Keywords
1. Introduction
As countries strive to achieve the Sustainable Development Goal of universal access to sexual and reproductive health care services — including modern contraceptive methods through Universal Health Coverage (UHC) strategies, and the Family Planning 2020 goal of expanding access for an additional 120 million women and girls in 69 of the world's poorest countries — policymakers and program managers have a heightened interest in providing contraceptive methods that better meet women's needs. A subcutaneous formulation of the injectable depot medroxyprogesterone acetate (DMPA-SC) is one such option for broadening the spectrum of contraceptive choices [
[1]
]. DMPA-SC combines the characteristics of an injectable contraceptive with a technology that facilitates task sharing of its delivery to community health workers (CHWs) as well as the possibility of self-injection by women.DMPA-SC is available in a prefilled, single-use injection device marketed as Sayana® Press. While DMPA-SC has many similarities to intramuscular DMPA (DMPA-IM) — it is taken every 3 months, is highly effective and has a similar side effect profile — it also has some significant differences:
- •A lower dose of DMPA (104 mg for DMPA-SC versus 150 mg for DMPA-IM) that achieves similar systemic drug levels.
- •Smaller needle size (2.5 cm for DMPA-SC versus 3.8 cm for DMPA-IM).
- •Subcutaneous administration that is usually less painful than intramuscular injection, but skin reactions are more common.
- •An all-in-one device that reduces the commodities needed and requires less skill to administer.
DMPA-SC is currently registered in 33 countries by government authorities or through a World Health Organization (WHO) collaborative procedure []. Approximately one million doses of DMPA-SC have been used worldwide through introductory research studies, mostly in sub-Saharan Africa and South and Southeast Asia. Research to date has consistently demonstrated DMPA-SC's safety, effectiveness and acceptability to both users and health care providers [
3
, 4
, 5
, 6
, 7
]. While this consistency is encouraging, further evidence would help guide acceptable, efficient and effective ways to maximize its potential.2. Overview of key findings
In this issue of Contraception, a series of papers describing research carried out in six countries [Burkina Faso, Democratic Republic of the Congo (DRC), Malawi, Nigeria, Senegal and Uganda] provide insights into how this method might expand access and meet the needs of more women. Several articles address the acceptability and feasibility of task sharing delivery with CHWs, as well as the potential for self-injection by women. Articles in this issue also explore the potential of delivery through private-sector social marketing platforms and examine the costs and cost-effectiveness of providing DMPA-SC and other injectable contraceptives through different channels.
Three papers present evidence of the feasibility and acceptability of both CHW administration and self-injection in DRC. Hernandez and colleagues interviewed two cadres of community-level providers: medical and nursing students who administered DMPA-SC in a community setting or who taught women how to self-inject and CHWs who provided DMPA-SC in rural areas. Over 90% of these providers reported being comfortable or very comfortable interacting with clients, and more than three quarters of them were very comfortable performing an injection [
[8]
]. In the same study, Mwembo and colleagues assessed the acceptability and feasibility of DMPA-SC among 252 women on the initial injection date and 3 months later. Of the 239 women interviewed at follow-up, 92% would recommend DMPA-SC to a friend or family member, and 95% would choose to continue receiving DMPA-SC from a CHW rather than in a health facility [[9]
]. Bertrand and colleagues assessed the acceptability and feasibility of self-injection in two urban and one rural areas of Kinshasa, DRC; three quarters of women opted for self-injection over being injected by the CHW for reasons of convenience and personal agency. Among the 415 women choosing self-injection, 97% described the self-injection process as easy after 3 months [Mwembo A, Emel R, Koba T, Bapura Sankoko J, Gay R, Bertrand JT. Acceptability and feasibility of the distribution of DMPA-SC by community health workers in the rural province of Lualaba in the Democratic Republic of the Congo. Contraception [Under review; submitted to the the DMPA-SC supplement in Contraception].
[10]
].Further evidence of the feasibility and acceptability of self-injection is provided by studies from Malawi and Uganda. Burke and colleagues implemented a 12-month randomized controlled trial in Malawi in which 731 women seeking contraceptive services at Ministry of Health clinics or through CHWs in rural communities were randomly assigned to receive DMPA-SC administered by a provider or be trained to self-inject. After 3 months, 92% of women self-injecting said that the procedure was easy or very easy. Moreover, 78% of women in the provider-administered group indicated that they would consider self-injection at the 9-month follow-up. Women articulated that DMPA-SC self-injection saved them time and money, while providers noted that it reduced their workload and saved them time [
11
, - Burke H.
