Based on evidence and experience, countries worldwide are adding the option of DMPA-SC self-injection to their contraceptive method mix.
Self-injection has the potential to reduce access-related barriers for women, increase contraceptive continuation rates, and enhance women’s autonomy. There are strong data that women, including women in low-resource settings, can self-administer DMPA-SC safely and effectively, and that they like doing so.
Results From the Uganda Self-Injection Best Practices Project
We used qualitative and quantitative data to evaluate the differing experiences of adolescents and adult women in the contraceptive self-injection program in primary care settings in Uganda. From these results, we assessed barriers to adolescent DMPA-SC self-injection access and continuation and provide recommendations to address them.
The Self-Injection Best Practices project (2017–2019) in four districts trained clinic-based providers and Village Health Teams to provide self-injection training in clinics, community settings, and small group meetings for adolescent girls and young women. More than 12,000 women of reproductive age received self-injection services through the program, including 2,215 under 20 years. Structured surveys (n = 1,060) and in-depth interviews (n = 36) were conducted with randomly selected adolescent participants between July and November 2018. Mixed-effects logistic regression was used to assess quantitative differences in outcomes of interest between age groups.
The study found no significant difference in self-injection proficiency or continuation between adolescents and adult women; 92.6% of adolescents self-injected independently when due for reinjection. Adolescents were significantly less likely than adults to report first hearing about self-injection from a community health worker. More adolescents expressed concern over discovery when seeking contraception at a clinic and fear of their DMPA-SC units being discovered at home. Adolescents were significantly less likely than adult women to mention convenience as a rationale for self-injecting, and more likely to mention wanting to learn a new skill and/or that friends recommended self-injection.
Self-injection is a promising method of contraception for adolescents in Uganda, given comparable proficiency and continuation relative to adult women. Policies and programs should ensure rights-based access to a range of methods, including self-injection for this age group.
Self-care reproductive health innovations are increasingly valued as practices that enable women to manage their fertility with greater autonomy. While self-care, by definition, takes place beyond the clinic walls, many self-care practices nonetheless require initial or follow up visits to a health worker. Access to self-care hinges on the extent to which health care workers who serve as gatekeepers find the innovation appropriate and practical. Self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is being introduced and scaled in many countries. In late 2018, health workers in Uganda began offering self-injection of DMPA-SC in the public sector, and this study examines health workers’ views on the acceptability and feasibility of training women to self-inject. We conducted in-person interviews with 120 health workers active in the self-injection program to better understand provider practices, program satisfaction, and their views on feasibility. A subset of 77 health workers participated in in-depth interviews. Quantitative data was analyzed using Stata (v14) software, and chi square and student t tests used to measure between group differences. Qualitative data was analyzed using Atlas.ti, employing an iterative coding process, to identify key themes that resonated. The majority of health workers were very satisfied with the self-injection program and reported it was moderately easy to integrate self-injection training into routine service delivery. They identified lack of time to train clients in the clinic setting, lack of materials among community health workers, and client fear of self-injection as key challenges. Community health workers were less likely to report time challenges and indicated higher levels of satisfaction and greater ease in offering self-injection services. The relatively high acceptability of the self-injection program among health workers is promising; however, strategies to overcome feasibility challenges, such as workload constraints that limit the ability to offer self-injection training, are needed to expand service delivery to more women interested in this new self-care innovation. As self-injection programs are introduced and scaled across settings, there is a need for evidence regarding how self-care innovations can be designed and implemented in ways that are practical for health workers, while optimizing women’s successful adoption and use.
Contraceptive self-injection (SI) is a new self-care practice with potential to transform women’s family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women’s experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10–17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.
This guidance from the World Health Organization (WHO) aims to provide a people-centred, evidence-based normative guideline that will support individuals, communities, and countries with quality health services and self-care interventions, based on PHC strategies, comprehensive essential service packages and people-centredness. The guidance includes a “strong” recommendation for self-administered injectable contraception, stating that this should be made available as an additional approach to deliver injectable contraception for individuals of reproductive age.
This opening plenary of the Making Self-Injection Count workshop highlighted how self-injection data can help close the gender data gap by providing key information and insights on the experiences of women and adolescents. Presenters discussed how self-injection can contribute to contraceptive autonomy by enabling women and girls to make and actualize their own decisions. The session featured personal stories from a self-injection ambassador, self-injection provider, and self-injection client.
