Original research article Health services at the clinic level and implantable contraceptives for women Davy M. Chikamata a,* , Suellen Miller b a Medical Officer/Area Manager, Department of Reproductive Health and Research, Family and Community Health, World Health Organization, Geneva, Switzerland b Expanding Contraceptive Choice Program, Population Council, New York, NY, USA Received 15 August 2001; accepted 9 October 2001 Abstract The quality of implant service provision, particularly counseling, has been associated with successful use and with fewer discontinuations for side-effects. Requirements necessary for quality service provision include cadres of health care workers who can provide implants, training curriculum, duration of training, and training techniques; knowledge of the facilities, surgical equipment, and other supplies necessary; infection prevention steps to safely provide implants; techniques for managing side-effects; methods for managing difficult implant removals, the importance of maintaining close relationships with implant clients, and establishing communication and notification systems for removal (and sometimes replacement) when the effective life-span of the implants has been reached. In this article we review the components and training necessary for the establishment and maintenance of quality implant service delivery systems, discuss the implications of providing more than one type of implant, and describe trends in use. © 2002 Elsevier Science Inc. All rights reserved. Keywords: Contraceptive implants; Quality of care; Service delivery; Counseling 1. Introduction In the last 15 years, implantable contraceptives for women have been registered in more than 60 countries [1]. The first of these implants to be registered for use, Norplant, a six-capsule implant system developed by the Population Council, contains levonorgestrel and has been used by over 4 million women in both developed and developing coun- tries [2]. In the last few years, additional contraceptive technologies, using fewer implants (capsules or rods) and containing various progestogens, have been approved by drug regulatory authorities in some countries [3]. Because these newer technologies use fewer implants, they offer advantages both to users and providers: faster insertions and removals and smaller, less visible insertion sites. Although implants are growing in type and in popularity in some countries, they still represent only a small portion of the contraceptive method mix in many countries. In Indo- nesia, implants have been used by over 3,000,000 women and make up 11% of the method mix [3]. In the US, on the other hand, implants are used by only 2% of contracepting women [4]. Knowledge of implants remains low, even in places where general knowledge of modern contraceptives is high. For example, in the 2000 Ethiopian Demographic Health Survey (DHS), knowledge of contraceptives was 85% of currently married women and 90% of currently married men; however, knowledge of implants was 13% and 15%, respectively [5]. Delivering quality contraceptive implant services re- quires some modifications in routine family planning ser- vice provision. Poor quality services, which can be identi- fied as inadequate or incomplete counseling, refusal to provide removal on demand, charging more for removal than insertion, and deep or incorrect placement of implants (which may subsequently require long and painful remov- als), are all problems that can destroy the credibility of providers and service delivery sites, as well as rapidly ruin the reputation of implants. This has happened in the US and elsewhere [6,7]. In this article, we review the components and training  The views expressed in this article are those of the authors and not the views of WHO. * Corresponding author. Tel.: +41-22-791-4148; fax: +41-22-791- 4171. E-mail address: chikamatad@who.int (D. Chikamata). Contraception 65 (2002) 97–106 0010-7824/02/$ – see front matter © 2002 Elsevier Science Inc. All rights reserved. PII: S0010-7824(01)00280-3