Guest contributors are Jennifer Drake, PATH’s Advancing Contraceptive Options portfolio director, and Kimberly Whipkey, a PATH policy and advocacy officer.
Recent evidence on self-injection of a new injectable contraceptive called subcutaneous DMPA(DMPA-SC) is providing one possible answer to an age-old question in family planning: How do we address barriers that make it difficult for women to keep using contraception consistently?
According to three recent studies, women who self-inject with DMPA-SC in their own homes or communities may continue using injectable contraception longer than those who receive injections from providers. In many Family Planning 2020 (FP2020) countries, injectable contraception is already popular, but often requires women to return to clinics every three months for injections. This can pose a significant barrier to consistent contraceptive use, especially for women who live in rural and remote areas. These new findings on self-injection should be very good news for women who like injectable contraception—if the global FP field has the courage to put this option for pregnancy prevention directly in women’s hands.
The ability of women and girls to make informed decisions about their sexual and reproductive health, including access to a contraceptive method that meets their needs and preferences, is critical. In fact, it is essential for meeting global goals, such as FP2020 and the Sustainable Development Goals (goals 3 and 5 in particular).
Yet too often, women in low-resource settings start and then stop using a modern method even though they want to avoid pregnancy or space births—known as contraceptive discontinuation. There are many reasons why women discontinue use of an FP method. These include method-related concerns (like side effects) and issues related to the service environment (like the accessibility and quality of services and commodity stockouts). If women discontinue use and don’t switch to another effective contraceptive option, then they are at risk of unintended pregnancy—which could lead to dangerous health outcomes.
Injectable contraceptives are widely used in many FP2020 countries because they are effective, safe, and private. Traditionally, injectables are delivered with a needle and syringe and injected into a muscle (using a product known as intramuscular DMPA or DMPA-IM). DMPA-SC (Sayana® Press1) makes injections simpler because it is injected into the fat underneath the skin, using a device that combines the contraceptive drug and needle in a single unit that is small and easy to use. Studies demonstrate that women can safely and effectively self-inject DMPA-SC with training, and that they like self-injection. Self-injection helps address some of the reasons why women may discontinue contraceptive use, such as challenges with paying for travel to the clinic and lengthy travel times and long lines at the clinic.
Starting in 2016, PATH conducted a study2 in Uganda that examined whether self-injection of DMPA improved women’s continued use of injectable contraception. Women who self-injected had significantly higher continuation rates at 12 months than women who received DMPA-IM from facility-based health workers. Self-injection appeared to help increase continuation for women younger than 25 in particular—a noteworthy finding given that younger women tend to have higher rates of contraceptive discontinuation than older women. A related initiative led by PATH in Uganda is helping to gather evidence on how best to deliver self-injection in the context of routine FP service delivery, beyond research.
PATH’s results align with recent reports from FHI 3603 in Malawi and Planned Parenthood in the United States, both of which found higher continuation for women who self-inject relative to those who receive DMPA injections from health workers. Specifically, results from the FHI 360 study showed that self-injection led to a more than 50 percent increase in continuous DMPA-SC use over 12 months compared to provider administration, while results from the Planned Parenthood study indicated that one-year DMPA continuous use was 69 percent in the self-administration group versus 54 percent in the clinic-administration group.
While these findings are encouraging, no one method (including DMPA-SC) will be a magic solution for all women. Different FP methods work for different women at different points in their lives. For DMPA injectables, uncertainty remains on whether the method may increase a woman’s risk of acquiring HIV if she has sex with an HIV-positive person without also using a form of protection against sexually transmitted infections (like male or female condoms), and this may dissuade some women from using DMPA injectables. Self-injection, moreover, won’t address unmet need or contraceptive discontinuation on its own. For example, some women who use injectable contraception don’t want to try self-injection, and a small group of study participants in PATH’s study in Uganda discontinued because of challenges with self-injection.
For women who choose to use injectable contraception and are open to administering it themselves, self-injection of DMPA-SC is emerging as an important way to help them keep using the method for as long as they wish. Continued contraceptive use is not only good for a woman and her own reproductive health, but it also can also help country governments make progress toward commitments to reduce unmet need, increase method choice, and expand access. Finally, encouraging evidence-based women’s self-care practices like self-injection can help equip women with health knowledge and skills, alleviate human resource shortages in health systems, and reinforce the internationally agreed upon human right to good health.
This blog series is a collaboration with K4Health and can also be found on its topic page on contraceptive technology innovation.