Practical training of health care providers in insertion of contraceptive implants: findings from two Brazilian centres

Mariane N. De Nadai, Carolina S. Vieira, Ilza M. U. Monteiro, Cassia R. T. Juliato, S. A. Franceschini, E. M. M. Yamaguti, G. C. Braga & L. Bahamondes

To cite this article: Mariane N. De Nadai, Carolina S. Vieira, Ilza M. U. Monteiro, Cassia
R. T. Juliato, S. A. Franceschini, E. M. M. Yamaguti, G. C. Braga & L. Bahamondes (2021): Practical training of health care providers in insertion of contraceptive implants: findings from two Brazilian centres, The European Journal of Contraception & Reproductive Health Care, DOI: 10.1080/13625187.2021.1942448
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Practical training of health care providers in insertion of contraceptive implants: findings from two Brazilian centres
Mariane N. De Nadaia , Carolina S. Vieiraa, Ilza M. U. Monteirob , Cassia R. T. Juliatob, S. A. Franceschinia,
E. M. M. Yamagutia, G. C. Bragaa and L. Bahamondesb
aDepartment of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of S~ao Paulo. Avenida Bandeirantes, Ribeir~ao Preto, Brazil; bDepartment of Obstetrics and Gynecology, Faculty of Medical Science, University of Campinas, Campinas, Brazil

Received 29 April 2021
Revised 27 May 2021
Accepted 8 June 2021

KEYWORDS : Etonogestrel; education; Brazil; contraception; health personnel


The choice of contraceptive method is a decision that must be made by women after appropriate guidance from their health care provider regarding effectiveness, safety, risks and non-contraceptive benefits. The health care provider is the main source of information regarding contraception and this information can impact women’s contraceptive decision-making [1]. However, sometimes the lack of infor- mation and myths or inadequate training of providers regarding contraception, especially on long-acting revers- ible contraceptive (LARCs) methods, can negatively affect patient choice and continuation rate.

The etonogestrel (ENG) subdermal contraceptive implant is one of the most effective LARC method. Although inser- tion and removal are simple procedures, it is important to follow the manufacturer’s instructions [2] to avoid incorrect insertions and complications such as intravascular insertion with migration of the implant to the pulmonary artery, neurovascular injuries, paraesthesia and pain [3,4]. The insertion into a region distant from neurovascular struc- tures reduces the injury rate in the event of improper deep insertion [5]. Thus, information about the method, training and familiarisation with the product by health care profes- sionals are essential to reduce the risks of complications.

Education about contraceptive implant and intrauterne device during residency program is also associated with the increase of LARC offer to the population [6,7]. One study have shown that theoretical and practical training (both with models and women) on LARCs can change
awareness and attitudes, and correct practices related to their use [8].

Despite the many years elapsed from the introduction of the ENG implant into the Brazilian market, its use is still very low, not different than that of other LARC methods. In Brazil, it is estimated that only 1.9% of women aged 15- 49 years old who are married or in a civil union use LARC methods. This is one of the reasons for the high rates of unplanned pregnancy in the country [9,10]. Due to the paucity of data, the objectives of our study were to evalu- ate the impact of clinical training on the use of ENG- implants on the attitudes of health care professionals regarding this contraceptive. We compared the knowledge on insertion and removal techniques, and attitudes towards adverse effects and outcomes before and after health care professional training.


We conducted a cross-sectional study in which a question- naire was sent to health care providers after they had received clinical training in insertion and management of the ENG-implant (Implanon NXTVR , N.V.Organon, OSS Netherlands), conducted from 2012 to 2019 at the training centres of the Department of Obstetrics and Gynaecology, University of Campinas Medical School (Unicamp) and of the Faculty of Medicine of Ribeir~ao Preto – University of S~ao Paulo (FMRP USP). This study was approved by the Ethical Committees of both institutions. During training at both institutions, participating physicians received a lecture with a theoretical explanation about the product, its char- acteristics, management of side effects and techniques for its insertion and removal. Soon after, the physicians under- went practical training with anatomical models. Next, they were invited to insert the implant in women who wished to use it and who had received guidance about all the contraceptive methods available at the clinic. These health care provider trainings were carried out through an agree- ment between the aforementioned institutions and MSD; however, the manufacturer was not involved in the training except for the recruitment of health care providers and for financial support. Until 2016, we used the old model of ImplanonVR , and after that we used Implanon NXTVR . We excluded participants who refused to complete the survey questionnaire for any reason.

Instruments for data collection

The information provided by physicians was collected in a structured questionnaire sent by an electronic system (Google applied forms [Appendix]) with only a few ques- tions to avoid a high rejection rate. The questionnaire was developed by the authors who were also the training coor- dinators and was based on previous publications [8,11]. This questionnaire contained questions about the health care participants’ demographic and professional data (such as whether they had been medical residents in Obstetrics and Gynaecology, the time elapsed since graduation, work- place [private, public or both], access to LARCs at the work- place, and questions about previous experience with LARCs). In addition, questions were asked about post- training experience in the insertion and handling of the ENG implant, such as the number of insertions after train- ing, difficulties in insertion or removal after training and their own avaliation about her/his trust on the safety issues regarding the insertion of the ENG-implant. The physicians who agreed to participate in the survey returned the ques- tionnaire electronically. There was no financial compensa- tion for the participants.


