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The Training Resource Package for Family Planning Contraceptive Implants Module

Contraceptive Implants (Implants): Session PlanNotes to Facilitator:

The slides and session plan provide presentation support for conveying technical information and for conducting the interactive learning activities.

To use this presentation most effectively, please: • Read the Contraceptive Implants Facilitator’s Guide (available on the TRP website

at: http://www.fptraining.org/content/faciliatators-guide-implants) for guidance on selecting and adapting TRP materials for the learning needs of your audience.

• Next read this session plan, which includes detailed learning objectives for this module and describes how to use this presentation and other materials required to prepare for and conduct the learning activities

Training Process ResourcesSession I: Characteristics of ImplantsSession Objective: Describe the characteristics of implants.Welcome and Introduction (10 min.)

• Greet participants and introduce yourself.• See the Conducting Training tab in the TRP website

(available at: http://www.fptraining.org/content/conducting-training) for ice breaker options.

ObjectivesDiscussion (5 min.)

Explain:

• Contraceptive implants are a safe and highly effective family planning (FP) option for most women.

• This presentation provides an overview of the characteristics of this method. It also provides training on how to counsel, screen, and provide follow-up to clients who are interested in using implants to regulate their fertility.

• The session is designed to address the implant-related objectives listed in the Facilitator’s Guide and on the slide set.

• During this training you will learn and demonstrate these skills during role plays and other activities. You will also be encouraged to think about what it will be like to perform these tasks on-the-job.

• Review objectives with participants.

Basic Slide Set #1: Slide 2-3: Objectives

Last revised: 9 August 2018 of 51

http://www.fptraining.org/content/conducting-training

http://www.fptraining.org/content/faciliatators-guide-implants


Training Process Resources• Solicit input about whether the planned objectives match

participant’s expectations of the training. Pre-Test Questionnaire (30 min.) Distribute the pre-test.

Evaluation Tool: The Contraceptive Implants Pre-Test

What are Implants? Discussion (30 min.)

Ask the participants: Which brands of implants are available in the facility where they work (or in their country, pharmacy, or program). Allow participants to answer and add to the participants’ responses as needed.

Explain:

• Implants are hormone-filled rods (sometimes referred to as capsules) that are inserted under the skin in a woman’s upper arm.

• Jadelle®, Levoplant/Sino-implant (II)®, ImplanonNXT®/Nexplanon®, and Norplant® are types of implants.

• Jadelle is a two-rod system that is effective for five years.

• Levoplant/Sino-implant (II) is a two-rod system that is identical to Jadelle but labeled for up to three years of use, although efforts are under way to extend the labeled use to five years. Sino-implant (II) is now being sold under the global brand Levoplant.

• ImplanonNXT/Nexplanon is a single-rod system that continually releases a low, steady dose of the progestin etonogestrel for up to three years. It replaces Implanon, and is identical to Implanon except for its applicator and that it is radiopaque, which means that it can be seen in medical imaging (x-ray, CT-scan, ultrasound, etc.)

• Norplant was the first progestin-only implant system developed. It consisted of six thin, flexible capsules made of silicone. Norplant is no longer being manufactured but many women who had it inserted are still relying on it for contraceptive protection. Norplant is labeled for five years of use, but studies have found that it is effective for seven years which may provide current users with additional years of protection.

• The newer implant systems—Jadelle, Levoplant/Sino-

Basic Slide Set #1: Slide 4: What are Implants?

Handout #1: FAQ−Effectiveness of Progestin-Only Implants Beyond Labeled Use



Training Process ResourcesImplant (II), and ImplanonNXT—have fewer rods than Norplant, making insertion and removal much easier. The newer implants are also more comfortable for the user.

• For the remainder of this presentation and in other collateral materials, we will refer mostly to one-rod or two-rod systems rather than specific brands.

• Distribute the handout FAQ−Effectiveness of Progestin-Only Implants Beyond Labeled Use. Participants can use this FAQ to respond to clients’ questions about the duration of effectiveness for the various implant systems.

• Introduce the types of implants available in the country.

• Provide copies of the tools/job aids that providers will be using at their workplace during interactions with clients. Throughout this presentation, encourage providers to look at the sections that they can use to support efforts to counsel and provide information on implants.

Key Points for Providers and ClientsLecturette (5 min.)

• Give an overview of the key points about implants (What are they, how do they work, what to expect, important points about implants).

Basic Slide Set #1: Slide 5: Key Points for Providers and Clients

Key Points for ClientsDiscussion (5 min.)

Ask the participants: “What do you think are the most important messages to give clients about implants.” Allow participants to answer and add to the participants’ responses as needed.

Basic Slide Set #1: Slide 6: Key Points for Clients

EffectivenessDiscussion (10 min.)

• The purpose of this activity is to emphasize the effectiveness of implants.

• The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are sterilization and IUDs.

• Ask participants: Where would you put progestin-only implants on this list? <after participants respond, click the mouse to reveal the answer>

Basic Slide Set #1: Slide 7: Effectiveness of Implants

Optional Advanced Slide Set Slide 2: Contraceptive Method Effectiveness



Training Process Resources• Conclude by emphasizing that implants would be in top

tier of methods, as they are one of the most effective reversible methods available. As commonly used, implants are more effective than sterilization and IUDs.

• Use Optional Advanced Slide 2 to review and compare the effectiveness of FP methods during correct and consistent use and common use.

Relative EffectivenessLecturette (5 min.)

• Explain that there is another way to look at effectiveness. In this slide we look at how effective FP methods are as they are commonly used.

• The slide shows the number of women who would get pregnant if 1,000 women used a method for one year. So, if 1,000 fertile women who were having sex, but not using any protection from pregnancy, 850 of them would become pregnant.

• But, if the same 1,000 women were using an implant, fewer than one would become pregnant.

• As a part of good counseling, it is important to inform clients about how effective each method is.

Ask participants: • What if these same women were using an injectable? How

many would become pregnant.

Basic Slide Set #1: Slide 8: Relative Effectiveness of FP Methods

Method EffectivenessRole Play (20 min.)

The purpose of this activity is to give participants an opportunity to practice explaining the effectiveness of implants using two job aids: Comparing Effectiveness of Family Planning Methods and If 100 Women Use a Method for One Year, How Many Will Become Pregnant?

• Explain that one of the charts shows the number of women who would be pregnant if they used the method perfectly (perfect use) or if they occasionally used the method incorrectly or forgot to use it sometimes.

• Ask participants: Why is it difficult to use a method perfectly? Is it realistic to think that all methods will be used perfectly? Why or why not? How can a provider

Handout #2: Comparing Effectiveness of Family Planning Methods

Handout #3: Alternate Effectiveness Chart: If 100 Women Use a Method for One Year, How Many will Become Pregnant?



Training Process Resourcesinfluence how effectively a woman uses the method she is given? (Answers should include how counseling about a method influences its use).

• Distribute copies of these job aids for participants to use.

• Remind participants that clients consider method effectiveness a key factor when making a decision about which method to use.

• Explain that the chart on the previous slide is not necessarily easy for clients to understand. These two job aids present the information in a more understandable format.

• Explain that: If 100 women use implants for 1 year, less than 1 woman will become pregnant.

• Before practicing with the tools, ask participants to answer following questions:

1. How might you use these tools to help explain how effective implants are compared to other contraceptive methods?

2. How do these job aids compare with other ways you have explained method effectiveness to clients?

• Allow the groups to role play how to explain using the two job aids with clients for about 15 minutes.

Role Play Instructions:

• Instruct participants to pair off with a person sitting next to them.

• One person should play the role of the provider, while the other pretends to be a client.

• Providers should use one of the job aids to explain implant effectiveness as if they were interacting with an actual client. Encourage “clients” to ask questions.

• Give partners several minutes to practice.

• To conclude the activity, ask participants to gather as a large group and talk about the experience. Find out how well they thought the tools worked, whether they were helpful to the clients, and what they learned from this experience.



Training Process Resources• Remind participants that they will have various

opportunities to practice client-provider interaction and counseling, rotating client and provider roles, throughout the session.

Explaining How Implants WorkLecturette (5 min.)

• Explain that implants prevent pregnancy in two ways:

1. They prevent the release of eggs from the ovaries by suppressing the hormones that cause ovulation. When there is no egg, there is nothing for sperm to fertilize.

2. Implants also cause the cervical mucus to thicken. The thicker mucus acts as a barrier, making it more difficult for sperm to enter the uterine cavity. In the unlikely event that a woman does ovulate, this barrier of mucus greatly reduces the chance that the egg will be fertilized.

• Implants do not disrupt an existing pregnancy and have no adverse effect on a woman or a fetus if accidentally inserted in the arm of a woman who is already pregnant.

