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Session II, Slide #1
Contraceptive Implants
Session II: Who Can and Cannot Use Implants
Session II, Slide #2
Characteristics of Implants
Why might these women be interested in using implants?
• Breastfeeding mother
• Adolescent
• Infected with HIV
• Has little to no access to a health care facility
• Desires no more children
Session II, Slide #3
Implants Are Safe for Nearly All Women
– Have just had an abortion, miscarriage or ectopic pregnancy
– Are breastfeeding (starting as soon as 6 weeks after childbirth, WHO/MEC)
– Have anemia now or in the past
– Have varicose veins
• Almost all women can use implants safely, including women who:
– Have or have not had children
– Are not married
– Are of any age including adolescents and women over 40 years old
– Are infected with HIV
• 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.
Session II, Slide 4
But usually cannot use implants if:
Most women can safely use implants
Breastfeeding 6 weeks or
less/WHO MECMay be pregnant Some other serious
health conditions
Who Can and Cannot Use Implants (part 1)
Session II, Slide 5
Who Can and Cannot Use Implants (part 2)
Most women can safely use implants. But usually cannot use implants if:Breastfeeding 6 weeks or less
• Ask her to come back when baby is 6 weeks old. Urge her to keep breastfeeding. (Based on WHO MEC categorization)
May be pregnant • If in doubt, use pregnancy checklist or perform pregnancy test.
Some other serious health conditions
• Has 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).
Session II, Slide #6
Medical Eligibility Criteria
What are medical eligibility criteria?
Define the categories.
Review the job aid.
Session II, Slide # 7
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Source: WHO, 2010.
Category Description With clinical judgment
1 No restriction for use Use the method under any circumstances
2Benefits generally outweigh risks
Generally use the method
3Risks usually outweigh benefits
Use of method not usually recommended, unless other methods are not available/acceptable
4 Unacceptable health risk Method not to be used
Session II, Slide # 8
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Source: WHO, 2010.
CategoryWhen clinical judgment
is limited
1
Use the method
2
3
Do not use the method
4
Session II, Slide #9
Category 1 and 2 Examples (not inclusive):
Who Can Start Implants
WHO Category Conditions (selected examples)
Category 1
Adolescents, 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 disorders
Category 2
Blood 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 disease
Implants are safe for nearly all women.
Source: WHO, 2010.
Session II, Slide #10
Category 3 and 4
Who Should Not Start Implants
A small number of women may not be able to use implants.
WHO Category Conditions (selected examples)
Category 3
Acute 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 4 Current breast cancer
Source: WHO, 2010.
Session II, Slide #11
Implant Use by Women with HIV
• Women with HIV or AIDS can use without restrictions
• Some ARV drugs reduce blood progestin level
• Efficacy is not affected because implants provide consistent dose of hormone over time
• Dual method use should be encouraged
Source: WHO, 2010; Mildvan, 2002.
WHO Eligibility CriteriaWHO Eligibility Criteria
Condition Category
HIV-infected 1
AIDS 1
ARV therapy 2
Session II, Slide #12
Implant Use by Postpartum Women
• Non-breastfeeding women can initiate immediately postpartum
• Breastfeeding women – Before 6 weeks
postpartum (WHO/MEC)
– No restrictions after 6 weeks postpartum
Source: WHO, 2010.
WHO Eligibility CriteriaWHO Eligibility Criteria
Condition Category
Non-breastfeeding
1
Breastfeeding<6 weeks
3
Breastfeeding≥6 weeks
1
Session II, Slide #13
Understanding 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.
The checklist also gives instructions
about initiating implants.
Session II, Slide #14
When 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 old
– Abstained from intercourse since last menses or delivery
– Had 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 correctly
• If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or by waiting till next menses.
Source: WHO, 2004 (updated 2008).
Session II, Slide #15
When to Start Implants (part 2)
• First 7 days of menstrual cycle (5 days for Implanon),
no backup method needed
• After 7th day of menstrual cycle (5th for Implanon), rule out pregnancy and use backup method for 7 days
• Postpartum– Not breastfeeding: immediately (no need to rule out
pregnancy until 4 weeks postpartum)
– Breastfeeding: delay 6 weeks (WHO/MEC)
Source: WHO, 2004 (updated 2008).
Session II, Slide #16
When to Start Implants (part 3)
• Postabortion or miscarriage: immediately; without backup
• Switching from a hormonal method: immediately if it was used consistently and correctly– Injectable users can have implants inserted within the
reinjection window; without backup
• After using emergency contraceptive pills:– Insert within 7 days after start of next menstrual
period (5 days for Implanon); provide with backup method during interim
Source: WHO, 2004 (updated 2008).