- Chen M.
- Buluzi M.
- Fuchs R.
- Wevill S.
- Venkatasubramanian L.
- et al.
Factors affecting discontinuation, and women's satisfaction, use, storage, and disposal of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) during a randomized trial.
Contraception. 2018; ([Under review; submitted to the the DMPA-SC supplement in Contraception])
12
].In Uganda, Cover and colleagues compared the continuation rates of self-injection (561 women) with administration by a facility-based health worker (600 women) using a nonrandomized, prospective cohort study. Multivariate analysis showed that self-injecting reduced the likelihood of discontinuation by 46%, particularly among younger women [
[13]
]. A randomized controlled trial, recently published elsewhere by Burke et al., has also shown significantly higher 12-month continuation rates for women who self-inject at home (73%) compared with women receiving the injections from a provider (45%) [- Cover J.
- Namagembe A.
- Tumusiime J.
- Nsangi D.
- Lim J.
- Nakiganda-Busiku D.
Continuation of injectable contraception when self-injected vs. administered by a facility-based health worker: a nonrandomized, prospective cohort study in Uganda.
Contraception. 2018; ([In Press; included in the DMPA-SC supplement])https://doi.org/10.1016/j.contraception.2018.03.032
[14]
].- Burke H.
- Chen M.
- Buluzi M.
- Fuchs R.
- Wevill S.
- Venkatasubramanian L.
- et al.
Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomized controlled trial.
Lancet Glob Health. 2018; https://doi.org/10.1016/S2214-109X(18)30061-5
MacLachlan and colleagues prospectively compared 12-month continuation rates for DMPA-SC and DMPA-IM provided by facility-based health workers in Burkina Faso (990 women) and by Village Health Teams (1224 women) in Uganda. The analysis found no difference between DMPA-SC and DMPA-IM in either country, though continuation rates for women using both methods provided by Village Health Teams in Uganda were significantly higher (78% of the DMPA-SC group and 77% of the DMPA-IM group) than for women receiving their methods at health facilities in Burkina Faso (50% of the DMPA-SC group and 47% of the DMPA-IM group) [
[15]
].- MacLachlan E.
- Namagembe A.
- Tumusiime J.
- Mubiru F.
- Atuyambe L.
- Kasasa S.
- et al.
Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from Burkina Faso and Uganda.
Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
Liu and colleagues contributed two papers that explore the role of social marketing through a private-sector urban community-based distribution (CBD) model in South West Nigeria. One paper assessed the role of sociodemographic factors and service quality on continuation through telephone interviews with a convenience sample of 541 women who obtained their first dose of DMPA-SC through private-sector providers, and through follow-up interviews with 342 of those women 3 months later. Women with some college education and those with four or more children were more likely to obtain a second dose, as were those who received higher quality counseling initially [
[16]
]. The second paper also analyzes distributor performance indicators and in-depth interviews with 57 providers and 42 DMPA-SC users. This analysis found that the CBD model was not successful in reaching younger, unmarried women and became financially unsustainable; indeed, the program had to switch to distribution through high-volume family planning facilities to be sustainable [[17]
].- Liu J.
- Schatzkin E.
- Omoluabi E.
- Erinfolami T.
- Ayodeji K.
- Ogunmola S.
- et al.
Introducing the subcutaneous depot medroxyprogesterone acetate injectable contraceptive via social marketing: lessons learned from Nigeria's private sector.
Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
The costs and cost-effectiveness of DMPA-SC and DMPA-IM were compared in various settings in two papers by Di Giorgio and colleagues. One paper used four cross-sectional microcosting studies in Burkina Faso, Uganda and Senegal to compare the costs of administering DMPA-SC through facility-based health workers, community-based health workers and self-injection with the costs of facility-based and community-based administration of DMPA-IM. The findings suggest that the costs of community-based distribution of both methods and self-injection are lower than facility-based delivery [
[18]
]. The second paper used economic modeling to analyze a hypothetical cohort of one million women to compare the cost-effectiveness of self-injected DMPA-SC with health-worker-administered DMPA-IM in Uganda. The authors found that self-injected DMPA-SC could prevent an additional 10,828 unintended pregnancies and 1620 maternal DALYs per year compared to DMPA-IM administered by facility-based health workers [- Di Giorgio L.
- Mvundura M.
- Tumusiime J.
- Namagembe A.
- Ba A.
- Belemsaga-Yugbare D.
- et al.
Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal.