• However, in the rare event that a woman is found to be pregnant with an implant in place, the device should be removed.

Basic Slide Set #1: Slide 9: Implants: Mechanism of Action

Characteristics of ImplantsBrainstorming (10 min.)

The purpose of this activity is to keep participants focused on how they translate technical information into concepts that their clients can understand.

Brainstorming instructions:

• Ask trainees to brainstorm first a list of positive characteristics (advantages) and then negative characteristics of implants.

• Write these suggested characteristics on a flip chart. Then show the slide of implant characteristics and compare them to the list generated through brainstorming.

Basic Slide Set #1: Slide 10: Implants: Characteristics

Health Benefits of ImplantsLecturette (5 min.)

• In addition to being an effective way to prevent pregnancy, implants offer other health benefits.

Basic Slide Set #1: Slide 11: Implants: Health Benefits



Training Process Resourceso Physicians have observed that women who use

implants tend to have fewer cases of symptomatic pelvic inflammatory disease, or PID. It is not clear if this is due to actual prevention of PID or whether using implants makes PID symptoms less severe.

o Because most implant users experience an overall reduction in the amount of menstrual blood loss, implant use can reduce the likelihood of iron-deficiency anemia.

o Because implants are so effective at preventing pregnancy, they dramatically lower a woman’s chances of having an ectopic pregnancy, which is a potentially life-threatening condition. The risk of ectopic pregnancy is reduced by a factor

of more than 100; the rate of ectopic pregnancy among women using implants is 6 per 100,000 women per year compared with 650 per 100,000 women per year among women using no contraceptive method.

In the rare event that implants fail and pregnancy occurs, providers must be aware that an ectopic pregnancy is possible and be prepared to treat this life-threatening condition.

Side Effects of ImplantsLecturette (10 min.)

• Remind participants that as with many contraceptive methods, there are some side effects associated with implants that are not harmful but may be unpleasant.

• Women’s preferences for certain methods are often related to side effects.

• Ask the participants: What side effects of implants, have you heard about?

• Show slides 12 and 13 on side effects. Explain that many women who use implants experience side effects.

• The most commonly reported side effects are menstrual changes. Light bleeding or spotting, irregular bleeding that occurs frequently, prolonged bleeding that lasts more than eight days, infrequent bleeding, and amenorrhea are the types of menstrual irregularities that women report. In the first year of implant use, most women experience

Basic Slide Set #1: Slide 12: Possible Side Effects of Implants (part 1)

Basic Slide Set #1: Slide 13: Possible Side Effects of Implants (part 2)

Optional Advanced Slide Set Slide 3: Menstrual Bleeding Patterns in Users of Two-Rod Implants

Optional Advanced Slide Set Slide 4: Menstrual Bleeding Patterns in



Training Process Resourcesmenstrual changes that deviate from their normal bleeding pattern.

• Typically, the frequency of these menstrual changes—especially prolonged bleeding—decreases with time and is less of a problem by the end of the first year of use. These menstrual irregularities are not usually medically harmful, but they may be unacceptable for some women.

• The type of implant can also have an impact on the bleeding pattern that users experience. For example, ImplanonNXT users are more likely to experience infrequent or no menstrual bleeding than prolonged bleeding.

• For more detailed information on bleeding side effects see the optional advanced slides. Some providers may be interested to know whether there are any negative metabolic effects of contraceptive implants. A review of the available research on metabolic effects shows that Jadelle and ImplanonNXT appear to have no clinically important effects on liver, kidney, or thyroid function. For this information, see Optional Advanced Slide 5.

ImplanonNXT Users

Optional Advanced Slide Set Slide 5: No Significant Metabolic Effects

Implants Fact Sheet Brainstorming (10 min.)

The purpose of this activity is to give participants an opportunity to review the characteristics of implants and explore the contents of the fact sheet.


• Introduce the fact sheet and ask participants to review the first page.

• Ask participants if there are any additional comments or questions about the characteristics of implants.

• Discuss and clarify as needed.

• Ask participants to consider how they might be able to use the fact sheet in their work. Remind participants that although it might be useful for helping providers to remember important information to share with clients, the fact sheet is not intended to be used as a brochure to be distributed to clients.

• Ask participants to review the page two of the fact sheet. Inform the participants that the next segment of the

Basic Slide Set #1: Slide 14: Group Activity: Implants Fact Sheet

Handout #4: Fact Sheet: Implants



Training Process Resourcestraining will address the issues outlined on page two of the fact sheet.



Training Process ResourcesSession II: Who Can and Cannot Use ImplantsSession II Objective: Demonstrate how to screen women for medical eligibility to use implants.Characteristics of ImplantsDiscussion (10 min.)

• The purpose of this activity is to ensure that participants understand how the characteristics of implants might affect a client’s choice of or eligibility for implants.

• Ask participants for reasons why women listed in the slide might prefer or avoid implants. Click the mouse to reveal the next example. Move through each case quickly and mention the following points.

• Breastfeeding mother: o Because implants do not reduce the quantity of breast

milk or decrease the duration of lactation, they can be used by breastfeeding mothers.

o After insertion, a woman has three to five years of highly effective protection from unintended pregnancy, which is an ideal child-spacing interval for the health of the mother and the child.

o Note to Facilitator: Slides 2 and 3 represent 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 will be more fully discussed at that time.

• Adolescent: o Young women may be especially interested in implants

because there is nothing to do or remember after insertion.

o Also, fertility returns quickly after implants are removed, so women who wish to plan a pregnancy can do so easily.

o Young women can use implants to delay a first pregnancy or to space subsequent pregnancies.

o Studies show that adolescent mothers who choose implants over pills have higher rates of continued use and lower rates of new pregnancy.

o Note to Facilitator: If country guidelines support use of implants by adolescents, distribute Handout #5:

Basic Slide Set #2: Slide 2: Characteristics of Implants

Handout #5: Implants for Adolescents



Training Process ResourcesImplants for Adolescents: An Option Worth Considering for Healthy Timing and Spacing of Pregnancy. Some providers might have biases against providing implants to adolescents and neglect to mention this contraceptive option when counseling younger clients.

• Infected with HIV: o Implants are one of the most effective methods

available and are an excellent choice for women with HIV who wish to avoid unintended pregnancy.

o Women with HIV who are on antiretroviral therapy can use implants effectively because they do not interact with ARV drugs. However, women taking the ARV efavirenz should be advised to also use condoms, as efavirenz may reduce the effectiveness of implants.

• Little to no access to a health care facility:o Implants may be a good choice for women with limited

access to health care because routine periodic visits are not necessary, and implants provide long-term protection from pregnancy. A minor surgical procedure is necessary for both insertion and removal.

• Desires no more children:o Implants are an excellent alternative to sterilization for

women who want to stop childbearing.

Implants are Safe for Nearly All WomenLecturette (10 min.)

• Nearly all women can use implants safely and effectively, including women who:o Have or have not had childreno Are not marriedo Are of any age, including adolescents and women over

40 years oldo Have just had an abortion, miscarriage or ectopic

pregnancyo Smoke cigarettes, regardless of age or number of

cigarettes smokedo Are breastfeeding, beginning immediately after birtho Have anemia now or in the pasto Have varicose veinso Are infected with an HIV, whether or not on

antiretroviral therapy

Basic Slide Set #2: Slide 3: Implants are Safe for Nearly All Women



Training Process Resourceso Most health conditions do not affect safe and effective

use of implants and only few conditions or situations may affect a woman’s eligibility to use progestin-only implants.

• In addition, many women who cannot use contraceptive methods that contain estrogen can safely use implants.

• WHO medical eligibility criteria were developed to reassure providers about some conditions that do not interfere with safe use of contraceptives and highlight all conditions that might affect women’s eligibility to use any given contraceptive method.

Who Can and Cannot Use ImplantsDiscussion (15 min.)

• 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.

• Introduce job aids that help participants understand eligibility criteria (and that they may also use at their worksites), such as the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use.

Basic Slide Set #2: Slide 4: Who Can and Cannot Use Implants (Part 1)

Basic Slide Set #2: Slide 5: Who Can and Cannot Use Implants (Part 2)

Medical Eligibility Criteria Brainstorming (25 min.)

This activity has two purposes:1. To give participants an opportunity to share what they

know about the eligibility criteria used in their national FP guidelines or the WHO medical eligibility criteria (WHO MEC) so that the facilitator can determine whether the participants understand the criteria and how they are used or whether they need additional background information before proceeding.

