The ability of individuals to space, time, and limit pregnancies in alignment with their preferences, with or without the support of a healthcare provider

This Family Planning High Impact Practice brief outlines the principles and practices of contraceptive self-care: the ability of individuals to freely and effectively space their pregnancies, time their pregnancies, and prevent pregnancies in alignment with their fertility preferences, with or without the support of a healthcare provider. This is facilitated by the integration of contraceptive self-care interventions into policies, programs, and delivery channels across health systems including family planning and reproductive health.

Quality of family planning counseling is likely associated with whether or not women continue to use the same contraceptive method over time. The Method Information Index (MII) is a widely available measure of contraceptive counseling quality but little is known about its association with rates of method continuation. Using data from a prospective cohort study of 1,998 social franchise clients in Pakistan and Uganda, we investigated the relationship between reported baseline MII and the risk of method continuation over 12 months using survival analysis and Cox proportional hazard models. Higher scores on the 3-question Method Information Index (MII)—measuring client-reported receipt of contraceptive information—was associated with continued use of family planning over 12 months. We recommend incorporating use of the MII in routine assessments of family planning service quality.

Global Health: Science and Practice. March 2019, 7(1):87-102. https://doi.org/10.9745/GHSP-D-18-00407

Drug shops and pharmacies have long been recognized as the first point of contact for health care in developing countries, including family planning (FP) services. Drug shop operators and pharmacists should not be viewed as mere merchants of short-acting contraceptive methods, as this ignores their capacity for increasing uptake of FP services and methods in a systematic and collaborative way with the public sector, social marketing groups and product distributors. We draw on lessons learned from the rich experience of earlier efforts to promote a variety of public health interventions in pharmacies and drug shops. To integrate this setting that provides convenience, confidentiality, access to user-controlled contraceptive methods (i.e., pills, condoms and potentially Sayana Press®) and a gateway to clinic-based FP services, we propose three promising practices that should be encouraged in future interventions to increase access to quality FP services.

Understanding whether hormonal contraception increases women’s risk of HIV acquisition is a public health priority. This review summarizes recent epidemiologic and biologic data, and considers the implications of new evidence on research and programmatic efforts. Two secondary analyses of HIV prevention trials demonstrated increased HIV risk among depot medroxyprogesterone acetate (DMPA) users compared with nonhormonal/no method users and norethisterone enanthate (NET-EN) users. A study of women in serodiscordant partnerships found no significant association for DMPA or implants. Two meta-analyses found elevated risks of HIV among DMPA users compared with nonhormonal/no method users, with no association for NET-EN or combined oral contraceptive pills. In-vitro and animal model studies identified plausible biological mechanisms by which progestin exposure could increase risk of HIV, depending on the type and dose of progestin, but such mechanisms have not been definitively observed in humans. Recent epidemiologic and biologic evidence on hormonal contraception and HIV suggests a harmful profile for DMPA but not combined oral contraceptives. In limited data, NET-EN appears safer than DMPA. More research is needed on other progestin-based methods, especially implants and Sayana Press. Future priorities include updating modeling studies with new pooled estimates, continued basic science to understand biological mechanisms, expanding contraceptive choice, and identifying effective ways to promote dual method use.

Progestin-only contraceptive injectables and implants are highly effective, longer-acting contraceptive methods that can be used by most women in most circumstances. Globally, 6% of women using modern contraception use injectables and 1% use implants. Injectables are the predominant contraceptive method used in sub-Saharan Africa, and account for 43% of modern contraceptive methods used. A lower-dose, subcutaneous formulation of the most widely used injectable, depot-medroxyprogesterone acetate, has been developed. Implants have the highest effectiveness of any contraceptive method. Commodity cost, which historically limited implant availability in low-resource countries, was markedly lowered between 2012 and 2013. Changes in menstrual bleeding patterns are extremely common with both methods, and a main cause of discontinuation. Advice from normative bodies differs on progestin-only contraceptive use by breastfeeding women 0–6 weeks postpartum. Whether these methods are associated with HIV acquisition is a controversial issue, with important implications for sub-Saharan Africa, which has a disproportionate burden of both human immunodeficiency virus (HIV) and maternal mortality.

This study aimed to evaluate DMPA-SC (Sayana Press) management and administration in low-resource settings, focusing on how the delivery logistics, administration time, storage and waste-management requirements compare to the traditional intramuscular DMPA injectable (DMPA-IM).

Cover J, Blanton E, Ndiaye D, Walugembe F, Lamontagne DS. Operational assessments of Sayana® Press provision in Senegal and Uganda. Contraception. 2014 May;89(5):374-8. https://doi.org/10.1016/j.contraception.2014.01.005. Epub 2014 Jan 18. PMID: 24565737.

This study evaluated the pharmacokinetic profile of medroxyprogesterone acetate (MPA) following injection of Depo-SubQ Provera 104 (DMPA-SC) in the upper arm, a preferred injection site in developing countries. Injection of Depo-SubQ Provera 104™ in the upper arm provided sufficient MPA levels for contraceptive protection for 3 months (13 weeks). The uptake and metabolism of MPA when injected in the upper arm may be different from the abdomen and thigh.

FHI 360’s PROGRESS project worked with ministries of health and local partners in Senegal and Uganda to conduct an acceptability study of the subcutaneous delivery of injectable contraceptives with the Uniject™ device (DMPA-SC, Sayana® Press). The study assessed acceptability among family planning clients and providers, including community health workers, and offered recommendations for the introduction of this method.

This operational assessment in Uganda examines the extent to which DMPA-SC (brand name Sayana^® Press) facilitates the logistics of managing and administering injectable contraception and assesses whether providers in Uganda find benefits in this new presentation.

This study assessed the extent to which Sayana Press simplifies the logistics of managing and administering injectable contraception and whether providers in Senegal found this new presentation to be more practical and preferable to the standard syringe-vial injectable contraceptive. The operational assessment leveraged the acceptability study conducted by FHI 360 in Thies, Mbour, and Tivaouane by targeting the same 12 clinics from that study and asking providers who participated to reflect on their experience managing and administering Sayana Press. Semi-structured interviews with one provider from each of the 12 clinics and 9 affiliated CBD agents (matrones) for a total of 21 interviews, provided quantitative and qualitative data on the merits, challenges, and appeal of Sayana Press relative to DMPA-IM.