“…normally they come for removal, and they go back with a new implant inserted”: Implant Removal and Immediate Reinsertion in Rwanda
This qualitative study reveals that in Rwanda, where contraceptive implant use is high, the assurance of accessible removal services and the common practice of immediate reinsertion or method switching foster user confidence and contribute to sustained family planning engagement.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the landscape of public health, few tools offer as much freedom as family planning. It allows individuals and couples to decide the number and timing of their children, a choice that ripples outward to improve health, economic stability, and personal autonomy. For decades, a specific type of birth control has risen to prominence across sub-Saharan Africa: the contraceptive implant. This is a tiny, flexible rod, about the size of a matchstick, that a healthcare provider places just under the skin of a person's upper arm. Once inserted, it releases hormones that prevent pregnancy for several years, offering a reliable, "set-and-forget" solution that requires no daily action from the user. However, the true measure of a family planning system's success is not just how easily people can start using these methods, but how freely they can stop. The ability to remove a device on demand is a fundamental right; without it, trust in the system erodes, and the promise of bodily autonomy remains unfulfilled.
In Rwanda, a nation often cited as a success story for public health, the use of modern contraception has surged dramatically over the last two decades. By 2025, nearly seven out of ten married women were using a modern method, with the implant being the most popular choice by a wide margin. To understand how this high level of trust is maintained, a team of researchers from Western Washington University and local Rwandan institutions traveled to two districts in the country to listen to the stories of the people involved. They spoke with nurses who provide the care and the women who use the implants, asking a simple but critical question: what happens when a woman wants the implant out?
The researchers conducted a series of in-depth conversations and group discussions with over one hundred participants. They listened to nurses describe their daily work and asked women to share their experiences with the device, from the moment of insertion to the moment of removal. The findings revealed a health system that operates with a clear and consistent rule: a woman can have her implant removed at any time she desires. There are no hidden barriers, no mandatory waiting periods, and no refusals based on the timing of the request. If a woman decides she wants the device out because she is ready for another child, or because she is experiencing side effects she can no longer tolerate, the nurses remove it immediately. While providers may take a moment to counsel a client who wishes to remove the device early, ensuring she understands her reasons and exploring if the issue can be resolved, the final decision always rests with the woman. If she insists on removal, the procedure happens.
This freedom to remove the implant on demand appears to be a cornerstone of the implant's popularity in Rwanda. The study found that when women reach the end of the implant's recommended three-year lifespan, they frequently return to the clinic not to stop using contraception, but to swap the old device for a new one. In many cases, the removal and reinsertion happen in the same visit. This cycle of immediate replacement suggests that women feel secure in their choice; they know that if the method ever stops working for them, they are not trapped. The researchers noted that this confidence encourages women to start using the implant in the first place, creating a positive feedback loop where the ease of removal fuels the willingness to begin.
However, the study also uncovered a layer of anxiety that exists alongside this freedom. Many women and even some nurses hold a deep fear that leaving an implant in the arm past its expiration date could be dangerous, with some comparing an "expired" implant inside the body to spoiled food that could cause serious harm or even death. There is also a widespread belief that fertility returns instantly the moment the three-year mark passes, leading to fears of an immediate, unwanted pregnancy. The researchers point out that medical evidence suggests the implant remains effective for longer than the recommended three years and that leaving it in place beyond that time does not cause the toxic effects some fear. Despite this, the cultural perception of the implant as a "time-sensitive" object drives many women to visit clinics weeks or even months before their scheduled removal date, eager to get a fresh device before the old one "expires."
When women do choose to remove their implants early, the reasons are usually straightforward. The most common causes are side effects that become unmanageable or a desire to become pregnant. In these instances, the healthcare system responds with flexibility. If a woman is struggling with side effects, the nurse removes the device and often helps her find an alternative method, such as condoms, to bridge the gap until she is ready for another long-term solution. If a woman wants to conceive, the removal is immediate, and she is encouraged to try for a pregnancy right away. The study highlighted that while some women switch to different methods after removal, the vast majority return to the implant, drawn by its familiarity and the assurance that they can remove it whenever they need to.
The researchers concluded that Rwanda's approach offers a powerful model for other regions. By treating the removal of a contraceptive device as a guaranteed right rather than a privilege, the country has built a system where trust is maintained. The ability to walk into a clinic and have a device removed on demand, without judgment or delay, gives women a sense of control that encourages them to stay engaged with family planning services. While there are still misconceptions about the safety of expired devices and the speed of fertility return, the core mechanism of the system—voluntary, on-demand removal—is functioning exactly as intended. It is a system built on the understanding that true reproductive freedom includes the power to say "stop" whenever a person chooses.
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