January 6th, 2011
Yesterday evening (05_01_11) Channel 4 News featured a story about the contraceptive implant (Implanon). They revealed a number of NHS trusts have paid £200,000 in clinical negligence compensation to women who’ve become pregnant or experienced injury when using the contraceptive implant. 584 women have reported unplanned pregnancies, and 1067 complained about scarring or other injuries to the Medicines and Healthcare Regulatory Agency. At this time it is not clear how Channel 4 heard about this story. It could be through their own research, from a tip off within the MHRA, or direct contact from a law firm.
This story was hotly adopted by the rest of the media, particularly broadcast media and newspapers, with coverage like:
Evening Standard – Ban this contraceptive implant pleads mother scarred for life
Telegraph – Woman whose marriage collapsed after Implanon implant ‘failed’ among those suing NHS
Guardian – Hundreds become pregnant despite contraceptive implant Implanon
The majority of these reports were characterised by a lack of context for the numbers given, and no reproductive health care experts/medics to put this data into context. I’ll focus on why this is a problem shortly, but first, here’s what you need to know about the contraceptive implants.
Contraceptive Implants (Implanon)
Implants are small, flexible tubes around 4cms long that contain the hormone progestogen and are injected under the skin in a woman’s upper arm. They are a form of a hormonal contraception, so they release hormones over a period of time (3 years) and fall into the category of Longer Acting Reversible Contraception (LARC). (Implants used before 2010 go under the brand name Implanon, those fitted after this date are called Nexaplanon. The latter has reportedly been designed to be easier to insert).
This kind of contraceptive is suitable for women who find it difficult to remember to take the pill every day, and who are certain they don’t want to be pregnant for a set amount of time. It’s around 99% effective if fitted correctly and used according to instructions. But, as like any form of contraception it isn’t 100% effective and because it only prevents pregnancy, condoms should also be considered to protect against STIs.
It has a number of side effects including periods stopping (which some women see as an advantage), irregular bleeding, acne, sore breasts, mood changes, and reduced sex drive.
Its use is recommended only after considering other contraceptive options and a thorough discussion and health assessment with your GP/Family Practitioner or Reproductive Health Clinic.
You can find out more about the contraceptive implant here, here, and here. (A statement from the MHRA on implanon can be found here).
Why is the media coverage problematic?
Press coverage on this story has been largely context free. That has meant we’ve been told how many women have experienced problems but not within any timeframe; how many problems were reported as compared to women not experiencing difficulties; how the implant compares with failure rates of other kinds of contraception; how many of the pregnancies were present before the woman went on Implanon and how many occurred due to incorrect fitting of the implant?
Without this information the majority of media coverage suggests that the Contraceptive Implant is not an effective form of contraception, is always painful to fit and remove, will cause disfigurement when removed, and result in an unplanned pregnancy where women will be forced to have a termination.
Because this information is misleading, and doesn’t come with additional reproductive health details to put it into context, it fails to make clear the positive aspects of implants for women who choose this method, nor that the majority of women who select the implant do not experience problems.
The coverage is also irresponsible because of the timing of the story. The post-Christmas and New Year period is always busy within General Practice and Reproductive Health Clinics. Not least because of people who have had unprotected sex over the holiday season will be anxious about pregnancy and seeking advice about their options.
The difficulty in criticising the story as it stands, is that you can find yourself easily cast in an unsympathetic role. In healthcare terms proportionally 584 cases compared with the number of people using contraceptive implants (1.4 million according to the Department of Health) is pretty low. That is of no comfort to those who experienced an unplanned pregnancy when they thought they were protected by a contraceptive. So in critiquing the media coverage here we need to be mindful it is based on difficult and upsetting cases that will have had widespread impact on people’s lives.
It is negligent of the media to not report this within any appropriate context. The result is scaremongering and is not helpful to anyone. Including those who have had bad experiences with the contraceptive implant.
What does the data show?