2. To introduce job aids that help participants understand eligibility criteria (and that they may also use at their worksites), such as the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or the Quick Reference

Basic Slide Set #2: Slide 6: Medical Eligibility Criteria

Basic Slide Set #2: Slides 7 and 8: WHO’s Medical Eligibility Criteria, Categories for IUDs, Hormonal and Barrier Methods

Basic Slide Set #2: Slide 9: Who Can Start Implants



Training Process ResourcesChart for the WHO Medical Eligibility Criteria for Contraceptive Use.


• Use slides 7 and 8 to introduce the concept of medical eligibility and determine whether participants have an adequate foundation. Explain the 4 categories.

• List 10-15 medical criteria on a flip chart. Ask participants to find the appropriate category on the WHO MEC Wheel or the Quick Reference Chart. If time allows, this exercise can be made into a game using teams to determine the correct answers. Ask several participants to share one thing that they know about the eligibility criteria in their national FP/RH guidelines (if they exist) or the WHO MEC.

Category 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 later); 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), women who are breastfeeding a baby younger than 6 weeks old; diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, or multiple risk factors for cardiovascular

Basic Slide Set #2: Slide 10: Who Cannot Start Implants

Handout # 6: WHO Medical Eligibility Criteria Wheel for Contraceptive Use

Handout # 7: The Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use



Training Process Resourcesdisease.

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.

• In some cases, a condition or characteristic is assigned to one category for initiation and another for continuation of the method. In other words, the category may depend on whether a woman with the condition wishes to initiate the contraceptive method or was already using that method when she developed the condition.

• 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 9-10 to provide an overview of the medical eligibility criteria for implants.

• Although progestin-only implants are safe for most women, there are some exceptions.

o According to the 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.

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.



Training Process Resourceso Women with category 4 conditions should not use

implants. Current breast cancer is the only category 4 condition.

o WHO also notes that, 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.

Implant Use by Women with HIVDiscussion (10 min.)

• Ask participants: Let us take a closer look at the conditions and categories pertaining to clients with HIV.

• Use slide to present the following:

o According to the MEC, progestin-only implants can be used without restrictions by women with HIV, including those with mild, severe, or advanced HIV clinical disease. These are considered category 1 conditions. This table shows the specific WHO recommendations.

o HIV-positive women who are on antiretroviral (ARV) therapy can also use progestin-only implants with no restrictions, but follow-up may be required in some cases. This is because progestin blood levels are slightly reduced by some ARVs. However, these reductions are probably not enough to affect contraceptive efficacy because implants provide a consistent dose of hormone over time. However, the ARV efavirenz may reduce the effectiveness of implants, so women taking it should use condoms along with the implant to provide better protection from pregnancy.

o As with other hormonal methods, progestin-only implants do not provide protection from STIs.

• Ask 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>

o Women with HIV who choose to use implants should be counseled about dual method use and should

Basic Slide Set #2: Slide 11: Implant Use by Women with HIV



Training Process Resourcesconsider using condoms in addition to hormonal methods. Condoms provide additional protection from pregnancy in the event that the effectiveness of progestin-only implants is reduced. Condoms also provide protection against STI/HIV transmission.

o WHO classifies nucleoside reverse transcriptase inhibitors (NRTIs) as category 1 and most non-nucleoside reverse transcriptase inhibitors (NNRTIs) and ritonavir and ritonavir-boosted protease inhibitors as category 2 conditions for progestin-only implants. Because ARV therapy is a multidrug regimen that always contains a category 2 drug, ARV therapy is a category 2 condition. This means that women on ARV therapy can generally use progestin-only implants, although follow-up may be required in some cases.

Implant Use by Postpartum WomenLecturette (5 min.)

• Ask participants: Let us take a closer look at the conditions and categories pertaining to postpartum clients.


o Breastfeeding and non-breastfeeding women can initiate implants immediately postpartum.

o The recommendations for breastfeeding women not to start implants until at least 6 weeks postpartum has been updated. Breastfeeding women may not start implants at any time postpartum. Implants do not harm breastfeeding infants or reduce breast milk production. In many settings, they are one of the few methods available to postpartum women and these women should be supported in freely accessing the method.

• 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?

Basic Slide Set #2: Slide 12: Implant Use by Postpartum Women

Understanding the Implant ChecklistExperiential Learning Exercise (15 min.)

The purpose of this activity is to introduce participants to the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants, to provide an overview of its purpose, and to show how to use it.

• Distribute an implant checklist to each participant.

Basic Slide Set #2: Slide 13: Understanding the Implant Checklist

Handout #7: Quick Reference Chart for the WHO Medical Eligibility



Training Process Resources• 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 1–5, are at the top of the checklist.

• Ask participants to pair themselves with the person sitting next to them and take turns reading questions 1–5 on the checklist and finding the condition on the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use. Ask the pairs to verify that all the category 3 and 4 conditions for implants on the MEC chart are represented in the questions on the checklist. Allow participants about three to four minutes to examine the checklist questions and compare them with the MEC chart.

• Ask participants:

o 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.

o How have you determined a client’s medical eligibility for implants in the past and how might the checklist facilitate that process?

• Accept responses from several participants and discuss any concerns that participants may raise.

• Draw attention to questions 6–11 and emphasize that providers should follow the instructions for this set of questions to identify women who are not pregnant or those who might be pregnant and require a pregnancy test to rule out pregnancy.

• Tell providers that the final set of instructions provides

Criteria for Contraceptive Use

Handout #8: Checklist for Screening Clients Who Want to Initiate Contraceptive Implants



Training Process Resourcesdetails about initiating the method, especially whether the client will need to use a backup method initially.

Implant Eligibility Checklist (1)Brainstorming (10 min.)

The purpose of this exercise is to give participants a chance to use Handout #8, the Contraceptive Implant Checklist.

• Describe the following scenario (1): Your client is a healthy 24-year-old woman who gave birth to her first child five months ago. She has been fully breastfeeding and has not had a menstrual period since giving birth. She is returning to work in two weeks and will begin supplementing with formula.

• Ask participants to consider the client description when answering these questions:

1. Which question(s) on the checklist address this client’s condition or situation? Encourage participants to review the checklist and locate the question(s) relevant to this client’s situation. Ask them to read the explanation for question #10. In this situation she would reply “YES” to question #10 because she had a baby less than 6 months ago, is fully breastfeeding, and has had no menstrual period since then.

2. Considering the client’s condition and the explanation provided in the checklist, is this client a good candidate for progestin-only implants?Review with the participants why the client is medically eligible for implants. Because the client is healthy, she would answer “NO” to questions #1–5. She would also answer “YES” to question #10, so the provider can be reasonably sure that she is not pregnant because she is still protected from pregnancy by the lactational amenorrhea method (LAM).

3. What would be your course of action for this client? Discuss with participants why the correct course of action is to counsel the client about using progestin-only implants. If everything is acceptable to the client, the provider may proceed with implant insertion.

Handout #7: Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use


Handout #9: Using the Implant Eligibility Checklist


Handout #7: Quick Reference Chart for the WHO



Training Process ResourcesThe purpose of this exercise is to give participants a chance to use Handout #8, the Contraceptive Implant Checklist.

• Describe the following scenario (2): Your client is a 30-year-old woman who is married, monogamous, and has three children. She has HIV but has no symptoms and has no other health problems. She has been using condoms consistently and correctly but is still concerned that she might become pregnant.

Ask participants to consider the client description when answering these questions:

1. Which question(s) on the checklist address this client’s condition or situation?Encourage participants to review the checklist and locate the question(s) relevant to this client’s situation. Ask them to read the explanation for question #8.

2. Considering the client’s condition and the explanation provided in the checklist, is this client a good candidate for progestin-only implants?Review with the participants why the client is medically eligible for implants. Although the client has HIV, HIV is not a condition that limit use of implants. Because the client is otherwise healthy, she would answer “NO” to questions #1–6. She would also answer “YES” to question #12, so the provider can be reasonably sure that she is not pregnant because she has been using condoms consistently and correctly.

3. What would be your course of action for this client? Discuss with participants why the correct course of action is to counsel the client about using progestin-only implants. The client should also be encouraged to continue using condoms to prevent sexually transmitted infections. If everything is acceptable to the client, the provider may proceed with implant insertion.

Medical Eligibility Criteria for Contraceptive Use

Handout #8: Checklist for Screening Clients Who Want to Initiate Implants



The purpose of this exercise is to give participants a chance to use Handout #8, the Contraceptive Implant Checklist.

• Describe the following scenario (3): Your client is a 42-year-old woman with five children. Six months ago, she was admitted to the hospital with severe chest pain and shortness of breath. She was diagnosed with a blood clot in

Handout #7: Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use

Handout #8: Checklist for



Training Process Resourcesher lung. She is now on anticoagulant therapy (blood thinners). She has no other health problems. She has not had sex since her last menses.