Contraception. 2018; ([In Press; included in the DMPA-SC supplement])https://doi.org/10.1016/j.contraception.2018.05.018
[19]
].- Di Giorgio L.
- Mvundura M.
- Tumusiime J.
- Morozoff C.
- Cover J.
- Drake J.K.
Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda.
Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
3. Results confirm potential of DMPA-SC
The findings from these papers provide further evidence and reinforce results from previous studies that task sharing with CHWs and self-injection by women are feasible and acceptable [
3
, 4
, 5
, 6
, 20
, 21
, 22
, 23
, 24
, 25
].In all of the studies that trained CHWs to give DMPA-SC injections, the workers quickly gained skill and confidence. As demonstrated in the DRC pilot, medical and nursing students were also able to quickly master the injection technique [
[10]
]. Task sharing with CHWs helps to address health workforce shortages and expands access to services, particularly in rural areas where facility-based care is often far from where many women live []. CHWs can be a more acceptable cadre of health provider for some women, although they may not provide the anonymity within their community some women would need to use contraception. Community-based distribution may also reduce costs and improve method continuation when compared with facility-based provision; indeed, many countries are already revising their policies and protocols to allow and support CHWs to give contraceptive injections. As countries do so, they need to ensure that CHWs have adequate training and supervision, and that referral mechanisms are in place should women need follow-up care or wish to switch to a different contraceptive method.These papers further expand the evidence base for self-injection of DMPA-SC. The studies showed that any initial fears were quickly overcome, the injection skill was easily learned, and women were able to safely store the devices at home and to track their next injection date. Self-injection is convenient and eliminates the need to seek provider-based care every 3 months, which may be important for women living in remote areas or having little time available to visit a facility. Moreover, the significant reductions in discontinuation when women self-inject are particularly encouraging, indicating that self-injection empowers women to have autonomy and control over their method of contraception. As one of the main reasons for injectable discontinuation generally is side effects [
[27]
] and because women who self-inject will not necessarily have regular follow-up visits with providers, it would be important for those choosing self-injection to receive sufficient and correct information about how to self-manage side effects and the availability of help through providers if needed [[16]
]. Self-injection is consistent with the World Health Organization's recognition of self-care as a means to empower individuals, families and communities and with the potential of improving the efficiency of health systems and contributing towards health equity []. As with task sharing to CHWs, programs that include self-injection will need to ensure that adequate training, safety oversight and follow-up support are fully available to women who choose this approach. To be able to routinely support self-injection, however, community acceptability of self-care and the implications for health systems reorganization will need careful attention.DMPA-SC is safe and suitable for nearly all women but is not recommended for women who are breastfeeding and less than 6 weeks postpartum and for women with certain cardiovascular conditions. WHO's Medical Eligibility Criteria have a category 2 recommendation for women at high risk of HIV wanting to use injectable contraception — meaning that the advantages of using the method generally outweigh potential risks and that women should be advised of the concern regarding a link between use of these methods and potential increased risk of HIV, about the uncertainty over whether the link is causal and about how to minimize HIV risk; this recommendation also applies to DMPA-SC.
As several of the papers indicate and as documented elsewhere, the continuity of DMPA-SC product supply has been inconsistent, with stockouts reported [
29
, 30
]. While stockouts are also common for other injectable commodities, systems that support a continuous supply of commodities, particularly to women themselves if they are self-injecting, will be essential if discontinuation is to be avoided.The cost of the DMPA-SC product is critically important for policymakers deciding whether and how to incorporate the method into their program's contraceptive options. The cost of Sayana® Press has been guaranteed by the manufacturer at US$0.85 through 2022 (DMPA-SC Donor Group, 2018, personal communication); ensuring that the method continues to be available at this cost or lower, including through ensuring generic products, will be critical. While the cost of DMPA-IM is slightly lower (typically $0.70–$0.80), the analyses by Di Giorgio and colleagues suggest that community-based distribution of DMPA-SC at the current cost may be the same as for DMPA-IM [
[18]
]. Another study by the same lead author and colleagues [- Di Giorgio L.
- Mvundura M.
- Tumusiime J.
- Namagembe A.
- Ba A.
- Belemsaga-Yugbare D.
- et al.
Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal.
Contraception. 2018; ([In Press; included in the DMPA-SC supplement])https://doi.org/10.1016/j.contraception.2018.05.018
[19]
] shows that the training aid used for self-injection is a key determinant of cost-effectiveness of self-injection compared to provider-administered DMPA-IM. The use of a lower-cost training aid makes self-injection cost-effective [- Di Giorgio L.