The contraceptive implant was introduced in the UK in 1999. It has been used by around 1.4 million women over the past 11 years. This figure comes from the Department of Health although is still unclear if that means women in UK or Europe. Some practitioners feel the 1.4 million figure is high, even over an 11 year period. Part of the problem with this story is the uncritical media coverage is throwing numbers around like there’s no tomorrow, but health agencies have also been somewhat unclear on exact figures and where they’ve sourced them from. This leaves us with the less than ideal situation of matching unclear data from media coverage with unclarified data from the Department of Health/NHS. NHS advice is the 584 pregnancies reported seem to be mostly related to incorrect insertion of the device rather than the device itself being faulty. It is not clear how many of these pregnancies had begun before the device was fitted. Currently around 800,000 women in the UK are believed to be using this method of contraception. 14 women have been compensated for either getting pregnant while using the implant or being injured through incorrect insertion or removal (source info here). While the figures from media and health sources remain unclear what does seem to be fair to claim is the number of women who use the contraceptive implant without difficulty far outweighs those who have experienced problems.
Long Acting Reversible Contraception has been recommended for use by the National Institute for Clinical Excellence (NICE) (details here). This has resulted in reproductive health practitioners recommending the use of the contraceptive implant and other LARC options (e.g. the IUD) to women seeking contraception. The guidance states women being offered LARC should have this as part of ‘women centred care’:
“This guideline offers the best-practice advice on the provision of information and care for women who are considering or using LARC. Treatment and care should take into account women’s individual needs and preferences. Women who are considering using or who use LARC should have the opportunity to make informed decisions about their care and treatment. If a woman does not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines, Reference guide to consent for examination or treatment (2001) (available from www.dh.gov.uk).
Good communication between healthcare professionals and women is essential. It should be supported by the provision of evidence-based information offered in a form that is tailored to the needs of the individual woman. The treatment, care and information provided should be culturally appropriate and in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.”(p.5)
Whether this was always completely followed in a drive to encourage women to opt for LARC is not clear. Careful assessment of this should be made within the context of health care practitioners working hard to encourage their clients to have a range of contraception choices. It should not detract from wider discussions about uptake and overall safety, but is relevant if health practitioners or patients felt pressured towards LARC as opposed to other forms of contraception. This is a highly sensitive area to address and given the media’s poor record of talking about the issue so far is a worry that critical discussions around the promotion and uptake of LARC could be further used to devalue health professionals or scaremonger around contraception choices.
What could the result of this coverage be?
Perhaps unsurprisingly the media coverage has led to a lot of anxiety among the public. Women are worried about whether they were right to choose this method of contraception – and whether they might still find themselves pregnant or will face painful removal procedures resulting in permanent scarring.
Anecdotal reports from reproductive health clinics and GPs, as well as reproductive health charities suggest the number of calls from concerned women and their partners have risen dramatically today. We will have to see longer term what could also be the result of this coverage but it is not unreasonable to assume it could lead to women using the implant wanting it removed. Other women may be put off selecting this method, seeing it as ineffective and unsafe. It is reminiscent of the 1990s when media scares over the contraceptive pill led to widescale rejection of this method (and subsequent unplanned pregnancies).
Was the media wrong to cover this story?
No, they weren’t wrong. This is an interesting story. However it’s not exactly ‘news’ (problems with the contraceptive implant and legal actions have been noted for some years). It didn’t need to have been reported right now, particularly during a time when health services are under pressure. It should have been reported within a clear context to allow people to understand there have been problems with the contraceptive implant, but it is a method of contraception that suits many women, is effective and widely used.
What to do if you are worried?
If you are already using the Contraceptive Implant and are not experiencing any problems you probably don’t need to worry. However if this coverage has concerned you then you can speak to your GP, Reproductive Health Clinic or call the FPA on 0845 122 8690.
Remember this form of contraception is more than 99% effective and for the majority of women who opt to use it they experience no problems and are happy with it as their contraceptive choice.
If you’re using the Contraceptive Implant and are experiencing side effects or think you may be pregnant see your GP or Reproductive Health Clinic as soon as you can. Make your situation clear when you call so they can prioritise you for an appointment.
If you can feel your implant below the skin near where it was inserted it will continue to work effectively (but again do ask for a second opinion if you are worried). If you cannot feel your implant or are in any way worried it isn’t working then either avoid sex or use condoms until you have seen your GP or Reproductive Health Clinic.
It goes without saying that you should not try and remove the implant yourself. This has to be done by a professional and only if you are experiencing problems.
If you are thinking about using the implant but are now worried to do so, talk to your GP or Reproductive Health Clinic staff who can discuss your contraception choices and see which suits you best.
If you are not using the implant but still have anxieties about your contraception choices then do talk to a health professional about your concerns.