Ask participants to consider the client description when answering these questions:

1. Which question on the checklist addresses this client’s condition or situation?Encourage participants to review the checklist and locate the question(s) relevant to this client’s situation. Ask them to read the explanation for questions #2 and #9.

2. Considering the client’s condition and the explanation provided in the checklist, is this client a good candidate for implants?Review with the participants why the client is medically eligible for implants. She should answer NO to question #2 because she does not currently have blood clots in her legs or lungs and she is on anticoagulant therapy. However, because of her history with blood clots, she may answer YES to the question. If so, the provider has the opportunity to probe further and confirm that she does not currently have clots in her legs or lungs as she has been on anticoagulant therapy for six months. The provider can be reasonably sure the client is not pregnant because she has not had intercourse since her last menses.

3. What would be your course of action for this client? Discuss with participants why the correct course of action is to counsel the client about using progestin-only implants. The client should also be encouraged to continue with her anticoagulant therapy and inform other health care providers whom she sees that she is using implants and taking blood thinners. If everything is acceptable to the client, the provider may proceed with implant insertion. If her menses started more than seven days ago, tell her to use condoms or abstain for the next seven days.

Screening Clients Who Want to Initiate Implants


When to Start Implants (part 1)Discussion (10 min.)

Remind participants that questions #7–12 in the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants are used to rule out pregnancy as part of the screening process for

Basic Slide Set #2: Slide 14: When to Start Implants (part1)



Training Process Resourcesinitiating implants.

• 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>

• Progestin-only implants can be initiated anytime during the menstrual cycle as long as the provider can be reasonably sure the woman is not pregnant.

• A provider can be reasonably certain that a woman is not pregnant if any of these situations apply:

o The woman is fully breastfeeding, has no menses, and her baby is less than six months old.

o She has abstained from intercourse since her last menses or since delivery.

o She has given birth in the past four weeks.

o Her monthly bleeding started within the past seven days.

o She had a miscarriage or an abortion in the past seven days.

o She has been using a reliable contraceptive method consistently and correctly.

• If none of these situations apply, a provider can use a urine pregnancy test or conduct a bimanual pelvic exam to determine if the woman is pregnant. If no other means to rule out pregnancy are available, a provider can ask a woman to come back at a time of her next menses and use a backup contraceptive method in a meantime.

When to Start Implants (part 2)Lecturette (5 min.)

• 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.

Basic Slide Set #2: Slide 15: When to Start Implants (part 2)



Training Process Resources• 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 ImplanonNXT, 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, 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.

When to Start Implants (part 3)Discussion (5 min.)

• Implants can be initiated immediately following an abortion or miscarriage without need for a backup method.

• If a woman is switching to implants from a hormonal method, she can have the implants inserted immediately provided that she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain that she is not pregnant. There is no need for her to wait for her next monthly bleeding. There is no need for her to use a backup method.

• If she is switching from injectables, she can have implants inserted anytime during the reinjection window. There is no need for a backup method.

• If a woman has taken emergency contraceptive pills, it is recommended that she delay implant insertion until her menses return to ensure that emergency contraception was effective. Implants can be inserted within the first seven days after the start of her menstrual period or any other

Basic Slide Set #2: Slide 16: When to Start Implants (part 3)



Training Process Resourcestime it is reasonably certain that she is not pregnant. Give her a backup method such as condoms, or oral contraceptives to start the day after she finishes taking the emergency contraceptive pills, until the implants can be inserted.



Training Process ResourcesSession III: Providing ImplantsSession III Objective: Demonstrate how to provide implants.When to Start Implants (A Review)Group Work (15 min.)

The purpose of this activity is to allow participants to think about how they would apply what they have learned about when to initiate implants. The activity can be conducted in a large group or small groups as long as participant responses are monitored by a facilitator. Encourage participants to use the job aid, Checklist for Screening Clients Who Want to Initiate Contraceptive Implants, to help them determine what to do in each case.

• Ask participants to explain what they would do in each case. The correct approaches for each case are outlined below.

o In day 4 of menstrual cycle —can have implants inserted immediately, no need to rule out pregnancy or use a backup method (regardless of type of implant being inserted)

o Condom user in day 8 of menstrual cycle —ensure client has used condoms consistently and correctly, can have implants inserted immediately, instruct her to continue using condoms for 7 more days

o 2½ weeks postpartum, not breastfeeding —can have implants inserted immediately, no need to use a backup method

o 2½ weeks postpartum, currently breastfeeding and wishes to continue— can have implants inserted immediately, no need to use a backup method

o Injectable user, amenorrhoeic, within reinjection window—can have implants inserted immediately, no need to rule out pregnancy or use a backup method.

o IUD user, mid-cycle, has had sex since her last menses—can have implants inserted immediately, remove IUD during the next menstrual cycle (this is because ovulation may have already occurred and viable sperm may be present in her fallopian tubes so implants even in combination with a back-up method would not be effective).

Basic Slide Set #3 Slide 2: When to Start Implants (A Review)




Training Process Resourceso After taking emergency contraceptive pills (ECPs)

—can be inserted within seven days after the start of her next monthly bleeding or any other time it is reasonably certain she is not pregnant; give her a backup method, or oral contraceptives to start the day after she finishes taking the ECPs, to use until the implants are inserted.

Key Counseling Topics for Implant UsersDiscussion/Role Play (30 min.)

• Ask participants: What are the key counseling topics for new Implant users? <allow participants to respond, affirm correct responses and click mouse to reveal the list>


o After a client makes an informed choice to use implants, and you determine that she has no known conditions that would prohibit use, you and the client should discuss in greater detail how to use implants and address any additional questions or misconceptions that the client may have about the characteristics of implants.

o Specifically, you should discuss how safe and effective implants are, how efficacy is affected by a woman’s ability to take pills on time, how implants work, health benefits, and possible side effects

o You should also discuss the fact that implants do not protect against STIs/HIV.

o During counseling, help the client to assess her risk of acquiring or transmitting infection and discuss the benefits and feasibility of condom use to reduce that risk. Explain how to use condoms correctly and consistently and, if needed, help women develop and practice strategies to negotiate condom use with their partners.

o Tell the client that if she is diagnosed with any serious new health problem she should inform her health care provider she has a contraceptive implant in place.

o Finally, discuss when to return, and tell the client about the warning signs of possible complications. We will discuss the warning signs in a few moments.

Basic Slide Set #3 Slide 3: Key Counseling Topics for Implant Users



Training Process Resources• Role play instructions:

o Divide participants into groups of three. Ask the members of each group to choose who will play the role of client, provider, or observer.

o The observer will observe the roleplay and then make suggestions for improvement.

o Explain that each participant will play each role during the activity.

o The “provider” will explain about what implants are, effectiveness, how they work, advantages and disadvantages, client instructions, and when to return to the provider. The “provider” may use local counseling material if available.

Correcting Rumors and Misunderstandings about ImplantsBrainstorming (20 min.)

• Explain that rumors are unconfirmed stories that are transferred from one person to another by word of mouth. In general, rumors arise when:

o An issue or information is important to people, but it has not been clearly explained.

o There is nobody available who can clarify or correct the incorrect information.

o The original source is perceived to be credible.

o Clients have not been given enough options for contraceptive methods.

o People are motivated to spread them for political reasons.

• A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.

• Ask participants: What are some common misconceptions about implants? <participants brainstorm; write the answers on a flip chart>

1. Discuss methods for counteracting rumors and misinformation

Basic Slide Set #3 Slide 4: Correcting Rumors and Misunderstandings

Handout #10: Correcting Rumors and Misconceptions about implants



Training Process Resources2. When a client mentions with a rumor, always listen

politely. Don't laugh.

3. Define what a rumor or misconception is.

4. Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor.

5. Explain the facts.

6. Use strong scientific facts about FP methods to counteract misinformation.

7. Always tell the truth. Never try to hide side effects or problems that might occur with various methods.

8. Clarify information with the use of demonstrations and visual aids.

9. Give examples of people who are satisfied users of the method (only if they are willing to have their names used). This kind of personal testimonial is most convincing.

10. Reassure the client by examining her and telling her your findings.

11. Counsel the client about all available FP methods.

• Refer back to the flipchart and ask participants how they could counteract each rumor or misconception.

Additional Key Counseling TopicsBrainstorming and Discussion (10 min.)

