The Case for Implant Removal Indicators Now

New study results from Mozambique

Like many health care providers in Mozambique, I inserted my first contraceptive implant around 2013—the year our country began offering insertions at static health facilities.

Almost immediately, high client demand, investments from our Ministry of Health and donors, and drops in manufacturer prices drove a surge in popularity of these long-acting reversible contraceptives (LARCs). By 2015, implants became the third most used method of contraception among women of reproductive ages 15–49.

graph indicating increase in implant insertions from 2013 (32,000) to 2018 (324,000)

Source: Ministry of Health, HMIS-Sistema de Informação de Saúde para Monitoria e Avaliação

This was good news for all of us who believe women deserve access to a full range of contraceptive options. Implants are among the most effective methods available (typical implant use results in less than 1 pregnancy per 100 users over the first year of use). But this unparalleled increase in implant insertions also raised a red flag—

Every single woman who gets an implant will one day need that implant removed.

We need to support providers in Mozambique to effectively track and respond to an impending wave of implant removals.

In three to five years post-insertions (Implanon® and Jadelle® respectively), all implants must be removed by a skilled provider. And that day might come sooner for women who are experiencing unwanted side effects.

So the question is, how can we ramp up the quality counseling and removal services women need when…

•  Skilled service providers, including those able to perform difficult removals, are often unavailable?

•  Many providers who complete competency-based trainings have little practical experience in retaining their removal skills?

•  There’s simply not enough reliable implant removal data—making it almost impossible for ministries, program managers, and health facility staff to use evidence to address gaps and take action?

Today, we have an answer. As Mozambique prepares for an imminent wave of implant and IUD removals, I believe results from our new study should point the way forward.

Health care provider inserts implant

New Study Findings: Using Data to Improve the Quality of Care for Women Seeking Removals

As Clinical Services Director for the Integrated Family Planning Program (IFPP), I am pleased to share new findings from our collaborative study with USAID’s Evidence to Action (E2A) Project and Mozambique’s Ministry of Health.

We teamed up with E2A, a member of the Implant Removal Task Force and the lead of its data sub-group, to test the feasibility of including the following six removal indicators for long-acting reversible contraception in Mozambique’s national family planning register and health management information system:

1. Reason for client visit
2. Reason for seeking removal
3. Time since insertion
4. Removal outcome
5. Reason for referral
6. Client visit outcome

You can see the full results of the study here, including the perceived benefits and challenges of including these six indicators. For now, I’ll leave you with one story that brings to life the power of these indicators in action.

When Data Surprises You and Triggers Action

One day in 2019, our study team huddled together in an office in Washington, our faces lit by the light of our laptop screens. We combed through and analyzed the implant removal indicators. What we saw surprised us.

I was struck by the large number of women who cited “vaginal bleeding” as their reason for seeking implant removal.

Vaginal bleeding is a common side effect of all hormonal methods of contraception, including implants. It’s a concern we can alleviate with quality counseling and care from providers. So why were so many women coming to the facility worried about this treatable side effect—and leaving with their implant removed?

I immediately said, “We really have to strengthen counseling.” And our project team got to work.

We reviewed our IFPP training and conducted supportive supervision and facility-level data discussions geared toward drafting a plan to close this gap. We learned that, sometimes, providers don’t provide enough counseling pre- and post-insertion to let clients know they may experience vaginal bleeding and that these side effects can be treated.

We strengthened our counseling training module. 

We conducted an additional training of trainers at the Ministry of Health focused on the practice of implant removal, as well as counseling and treatment of side effects.

And while we have to wait until next quarter’s data to see if our changes lead to different outcomes, one thing is clear: we simply could not have spotted and addressed this issue like we did without the results of the study, since FP managers would have not been aware of the importance of pre- and post-insertion counseling and the barriers to implant removal.

And we’re not alone in recommending their use. Service providers involved in the study overwhelmingly told us that the additional indicators were useful and easy to record.

“It shows that if the health provider does a proper counseling at the insertion [and at] subsequent visits and [ensures] proper management of side effects,” said one health provider, “method retention could be higher.”

Just think of the difference that could make for Mozambique’s contraceptive prevalence rate, for the quality of care we provide, and—most importantly—for the full and informed method choice of women across our country.



Assessing the Feasibility of Including Removal Indicators for Long-Acting Reversible Contraceptives in Mozambique’s National Family Planning Registers