Between 2016 and 2019, 290 physicians were trained. Of these, 139 (47.9%) completed the questionnaires. On aver- age, each trainee inserted two implants (range one to four) during training; 98.6% of the trainees who responded the survey reported dealing with contraception matters on a daily basis (Table 1). Among them, 99.3% had been resi- dents in Gynaecology and Obstetrics; however, only 10.2% reported previous training in implant insertion (Table 1). Before training, 45.7% of the trainees had not previously inserted Implanon (Table 1). Among the reasons reported for not including this contraceptive in their daily practice were insecurity or lack of knowledge in the insertion tech- nique (83.6%) and lack of the implant at the work place (in case of public service [27.9%]). After training, 78.2% of the trainees began to offer Implanon to patients, and inserted up to five implants/month; 17.6% inserted between six to ten/month. None of the interviewees reported having diffi- culty with insertions after training, with 89% of them reporting feeling confident or very confident in relation to the Implanon insertion procedure (Table 2). Further, 78.2% of respondents reported no difficulties in removals and 87.9% reported feeling confident or very confident regard- ing the implant removal; however, 16.8% did not have an opportunity to remove any implant (Table 2).


Findings and interpretation

Unplanned pregnancies are a worldwide health problem, accounting for about 40% of total pregnancies [12]. In Brazil, these percentages reach 55% [13–15]. Although LARCs are among the most effective contraceptive meth- ods [16], they still represent <2% of the prevalence of con- traceptives used by 15-49 years old Brazilian women in a stable union [10, 14]. In Brazil, there is only one contracep- tive implant approved by the health authority (Implanon NXTVR ), which is considered cost-effective in the prevention of unplanned pregnancy [17]. Proper health care provider guidance on contraceptives, including information on effectiveness, possible side-effects and non-contraceptive benefits [18], increase its choice by women and such guid- ance is now one of the main tools to reduce unplanned pregnancies [19]. There are reports in the literature show- ing that clinical training can change awareness, attitudes and guidance of women regarding more effective and long-acting contraceptives [8]. Thus, when health care pro- fessional has knowledge about all methods, including LARCs, and they are confident as to the proper insertion and removal techniques, they can offer adequate guidance, deter the spread of myths and barriers among users (and potential users) and can contribute to reduce early remov- als and improve continuation rates. Our findings support this statement, showing that there is an increase in the prescription of Implanon NXT by trained participants. We are aware that skills on contraceptive provision acquired during medical residency either in Obstetrics and Gynaecology or in Family Medicine lead to improved patient-centred care. It is a fact that physicians who receive training in LARC provision during residency are more likely to provide proper guidance and provision on LARC [20]. However, many health care professionals do not receive training on contraceptive methods in medical school or during the residency, as also shown in our results (Table 1). In a US-based survey with more than 1,200 gynaecologists, 92% reported training during residency in intrauterine device (IUD) placement; but only 50.8% reported training in implant placement and removal [7]. Relevance of the findings: implications for clinicians and policy-makers In the US, training with anatomical arm models in insertion and removal of Implanon is mandatory before starting insertions in patients, according to the United States Food and Drug Administration (US-FDA), and this requirement has been successful [15,21]. Consequently, health care pro- vider clinical training is important in implant use, consider- ing that it is a simple procedure, although training is time- consuming and has a high cost [21,22]. In addition, contraceptive provision in Brazil is gynae- cologist-centred and it is rare that public institutions (and private offices) include nurses and family doctors trained in contraceptive provision. One of the barriers in contracep- tive use in Brazil is the lack of provision of contraceptives at the primary health care network due to insufficient and poorly qualified technical teams which impact on planning and organisation of the health care network [23]. Recently, a Brazilian study showed that the clinical performance of IUDs was equal when inserted by doctors, medical students (interns), residents and nurses [24] and often IUD insertion can be more difficult than implant insertion [24,25]. Thus, guidance and training programs in LARC are essential to increase the rates of LARC use in Brazil, contributing to reduce unplanned pregnancy rates [16]. Strengths and limitations of the study The strength of our study is that we had a large number of participants and a moderate rate of survey responses. Also, the first to assess the attitudes of health professionals after training in Brazil. As a limitation of the study, we can men- tion that there was no follow-up of these health professio- nals to know if the impact of the training was maintained over time. We can also emphasise that all participants had the opportunity to insert the implant, but not everyone had the chance to remove the device in patients during training. Thus, we suggest that in future training, efforts are made so that all participants have a chance to perform at least one implant removal. Conclusions Theoretical and practical training are important to prepare health care professionals, clarify doubts and promote higher rates of use of contraceptive implants in Brazil, con- tributing to reduce the rates of unintended pregnancies. Author contributions All authors contributed to the design of the study, were involved in the data collection, data analysis and/or interpretation. Also, all authors contributed to manuscript writing/substantive editing and review and approved the final draft of the manuscript. Disclosure statement LB received an honorarium from MSD as speaker and member of Boards. The other authors declare no conflict of interest. Funding This study received partial financial support from the Fundac¸a~o de Apoio a` Pesquisa do Estado de Sa~o Paulo (FAPESP) award No. 2015/ 20504-9 (Campinas centre) and from the Brazilian National Research Council (CNPq) grant No. 573747/2008-3. Mariane N. De Nadai Ilza M. U. 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