Session II, Slide #1

Contraceptive ImplantsSession II:

Who Can and Cannot Use Implants

Session II, Slide #2

Characteristics of ImplantsWhy might these women be interested in using implants?

• Breastfeeding mother

• Adolescent

• Infected with HIV

• Has little to no access to a health care facility

• Desires no more children

Session II, Slide #3

Implants Are Safe for Nearly All Women

– Have just had an abortion, miscarriage or ectopic pregnancy

– Are breastfeeding (starting as soon as 6 weeks after childbirth, WHO/MEC)

– Have anemia now or in the past

– Have varicose veins

• Almost all women can use implants safely, including women who:

– Have or have not had children

– Are not married

– Are of any age including adolescents and women over 40 years old

– Are infected with HIV

• Most health conditions do not affect safe and effective use of implants.

• Many women who cannot use methods that contain estrogen can safely use implants.

Session II, Slide 4

But usually cannot use implants if:

Most women can safely use implants

Breastfeeding 6 weeks or

less/WHO MECMay be pregnant Some other serious

health conditions

Who Can and Cannot Use Implants (part 1)

Session II, Slide 5

Who Can and Cannot Use Implants (part 2)

Most women can safely use implants. But usually cannot use implants if:Breastfeeding 6 weeks or less

• Ask her to come back when baby is 6 weeks old. Urge her to keep breastfeeding. (Based on WHO MEC categorization)

May be pregnant • If in doubt, use pregnancy checklist or perform pregnancy test.

Some other serious health conditions

• Has blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use implants.

• Ever had breast cancer.• Unexplained vaginal bleeding. If the bleeding suggests a

serious condition, help her choose a method without hormones to use until unusual bleeding is assessed.

• Serious liver disease or jaundice (yellow skin or eyes).• Takes pills for tuberculosis (TB), fungal infections, or

seizures (fits).

Session II, Slide #6

Medical Eligibility Criteria

What are medical eligibility criteria?

Define the categories.

Review the job aid.

Session II, Slide # 7

WHO’s Medical Eligibility CriteriaCategories for IUDs, Hormonal and Barrier Methods

Source: WHO, 2010.

Category Description With clinical judgment

1 No restriction for use Use the method under any circumstances

2 Benefits generally outweigh risks Generally use the method

3 Risks usually outweigh benefits

Use of method not usually recommended, unless other methods are not available/acceptable

4 Unacceptable health risk Method not to be used

Session II, Slide # 8

WHO’s Medical Eligibility CriteriaCategories for IUDs, Hormonal and Barrier Methods

Source: WHO, 2010.

Category When clinical judgment is limited

1Use the method

2

3Do not use the method

4

Session II, Slide #9

Category 1 and 2 Examples (not inclusive):

Who Can Start Implants

WHO Category Conditions (selected examples)

Category 1

Adolescents, post-abortion, postpartum in non-breastfeeding women, heavy smokers, women being treated for high blood pressure, valvular heart disease, endometriosis, endometrial or ovarian cancer, thyroid disorders

Category 2

Blood pressure ≥160/100, history of blood clots in legs or lungs, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for cardiovascular disease

Implants are safe for nearly all women.

Source: WHO, 2010.

Session II, Slide #10

Category 3 and 4

Who Should Not Start ImplantsA small number of women may not be able to use implants.

WHO Category Conditions (selected examples)

Category 3

Acute blood clots in deep veins of legs or lungs, unexplained vaginal bleeding, history of breast cancer, severe liver disease, infection or tumors, and certain cases of systemic lupus. Breastfeeding before 6 weeks postpartum.Continuation only: ischemic heart disease, stroke, migraine with aura.

Category 4 Current breast cancer

Source: WHO, 2010.

Session II, Slide #11

Implant Use by Women with HIV

• Women with HIV or AIDS can use without restrictions

• Some ARV drugs reduce blood progestin level

• Efficacy is not affected because implants provide consistent dose of hormone over time

• Dual method use should be encouraged

Source: WHO, 2010; Mildvan, 2002.

WHO Eligibility CriteriaWHO Eligibility Criteria

Condition Category

HIV-infected 1

AIDS 1

ARV therapy 2

Session II, Slide #12

Implant Use by Postpartum Women

• Non-breastfeeding women can initiate immediately postpartum

• Breastfeeding women – Before 6 weeks

postpartum (WHO/MEC)

– No restrictions after 6 weeks postpartum

Source: WHO, 2010.

WHO Eligibility CriteriaWHO Eligibility Criteria

Condition Category

Non-breastfeeding 1

Breastfeeding<6 weeks 3

Breastfeeding≥6 weeks 1

Session II, Slide #13

Understanding the Implant Checklist

Read questions 1–6 in the checklist and match them with the conditions and categories on the MEC quick reference chart.

This set of questions identifies women

who should not use

implants.

This set of questions identifies

women who are not

pregnant.

The checklist also gives instructions

about initiating implants.

Session II, Slide #14

When to Start Implants (part 1)• Anytime a provider is reasonably certain a woman is not

pregnant.

• Pregnancy can be ruled out if any of these situations apply: – Is fully breastfeeding, has no menses, and baby is between 6 weeks and 6

months old

– Abstained from intercourse since last menses or delivery

– Had a baby in the past 4 weeks (if not breastfeeding)

– Started monthly bleeding within the past 7 days (5 days for Implanon)

– Had a miscarriage or abortion in the past 7 days (5 days for Implanon)

– Is using a reliable contraceptive method consistently and correctly

• If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or by waiting till next menses.

Source: WHO, 2004 (updated 2008).

Session II, Slide #15

When to Start Implants (part 2)• First 7 days of menstrual cycle (5 days for Implanon),

no backup method needed

• After 7th day of menstrual cycle (5th for Implanon), rule out pregnancy and use backup method for 7 days

• Postpartum– Not breastfeeding: immediately (no need to rule out

pregnancy until 4 weeks postpartum) – Breastfeeding: delay 6 weeks (WHO/MEC)

Source: WHO, 2004 (updated 2008).

Session II, Slide #16

When to Start Implants (part 3)• Postabortion or miscarriage: immediately; without

backup

• Switching from a hormonal method: immediately if it was used consistently and correctly– Injectable users can have implants inserted within the

reinjection window; without backup

• After using emergency contraceptive pills:– Insert within 7 days after start of next menstrual

period (5 days for Implanon); provide with backup method during interim

Source: WHO, 2004 (updated 2008).