By the end of this session, participants were able to:
Describe the importance of self-injection for contraceptive autonomy, and self-injection in the context of self-care.
Describe the landscape of self-injection data availability.
Understand experiences of self-injection from the lens of a provider, user, and advocate.
While progress is being made, self-injection data availability is still limited compared to other contraceptive data sets.
Disaggregation by client age, district, and DMPA-SC delivery mode (self-injected vs. provider-administered DMPA-SC) is essential to DMPA-SC data tracking.
High-quality data systems give us insight into women’s and girls’ preferences, client access to family planning, provider training needs, and global supply management opportunities.
This brief details the strong body of evidence and experience with self-injection of DMPA-SC in low-resource settings, including how the practice can reduce access-related barriers, improve contraceptive continuation, and enhance women’s autonomy.
This article compares results from interviews with DMPA-SC providers in two separate pilot studies: 1) 53 medical and nursing school students teaching women how to self-inject (2016–2017); and 2) 34 lay community health workers providing DMPA-SC in rural areas of Lualaba (2017). All providers gave information on socio-demographic characteristics, recruitment,) training, supervision, experience and satisfaction with the provision of DMPA-SC. The paper examines variations in responses from the different provider cadres.
The DMPA-SC Access Collaborative has produced the brief and program design guide linked below to support countries and partners that are planning and rolling out DMPA-SC self-injection as part of an expanded range of contraceptive methods delivered through informed choice programming.
The Recommendations for Contraceptive Self-Injection brief summarizes the latest key findings, insights and recommendations the AC has accumulated through six years of technical assistance to ministries and partners engaged in self-injection program introduction and scale-up. These practices should be universally considered and implemented to increase program success.
The Contraceptive Self-Injection Program Design Guide is a comprehensive tool that outlines optimal program models for DMPA-SC self-injection. It was originally developed in 2020 based on the self-injection program rollout in Uganda, the first country in sub-saharan Africa to offer contraceptive self-injection outside of a research setting. The guide has been updated in 2022 to reflect subsequent learnings, evidence, and data from scale-up efforts. The program design guide:
Walks users through each step of a self-injection program, including all components related to health workers and clients.
Highlights essential evidence on self-injection program design.
Establishes areas where more research is needed.
Draws attention to key moments for program design decision-making.
Links users to additional resources and tools for program development.
We want to hear from you! We welcome your reflections on the Contraceptive Self-Injection Program Design Guide. Do you have feedback for consideration? By completing this short survey open through November 30, you can help us ensure these resources are meeting the needs of key stakeholders.
The DMPA-SC Access Collaborative has compiled the list linked below featuring presentations, posters, and events on the topic of DMPA-SC, including self-injection and self-care, to be featured at the International Conference on Family Planning on November 14-17, 2022. The list includes more than 60 abstracts highlighting the latest DMPA-SC research and implementation experience from a diverse array of partner organizations including the AC.
Lessons learned from training and support for health workers in the public and private sectors
Malawi has made significant progress in scaling up DMPA-SC and self-injection in the public sector with 100% of service delivery points activated. The country has also learned valuable lessons through private sector pilots and is in the process of finalizing new guidelines to authorize pharmacies and drugstores to provide self-injection training to clients. The country’s approach is widely appreciated as an example of effective government-led and partner-supported scale-up involving both the public and private sector.
This webinar hosted by the PATH-JSI DMPA-SC Access Collaborative Learning and Action Network on August 3, 2022 featured public and private partners’ insights on national scale-up of DMPA-SC and self-injection, with a focus on provider training and supportive supervision as well as strong cross-sectoral partnerships. Speakers included representatives from the Malawi Ministry of Health Reproductive Health Directorate, Clinton Health Access Initiative, FHI 360, and Population Services International.
Drawing from program data and research, panelists discussed practical lessons learned from Malawi’s national scale-up of public-sector provider training, public provider reflections on integrating self-injection, and experiences from a private sector provider training pilot. These lessons may benefit governments and public and private partners in other contexts who are in the process of introducing or scaling up DMPA-SC for self-injection.