The DMPA-SC Update is a periodic newsletter from the PATH-JSI DMPA-SC Access Collaborative highlighting global efforts to expand access to the self-injectable DMPA-SC in the context of a full range of family planning options. Click here to subscribe. For more information, please contact FPoptions@path.org.

An in-depth look at DMPA-SC and self-injection introduction in Zambia

The DMPA-SC Access Collaborative (AC) hosted this virtual discussion on February 16, 2023 to explore the challenges of introducing new contraceptive methods in the context of informed choice programming. This webinar focused on findings from a recent study conducted in Zambia which aimed to determine:

• The barriers to clients’ ability to exercise autonomy in their choice of family planning methods and modes of administration.
• The extent to which provider perceptions and method bias affect access to self-injection as a new contraceptive option.

This research was conducted as part of the AC’s broader learning agenda and focused on the potential risks to informed choice that could arise as new products or service innovations are integrated in family planning programs. While a new intervention is intended to expand contraceptive access and options, its introduction may inadvertently convey to providers that it is inherently better than existing products or practices. In the case of DMPA-SC, providers may promote self-injection over provider administration. Alternatively, providers may feel hesitant about a new method and withhold information. In either case, the client’s right to receive accurate information about a variety of methods and to make an informed choice about her reproductive health care is compromised. To explore these questions, the AC conducted a literature review and study interviewing both clients and providers to understand how DMPA-SC and self-injection are being offered in Zambia’s Copperbelt Province.

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 family planning 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.

Please contact FPoptions@path.org for further information or requests for assistance.

Results From the Uganda Self-Injection Best Practices Project

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.

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.

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.

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.

In this session from the Making Self-Injection Count workshop, presenters discussed challenges to data use for decision-making and shared examples of how countries and programs have made data actionable in other health areas, specifically Malaria and immunization. The presentation included an example of an application of routine family planning data, including a new analysis of self-injection data from Senegal, and wrapped up with a panel Q&A focused on solutions.

Objectives

By the end of this session, participants were able to:

• Understand key principles for fostering data use for decision-making.
• Understand how countries and programs have used routine health data for decision-making.
• Identify strategies to overcome challenges to data use.
• Consider data quality and understand how it can be evaluated.

Key takeaways

• Better data will lead to better decision-making and better health outcomes.
• Data should:
  • be subjected to quality audits.
  • be delivered in a form that works for each intended audience and in alignment with their goals.
  • be shared with those who contributed the data and who have control over how services are offered.
  • include visualizations that effectively convey key details.
  • be iterative and ongoing.
• There is a need for standardized metrics that allow for comparability among countries.

Presenters

• Jonathan Drummey, Data Visualization Specialist, PATH
• Fred Njobvu, Technical Advisor, Center for Digital & Data Excellence, PATH
• Marie-Reign Rutagwera, Strategic Information Advisor, PAMO Plus, PATH
• Jessica Williamson, Data Analyst, Track20 Project, Avenir Health