The facts on family planning clearly show that we need to do more in the United States to reduce the high rate of unintended pregnancy. In fact, some surveys report that the United States has the greatest rate of unintended pregnancy of all developed countries.
Many economic analyses indicate that every $1 that is spent on family planning in this country saves $3 or $4 in pregnancy-related and neonatal care for unintended pregnancies. Legislators and leaders of the American College of Obstetricians and Gynecologists, recognizing the importance of preventing unintended pregnancy, have jointly proposed a multipronged strategy to reduce unintended pregnancy in the United States (see “We begin by strengthening family planning…,”). These health-system efforts will be most effective if they are combined with the development and deployment of more long-term contraceptive methods that do not require daily active use by the patient.1
A strategy to reduce unintended pregnancy should be multipronged. Working together, leaders of ACOG and members of the US Congress have urged that such a strategy should:
- increase funding for family planning programs
- expand family planning services for low-income women
- ensure access to prescription contraceptives through equitable coverage of contraceptives in health plans
- improve awareness among patients and providers about emergency contraception options
- provide compassionate assistance for victims of rape, including access to emergency contraception
- reduce pregnancy among adolescents by expanding pregnancy prevention programs that focus on this vulnerable group
- provide comprehensive sex education
- ensure the medical accuracy of information in federally funded sex, contraception, and sexually transmitted infection education programs (currently, provided for by US Senate Bill 21 and US HR Bill 819).
A new long-term option is approved
Among the most effective long-term reversible contraceptives are intrauterine devices (IUDs) and long-term progestin contraceptives. As I noted in the Editorial in the April 2007 issue of OBG Management,2 use of the IUD in the United States lags behind that in all other developed countries; that lag is likely a contributor to the high rate of unintended pregnancy in this country.
Recently, the US Food and Drug Administration approved an implantable contraceptive, sold under the brand name Implanon. This single-rod device, 4 cm long and 0.2 cm in diameter, contains a core of 68 mg of etonogestrel (3-keto-desogestrel) within a membrane of ethylene vinyl acetate. It is inserted under the skin of the arm and is effective for as long as 3 years.
The contraceptive effect of Implanon is established within 24 hours after insertion; ovulation and fertility return within 1 month after the implant is removed.3 The Pearl Index for Implanon is approximately 0.38 pregnancies for every 100 women-years of use, which means that it is a highly effective reversible contraceptive.4
Training is required
ObGyns are now completing intensive training programs to learn how to insert and remove Implanon rods. These programs are designed to ensure that all clinicians who offer the system to their patients complete a standardized curriculum and practice insertion and removal of Implanon, using a lifelike simulator, before they are certified to do so. Including simulator training in the curriculum is one of the first examples of nationwide use of a standardized simulation training exercise to advance clinical skills in obstetrics and gynecology.
I completed Implanon training recently, and found that the objectives of the curriculum were well met by the experience. I was impressed that simulation training was part of the program.
Implanon is designed to be inserted subdermally so that it is palpable after insertion. The device and applicator are beautifully engineered, I found, and the insertion device is well-balanced and fits comfortably in the hand. The needle is designed to smoothly penetrate the skin and subcutaneous tissues. In a review of comparative studies of Implanon and the older Norplant implantable contraceptive, Implanon was more quickly inserted (1.1 min versus 4.3 min, respectively) and removed (2.6 min versus 10.2 min).5 Complications associated with removal were more common with Norplant (4.8% ) than with Implanon (0.2%).
After insertion, the Implanon rod is almost always palpable just below the skin along the inner aspect of the upper arm. If the rod is not palpable, it can be located using an ultrasound transducer operating at 10 to 15 MHz6 or by magnetic resonance imaging.