Self-injected contraceptives: does the investment reflect women’s preferences?

Abstract

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an innovative contraceptive method aimed at meeting women’s unique circumstances and needs, largely due to its ability to be self-injected. Substantial research and advocacy investments have been made to promote roll-out of DMPA-SC across sub-Saharan Africa. To date, research on the demand for DMPA-SC as a self-injectable method has been conducted largely with healthcare providers, via qualitative research, or with highly specific subsamples that are not population based. Using three recent rounds of data from Performance Monitoring for Action, we examined population-representative trends in demand, use, and preference for self-injection among current non-users in Burkina Faso, the Democratic Republic of Congo (Kinshasa and Kongo Central regions), Kenya, and Nigeria (Lagos and Kano States). We found that while over 80.0% of women had heard of injectables across settings, few women had heard of self-injection (ranging from 13.0% in Kenya to 24.8% in Burkina Faso). Despite initial increases in DMPA-SC prevalence, DMPA-SC usage began to stagnate or even decrease in all settings in the recent three years (except in Nigeria-Kano). Few (0.0%–16.7%) current DMPA-SC users were self-injecting, and the majority instead were relying on a healthcare provider for administration of DMPA-SC. Among current contraceptive non-users wishing to use an injectable in the future, only 1.5%–11.4% preferred to self-inject. Our results show that self-injection is uncommon, and demand for self-injection is very limited across six settings, calling for further qualitative and quantitative research on women’s views on DMPA-SC and self-injection and, ultimately, their contraceptive preferences and needs.

Service Delivery Considerations for Introducing New Injectable Contraceptives Lasting 4 and 6 Months in Nigeria and Uganda: A Qualitative Study

“…These data show that only up to 17% of current DMPA-SC users across the settings report self-injecting and that among contraceptive nonusers considering use of injectables in the future, less than 12% wished to self-inject. 29 The lack of enthusiasm for self-injection both in the present research as well as the Performance Monitoring and Action survey results could be the result of a number of factors, including lack of awareness due to limited marketing campaigns, insufficient provider training and promotion among health workers, DMPA-SC supply challenges that discourage providers from prescribing and supporting self-injection, among other causes. 29 Fear of self-injection has also been identified as a barrier to self-injection, 30 and this also came up several times in the present study.…”

Acceptability and effectiveness of empathy-based provider training and community-level awareness activities on self-injectable contraceptive use in Niger, Lagos, and Oyo States, Nigeria: A mixed methods program evaluation

“…However, concurrent delivery of the supply-and demand-side intervention components prevents disentanglement of the relative contributions of each. In the context of very low baseline awareness and uptake of a newly introduced method such as DMPA-SC in Nigeria [14], however, such community-based activities are essential for ensuring that service providers receiving didactic instruction also have access to DMPA-SC clients to complete the practical component of the training. It was this combination of instruction with observed practice that was highlighted by many interviewed providers as most valuable for solidifying learnings and con dence to provide SI, and corresponds with best practice in clinical instruction (see, for example, [30]).…”

“…Nigeria moved quickly to develop national DMPA-SC guidelines and policies, including a ve-year "roadmap" to scale DMPA-SC nationally [13]. Despite the supportive policy environment, awareness of contraceptive self-injection remains low: While nationally representative information on knowledge, awareness, and practice of contraceptive self-injection are not yet available, the Performance Monitoring for Action (PMA) program estimates that -despite high awareness of injectable contraception -only 21% of women of reproductive age in both Kano and Lagos States had ever heard of contraceptive self-injection as of 2020-2021 [14]. As a result, DMPA-SC comprises just 9.6% and less than 1% of the contraceptive method mix in Kano and Lagos, respectively [15].…”

Testing a counseling message for increasing uptake of self-injectable contraception in southern Malawi: A mixed-methods, clustered randomized controlled study

“…Consistent with the High Impact Practice of engaging men in family planning [ 27 ], we also recommend developing informational materials targeting men and boys to combat negative rumors about DMPA-SC and self-injection and increase male support. Indeed, a recent analysis of population-based data from Burkina Faso, the Democratic Republic of Congo, Kenya and Nigeria found low use of and demand for self-injection; the authors called for more demand generation since they observed that only one country included in the analysis had promotional campaigns about self-injection [ 28 ]. However, before embarking on demand generation campaigns governments need to ensure there is sufficient supply to meet demand.…”