- Mvundura M.
- Tumusiime J.
- Morozoff C.
- Cover J.
- Drake J.K.
Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda.
Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
[19]
]. Further innovations in DMPA-SC service delivery, such as group training of women for self-injection or lower-cost training aids, may also help to further improve cost-effectiveness. Liu's finding that delivering DMPA-SC using a private-sector social marketing approach was only sustainable for high-volume family planning facilities is disappointing but not surprising [- Di Giorgio L.
- Mvundura M.
- Tumusiime J.
- Morozoff C.
- Cover J.
- Drake J.K.
Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda.
Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
[17]
]. Development of delivery and financing systems for DMPA-SC that can reach and are affordable for all women who would like to use this method is still in early stages, and experimentation with various financing and delivery models could lead to more viable mechanisms.- Liu J.
- Schatzkin E.
- Omoluabi E.
- Erinfolami T.
- Ayodeji K.
- Ogunmola S.
- et al.
Introducing the subcutaneous depot medroxyprogesterone acetate injectable contraceptive via social marketing: lessons learned from Nigeria's private sector.
Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
4. Conclusion: moving forward
Ensuring that all women wanting to use a contraceptive method have the widest possible range of options must be a cornerstone of UHC. While essentially a new way of delivering an existing method of contraception, DMPA-SC has the potential to significantly expand women's contraceptive options — and to increase personal autonomy through self-care. These papers provide further evidence that DMPA-SC can safely and effectively be task-shared by community-based health workers across different contexts and health systems, and that self-injection by women is safe, effective and acceptable.
The recently updated “Family Planning: A Global Handbook for Providers” includes guidance for providing DMPA-SC, including on instructing women how to self-inject [
[31]
]. WHO is in the process of systematically reviewing the evidence on self-injection of contraceptives with a view to updating its recommendations — studies such as these are an important contribution. This review also contributes to a broader initiative by WHO that seeks to operationalize the principle of people-centered primary health care, which is promoted in its 13th Global Programme of Work as the primary means for countries to achieve UHC [[32]
]. WHO has recently launched an initiative to explore and promote investment in health care interventions — including services, behaviors and information — which can be initiated by individuals to enable autonomy and agency in health care. User-initiated interventions incorporate diagnostics, screening, preventive, treatment, and illness management actions and products; examples for sexual and reproductive health include self-injection of contraceptives and over-the-counter emergency contraception, self-testing for sexually transmitted infections (including HIV) and pregnancy, self-medication for abortion and HIV, self-sampling for HPV testing and self-monitoring of fertility. There is an urgent need to fully understand the safety and quality of such interventions and products, and to ensure appropriate support and accountability mechanisms in the health system, particularly for vulnerable and marginalized women and girls.- WHO
Draft thirteenth general programme of work, 2019-2023.
http://www.who.int/about/what-we-do/gpw-thirteen-consultation/en/
Date: 2018
Date accessed: April 2, 2018
Finally, it is important to consider the implications of this new method for the existing injectable contraceptive methods. Progestogen-only injectables can be delivered through both facility-based and CHW programs. Self-injection with DMPA-SC has been shown to be feasible and acceptable and can reduce rates of discontinuation in research settings. It may be challenging, however, for some women to self-administer an injection — and many women lack the privacy and confidentiality at home that they may need to be able to use contraception effectively. Moreover, a self-administration model must always include women's access to a qualified health worker who can provide information and help manage any complications. DMPA-IM requires 3-monthly contacts with a health provider, which can be problematic for many women, but for some women, these regular interactions with the health system can be reassuring and offer opportunities to address a wider range of health issues beyond contraception. In summary, it is to be hoped that the introduction of DMPA-SC complements existing injectable contraceptives so as to broaden women's contraceptive options.
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- Introducing the subcutaneous depot medroxyprogesterone acetate injectable contraceptive via social marketing: lessons learned from Nigeria's private sector.Contraception. 2018; ([Under review; Submitted to the DMPA-SC supplement in Contraception])
- Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal.Contraception. 2018; ([In Press; included in the DMPA-SC supplement])https://doi.org/10.1016/j.contraception.2018.05.018
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Article info
Publication history
Published online: August 23, 2018
Accepted:
August 10,
2018
Received in revised form:
August 10,
2018
Received:
August 9,
2018
Footnotes
☆The authors alone are responsible for the views expressed in this commentary, and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
☆The authors alone are responsible for the views expressed in this commentary, and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
Identification
Copyright
© 2018 Published by Elsevier Inc.
