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SHORT COMMUNICATION

Counselling styles and their effect onsubdermal contraceptive implant

continuation rates

Joshua Rubenstein*, Punam Rubenstein{, Janet Barter { and Rudiger Pittrof {

*Barts and The London School of Medicine and Dentistry, London, and {Department of Reproductive and Sexual

Health Care, Enfield Community Services, Town Clinic, Enfield, UK

A B S T R A C T Objectives This study compares whether counselling style prior to insertion of subdermal

implants (SDIs) affects continuation rates at one-year post-insertion. Two senior doctors in a

North London Integrated Sexual Health Clinic counselled patients in different ways.

Method This was a study involving 50 patients. Of these 25 received ‘cautious’

counselling: they were advised to think carefully about having a SDI inserted and the

counsellor emphasised the risks and relative inconvenience of inserting and removing the

implant. The second group of 25 women received ‘just-try-it’ counselling; this consisted of

encouraging the patients to have a SDI inserted and emphasising the reversibility of the

method.

Results Continuation rates were 92% (23/25) for the ‘cautious’ approach and 80% (20/25)

for the ‘just-try-it’ approach. More SDI acceptors in the ‘just-try-it’ group (5/25) first learned

about the existence of this contraceptive method during the same consultation in which the

implant was inserted than in the ‘cautious’ group (1/25). All six of these immediate acceptors

kept their implant for at least a year.

Conclusion Continuation rates did not differ much between the two counselling styles

and approaches were compatible with high continuation rates. Lowering the barriers to SDI

use can benefit patients and reduce costs to the health economy.

K E Y W O R D S Subdermal implant; Implanon1; Continuation rates; Counselling styles

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I N T R O D U C T I O N

Contraceptive counselling prior to starting a method,

in addition to providing the information required for

informed consent, is also thought to improve satisfac-

tion with and adherence to the contraceptive method

used1,2.

The most effective long acting reversible contra-

ceptive, the subdermal implant (SDI), has typical user

pregnancy rates of less than 1 in 1000 over three years

and is recommended as a first line option3,4. Insertion

and removal of the implant are simple but invasive

Correspondence: Punam Rubenstein, Department of Reproductive and Sexual Health Care, Enfield Community Services, Town Clinic, Enfield EN1

1NJ, UK. Tel: þ 44 20 8362 7630. Fax: þ 44 20 8364 6691. E-mail: [email protected]

The European Journal of Contraception and Reproductive Health Care, June 2011;16:225–228

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procedures and while SDIs are cost-saving if kept in

for more than one year 3 start-up costs are high. It is

currently not known how different approaches to

contraceptive counselling affect continuation rates.

M A T E R I A L S A N D M E T H O D S

This retrospective cohort study was carried out to

compare the SDI one-year continuation rates among

the patients of two senior doctors (JB and PR) at a

North London integrated sexual health service. Both

doctors had more than 15 years experience in specialist

contraceptive care and adhered to national guidelines

on SDIs3. When explaining SDIs’ advantages and

disadvantages (e.g., menstrual disturbance) both pro-viders used similar language. Both practised patient-

centred medicine and followed internal procedures

including completing a check list to ensure that

patients receive all relevant information and provide

informed consent. Consultation styles of the two

doctors differed considerably. One (JB) used the ‘just

try it’ approach: she stressed the reversibility of SDIs

and the ease with which they could be removed, and

encouraged patients to try using one. The other

doctor (PR) resorted to a ‘cautious’ approach: she

would warn patients that the decision to have a SDI is

not trivial, and would emphasise that insertion and

removal of the implant are invasive procedures.

Ethical approval for this study was not sought as it

was originally conceived as a clinical audit.

Patient selection

In the UK providers have to keep a log book of SDI

insertions to satisfy their requirements for recertifica-

tion. These log books were used to identify patients

who received a single rod etonorgestrel SDI (Im-

planon1

) before February 2009. Only patients withmobile phones and adequately completed records

were eligible for participation. In February and March

2010 we contacted consecutive, age-matched patients.

We started by phoning women who had their implant

inserted in February 2009 and worked back through

the log book. We continued until the initial age-

matched sample was completed (age 518 years: five

patients each; age 18–25 years: ten patients each; age

26 years and over: ten patients each). The final patient

whom we contacted had her implant inserted in May

2007.

Data collection and analysis

Patients were contacted by mobile phone (by JR and

PR) and, after giving verbal consent to participation inthe study, were asked:

(1) Do you still have the implant and if not when

was it removed?

(2) On the day of receiving the implant did you

specifically attend for this purpose?

(3) How long, prior to insertion, had you heard

about the implant?

(4) Did you receive enough information before the

implant was fitted?

(5) Do you think you made the right decision about

having the implant?

Duration of implant use and continuation rates of

one year or longer were calculated for the different

counselling styles and Fisher’s exact test was used to

assess statistical significance.

R E S U L T S

We attempted to contact 71 women. Twenty could

not be reached and none declined to participate. Onewas excluded because she had learning difficulties.

Hence, data were collected pertaining to 50 women.

Continuation rates were 92% (95% confidence

interval [CI]: 81.4–100%; n¼ 23/25) for the cautious

counselling approach and 80% (95% CI: 64.3–95.7%;

n¼ 20/25) for the ‘just try it’ counselling approach.

The difference was not statistically significant

( p¼ 0.21).

