Progress and Potential of Self-Care: Taking Stock and Looking Ahead

The momentum around self-care is building through an array of self-care practices, policies, and interventions worldwide. This report aims to take stock of the SRH self-care field and document its progress. It is intended to provide a resource for global and national advocacy, to inform implementation of self-care guidelines, and to link the reader to evidence and learning exchanges. It includes case examples describing the process of introducing and scaling up DMPA-SC self-injection in Malawi and Nigeria.

On March 21, 2023, the DMPA-SC Access Collaborative hosted this webinar highlighting the strengths and gaps of monitoring scale-up in the context of efforts to institutionalize DMPA-SC and self-injection in national family planning programs. The discussion focused on findings from Madagascar, Nigeria, Uganda, and Zambia, touching upon national goals for DMPA-SC, in-country perspectives on the value proposition of DMPA-SC, and suggested indicators for use in tracking the scale-up of a new product.

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.

The private sector holds great potential to reduce unmet need for family planning, and many countries are poised to adopt a total market approach for increasing contraceptive access through private pharmacies and drug shops. Policies supporting scale-up of family planning service provision and expanding method options such as DMPA-SC self-injection, must be prioritized in these entities.

The PATH-JSI DMPA-SC Access Collaborative and partners have gained valuable insights with relevance to private sector engagement on self-injection. This webinar held February 15, 2022 highlighted lessons learnt, challenges, recommendations, and considerations for policies supporting private sector engagement in self-injection in different country contexts. Specific topics included:

• Financing and commodity production ecosystems
• Procurement and supply chains
• Service delivery and programming
• Data reporting and monitoring
• Advocacy
• Demand generation

The discussion was moderated by Allen Namagembe, Deputy Project Director, Uganda DMPA-SC Access Collaborative, PATH.

Panelists:

• Dr. Kayode Afolabi, Director and Head, Reproductive Health Division, Federal Ministry of Health, Nigeria
• Dr. Daniella Munene, Member, National Executive Committee, Pharmaceutical Society of Kenya
• Dr. Hortense Randrianaivo, President, Association of Pharmacists of Madagascar
• Mr. Célestin Compaore, Regional Project Director, DMPA-SC, Jhpiego, Burkina Faso

The DMPA-SC Access Collaborative has published a collection of briefs on countries where we have provided focused technical assistance between 2017 and 2021. This includes the Democratic Republic of the Congo, Kenya, Madagascar, Nigeria, Uganda, and Zambia. Each brief describes the country’s introduction and scale-up experiences for DMPA-SC and self-injection, including accomplishments, challenges, innovations, key lessons, factors for success, and plans for the way forward.

The DMPA-SC Access Collaborative hosted this April 21, 2021 webinar highlighting lessons learned to date through four years of data-driven technical assistance and coordination to ensure that women have increased access to self-injection as a contraceptive option, delivered through informed choice programming. The discussion focused on key topics for the introduction and scale-up of self-injection—and self-care interventions more broadly—at the country level including:

• Policy and advocacy for new product introduction.
• How to coordinate scale-up of a new product.
• Using data to inform program introduction and scale-up.
• Effective innovations and adaptations in provider training.

This discussion was moderated by Monica Mutesa, Zambia Country Coordinator, DMPA-SC Access Collaborative, PATH. Speakers included:

• Caitlin Corneliess, Project Director, DMPA-SC Access Collaborative, PATH
• Adewole Adefalu, Nigeria Country Coordinator, DMPA-SC Access Collaborative, JSI
• Allen Namagembe, Uganda Deputy Director, DMPA-SC Access Collaborative, PATH
• Avotiana Rakotomanga, Madagascar Country Coordinator, DMPA-SC Access Collaborative, JSI
• Alain Kabore, Regional Technical Advisor, DMPA-SC Access Collaborative, PATH

For more information, please contact FPoptions@path.org.

This webinar presented key findings from a two-phased research program funded by The Bill & Melinda Gates Foundation in Nigeria and Uganda. The first phase was a qualitative exploration within Focus Group discussions (total sample n=600 in 100 Focus Groups (n=6 per FG) across 8 different FG types and split across 2 urban and 2 rural settings per country) with women and their male partners (separately). The second phase was a quantitative survey with women (total sample n=1,410 women) split across 4 regions within each country.

The research explored several central topics:

• The various contraceptive journeys and experiences of women and their male partners, including satisfied and discontinued users of the injectable contraceptive (Depo), satisfied users of the DMPA-SC (Sayana Press), naïve users of modern contraceptive and those using traditional methods.
• Factors which lead to discontinuation and experiences with/perception of side effects.
• Gauged level of acceptability and preference for certain injectable attributes, in particular the impact of DMPA-SC 3 months or a potential 6 month injectable on likelihood to try. We tested 3 fully developed concepts and vary the most impactful features from phase 1 with women.
• Developed a forecast model for Depo, DMPA-SC 3-month and a potential 6-month injectable in Nigeria and Uganda.

In Nigeria, 20% of women wish to use family planning and reproductive health services, but do not have access to them (USAID 2016). While family planning services and products are available at many public and private facilities, only 11% of women nationwide currently use a modern contraceptive method (NPC 2014). Along with male condoms and pills, injectables are among the most popular methods. However, they are more difficult to access because a trained healthcare worker must administer it with a needle and syringe. Launched in Nigeria in 2014, Sayana® Press is an all-in-one injectable contraceptive designed to overcome barriers to accessing family planning. The unique injection system eliminates the need for a needle and syringe, and enables health workers to administer the injection with basic training. With its ease of application and efficacy, widely distributing Sayana Press is the latest effort to expand contraceptive choice and access for all Nigerian women.

This policy landscape can be leveraged by applicants interested in applying to the DMPA-SC Regulatory Advocacy Catalytic Opportunity Fund (COF). The landscape was originally developed in 2020 to understand policies and regulations, including over-the-counter regulations, that impact women’s access to DMPA-SC and identify short- and long-term advocacy opportunities. In 2022, it was refreshed to understand policy shifts and additional advocacy opportunities in a subset of 12 of the original 18 countries currently eligible for the Regulatory Advocacy COF. Insights from the policy landscape have informed the design and eligibility criteria of the Regulatory Advocacy COF, proactively identified opportunities, and provided frameworks and guidance for interested applicants.

The desire for private sector family planning programs to have the ability to overbrand/overpackage the Pfizer Inc. DMPA-SC product, Sayana® Press, has existed since initial product introduction planning discussions among global partners in 2008–2009. The PATH-JSI DMPA-SC Access Collaborative solicited input from the team’s regional technical advisors, country coordinators, and local partners to better understand the status of overbranding, and any related advocacy­­, in the countries where we work.