This brief summarizes recent evidence from African countries on the costs and cost-effectiveness of DMPA-SC. Key findings include that DMPA-SC may help reduce service delivery costs by catalyzing expansion of channels closest to women and that self-injected DMPA-SC is cost-saving as compared to clinic-administered DMPA-IM when accounting for costs to women and health systems.

This brief offers concise, evidence-based information to help answer common questions and dispel myths about injectable contraception. Myths are not stated directly because repeating a myth may reinforce it in people’s minds.

The working meeting on “The Future of DMPA-SC: Expanding access and options in 2019” was held in November 2018 as a pre-meeting before the International Conference on Family Planning (ICFP) in Kigali, Rwanda was intended to bring together colleagues and partners working to introduce and scale-up subcutaneous DMPA (DMPA-SC) in 14 countries to exchange challenges, successes, and lessons learned—and to plan together how they can continue to expand women’s access and options with DMPA-SC.

As countries strive to achieve the Sustainable Development Goal of universal access to sexual and reproductive health care services — including modern contraceptive methods through Universal Health Coverage (UHC) strategies, and the Family Planning 2020 goal of expanding access for an additional 120 million women and girls in 69 of the world’s poorest countries — policymakers and program managers have a heightened interest in providing contraceptive methods that better meet women’s needs. A subcutaneous formulation of the injectable depot medroxyprogesterone acetate (DMPA-SC) is one such option for broadening the spectrum of contraceptive choices. DMPA-SC combines the characteristics of an injectable contraceptive with a technology that facilitates task sharing of its delivery to community health workers (CHWs) as well as the possibility of self-injection by women. DMPA-SC is available in a prefilled, single-use injection device marketed as Sayana® Press. While DMPA-SC has many similarities to intramuscular DMPA (DMPA-IM) — it is taken every 3 months, is highly effective and has a similar side effect profile — it also has some significant differences:

• A lower dose of DMPA (104 mg for DMPA-SC versus 150 mg for DMPA-IM) that achieves similar systemic drug levels;
• Smaller needle size (2.5 cm for DMPA-SC versus 3.8 cm for DMPA-IM);
• Subcutaneous administration that is usually less painful than intramuscular injection, but skin reactions are more common;
• An all-in-one device that reduces the commodities needed and requires less skill to administer.

DMPA-SC is currently registered in 33 countries by government authorities or through a World Health Organization (WHO) collaborative procedure. Approximately one million doses of DMPA-SC have been used worldwide through introductory research studies, mostly in sub-Saharan Africa and South and Southeast Asia. Research to date has consistently demonstrated DMPA-SC’s safety, effectiveness and acceptability to both users and health care providers. While this consistency is encouraging, further evidence would help guide acceptable, efficient and effective ways to maximize its potential.

In the Democratic Republic of the Congo (DRC), the Ministry of Health authorizes only physicians and nurses to give injections, with one exception-medical and nursing students may also give injections if supervised by a clinical instructor. The emergence of the injectable contraceptive Sayana Press in some African countries prompted the DRC to test the acceptability and feasibility of distributing Sayana Press and other contraceptive methods at the community level through medical and nursing students. Sayana Press is similar in formulation to the injectable contraceptive Depo-Provera but contains a lower dose and is administered subcutaneously using a single-use syringe with a short needle called the Uniject system. The Uniject system allows Sayana Press to be administered by community health workers without clinical training or by self-injection. In this pilot, the advocacy objective was to obtain approval from the Ministry of Health to allow medical and nursing students to inject Sayana Press, as a first step toward authorization for community health workers to provide the method. The pilot described in this article documents a process whereby an innovative approach moved from concept to implementation to replication in less than 2 years. It also paved the way for testing additional progressive strategies to increase access to contraception at the community level. Because the pilot project included a research component designed to assess benefits and challenges, it provided the means to introduce the new task-shifting approach, which might not have been approved otherwise. Key pilot activities included: (1) increasing awareness of Sayana Press among family planning stakeholders at a national conference on family planning, (2) enlisting the support of key decision makers in designing the pilot, (3) obtaining marketing authorization to distribute Sayana Press in the DRC, (4) implementing the pilot from July to December 2015, (5) conducting quantitative and qualitative studies to assess acceptability and feasibility, and (6) disseminating the findings to family planning stakeholders. Before the pilot, Sayana Press was relatively unknown in the DRC, and there was no precedent for medical and nursing students providing family planning methods or giving injections at the community level. In less than 12 months, the approach gained legitimacy and acceptance. The key Ministry of Health decision maker orchestrated the closing session of the dissemination meeting on next steps, paving the way for pilot tests of 3 new task-shifting approaches: insertion of Implanon NXT by medical and nursing students, self-injection for Sayana Press with supervision by students, and injection of Sayana Press by community health workers with no formal clinical training.