2Characteristics of Implants Why might these women be interested in using implants?Breastfeeding motherAdolescentInfected with HIVHas little to no access to a health care facilityDesires no more childrenAsk participants for reasons why these women might prefer or avoid implants. Then, click the mouse to reveal the next example. <Move through each case quickly and mention the following points>
3Implants Are Safe for Nearly All Women Almost all women can use implants safely, including women who:Have just had an abortion, miscarriage or ectopic pregnancyAre breastfeeding (starting as soon as 6 weeks after childbirth, WHO/MEC)Have anemia now or in the pastHave varicose veinsHave or have not had childrenAre not marriedAre of any age including adolescents and women over 40 years oldAre infected with HIVThis slide represents the international consensus on the initiation of implants and breastfeeding as reflected in the WHO MEC. For further information on the initiation of implants and breastfeeding, see slide 10. This consideration should be more fully discussed at that time. Most health conditions do not affect safe and effective use of implants.Many women who cannot use methods that contain estrogen can safely use implants.
4Who Can and Cannot Use Implants (part 1) Most women can safely use implantsBut usually cannot use implants if:Breastfeeding 6 weeks or less/WHO MECMay be pregnantSome other serious health conditionsAdapted from WHO’s Decision-making tool for family planning clients and providers.This slide represents the international consensus on the initiation of implants and breastfeeding as reflected in the WHO MEC. For further information on the initiation of implants and breastfeeding, see slide 10. This consideration should be more fully discussed at that time. Explain that most women can safely use implants as mentioned in the previous slide. Show the slides and discuss which women should not use implants.Ask several participants to share one thing that they know about the Medical Eligibility Criteria (MEC) in their national FP/RH guidelines (if they exist) or the WHO MEC.
5Who Can and Cannot Use Implants (part 2) Most women can safely use implants. But usually cannot use implants if:Breastfeeding 6 weeks or lessAsk her to come back when baby is 6 weeks old. Urge her to keep breastfeeding. (Based on WHO MEC categorization)May be pregnantIf in doubt, use pregnancy checklist or perform pregnancy test.Some other serious health conditionsHas blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use implants.Ever had breast cancer.Unexplained vaginal bleeding. If the bleeding suggests a serious condition, help her choose a method without hormones to use until unusual bleeding is assessed.Serious liver disease or jaundice (yellow skin or eyes).Takes pills for tuberculosis (TB), fungal infections, or seizures (fits).Adapted from WHO’s Decision-making tool for family planning clients and providers.This slide represents the international consensus on the initiation of implants and breastfeeding as reflected in the WHO MEC. For further information on the initiation of implants and breastfeeding, see slide 10. This consideration should be more fully discussed at that time.
6Medical Eligibility Criteria What are medical eligibility criteria? Define the categories. Review the job aid.Demonstrate how to use the WHO MEC Wheel or the Quick Reference Chart. Explain that implants are safe for the overwhelming majority of women. Use slides 7-8 to provide an overview of the medical eligibility criteria for implants.
7With clinical judgment WHO’s Medical Eligibility CriteriaCategories for IUDs, Hormonal and Barrier MethodsCategoryDescriptionWith clinical judgment1No restriction for useUse the method under any circumstances2Benefits generally outweigh risksGenerally use the method3Risks usually outweigh benefitsUse of method not usually recommended, unless other methods are not available/acceptable4Unacceptable health riskMethod not to be usedCategory 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions. According to the MEC, implants can be used without any restrictions by women with category 1 conditions. For example, progestin-only implants can be used freely by women of any age, including those who are less than 18 years old; women who are breastfeeding a baby older than six weeks (to be discussed on page 10); women who are heavy smokers; or women who have complicated valvular heart disease, endometriosis, endometrial or ovarian cancer, or thyroid disease.Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can use the method, but careful follow-up may be required. For women with category 2 conditions, the advantages of using this method outweigh the theoretical or proven risks. Progestin-only implants can generally be used by women with category 2 conditions, but careful follow-up may be required in some cases. Examples of such conditions include blood pressure above 160/100 mm Hg, a history of deep venous thrombosis/pulmonary embolism (DVT/PE), diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, or multiple risk factors for cardiovascular disease.Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. Women with Category 3 conditions generally should not use the method. However, if no better options for contraception are available or acceptable, the provider may judge that the method is appropriate, depending on the severity of the condition. In such cases, ongoing access to clinical services and careful follow-up will be required.Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used.Source: WHO, 2010.
