With high rates of unplanned pregnancies in SA among not just women but teenagers too, contraception has a vital role to play in healthcare.

Given the high rate of unwanted pregnancies, overburdened healthcare system, and other challenges we face in SA, it may be justifiable to promote a highly effective, safe, long-acting method of contraception as a first offer

“A key concern when it comes to contraception in SA, is that in spite of a relatively wide range of methods available, there is still a huge reliance on short term hormonal contraceptives (pills and injectables),” said Dr Saiqa Mullick (Director of Implementation Science at Wits Reproductive Health and HIV Institute). “Long-acting methods such as the IUD and contraceptive implant need to be more widely available particularly for those women who want to space pregnancies or do not want to fall pregnant.

Dr Mullick believes more needs to be done to adequately educate women on long acting methods, and its benefits and effectiveness. “Our research shows that although family planning services are well attended it is often a missed opportunity to provide women with information on other sexually transmitted infections including HIV and to ensure clients have dual protection from both pregnancy and HIV/STIs.”

Concerns

First introduced into the public facilities in SA in 2014, the contraceptive implant, although desired due to its long duration of protection from pregnancy, has experienced declines in use primarily as a result of side effects that women considered not tolerable. “The primary side effects that were reported as not tolerable was abnormal bleeding patterns and headaches,” said Dr Mullick. “Part of the problem was that providers did not have the knowledge about how to manage these side effects. Side effects were being managed by providers in the same manner as which injectable contraceptive side effects were managed, which included provision of combined oral contraception to resolve bleeding episodes. This unfortunately was not successful in managing these side effects. Women were also not adequately counselled on side effects.

“There is also concern around whether or not some types of hormonal contraception are associated with an increased risk of HIV acquisition. The Evidence for Contraceptive Options and HIV Outcomes (ECHO) study will definitively answer this question.”

Furthermore, providers reportedly felt training was not adequate and were not confident to insert the implant. “To a greater degree, providers were even more uncomfortable with removal and a nurse mentioned that she thinks that removals should be performed by doctors.

“From the National Department of Health circular sent in October 2014 regarding concomitant use of ARV, such as Efavirenz with the implant, providers were unsure how to proceed with HIV positive clients and stopped providing the implant to HIV-positive clients.

Education & counselling

It is well documented that good counselling is critical to the success of any new contraceptive method, hence counselling on method choice, excluding methods that are contraindicated, how the method works, side effects and how to manage them, when to come back to the health facility and the need for protection against HIV and other sexually transmitted infections should be emphasised during provider training.

“In addition to knowledge and counselling skills, providers need to be trained on how to provide/insert new methods and be competent with removals should the client want the method removed. Providers also need to be educated on completing the required routine data on method provision at the facilities they work in, the purpose of why this data needs to be collected and how this data will be used to improve the service,” said Dr Mullick. “Providers also need to be aware of their responsibilities to uphold the sexual and reproductive rights of all individuals so that personal biases and attitudes, for example around young people being sexually active, do not interfere with the provision of methods.”

According to Dr Mullick, their research indicated that nurses were the primary source of information when it came to contraceptive methods. However, women also receive information from other sources, their peers, friends, and the media. “We need to be able to empower all sources to provide comprehensive and accurate information including job aids for providers and print information that can be shared with clients.”

“In most cases, a doctor or nurse who has been trained will be able to adequately counsel women on anticipating side effects and managing them. However, our study highlighted some gaps with the current training stressing the need to strengthen information and skills during the training on how to counsel users about the side effects and on how to manage side effects effectively.”