More SDI acceptors in the ‘just try it’ approach first

learned about the existence, benefits and risks of the

method during the same consultation in which the

implant was inserted (5/25) than in the ‘cautious’

counselling group (1/25). None of these six immediate

acceptors had their implant removed within a year of

insertion.

Twenty-three of the 25 women in the ‘cautious

group’ and 22 of the 25 in the ‘just-try-it group’ felt

that they had received enough information about

SDIs; in the ‘cautious group’ 21/23 and 19/22 in the

‘just-try-it group’ considered that they made the

correct decision to start using the SDI. Other results

are given in Table 1.

Counselling styles and Implanon1 continuation rates Rubenstein et al.

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D I S C U S S I O N

Few studies have addressed the impact of counselling

styles on SDI continuation rates. While our study has

methodological shortcomings (see below) it provides

reassurance that as long as a patient-centred approach is

taken SDI satisfaction and continuation rates can be high.

Continuation rates did not differ much between

providers with very different consultation styles. A

cautious ‘are you really really sure’ approach was not

associated with a materially higher continuation rate of

SDIs one year after insertion.

Further, consultation style in this study did not

appear to be related to the satisfaction of the patient

with her decision to have the implant.

This is in line with the findings of Harvey et al .1 and

Smith and Reuter 5 who found no significant difference

whencomparingcontinuation rates betweenwomen whoreceived their SDI immediately and those who had it

inserted after a ‘cooling off’ period.

As stated above, our study has methodological

shortcomings. Firstly, our sample was small. We were

not able to reach the sample size we had intended.

This was not surprising as our sample was recruited

from a highly mobile population. Furthermore we

used mobile phone numbers to contact our patients,

which are likely to be more frequently changed

than addresses. Secondly, recall bias was probably

introduced in patients’ responses during the telephone

interviews, because at least a year had elapsed between

SDI counselling and the telephone interview. Finally,

selection bias was introduced due to a high loss to

follow-up rate (28%), our decision to only look at

patients who accepted SDI insertion (and not those

who refused), and the non-random allocation of

participants to the doctors.

Ideally we would have liked to perform a

randomised controlled trial to answer our question;

however, this would have been difficult. Effective

provider-patient communication requires that the

provider is confident in the appropriateness of the

message given to the patient. As counselling styles

might reflect provider attitudes towards risk-taking it

is possible that a cautious provider adopting a ‘just try

it’ approach could be perceived by a patient as lacking

sincerity. Such a perception is more likely to lead to

non-acceptance or early discontinuation of SDIs. Asboth providers (JB and PR) were not working in the

same place at the same time and many patients

attended without an appointment, randomisation

would not have been possible.

C O N C L U S I O N

SDIs are one of the best methods of contraception

available; if continuation rates are high this will result

in absolute cost savings for the health economy3. Most

patients who receive a SDI are happy with it. Hence

Table 1 Comparison of outcomes according to counselling style

Patient information by

SDI continued 1 year

by counselling style

‘Just-try-it’

approach

’Cautious’

approach

Age 518 years (n¼5 in each group) 3 5

18–25 years (n¼10 in each group) 10 9

425 years (n¼10 in each group) 7 9

Original attendance specifically for SDI fitting 13/17 22/24

First heard about the SDI On day of SDI fitting 5/5 1/1

Within 1 week of fitting 1/1 2/2

Within 1 month of fitting 1/2 5/6

More than 1 month before fitting 13/17 14/16

Received enough information about SDIs before fitting 22/25 23/25Happy with the decision to have an SDI 24/25 23/25

SDI continuation 1 year 20/25 24/25

SDI: subdermal implant


Th E J l f C i d R d i H l h C 227

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lowering the barriers to SDI use can have important

benefits for the patient and the population.

Behaviour change is easier to achieve if the new

behaviour is ‘try-able’ and the barriers to adopting it are

easy to negotiate. It is therefore possible that a ‘just try it’

approach could lead to a higher rate of starting SDIs.

Our findings can reassure providers that this approach

can also lead to high SDI one-year continuation rates.

Declaration of interest: J. Rubenstein, P. Rubenstein

and R. Pittrof report no conflict of interest. J. Barter

receives occasional honoraria and educational grants

from Schering Plough, as well as from other

companies. The Department of RASH receives

support from Schering Plough in providing training

and Study Days for RASH staff and Enfield GPs and

Practice Nurses.

The authors alone are responsible for the content and

the writing of the paper. Schering Plough was not

involved in any aspect (interpretation or reporting of

the findings) of this study.

R E F E R E N C E S

1. HarveyC, Seib C, Lucke J. Continuationrates and reasons

for removal among Implanon users accessing two family

planning clinics in Queensland, Australia. Contraception

2009;80:527–32.

2. FlemingD, Davie J, Glasier A. Continuation rates of long-

acting methods of contraception: A comparative study of

Norplant implants and intrauterine devices. Contraception

1998;57:19–21.

3. National Institute for Health and Clinical Excellence. CG30.

Long acting reversible contraception: the effective and appropriate use of

long-acting reversible contraception. London: RCOG Press 2005.

4. Faculty of Sexual and Reproductive Healthcare. FSRH

Guidance: Progestogen-only implants. London 2008.

5. Smith A, Reuter S. An assessment of the use of Implanon

in three community services. J Fam Plann Reprod Health

Care 2002;28:193–6.


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