Subdermal implants as a new family planning program method: An implementation study of the Department of Health

• Main Authors: Solon, Orville, Ramos, Rebecca, Florentino, Jhiedon, Obach, Faith, Totanes, Robert, de Jesus, Nicco, Ungson, Paolo, Bajaro, Donna Faye E., Santiago, Chamuel, Kupahu, Jonathan
• Format: text
• Published: Animo Repository 2017
• Subjects: Contraceptives—Philippines; Medicine and Health Sciences
• Online Access: https://animorepository.dlsu.edu.ph/faculty_research/9522
• Institution: De La Salle University

This technical volume describes the implementation study on the introduction of subdermal implants conducted from May 2014 to August 2016 in four pilot sites in Cavite.The single-rod etonogestrel (ETG) subdermal implant (ImplanonTM) is a contraceptive containing the progestin etonogestrel, and is effective in preventing pregnancies for up to three years.In preparation for the nationwide rollout to introduce the subdermal implant in the family planning (FP) program, the Department of Health (DOH) piloted the introduction of the subdermal implant in selected pilot sites to assess the factors that may affect the integration of the subdermal implant as a new method in the national FP program.Based on discussions with stakeholders and agreements on site selection criteria, the pilot sites chosen for the pilot study were Tanza, Trece Martires City, Dasmariñas City, and General Mariano Alvarez. Preparatory activities and program inputs necessary for introducing a new FP method were implemented in the pilot sites, namely:1. Orientation and engagement of stakeholders, including local chief executives, and regional and local health officials;2. Integration of family planning services, including subdermal implants, in the service delivery network (SDN);3. Setup of a logistics management system to include subdermal implants;4. Training for nurses and midwives on FP Interpersonal Communication and Counselling (FP IPCC), specifically for subdermal implants;5. Training of physicians on FP IPCC and subdermal implant insertion and removal; and6. Conduct of Social Behaviour Change Communication (SBCC) and social mobilization activities through the Community Health Teams (CHTs), group counselling for FP, community meetings and assemblies, and the distribution of IEC materials.Service provision and implementation started in May 2014, wherein subdermal implants, together with the other FP program methods, were made available in all rural health units (RHUs) and health centers in the pilot sites. In addition, Gen. Emilio Aguinaldo Memorial Hospital (GEAMH), a provincial hospital which served as a common referral facility in the four pilot sites, was designated to serve as an additional service point for FP and as a referral facility for cases that required further medical evaluation or management.Demand generation was conducted through Community Health Team (CHT) members and Barangay Health Workers (BHWs). Clients were counselled based on a balanced presentation of FP methods and screened using the World Health Organization (WHO) Medical Eligibility Criteria (MEC).Inclusion of clients in the study lasted from May 19 to July 22, 2014. A total of 968 implant acceptors and 105 acceptors of other FP methods were given services and interviewed by trained enumerators for an exit survey. The questions in the exit survey elicited client demographics, reasons for accepting the FP method chosen, and client satisfaction in clinic services.The cohort of implant acceptors was instructed to follow up after three months and one year post-insertion, and yearly thereafter until three years, after which they were interviewed by trained enumerators for follow-up interviews. They were also instructed to consult anytime if they encountered problems or wished to have the implant removed or replaced after three years or any time, if desired. Questions in the follow-up interviews elicited client satisfaction with the implant, side effects experienced, or other experiences related to their clinic follow-up consultations. Aside from client interviews, key informant interviews (KIIs), and focus group discussions (FGDs), process documentation of activities and management issues were conducted to identify operational bottlenecks that may have affected the introduction of subdermal implants as a new FP program method.Preliminary findings from the study provided inputs for the drafting of the DOH’s Administrative Order No. 2015-0006, “Inclusion of Progestin Subdermal Implants as one of the Modern Methods Recognized by the National Family Planning Program,” that provided for the formal inclusion of implants as a program method. Subsequent findings were provided as inputs to related issuances of the DOH and PhilHealth.Clients generally gave high satisfaction scores for implants, citing its high effectiveness, long-term effect, and ease of use as features they liked about the method.The continuation rate of the cohort of acceptors over a period of two years was at 82 percent. The most common reason for implant removals was side effects, particularly headaches and menstrual changes. Continuation rate among acceptors is influenced by their number of children, marital status, waiting time in the facility, experience of side effects, and their mobility. These findings highlight the need to improve quality of care in the FP program.• The study experienced several challenges during its implementation, which can be minimized in the future through the following recommendations:1. Engage LGUs to provide counterpart funds for implementation, such as the provision of ancillary supplies and IEC materials, and the conduct of demand generation activities;2. Emphasize counseling and the management of side effects during training on implants;3. Ensure adequate cases for actual insertion and removal during the practicum training;4. Identify organic staff from the DOH Regional Office (RO) or Provincial Health Office (PHO) to conduct post-training evaluation and supportive supervision for implant providers;5. Conduct regular demand generation activities for family planning; Orient and train community health workers, such as community health teams and barangay health workers, to reach women with unmet need and to refer clients with concerns about using the method to service providers in the health facilities;6. Employ an efficient system for recording and reporting of actual use rates and monitoring commodity inventory for FP to facilitate the forecasting and timely delivery of FP supplies; and7. Improve the quality of service delivery through the following measures:a. Improve the screening and counseling process to level off expectations of acceptors on the potential side effects of the implant and to avoid or correct misconceptions about the use of the implant;b. Designate a regular schedule for insertion, removal, and follow-up services to ensure a referral system of providers who will accommodate insertion and removal requests should the regular service providers be unavailable during client visits;c. Ensure adequate recording and documentation in the FP Service Record Forms; andd. Ensure supply and provision of other FP methods in the facility.