• Ask participants: in addition to providing information on the characteristics of implants—including side effects, assessing the client’s eligibility, and addressing client misconceptions or questions—what are some other key counseling topics related to implants? <participants brainstorm; accept responses from several participants>

• Let us compare your responses with the slide. <click the mouse to reveal the list>

• In addition to the topics we have already discussed, it is imperative that during counseling about implants providers also:

• Explain the procedure used to insert and remove the implants. Use illustrations if possible. Include the length of

Basic Slide Set #3 Slide 5: Additional Key Counseling Topics



Training Process Resourcestime it takes to complete the procedure, who will perform it, and that it may be somewhat uncomfortable but not painful. We will review a job aid that can be used for this purpose.

• Provide post-insertion instructions so that a client knows how to care for the incision and when to return to the clinic if something does not seem right. We will also review these instructions in more detail.

• Explain how long the implants protect against pregnancy. Help women remember when they should come back to have the implants removed or replaced. All clients should be provided with the following information:

o Type of implant

o Date of insertion

o Month and year when implants will need to be removed

o Where to go in case of questions or problems

• A reminder card like the one shown on the slide can be useful for this purpose.

• Finally, the provider should advise a client about circumstances that require her to return, which are described in more detail on the next slide.

Counseling About Side EffectsLecturette (10 min.)

• Use the slide to present the following important points:

o Counseling—both prior to insertion and for women already using implants—is the best way to help women manage the side effects associated with progestin-only implants.

o The most common side effects of implants are irregular bleeding, prolonged bleeding, infrequent bleeding, or no bleeding at all. Headaches, mild abdominal pain, and breast tenderness are examples of less common side effects.

o Women who are considering using implants should be counseled that menstrual changes are expected and that they are not signs of disease or health problems. For most women, side effects will become less pronounced

Basic Slide Set #3 Slide 6: Counseling About Side Effects



Training Process Resourcesor will stop within the first year. Some women may not have any side effects.

o After an implant is inserted, the practitioner should tell the client to come back with any questions or concerns. Ongoing counseling and reassurance should be provided if needed.

o If the user continues to be concerned or finds the side effects unacceptable, it may be necessary to manage the side effects or remove the implants.

Implant Insertion and RemovalDiscussion and Role Play (20 min.)

• A client who has chosen an implant needs to know what will happen during insertion. Clients will want to know the following:

o Implants usually only take a few minutes to insert but can sometimes take longer.

o Complications related to the insertion are rare.

o The provider will carefully clean the area on the arm and will use sterile gloves and equipment.

o The client will receive a small injection under the skin so that she will not feel the implant being inserted. The injection may sting a bit.

o The client will be awake during the procedure.

o The provider will make a small incision on the inside of the upper arm.

o The provider will insert the implant (1 or 2 rods, depending on the type.

o After the implant has been inserted the provider will put on a small bandage and then gauze will be wrapped around the arm to keep the area clean.

• Role play instructions: ask for 2 volunteers to do a short role play on explaining implant insertion to a client.

Basic Slide Set #3 Slide 7: Implant Insertion and Removal

What Clients Need to Remember After InsertionLecturette (10 min.)


o Key messages that clients remember.

Basic Slide Set #3 Slide 8: What to Remember



Training Process Resourceso Scheduled follow-up visits are not necessary for

implant users, but clients should be advised to return to the clinic anytime they have questions or concerns.

o Discuss how to remember when to have the implant removed.

o Having contact with the client within the first two to six months may improve continuation among women experiencing side effects, because this is when such problems are most likely to occur.

o The provider should also ask whether the client’s reproductive goals have changed, as she may want to become pregnant or desire a long-acting or permanent method.

o If the client reports or complains about side effects, the provider should assess her symptoms and, if appropriate, reassure her that the side effects are not harmful and discuss ways to manage them.

o If the client has developed any conditions that are contraindications for continuing to use implants, or if the client finds side effects unacceptable, the provider should help her choose another method.

Supporting Method Continuation: Question to ConsiderBrainstorming (10 min.)

Ask participants to share any strategies that they have developed to support method continuation among their clients.

Assure clients that they are welcome to come back any time for any reason. Although there is no need for a routine follow-up visit, there are some reasons that an implant user might want to or should return.

Clients should be advised to come back for the following reasons:

o If she has problems or questions related to side effects or other issues or if she wants to try another method.

o If she experiences pain, heat, pus, or redness at the insertion site that becomes worse or does not go away—this may indicate an infection.

o If she notices a rod is coming out—since the implant



Training Process Resourcesshould be replaced after ensuring there is no infection or treating the infection if present.

o If she is concerned that she may be pregnant—since the implant should be removed if she plans to carry the pregnancy to term. But, it would be very rare to get pregnant with the implant in place, unless it is left in too long.

o If she has gained a lot of weight. This may decrease the length of time the rod is effective.

o If she suddenly feels that something is seriously wrong with her health; although, it is unlikely that the implant is the cause of the condition.

Helping Continuing UsersDiscussion (5 min.)

• Explain that no routine visit required for implants, but if she returns, ask:

o Whether satisfied with method or has questions.

o If she is concerned about bleeding changes.

o About new health problems or major life changes (plans for more children, change in STI/HIV risk).

o About significant weight changes (if using Jadelle, significant weight gain may affect the duration of the implants’ effectiveness).

o If she wants to continue using implant and has no new medical condition, remind her how much longer her implant will protect her.

Basic Slide Set #3 Slide 9: Helping Continuing Implant Users

Management of Implant Side Effects: Bleeding ChangesLecturette (10 min.)

• Ask participants: What is the most important thing that you can do for women who experience side effects? <participants brainstorm; accept responses from several participants> Compare responses with the slide.

• As we have discussed, the best way to reduce the anxiety some women feel when they experience side effects is to provide detailed information about possible side effects before implant insertion. If side effects occur, the first step is to address the client’s concerns through follow-up counseling.

Basic Slide Set #3 Slide 10: Management of Implant Side Effects: Bleeding Changes



Training Process Resources• If a client complains about irregular or breakthrough

bleeding, the provider should explain that implants make the uterine lining thinner, sometimes causing it to shed earlier than usual, resulting in this type of bleeding. It is also important to reassure the woman that this bleeding does not mean that anything is wrong and remind her that it will likely diminish with time.

• If the irregular bleeding is unacceptable to the client, the provider may recommend up to 800 mg of ibuprofen, or an equivalent amount of another non-steroidal anti-inflammatory drug (NSAID) other than aspirin, three times per day for five days. Women who are experiencing irregular bleeding should not take aspirin, since it may increase bleeding, not decrease it.

• If an NSAID does not provide relief, the provider can give a low-dose combined oral contraceptive (COC) containing the progestin levonorgestrel for 21 days. An alternative to COCs is to give 50 µg ethinyl estradiol daily for 21 days. If bleeding is prolonged or heavy—twice as long or twice as much as usual—the provider can suggest that the woman take iron tablets to help prevent anemia. If irregular or heavy bleeding continues to bother the client or starts after several months of normal monthly bleeding or amenorrhea, the provider should rule out a possible underlying condition unrelated to method use, such as uterine fibroids, an STI, genital cancer, or pregnancy.

• Amenorrhea is another common side effect of implants. Providers can reassure their clients that it does not indicate a health problem and no medical treatment is necessary. This side effect is similar to not having monthly bleeding during pregnancy.

• If side effects persist and are unacceptable to the client, the provider should help her choose another contraceptive method.

Management of Implant Side Effects: Non-Menstrual ProblemsLecturette (10 min.)

• There are several non-menstrual side effects that clients who are using implants may experience.

o If a client experiences frequent headaches that are not migraines, reassure her that ordinary headaches do not

Basic Slide Set #3 Slide 11: Management of Implant Side Effects: Non-Menstrual

Problems Last revised: 9 August 2018 of 51


Training Process Resourcesindicate dangerous conditions and usually diminish over time. Standard doses of painkillers such as aspirin, ibuprofen, paracetamol, or other pain relievers may be used to alleviate symptoms. However, if headaches get worse or occur more often after insertion of implants, they should be evaluated.

o Mild abdominal pain may be caused by many conditions, including enlarged ovarian follicles or cysts. Reassure the client that ovarian follicles or cysts usually disappear on their own and standard doses of painkillers or other local remedies will usually alleviate discomfort. To be sure the problem is resolving, see the client again in six weeks. There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. However, if abdominal pain becomes severe, refer at once for immediate diagnosis and care. This is especially true if the severe abdominal pain occurs with other signs or symptoms of ectopic pregnancy such as abnormal vaginal bleeding or no monthly bleeding (especially if this is a change from her usual bleeding pattern), light-headedness, dizziness, or fainting. Ectopic pregnancy is rare but can be life-threatening.

o Clients who experience breast tenderness may try wearing a supportive bra and can apply hot or cold compresses. They can also take standard doses of painkillers such as aspirin, ibuprofen, or paracetamol.

o In case of weight gain, review the client’s diet and counsel her about healthy eating habits and exercise as a way to better control her weight.

o If side effects persist and the client wants to stop using implants, health care providers should counsel about non-hormonal options and help the woman choose another method.

o If appropriate, for more advanced providers, discuss Optional Advanced Slide 6: Jadelle: Continuation Rates and Reasons for Discontinuation.

