Expanding Access to Injectable Contraception: Results From Pilot Introduction of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) in 4 African Countries

Stout, Anna L.; Wood, Siri; Barigye, George; Kaboré, Alain; Siddo, Daouda; Ndione, Ida

doi:10.9745/ghsp-d-17-00250

Cited by 27 publications

(26 citation statements)

References 11 publications

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“…Our findings on the acceptability of DMPA-SC as a method are consistent with the results of the pilot introduction of the method in Burkina Faso, Niger, Senegal and Uganda from 2014 to 2016 [17] , as well as our 2015 pilot in Kinshasa [16] . Our findings on high client satisfaction with self-injection concur with results from studies in Malawi and Uganda [18] , [19] ; clients who self-injected had higher continuation rates than those who received DMPA-SC from providers.…”

Section: Discussionsupporting

confidence: 88%

An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa

et al. 2018

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ObjectivesGiven the promise of DMPA-SC to increase community-level access to modern contraception in developing countries, we conducted an observational study to assess the acceptability and feasibility of DMPA-SC self-injection among women in Kinshasa, Democratic Republic of the Congo, and of medical/nursing (M/N) students as instructors for self-injection.Study designWomen who selected DMPA-SC at a community outreach event adjacent to a health center were interviewed upon acceptance (baseline) and then 3, 6 and 12 months later.ResultsOf 850 clients selecting DMPA-SC at baseline, 640 (75.3%) opted for self-injection over being injected by the M/N students for reasons of convenience and personal agency. Among these 640 self-injectors, 47.5% were anxious at baseline (for fear of needles or injecting incorrectly). Over 80% reported feeling very ready after training, confident that they knew how to self-inject and confident that they would remember the next injection date. By 3 months, 97% described it as easy. Half (54%) experienced side effects, mainly menstrual irregularities, the main reason for discontinuation. At 6-month follow-up, self-injectors cited effectiveness and ease of use as positive elements, though one quarter reported side effects. Their impressions of M/N students as instructors were highly positive.ConclusionsWhere DMPA-SC was free and easily accessible, the majority of women interested in DMPA-SC opted to learn self-injection. The M/N students performed well in instructing women to self-inject. Clients were highly satisfied with the services received, yet many did not recognize their student status, possibly because outreach occurred near a health facility. Once told, clients remained very favorable, suggesting strong motivation to receive their preferred contraceptive free, whoever the provider.Implication statementThis study provides additional evidence on the acceptability and the feasibility of the self-injection of DMPA-SC by users from a resource-limited setting.

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Section: Discussionsupporting

confidence: 88%

An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa

et al. 2018

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“…Currently, national scale-up of DMPA-SC is under way. Program monitoring data from Uganda's introduction found that health workers administered 29% of DMPA-SC doses to new users of family planning, thereby helping to address unmet need [11] .…”

Section: Introductionmentioning

confidence: 99%

Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda

et al. 2018

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ObjectiveThe aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda.Study designParticipants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product.ResultsTwelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda.ConclusionsThere is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso.ImplicationsThe subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users.

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“…The introduction of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in a number of African countries in 2014 has opened the door to the possibility of self-injection of injectable contraception [ 1 ]. Self-injection may offer greater discretion and increase access to the injectable, particularly for those who face challenges accessing clinic services.…”

Section: Introductionmentioning

confidence: 99%

Ugandan providers’ views on the acceptability of contraceptive self-injection for adolescents: a qualitative study

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Namagembe²,

Tumusiime³

et al. 2018

Reprod Health

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BackgroundSelf-injection of subcutaneous depot medroxyprogesterone acetate may offer greater discretion and increase access to injectable contraception, particularly for those who face challenges accessing clinic services. In particular, unmarried adolescents often encounter stigma when seeking services, and may also lack the financial means to travel to clinics on the quarterly basis that injectable contraception requires. Whether self-injection is offered to women on a wide scale basis, and to adolescents specifically, will depend in part upon the willingness of providers to train clients of diverse ages and educational backgrounds. This study explores the views of providers with regard to self-injection as an option for women and adolescents in Uganda.MethodsIn-depth qualitative interviews were conducted with family planning providers in Gulu district, to understand their views on injectable self-injection for women, with a specific focus on unmarried adolescents ages 15 to 19 years. The in-depth interviews, which lasted up to 60 min were audio-recorded, translated and transcribed simultaneously, and analyzed using Atlas.ti software to identify key themes and common perspectives.ResultsA total of 40 health care providers were interviewed with equal numbers of each type (public, NGO, and private clinics, pharmacies, and community-based health workers). While most providers were receptive to self-injection for adult women, fewer than half were supportive of adolescent self-injection. Their reservations focused on age, marital status and parity concerns around adolescent use of the injectable more broadly, and concerns about the ability of adolescents to self-inject safely.ConclusionsSelf-injection presents an opportunity to reduce the enormous burden on the public sector health system in Uganda, which is particularly compounded by the heavy reliance on injectable contraception requiring quarterly clinic visits. The results of this study reveal a level of cautious support for self-injection among providers when it comes to self-injection by adult women. With respect to adolescent clients, family planning policymakers and program implementers should design, implement, and evaluate self-injection interventions with the needs of adolescent clients uppermost in mind, recognizing that extra attention will likely be needed to reduce provider-imposed restrictions on adolescent access to this injectable delivery modality.

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Expanding Access to Injectable Contraception: Results From Pilot Introduction of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) in 4 African Countries

Cited by 27 publications

References 11 publications

An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa

An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa

Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda

Ugandan providers’ views on the acceptability of contraceptive self-injection for adolescents: a qualitative study

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