


THE PROMISE OF IMPLANTS What Women Like About Implants
Implants are a long-acting, reversible form of progestin-only contraception that release an ultra-low amount of progestin continuously into the bloodstream. Currently, 3 implants are available: Implanon H , Jadelle H , and Sino-implant II H (see Table). Women who use implants find them to be very convenient-they are effective immediately and offer up to 3 to 5 years of extremely reliable contraceptive protection upon one client action. Only a brief, very minor surgical procedure under local anesthesia is needed to place 1 or 2 matchstick-sized plastic rods beneath the skin of the inner upper arm. [4][5] Some women also like that pelvic exams and laboratory tests are not required and that implants can be used discreetly. Furthermore, implants do not interfere with sexual intercourse, and return to fertility upon removal is not delayed or negatively affected.

Unmatched Effectiveness
Effectiveness is a key feature for women and couples using contraception to avoid unwanted pregnancy, but in our experience, even family planning professionals do not always fully realize just how effective implants are: Only 1 unintended pregnancy occurs among every 2,000 implant users in the first year of use. 6 In contrast, failure rates in the first year of typical use of the commonly used resupply methods are considerably higher: 180 unintended pregnancies per 1,000 users of male condoms, 90 unintended pregnancies per 1,000 users of pills, and 60 unintended pregnancies per 1,000 users of the progestin-only injectable Depo-Provera H . 6 Thus, implants are 120 times more effective than the injectable, 180 times more effective than the pill, and 360 times more effective than the condom.

Suitable for All Reproductive Intentions and Nearly All Women
Implants are an excellent choice to achieve any reproductive intention-to delay a first pregnancy, space a subsequent birth, or end childbearing. Recommendations among normative bodies differ about the suitability of implants use by breastfeeding women during the first 6 weeks after childbirth, however. WHO guidance states that the risks outweigh benefits during this period. 7 The U.S. Centers for Disease Control and Prevention (CDC) advises that the benefits outweigh risks during the first 4 weeks and places no restrictions on use after 4 weeks. 8 The U.K.'s Royal College of Obstetricians and Gynaecologists (RCOG) places no restrictions on use of implants by breastfeeding women at any time. 9 Immediate postpartum provision of implants would offer expanded programmatic opportunity, as women are increasingly receiving safe delivery services and there is almost universal interest among postpartum women in avoiding a subsequent pregnancy for at least 2 years. 10 Implants also offer great promise for helping to meet the needs of younger women, who often face many barriers in accessing effective modern contraception. When implants were made available to young Kenyan women ages 18-24 seeking family planning, 24% selected the method. 11 The American College of Obstetricians and Gynecologists recommends that providers encourage adolescents ages 15-19 seeking contraception to consider implants and intrauterine devices (IUDs) as ''the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.'' 12

Rising Popularity
Although modern contraceptive use lags in sub-Saharan Africa, where only 1 in 6 married women uses it, contraceptive use has recently increased substantially in a number of Eastern and Southern African countries. 13 While this has been mainly due to increased use of injectables, implants use has also increased notably over a short time span in countries such as Ethiopia, Malawi, Rwanda, and Tanzania (see Box and Figure). For example, 1 in every 7 women using modern contraception in Rwanda currently relies on an implant, compared with less than 1 in 25 in 2005. 14 These trends suggest that wider availability of implants could lead to much greater use in other African countries and elsewhere where implants currently cannot be accessed widely or easily. High rates of user satisfaction (79%) and continuation (around 84% at 1 year of use) further support this likelihood. 6,17 Increasingly Affordable and Available Prospects for increased availability and use were greatly enhanced when Bayer HealthCare recently announced that it would cut the public-sector price of its contraceptive implant Jadelle in half, as a result of volume guarantees from international donor partners. 18 Beginning in January 2013, Jadelle will cost US$8.50 per set. The partnership initiative aims to make 27 million implants available to the public sector and non-commercial private sector in up to 69 low-income countries from 2013 to 2018. This is likely to be a signal milestone on the long road Implants are safe and suitable for nearly all women.
With only one action, women who use implants can be almost certain not to have an unintended pregnancy for up to 3 to 5 years.
Implants are over 100 times more effective than injectables and pills in typical use, and 360 times more effective than condoms. N Anticipatory guidance regarding common side effects of implants, especially about bleeding disturbances and their acceptability to the client within her sociocultural context. This is particularly important, as changes in menstrual patterns-irregular, infrequent, or no bleeding-while not harmful are expected. 20 The specific pattern in any given woman cannot be predicted with certainty, however.
N Capable and reassuring management of side effects, especially of bleeding changes, is thus often the difference between satisfaction and discontinuation. Side effects and

Appreciate and Nurture Providers
In addition to focusing on the client, programs must be attentive to the perspectives, needs, and workloads of providers. [22][23] Without adequate availability and distribution of skilled, motivated, and enabled providers, there can be little provision of implants. 24 In other words, ''No provider, no program.'' Fortunately for resource-constrained programs, many categories of health care providers-not only doctors but also nurses, midwives, auxiliary nurses, auxiliary nurse-midwives, and clinical officers-are capable, once trained, of safely providing implants. 25 Such ''task shifting'' or ''task sharing'' among health cadres is an accepted policy and programmatic reality. [25][26] Ethiopia has even launched a program to train and enable 15,000 rural community health extension workers (CHEWs) to insert Implanon, 27 whose one rod can be inserted easily in 1 to 2 minutes. (Removals are handled by referral to higher-level cadres.)