Optional Advanced Slide Set Slide 6: Jadelle: Continuation Rates and Reasons for Discontinuation

Management of Implant Side Effects: Problems Related to InsertionBrainstorming/Discussion (10 min.)

• Clients may sometimes experience problems related to the

Basic Slide Set #3 Slide 12: Management of Implant Side Effects:



Training Process Resourcesinsertion of implants.

• Ask participants to brainstorm what side effects may occur as a result of insertion and what advice would they give to the client. These problems can usually be addressed easily.

• For pain after insertion, check that the bandage on the client’s arm is not too tight. Put a new bandage on the arm and advise the client to avoid pressing on the site for a few days. Standard doses of aspirin, ibuprofen, paracetamol, or other pain reliever may also be helpful.

• If the woman experiences redness, heat, pain, or pus at the insertion site, this may indicate an infection. In this case, do not remove the implants. Clean the infected area with soap and water or antiseptic. Give oral antibiotics for 7 to 10 days. Instruct the client to take all the antibiotics. If the infection has not cleared after completing the course of antibiotics, ask the client to return for removal of the implants.

• In some cases, the client may develop an abscess—a pocket of pus under the skin caused by an infection. If this happens, clean the area with antiseptic. Cut open and drain the abscess, and treat the wound. Give the woman oral antibiotics for 7 to 10 days. Instruct the client to take all the antibiotics. If she still has signs of infection—such as heat, redness, pain, or drainage of the wound—after completing the antibiotics, ask the client to return for removal of the implants.

• Expulsion or partial expulsion of the implants often follows an infection. Ask the client to return for follow-up care if she notices an implant coming out.

Problems Related to Insertion

Managing Problems Reported as Side EffectsGroup Work (45 min.)

• If the national FP guidelines provide specific recommendations for management of implants side effects, photocopy, distribute, and refer to the guidelines.

• If the national guidelines do not provide specific recommendations, provide a copy of the pages from the Global Handbook that providers can use as a job aid. Refer to the section on Managing Any Problems: Problems Related as Side Effects or Complications. Divide participants into several groups. Divide the side effects

Handout #11: Implant Section of Family Planning a Global Handbook for Providers



Training Process Resourceslisted in the Global Handbook among the groups. Ask the groups to develop plans for managing each side effect. Allow 30 minutes for the groups to develop their plans and 15 minutes to report back.

Problems that May Require Switching from Implants to Another Method Brainstorming/Discussion (20 min.)

• As a review exercise, write 2 columns on a flip chart. Label one column side effect and the other management. Brainstorm the different side effects and their management.

• Explain that there are some serious health conditions that may require a client to stop using implants. These include:

o If a client experiences unexplained vaginal bleeding or heavy or prolonged bleeding that is suggestive of a medical condition not related to the method, she might need to discontinue use of implants. Refer the client or evaluate by taking her medical

history and doing a pelvic examination. Diagnose and treat as appropriate.

If no cause of bleeding can be found, consider stopping implants to make the diagnosis easier. Provide the client with another contraceptive method of her choice until the condition is evaluated and treated. The alternative method should be something other than progestin-only injectables or a copper-bearing or hormonal IUD.

If the bleeding is caused by an STI or PID, the client can continue using implants during treatment.

o Although women who have migraine headaches with an aura can initiate implants, implants should be removed if a woman develops migraines with aura after implants are inserted. The provider should help her choose a non-hormonal method.

o If a woman develops health conditions such as blood clots in the deep veins of the legs or lungs, heart disease due to blocked or narrowed arteries, severe liver disease, or breast cancer, the implants must be removed.

o Although women with ischemic heart disease and women who have had a stroke can initiate use of

Basic Slide Set #3 Slide 13: Problems that May Require Switching from Implants to Another Method (Part 1)

Basic Slide Set #3 Slide 14: Problems that May Require Switching from Implants to Another Method (Part 2)



Training Process Resourcesimplants, use of implants should be discontinued if these conditions develop or get worse while using implants. Remove the implants or refer for removal and give

the woman a backup method to use until her condition is evaluated. Refer her for diagnosis and care if she is not already receiving treatment.

o Finally, if a woman is pregnant, the implants should be removed. However, there are no known risks to a fetus conceived while a woman has the implants in place.

Complications from Implants are RareLecturette (5 min.)

• Whereas side effects—especially those related to menstruation—are relatively common with progestin-only implants, complications are uncommon or rare. They may include:

o Infection at the insertion site is an uncommon complication. If an infection occurs, it will most likely be within the first two months.

o Difficulty with removal may occur if insertion was done improperly or if removal is attempted by an untrained provider. However, if implants are properly inserted and removed by a trained provider, difficulty in removing implants is rare.

o Expulsion of an implant is a rare complication. If this occurs, it is most likely to happen in the first four months. If no infection is present, a fresh implant may be inserted through a new incision near the other rods or capsules to replace the one that was expelled.

Basic Slide Set #3 Slide 15: Complications from Implants are Uncommon or Rare

Explaining Implant Removal to the ClientDiscussion (10 min.)

• Provide a copy of the page from the Global Handbook that providers can use as a job aid while explaining the removal procedure to clients. This page is a summary of the procedure; it does not provide the detailed instructions required for providers who are learning how to remove implants. Removal training must be done under the supervision of an experienced mentor.

• Prior to removal, a provider should describe for the client

Basic Slide Set #3 Slide 16: Counseling about Implants: Explain Removal Procedure to Client

Handout #11: Implant Section of Family Planning a Global Handbook for Providers



Training Process Resourcesthat removing implants usually takes somewhat longer than insertion. Providers should also reassure clients that complications related to implant removal are rare.

• The simplified description, from the Global Handbook page shown on the slide, is designed to explain the removal procedure to clients. <participants take turns reading the steps aloud> o The provider uses proper infection prevention

procedures.o The woman receives an injection of local anesthetic

under the skin of her arm to prevent pain during implant removal. This injection may sting. She stays fully awake throughout the procedure.

o The health care provider makes a small incision in the skin on the inside of the upper arm, near the site of insertion.

o The provider uses an instrument to pull out each implant. A woman may feel tugging, slight pain, or soreness during the procedure and for a few days after.

o The provider closes the incision with an adhesive bandage. Stitches are not needed. An elastic bandage may be placed over the adhesive bandage to apply gentle pressure for two or three days and reduce swelling.

o If a woman wants to continue using implants, a new set of implants may be inserted through the same incision, either in the same or in the opposite direction.

o Providers must not refuse or delay when a woman asks to have her implants removed, regardless of the reason.

o All staff must understand and agree that clients must not be pressured or forced to continue using implants.

Infection Prevention Discussion (10 min.)

• Inserting and removing progestin-only implants are minor surgical procedures, and it is important that providers follow careful infection prevention procedures with every client.

o Use slide 17 to describe infection prevention procedures prior to implant insertion or removal.

o Use slide 18 to describe infection prevention procedures after implant insertion or removal.

Basic Slide Set #3 Slide 17: Infection Prevention: Prior to Implant Insertion or Removal

Basic Slide Set #3 Slide 18: Infection Prevention: After Implant Insertion or Removal



Training Process Resources• Ask participants to brainstorm: “What steps should you

take to prevent infection prior to, during, and after the insertion or removal procedure?” <participants brainstorm; accept responses from several participants; click the mouse to reveal the information on the slide>

• Distribute to each participant a copy of the Handout #12: Checklist: Providing Implants with Appropriate Infection Prevention Practices; review each step on page 5 of the checklist.

Handout #12: Checklist: Providing Implants, With Appropriate InfectionPrevention Practices

Implants: SummaryLecturette (5 min)

• Summarize the important points about implants.

Basic Slide Set #3 Slide 19: Implants: Summary

Role Plays (30 min.)

• Follow the step-by-step instructions in the Facilitator’s Guide section on facilitating role plays to prepare for and conduct this activity.

1. Discuss the learning objective of the role play activity.

2. Review the instructions for the client, provider, and observer roles and the other learning resources developed for the activity.