8When clinical judgment is limited WHO’s Medical Eligibility CriteriaCategories for IUDs, Hormonal and Barrier MethodsCategoryWhen clinical judgment is limited1Use the method23Do not use the method4According to WHO, in settings where clinical judgment is limited, category 2 conditions should be treated in the same manner as category 1 conditions. This means that women with category 1 and category 2 conditions should be able to obtain and use progestin-only implants without restrictions.Source: WHO, 2010.
9Implants are safe for nearly all women. Conditions (selected examples) Category 1 and 2 Examples (not inclusive): Who Can Start ImplantsImplants are safe for nearly all women.WHO CategoryConditions (selected examples)Category 1Adolescents, post-abortion, postpartum in non-breastfeeding women, heavy smokers, women being treated for high blood pressure, valvular heart disease, endometriosis, endometrial or ovarian cancer, thyroid disordersCategory 2Blood pressure ≥160/100, history of blood clots in legs or lungs, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for cardiovascular diseaseDiscuss conditions included in categories 1 and 2. Remind participants that implants are safe for most womenSource: WHO, 2010.
10Category 3 and 4 Who Should Not Start Implants A small number of women may not be able to use implants.WHO CategoryConditions (selected examples)Category 3Acute blood clots in deep veins of legs or lungs, unexplained vaginal bleeding, history of breast cancer, severe liver disease, infection or tumors, and certain cases of systemic lupus.Breastfeeding before 6 weeks postpartum.Continuation only: ischemic heart disease, stroke, migraine with aura.Category 4Current breast cancerAlthough progestin-only implants are safe for most women, there are some exceptions.According to the WHO MEC, progestin-only implants are not generally recommended for women with category 3 conditions. In these situations, the risks of using this method usually outweigh the advantages. Category 3 conditions include:Acute blood clot in deep veins of legs or lungs, unexplained vaginal bleeding, history of breast cancer, severe liver disease and most liver tumors, certain cases of systemic lupus and breastfeeding before 6 weeks postpartum.The condition of breastfeeding before 6 weeks postpartum is a special case that merits further consideration. Based on theoretical (i.e. not proven) reasons having to do with the concern that progestogens may negatively affect the neonatal liver or brain, the WHO MEC has classified breastfeeding before 6 weeks postpartum as a category 3. WHO also notes that “in many settings pregnancy morbidity and mortality are high, and access to services is limited. Progestin-only contraceptives may be one of the few types of methods widely available and accessible to breastfeeding women immediately postpartum.” Reflecting this consideration, after careful evaluation of the evidence and their own health systems and settings, some countries have made different classifications. The United States Center for Disease control (CDC) gives the condition of breastfeeding at 0-4 weeks a Category 2 and from 4-6 weeks a Category 1. The United Kingdom’s Royal College of Obstetricians and Gynaecologists: Faculty of Sexual and Reproductive Health Care give it a Category 1 from birth onward. The materials in this training package reflect the WHO classification.Women who develop ischemic heart disease, have a stroke, or develop migraine headaches with an aura while using implants should generally not continue using progestin-only implants. Women with category 4 conditions should not use implants. Current breast cancer is the only category 4 condition.Source: WHO, 2010.
11Implant Use by Women with HIV WHO Eligibility CriteriaConditionCategoryHIV-infected1AIDSARV therapy2Women with HIV or AIDS can use without restrictionsSome ARV drugs reduce blood progestin levelEfficacy is not affected because implants provide consistent dose of hormone over timeDual method use should be encouragedAsk participants: What advice should you give to clients with HIV who choose implants? <accept responses from several participants; click the mouse to reveal the next bullet>Source: WHO, 2010; Mildvan, 2002.
