What Goes in Must Come Out
Contraceptive implants are available to more women around the world than ever before, thanks in large part to the Implant Access Program (IAP), a collaboration among several donor agencies, governments, non-governmental agencies (NGOs), and the makers of the contraceptive implants Jadelle® (Bayer HealthCare AG) and Implanon®/Implanon NXT® (Merck/MSD) to lower the products’ unit price by 50% for the world’s poorest countries. Since the launch of the IAP in 2013, 25.2 million implants have been purchased under this price reduction. Corresponding increases in implant use reported in national surveys such as the Performance, Monitoring & Accountability 2020 (PMA2020) indicate that women are taking advantage of the new found accessibility of affordable implants. Prevalence of implant use among married women has increased by 39% and 44% in Ethiopia and Kenya, respectively, in the last two years, and implants are currently the most commonly used method in Burkina Faso.
While millions of implants are being adopted by women across the world, whether and to what extent providers, institutions, and health systems are prepared to handle the inevitable increase in demand for implant removal services is less clear. Women may desire removal for many reasons: having reached the duration of the method’s effectiveness, a desire to conceive, or an inability to tolerate side effects, among others. Whatever the reason, it is simply not good enough to offer implants to women; we must also ensure that they have access to quality, timely, and affordable removal services when they desire removal.
Emerging evidence suggests that capacity to provide quality implant removal services may be insufficient in many settings around the world. While more and more providers at all levels of the health system have been equipped to insert implants, many do not have the experience, skill, or supplies necessary for removals. Identifying and accessing providers who are comfortable and skilled in implant removal, especially more difficult removals, may present a significant barrier to implant users. For example, in some settings, removal services may involve a fee, which may or may not be affordable to all clients. Likewise, providers recognize that removals are often more laborious than insertions, and the extra time and resources required for removals can be a disincentive to offering the service.
To adequately address these barriers, perhaps it is most important to first examine what it means to provide high quality removal services that are accessible and available. Ideally, facilities offering removal services should be located within a reasonable distance from clients. These facilities (including mobile services) should staff skilled, confident providers; stock adequate supplies; and guarantee on-demand removal services. In areas where same-day removal is not feasible, priority should be placed on development of an accessible referral system. Women adopting implants should receive routine counseling regarding their removal options and be made aware that, in some cases, access to removal services may be limited or take time. It is also essential that women be offered the option of a contraceptive method at the time of removal, including another implant.
Providing access to removals also means ensuring that the service is affordable. Women wanting their implant removed may opt to keep the implant despite its expiration or endure side effects because they cannot afford the cost of removal. The solution to this problem is complex and largely dependent on individual country policies and national family planning funding strategies. However, one consideration should be the “bundling” of implant service fees, wherein clients pay one fee at the time of implant adoption to cover both insertion and removal. Providers could be reimbursed for removals through a subsidized voucher program, for example, which may provide an incentive for them to offer removal services more broadly. Marie Stopes International (MSI) has instituted such a voucher scheme in some of their country programs.
Ensuring access to quality removal services for all women who want and need them will require a coordinated effort on the part of providers, governments, technical assistance organizations, manufacturers, and donors. FHI 360 and Jhpiego are among the partner organizations who comprise the recently-formed Implant Removals Taskforce, which identifies and prioritizes issues related to provision of quality implant removal services. Areas of focus for the Taskforce include research gaps, data monitoring, service delivery models, and management of difficult removals. The research and data needs identified thus far include a better understanding of when and where women seek removals and for what reasons. Data on how long women keep their implants, especially in low-income countries, is extremely sparse, which limits efforts of health systems to accurately estimate volume of at particular times. Also, more complete data on reasons for early implant removal are needed in order to strengthen provider training on effective counseling messages. Similarly, very few studies have attempted to measure women’s access to removal services; however, recently-collected data from the last round of the PMA2020 survey in Kenya show hopeful signs, with only 4% of currently implant users reporting that they were unable to have their implant removed at the time they sought services.
As we celebrate the continued achievement of providing contraceptive implants to more women than ever before, we must continue to hold the big picture of comprehensive family planning services squarely in view. Providing safe, accessible and affordable access to implant removal will help ensure that women continue to enjoy the freedom of contraceptive choice.