3. View a demonstration role play and clarify any questions.

4. Conduct role plays in small groups based on the scenarios provided and discuss reactions.

5. Discuss the activity as a large group.

• Review Handouts #9 and #10 with participants. These include:

1. Five different role play scenarios, each with a client information sheet and observer information sheet.

2. The instruction sheet that describes the roles of providers, clients, and observers.

3. The Role Play Observation Checklist for Clinicians.

4. Role play scenario/information sheets for clients and observers for the role plays you have selected or adapted from Handout #14: Role Play Scenarios.

Handout #13:Role Play Scenarios

Conducting Training Tool: Facilitating Role Plays



Training Process Resources• Use the following questions to help the small groups

structure the feedback that they provide to each other after each role play.

o What was going on between the provider and client?

o What did the provider do that was effective in this situation?

o What might the provider consider doing differently if this situation were to happen again?

o How did the provider attend to the items on the counseling observation checklist and the case-specific observations included in the role play description?

• After the small groups conduct each role play, encourage the groups to talk about what happened during the role play from the perspective of the provider (self-assessment), the client (personal satisfaction with the interaction), and the observer (objective assessment using the Role Play Observation Checklist included in Handout #14, including the case-specific observations included in the role play description).

• Prepare a flip chart to display these discussion questions where the questions can easily be seen by all the participants in the small groups.

Case Studies (45 min.)

• Divide Participants into 4 groups.

• Distribute Handout #15 and #16. Give 2 groups Case Study #1 and #2. Ask each group to review the case studies and answer the questions.

• Allow each group 25 minutes to prepare their answers and five minutes to present their answers to the rest of the group.

Handout #14: Case Study #1

Handout #15: Case Study #2

Conducting Training Tool:Using Case Studies

The Implants Game Show (Optional)(1 hour)

• Become familiar with how to run the game before presenting it to the participants. Review and print the answer key to the game questions.

• Introduce the rules for the game show. Explain that the purpose of the game show is to provide a fun, light-hearted

Optional Slide Set: Implants Game Show



Training Process Resourcesreview of implants. o Each team will take turns picking a category and the

level of difficulty of the question. Show the game board, Slide 2 in the Optional PowerPoint Slide Set: Implants Game Show, to help with your explanation. Example: Under the category “Characteristics” there are five choices ranging in point value from 100 to 500. If your team picks the 100-point value, you will get a simple question on a characteristic of implants. If you answer the question correctly, your team will earn 100 points. If your team selects a 500-point question, it will be more difficult. But if you answer correctly, your team will earn 500 points.

o Explain that each team will have 15 seconds to discuss their response before the game show host (facilitator) calls time and they must provide an answer.

o If a team answers correctly, the points are awarded. If the team answers incorrectly, another team gets a chance to answer the question. To make the game more interesting and challenging, remove the points when a team answers a question incorrectly.

• Before starting the game, ask if there are any questions and provide clarity as needed.

• When a team selects a category and amount, click the corresponding square on the screen to reveal the question.

• If a team answers correctly, click the green circle at the bottom of the screen. The presentation provides positive feedback and automatically returns to slide 2 to allow selection of the next category and amount. Notice that after a category and amount is selected, it is no longer highlighted as an option.

• If a team answers incorrectly, click the red circle at the bottom of the screen. The presentation provides negative feedback and stays on the question to allow another team to answer.

• If no team answers the question correctly, click the blue circle, which provides no audible feedback but returns to slide 2 to allow selection of the next category and amount.

• Play the game as long as the group has energy or set a time limit before the start of the game.

• Divide participants into teams of four or five. To enhance the competition, place participants into groups



Training Process Resourcesfrom different sectors, regions, facilities, age groups, or other commonalities.

• Project slides 1 and 2 from the game show presentation and describe the categories of questions included in the game.

• Keep score during the game. Clarify questions as needed and remind participants of key concepts associated with the questions and answers.

• Keep it quick and fun. Remember that the goal is to review the session material. Do not feel obliged to complete the entire game. Continue to play only as long as the participants’ excitement and energy permit.

• Offer a prize to the winning team.Post-Test and Course Evaluation (30 min.) Evaluation Tool:

The Contraceptive Implants Post-test, Applied Learning Case Studies, and Course Evaluation



Session IV: Practicing Insertion and Removal Single-Rod ImplantSession Objective: To demonstrate insertion and removal procedures for single-rod implants.

*Note to trainer: There are slide sets for both single-rod (Session IV A and IV B) and double-rod implants (Sessions V A and V B). Choose the appropriate slide set for your program. This presentation is focused solely on the mechanics of the clinical procedure; refer to the basic presentation slide sets for guidance about counseling users and other implant-related issues.

Slide Set: Session IV A

One-Rod Implant Insertion: Required EquipmentLecturette (10 min)

• ImplanonNXT is the only one-rod system currently on the market. Similar to two-rod implants, ImplanonNXT is inserted sub-dermally.

• The basis for the successful use and subsequent removal of a one-rod implant is a correct and carefully performed sub-dermal insertion. The provider should give special attention to aseptic technique and careful surgical technique to minimize tissue trauma and to keep the implant from being inserted too deeply, thus becoming more difficult to remove.

• Providers with little experience in sub-dermal insertion should acquire the correct technique under the supervision of an experienced colleague.

• Use the illustration and the information on Slide 2 to describe the equipment required for the insertion procedure.

• Use the illustration on Slide 3 and the information below to describe individual components of the applicator and clarify their specific functions.

• Explain that insertion of ImplanonNXT is performed with the specially designed applicator (see Slide 3).

Slide 2: One-Rod Implant Insertion: Required Equipment

Slide 3: ImplanonNXT Applicator

Steps in ImplanonNXT Insertion Lecturette (30 min.)

• Use the illustrations and the information on the slides to describe each step in the insertion procedure.

• Use Slide 5 to:

Slides 4-16: ImplanonNXT Insertion Steps 1-13



o Explain that the insertion of ImplanonNXT is performed with the specially designed applicator. The ImplanonNXT insertion procedure is opposite to giving an injection. When inserting ImplanonNXT, the obturator must remain fixed while the cannula (needle) is retracted from the arm. For injections, the plunger is pushed and the body of the syringe remains fixed.

• Use Slide 8 to:o Remind providers that the needle must be inserted to its

full length or the implant will not be inserted properly. If partial protrusion occurs, discard the implant and reinsert a new sterile implant using a new applicator.

• Use Slide 12 to: o Instruct providers to make sure that they do not insert

the implant too deeply. Remind them that if the implant is placed too deeply, paresthesia (due to neural damage) and migration of the implant (due to insertion on the fascia or in the muscle) may occur. Improper insertions have been associated with rare cases of intravascular insertion. Moreover, the implant may not be palpable, and localization or removal can be difficult later.

• Use Slide 16 to instruct providers how to: o Make sure that they always verify the presence of the

implant by palpation and have the woman palpate it herself.

o Apply a sterile gauze with a pressure bandage to prevent bruising.

o Complete the user card and give it to the client. Explain that the user card records the batch number of the implant, the date of insertion, the arm of insertion, and the intended day of removal.

o Review the post-insertion instructions and key messages for implant users and address any final questions that the client may have. (See basic presentation slide sets for details).

o Dispose of the applicator and syringe properly. The applicator is for single use only and must be disposed of in a sharps container in accordance with local regulations for the handling of biohazardous waste.

*Note to trainer: Because ImplanonNXT is the only one-rod Slide Set: Session IV B



system currently on the market, these instructions are specific to ImplanonNXT. This presentation is focused solely on the mechanics of the clinical procedure; refer to the basic presentation slide sets for guidance about counseling users and other implant-related issues.

Steps in Implanon/ImplanonNXT RemovalLecturette (10 min.)

• Slide 2:

o Use the illustration and the information on the slide to describe the equipment required for the removal procedure.

o The removal of Implanon/ImplanonNXT should only be performed by a provider who is trained to perform the removal procedure.

o There have been occasional reports of displacement of the implant, usually involving minor movement from the original position. This may complicate localization of the implant and may require a somewhat larger incision and more time. The precise location of the implant is specified on the user card given to the woman at the time of insertion.

o In the rare cases where Implanon/ImplanonNXT has not been inserted correctly, the implant might not be palpable. If this occurs, there are other localization techniques that may be performed. If the implant is not palpable, it may be appropriate to seek consultation or provide a referral. If a woman wishes to avoid pregnancy, she may have another implant inserted―if she is eligible―or choose another method of contraception.

• Use Slide 3 to advise providers that:

o If they cannot feel the implant, it should be localized by medical imaging (one of four methods: CT scan, 2 dimensional x-ray, ultrasound, or MRI) before removal is attempted.

o Surgery without knowledge of the exact localization of the implant is strictly discouraged. Removal of deeply inserted implants should be conducted with caution in order to prevent damage to deeper neural or vascular structures in the arm.

