The DMPA-SC Access Collaborative provides data-driven technical assistance (TA), resources, and tools that countries need for designing, implementing, and monitoring the introduction and scale up of DMPA-SC self-injection as part of an expanded range of contraceptive methods, delivered through informed choice programming.

In addition to general information and evidence on DMPA-SC, partners can access the support outlined in the menu below by submitting a request through the technical assistance request form, also linked below. Your request can be submitted by emailing the completed form to FPoptions@path.org.

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.

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.

Updating family planning and reproductive health preservice training is an important approach to make an impact on the health workforce and foster successful programs. In 2021, the DMPA-SC Access Collaborative, in collaboration with Uganda’s Ministry of Health and Ministry of Education and Sports, conducted a regional training for clinical and health training institutions on the topic of DMPA-SC including self-injection. This training integrated DMPA-SC content into the health provider preservice curriculum, trained tutors, and helped advance national scale-up of self-injection. As a result, 92 Ugandan health training institutions included self-injection content in their preservice curriculum for nurses, midwives, and clinical officers, and 190 tutors were trained—which will help ensure training of many more providers in the future.

During this process, the Access Collaborative gained valuable insights with relevance to other country contexts. This webinar held on January 27, 2022 highlighted lessons learnt, challenges, recommendations, and considerations for the inclusion of self-injection content in provider preservice training. In the Ugandan context, these include:

• How inclusion of self-injection in preservice training can help reach FP2030 country commitments.
• Virtual preservice training approaches during the COVID-19 pandemic.
• Costs for the inclusion of self-injection in preservice training.
• The role of regulators and the Ministry of Health in ensuring availability of DMPA-SC for preservice training.

Over the past two years, a number of implementing partners have leveraged the Catalytic Opportunity Fund (COF) to support the scale-up of DMPA-SC in focal countries. The COF is a rapid funding mechanism administered by Clinton Health Access Initiative (CHAI) and managed by the DMPA-SC Operations Group, a group that responds to operational and service delivery issues in DMPA-SC and self-injection introduction and scale-up. The fund aims to support short-term DMPA-SC scale-up activities that unlock or generate additional resources. COF grantees carry out a diverse range of activities with short-term, small grants that make significant contributions to the national introduction and scale-up of DMPA-SC in their countries.

During this DMPA-SC Learning and Action Network (LAN) knowledge-sharing webinar held on May 19, 2021, successful COF grantees representing the Society for Family Health, Pathfinder International, Marie Stopes, and Jhpiego shared about the fund’s impact on their work and key lessons learned. The virtual discussion encouraged all stakeholders—program implementers, researchers, government officials, health providers, and members of civil society—to consider applicable strategies and mechanisms for efficient, sustainable, and scalable product introduction.

For more information, please contact the Access Collaborative LAN at dmpa-sc-lan@path.org or the CHAI COF at COF@clintonhealthaccess.org.

The Track20 Project, implemented by Avenir Health, monitors progress towards achieving the goals of the global FP2020 initiative, adding an additional 120 million modern method users between 2012 and 2020 in the world’s 69 poorest countries. Track20 works directly with governments in participating FP2020 countries to collect, analyze and use data to monitor progress annually in family planning and to actively use data to improve family planning strategies and plans. Track20 activities and efforts are focused on countries that chose to make a commitment to the FP2020 global initiative, referred to as Track20 Focus Countries. The remaining FP2020 countries, referred to as Additional Track20 Countries, will also receive some technical support.

PMA generates frequent, high-quality surveys monitoring key health indicators in nine countries in Africa and Asia. Data is available open-source for research, program planning, and policy-making. PMA family planning briefs provide a snapshot of select indicators through charts, graphs and tables. Key indicators for family planning include unmet need for family planning, modern contraceptive prevalence rate (​mCPR), and family planning access, equity, quality, and choice.