What health professionals can do
In the first instance you may need to recheck and advise women fitted with the contraceptive implant. It’s worth remembering the reasons why a contraceptive implant may fail and increase a risk of an unplanned pregnancy:
- Unrecognised non-insertion
- Unrecognised pre-existing pregnancy, or pregnancy risk, at the time of fitting
- Concomitant use of interacting medications
- Use beyond its 3 year lifespan.
If you are unsure about your skills in fitting implants or need retraining or support your local PCT or Sexual Health Service Provider should run courses. Book a place now if you feel underconfident or stressed by this story breaking.
You may find this story has increased your workload at a busy time so you may not be feeling inclined to tackle this story. However if you are able to do the following it could be very useful:
- Provide easily accessible information to your patients about the contraceptive implant
- Post resource information (such as the FPA details) around your clinic. A great resource has been created for you by @bishtraining (click here to download)
- Ask patients you know are using the implant or are considering using it if they have any concerns they need you to address
- Challenge poor or misleading media coverage if you are able
- Offer interviews with your local print and broadcast media to explain about the contraceptive implant and provide reassurance
- Request the DH/NHS who are circulating data about the use of contraceptive implants clarify the data (how long has it been collected for, where from, how much of an estimate is it) to help you put any questions your clients have in their proper context
What journalists can do
Much of this media coverage has been poor but there is still time for science/health journalists to challenge what has already been written and put a wider context on the story. Channel 4, after breaking this story, have now included more information on the Implant, but as others have noted this may be too little too late. All media covering this story in a simplistic and scaremongering way must bear responsibility of the repercussions on women’s reproductive health. It would be ironic if those papers gratuitously reporting on the NHS facing lawsuits over failed contraceptives could themselves be looking at similar lawsuits if they scare women enough to avoid contraceptive use and contribute to an unplanned pregnancy.
If you are in a position to rectify the poor coverage or explain more about the contraceptive implant that would be very helpful. This story, as with others on contraception, indicate journalists often have very basic understanding of contraception choices and how reproductive health services operate. If you know you’re not confident to cover stories of this time approach organisations like Brook or the FPA who can give you further information and advice.
Immediate tasks requiring attention from journalists are to:
- check the data that’s been talked about. Both from the MHRA and Department of Health. Source where the figures come from and put into specific context the number of problems women have experienced with the overall use of the contraceptive implant
- clarify the complaints made. How many of these were down to incorrect fitting of the device, faulty implants, pregnancy before the implant was fitted or injury from the implant or its removal (at present this information is not clear)
- try and track the source of this story. How did Channel 4 hear about it. In particular focus on whether this was brought to their attention by any law firms or a source within the MHRA.
- talk to the manufacturer of Implanon and identify from them their reports of problems/malfunctions/complaints recieved. So far most press coverage has focused only on MHRA and DH data (without clarifying those figures much). Additional attention should be paid to the manufacturers of the contraceptive implant who should have data on the number of devices provided along with complaints recieved and any legal actions taken. (They may, of course, not share this information, but it should still be sourced).
- provide information about the implant and what women can do if they want to use it, or are concerned about it, with links to sources of help
- give balanced accounts so while you may talk about women who’ve had awful experiences with implanon talk to those who may have had no problems and found it effective
- be careful not to make claims about the contraptive implant (or any form of contraception) without carefully investigating how it works.
- Talk to health professionals working in reproductive health to find out more about how the implant works, and which women it is suitable for (or not)
What everyone can do
If you spot poor coverage complain to the editor. If you are able to post comments to online coverage or call into broadcast media discussions do share accurate information about contraceptive implants and why this story is currently so problematic. The more we make it clear to the media we won’t put up with irresponsible reporting on our health, the less likely they may be to produce poor reportage in future. Obviously if you see good coverage, ensure this is flagged up and praised (some good examples here, here, here and here). If you have a blog, are on twitter or facebook you can also share accurate information and raise awareness over the poor media coverage.
With grateful thanks to
@DeborahAzizi for alerting me to this story and @dasilva_uk @K4Health @bishtraining @SexEdUKation @EdForChoice @bohaynowell @Abortion_Rights @NoRisks @BrookCharity @michaelgrayer @Matttskimo @dianthusmed for critical reflections on the coverage, data and health implications. And to my many friends working in reproductive healthcare and general practice for providing me with medical information for this post. (Please remember I’m not a medic and this isn’t a replacement for medical advice so speak to your GP or Reproductive Health Clinic or call the FPA on 0845 122 8690 if you are worried).