Slides 2-10: Implanon Removal Steps 1-7



• Slide 10:

o Use the information on the slide to clarify options for clients who decide to continue or discontinue the method.

o Remind providers to inform their clients that following removal, the contraceptive effects reverse quickly and a woman can become pregnant at a rate similar to women who have not used the method.



Session V: Practicing Insertion and Removal Double-Rod ImplantSession Objective: To demonstrate insertion and removal procedures for double-rod implants.Two-Rod Implant Insertion StepsLecturette/Discussion (30 min.)

• Use the illustration and the information on each slide to describe each step.

• Two-Rod Implant Insertion: Required Equipment (Slide 2)o Use the illustration and the information on the slide to

describe the equipment required for the insertion procedure.

• Two-Rod Implant Insertion: Trocar (Slide 3)o In 2010 USAID released an announcement1 that

Jadelle, which is a commodity offered through USAID’s procurement system, is now provided with a sterile, single-use, disposable trocar.

• Two-rod implant insertion steps:

o Step 1: Highlight that the optimal insertion area is in the inner surface of the upper arm about 8 to 10 cm above the elbow joint groove. (Slide 4)

o Step 4: Use the insertion card, pictured on the slide, to explain how the anesthetized areas map to the final placement of the implants. (Slide 7)

o Step 5: Mention that many providers prefer to insert the trocar directly through the skin without making an incision with the scalpel. The bevel of the trocar should always face up during the insertion. (Slide 8)

o Step 6: Remind providers that the trocar should not be forced. If they encounter resistance, they should try another direction. (Slide 9)

o Step 14: Remind providers that suturing the incision is not necessary. (Slide 17)

o Step 15: (Slide 18) Instruct providers how to: Apply a sterile gauze with a pressure bandage to

prevent bruising. Complete the user card and explain to the client the

information that is included on the card (e.g., batch

Slide Set Session V A

Slides 2-18



number of the implant, the date of insertion, the arm of insertion, and the intended day of removal).

Review the post-insertion instructions and key messages for implant users and address any final questions that the client may have. (See basic presentation slide sets for details).

Dispose of the trocar and syringe properly. The trocar is for single use only and must be disposed of in a sharps container in accordance with local regulations for the handling of biohazardous waste.

Two-Rod Implant RemovalLecturette/Discussion (15 min.)

• Use the illustrations and the information on each slide to describe each step in the removal procedure.

• Step 1 (Slide 3): Advise providers that:o If the implants cannot be felt, they may be located by

ultrasound or X-ray. o Surgery without knowledge of the exact localization of

the implant is strictly discouraged. Removal of deeply inserted implants should be conducted with caution to prevent damage to deeper neural or vascular structures in the arm.

• Step 2 (Slide 4): Advise providers that:o Anesthetic injected over the implants will obscure them

and make removal more difficult. o Additional small amounts of the anesthetic can be used

for removal of the second implant, if required.

• Post-removal Options (Slide 10): o Remind providers to inform their clients that following

removal, the contraceptive effects reverse quickly, and a woman can become pregnant at a rate similar to women who have not used the method.

Slide Set Session V B

Slides 2-10

Session VI: Infection PreventionSession Objective: To demonstrate infection prevention procedures for implant insertion and removal.Session VI Infection PreventionLecturette (30 min.)

• Although insertion and removal of implants are minor surgical procedures, careful infection prevention procedures must be followed with every client.

• Infection prevention during insertion and removal involves

Slide Set Session VISlides 2-6



aseptic technique (performing the procedures under sterile conditions).

• Proper infection prevention procedures minimize the chances of blood-borne infections such as HIV and hepatitis B and of infections at the insertion site.

• Infection at the insertion site may require early removal or cause spontaneous expulsion of implants.

• Generally, sterilization is required for instruments such as scalpels and needles that touch tissue beneath the skin. If sterilization is not possible or practical, instruments must be high-level disinfected (HLD).

• Preparing for insertion (Slide 2):o Although insertion and removal of implants are minor

surgical procedures, careful infection prevention procedures must be followed with every client. Infection prevention during insertion and removal involves aseptic technique (performing the procedures under sterile conditions).

o Proper infection prevention procedures minimize the chances of blood-borne infections such as HIV and hepatitis B and of infections at the insertion site. Infection at the insertion site may require early removal or cause spontaneous expulsion of implants.

o Generally, sterilization is required for instruments such as scalpels and needles. Have the client wash her entire arm and hand (the one she uses less often) with soap and water, and dry with clean towel or air-dry.

o Cover the procedure table and arm support with a clean cloth. Ask the client to lie on her back on the table so that the arm in which the implants will be placed is turned outwards and bent at the elbow and is well supported.

o Prepare a clean instrument tray and open the sterile instrument pack without touching the instruments or other items.

o For Jadelle and Sino-Implant (II), carefully open the sterile pouch containing the implants by pulling apart the sheets of the pouch and, without touching the rods, allowing them to fall into a sterile cup or bowl.

o For ImplanonNXT, remove the sterile applicator with the preloaded implant from the package by allowing it to fall on the sterile tray without touching it.



• Before insertion (Slide 3):o Wash hands thoroughly with antiseptic soap and water

and dry with clean towel or air-dry.o Put sterile or high-level disinfected gloves on both

hands before each procedure. o Clean the insertion site with a cotton or gauze swab

soaked in antiseptic solution and held in a sterile or high-level disinfected forceps.

o Use sterile surgical drape with a hole in it to cover the arm. The hole should be large enough to expose the entire area where the implants will lie once they are inserted. (If sterile drape is not available, use a clean drape or linen that has been washed, dried, ironed, and stored in a clean closet.)

o When giving local anesthetic, use a new disposable syringe and needle, from a sealed package, if available. An autodisable syringe is preferable.

• During Insertion: Jadelle and Sino-Plant (Slide 4):Jadelle and Sino-Implant (II):o To minimize risk of infection and/or expulsion, make

sure that the ends of the rods nearest to the incision are not too close (not less than 5 mm) to the incision. If the tip of the rod protrudes from or is too close to the incision, it should be carefully removed and reinserted in the proper position. Also, to enable easy removal of both rods from a single incision, it is important that the ends of the rods closest to the incision are not farther apart, one from the next, than the width (not length) of one implant.

o While inserting the implants, try not to remove the trocar from the incision. Keeping the trocar in place minimizes tissue trauma, decreases the chances of infection, and minimizes insertion time.

• During Insertion: ImplanonNXT (Slide 5):o After confirming that the rod is in the applicator,

remove the needle shield. If contamination occurs, use a new package with a new sterile applicator.

• After Insertion (Slide 6):o Press down on the incision with gauze for a minute or

so to stop any bleeding, and then clean the area around the insertion site with antiseptic solution on a swab.

o Use an adhesive bandage or surgical tape with sterile cotton to cover the insertion site. Check for any



bleeding. Cover with a dry compress and wrap gauze around arm tight enough to provide some compression to minimize bleeding under the skin (hematoma), but not so tight that it will cause pain and paleness in the arm.

o Dispose of the single-use applicator (for ImplanonNXT) and used disposable syringes and needles in a puncture-resistant container.

o Immediately after inserting or removing the implants, decontaminate the trocar, scalpel, syringe and needle, and any other non-disposable instruments by soaking them in a 0.5% chlorine solution for 10 minutes. Decontamination makes them safer for final processing of the instruments (described below).

o Dispose of contaminated objects (gauze, cotton, and other waste items) in a properly marked leak-proof container with a tight-fitting lid or in a plastic bag.

o If disposable gloves were used, carefully remove gloves by inverting and place in the waste container.

o If reusable gloves were used, immerse both gloved hands briefly in the chlorine solution to decontaminate the outside, and then remove the gloves by inverting.

o Clean instruments and gloves after they have soaked in the chlorine solution for 10 minutes (as described above).

o Wash instruments with a brush, using water and either liquid soap or detergent. Avoid bar soap or powdered soap, which can stay on the equipment.

o Rinse and dry the equipment. While cleaning, wear utility gloves and an apron.

o Sterilize instruments and gloves in a high-pressure steam autoclave or a dry-heat oven or with

o chemicals. If sterilization is not possible or practical, high-level disinfect them by boiling, by steaming, or with chemicals.

o Decontaminate all surfaces that could have been contaminated by blood, such as the procedure table or instrument stand, by wiping them down with 0.5% chlorine solution.

o Wash hands with soap and water and dry with clean towel or air-dry.

Source: Upadhyay, U.D. and Ramchandran, D., “Implants: Tools for Providers,” INFO Reports, No. 15, Baltimore, Johns Hopkins Bloomberg School of Public Health, The INFP Project, October 2007


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