12Implant Use by Postpartum Women WHO Eligibility CriteriaConditionCategoryNon-breastfeeding1Breastfeeding<6 weeks3Breastfeeding≥6 weeksNon-breastfeeding women can initiate immediately postpartumBreastfeeding womenBefore 6 weeks postpartum (WHO/MEC)No restrictions after 6 weeks postpartumAsk participants: Let us take a closer look at the conditions and categories pertaining to postpartum clients.Use slide to present the following:Non-breastfeeding women can initiate implants immediately postpartum.We have also discussed the different recommendations adopted by WHO and countries such as the US and UK regarding the use of implants earlier than 6 weeks postpartum based on theoretical concerns about possible negative effects of progestins on the fetal liver and brain. WHO has classified use at 0-6 weeks postpartum a classification of 3, while others have given it a lower classification (1 or 2). Unlike Combined Oral Contraceptives (COCs), implants do not have an effect on breast milk production.Ask participants about what they encounter with postpartum women. Is it easy or difficult for them to come back for insertion at 6 weeks postpartum?Source: WHO, 2010.
13Understanding the Implant Checklist Read questions 1–6 in the checklist and match them with the conditions and categories on the MEC quick reference chart.This set of questions identifies women who should not use implants.This set of questions identifies women who are not pregnant.Distribute an implant checklist to each participant.When introducing the checklist, mention that it should be used by providers to determine whether a client is medically eligible to use the method that she selected during an informed decision-making process.The questions on the checklist identify women who have health conditions—WHO category 3 or 4—that make it unsafe for them to use progestin-only implants. The checklist also incorporates questions that allow a provider to determine with reasonable certainty that a client is not pregnant.To use the checklist, providers ask the questions on the checklist and follow the instructions based on the client’s responses. Explain that the medical eligibility questions, questions 1–6, are at the top of the checklist.Ask participants: After examining the checklist and the MEC chart, are you confident that the checklist questions address the conditions that prohibit safe use of progestin-only implants? Explain why.How have you determined a client’s medical eligibility for implants in the past and how might the checklist facilitate that process?The checklist also gives instructions about initiating implants.
14When to Start Implants (part 1) Anytime a provider is reasonably certain a woman is not pregnant.Pregnancy can be ruled out if any of these situations apply:Is fully breastfeeding, has no menses, and baby is between 6 weeks and 6 months oldAbstained from intercourse since last menses or deliveryHad a baby in the past 4 weeks (if not breastfeeding)Started monthly bleeding within the past 7 days (5 days for Implanon)Had a miscarriage or abortion in the past 7 days (5 days for Implanon)Is using a reliable contraceptive method consistently and correctlyIf none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or by waiting till next menses.Ask participants: If a woman is medically eligible and wants to use implants, when can she initiate them? <participants brainstorm; accept responses from several participants>Let us compare your responses with the information on the next several slides. <click the mouse to reveal each bullet on the slide>Source: WHO, 2004 (updated 2008).
15When to Start Implants (part 2) First 7 days of menstrual cycle (5 days for Implanon), no backup method neededAfter 7th day of menstrual cycle (5th for Implanon), rule out pregnancy and use backup method for 7 daysPostpartumNot breastfeeding: immediately (no need to rule out pregnancy until 4 weeks postpartum)Breastfeeding: delay 6 weeks (WHO/MEC)Remind participants that the instruction boxes below the questions on the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants also provide guidance about when to initiate implants for women who are eligible.If two rod-implant systems, like Jadelle or Sino-implant (II), are initiated during the first seven days of the menstrual cycle—where day one is the first day of bleeding—no backup contraceptive method is necessary. With Implanon, no backup method is needed if it is initiated within the first five days of the menstrual cycle.If progestin-only implants are initiated more than seven days after the start of woman’s monthly bleeding (more than five days for Implanon), she should be counseled to use a backup contraceptive method such as condoms for the first seven days following insertion.A woman who is not breastfeeding may have implants inserted immediately after delivery. If a woman who is not breastfeeding wants to start using implants more than four weeks after she has given birth, it is necessary to rule out pregnancy before they can be inserted.Ideally, women who are breastfeeding should not start using implants until six weeks postpartum because of theoretical concern that hormones in breast milk may have an adverse effect on a newborn during the first six weeks after birth.Source: WHO, 2004 (updated 2008).
16When to Start Implants (part 3) Postabortion or miscarriage: immediately; without backupSwitching from a hormonal method: immediately if it was used consistently and correctlyInjectable users can have implants inserted within the reinjection window; without backupAfter using emergency contraceptive pills:Insert within 7 days after start of next menstrual period (5 days for Implanon); provide with backup method during interimSource: WHO, 2004 (updated 2008).