Ensure Access to Removal Services
Programs also need to ensure routine, regular, and reliable removal services for clients, beginning by planning for them at the outset of service expansion efforts. Failure to provide reliable and ready access to removal services could easily tarnish the method's image and undermine an entire family planning program.

Consider Use of Dedicated Providers and Mobile Services
A number of countries have successfully followed innovative public-private service delivery models that entail the use of ''dedicated providers.'' These providers focus primarily on delivering underutilized clinical contraceptive methods, including implants. (A wider range of method choices is generally available at the service site.) The service models have also typically entailed task shifting and provision of free services, either in static public-sector service sites or through mobile outreach. In Zambia, 18 retired midwives were placed at high-volume, public-sector facilities solely to provide long-acting and reversible contraceptives (LARCs). These dedicated providers inserted more than 22,000 implants and 11,000 IUDs in 14 months and reached younger and lower-parity women. 28 In Tanzania, a policy shift allowed nurses, as well as physicians, to provide implants. Subsequently, insertions more than doubled, from

Box. Implants Use on the Upswing in Eastern and Southern African Countries
Ethiopia, Malawi, Rwanda, and Tanzania have recently achieved notable increases in their modern method contraceptive prevalence rates (CPR), including for implants. As seen in the Figure, in only 5 to 6 years, implants use doubled in Malawi, quadrupled in Tanzania, and rose more than 15-fold in Rwanda and 17-fold in Ethiopia. 14 Implants have become the second most popular method in Ethiopia and the third most popular method in Rwanda. One of every 7 married women using modern contraception in Rwanda and 1 in every 8 in Ethiopia relies on an implant for her contraceptive protection. The CPR for implants in Rwanda is 6.3% among currently married women, 5.9% among sexually active unmarried women, and 6.4% among rural women. These are the highest rates in sub-Saharan Africa and among the highest in the world.

What accounts for this success? Among the most important factors have been:
N An enabling environment, with strong policy commitment from the highest levels downward, as manifested most recently by the Prime Ministers of Ethiopia and Rwanda at the London Summit, 15 and supportive service policies that encourage task sharing and task shifting; N On the supply side, training to ensure widespread insertion and removal skills and substantial donor support for purchase of commodities (3.7 million implants valued at US$72 million were purchased for these 4 African countries between 2009 and 2012) 16 ; and N On the demand side, a marked rise in implants knowledge, stimulated by communication activities in programs as well as by diffusion of knowledge among women themselves. In Ethiopia, knowledge of implants among married women ages 15-49 increased to 69% in 2011 from only 20% in 2005, and knowledge was even higher among sexually active, unmarried women (82%). 14 In Rwanda, where only half of married women knew of implants in 2005, such knowledge became universal (97%) by 2010. 14 Many cadres of health care providers can provide implants safely and effectively.  29 and nurses became the main providers of implants. In Malawi, where use of dedicated, non-physician providers and mobile services contributed substantially to wide use of female sterilization (prevalence of 10% among married women in 2010), 30 implants provision through the same service modalities and providers also rose (see Box).

Other Program and Health System Considerations
The following programmatic subsystems must be in place and functional to ensure that quality implant insertion and removal services can be regularly and reliably provided 19,24 : The environment also must be enabling and supportive, with: N Strong political commitment N Adequate and well-deployed financial and human resources N Service delivery policies, guidelines, and standards that permit task shifting and task sharing to allow other skilled cadres besides doctors to provide implants N No restrictions on access because of age, parity, marital status, HIV status, or socioeconomic status N Widespread gender equity Finally, recurrent costs for infrastructure and staff must be met. Despite these costs, the overall cost of implants per couple-year of protection (CYP) is comparable to or less than that of injectables or oral contraceptives, and cost effectiveness rises with longer use. [31][32][33] WHAT IS AT STAKE A woman in sub-Saharan Africa faces a 1 in 39 lifetime risk of maternal death, and a woman in South Asia has a 1 in 150 lifetime risk. 34 In contrast, the lifetime risk of maternal death in industrialized countries is 1 in 4,700. Nearly all maternal deaths-99%-occur in low-resource countries, 35 and for every instance of maternal mortality, 20 instances of serious morbidity (such as obstetric fistula) occur. 36 Risk of morbidity and mortality is higher among poorer women, who have less access to modern contraception including implants. Access is also more constrained for young women, among whom 44% of all unintended pregnancies in sub-Saharan Africa occur. 10 Satisfying unmet need for contraception could reduce maternal mortality by 29%, preventing more than 100,000 maternal deaths each year. 34 If only 1 of 5 sub-Saharan African women now using pills or injectables (that is, other, less effective hormonal contraception) were to switch to an implant, more than 1.8 million unintended pregnancies would be averted in 5 years, resulting in almost 600,000 fewer abortions and 10,000 fewer maternal deaths. 37 If even more women were to switch, or if women not currently using contraception were to access and use implants, even greater individual and public health would accrue. Meeting the need for effective modern contraception, including much wider provision of contraceptive implants to women who would want them, is not only a family planning and health issue-it is a matter of social justice and an equity imperative.

OUR CHALLENGE
The 2012 London Summit on Family Planning, attended by more than 150 leaders and representatives of governments and civil society, endorsed an ambitious goal of providing family planning to an additional 120 million women. 38 Widespread provision of implants in a quality manner offers a substantial way to help achieve this goal, if the global health community can rise to the challenge. We must do it right, and do it now.
The overall cost of implants per CYP is comparable to or less than that of injectables or pills.
Innovative models utilizing dedicated non-physician providers have increased availability and use of implants.
Meeting unmet need for contraception could prevent more than 100,000 maternal deaths each year.