Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial

Injectable contraceptives are the most popular modern contraceptive method in sub-Saharan Africa because of their effectiveness, long-acting nature, potential for discrete use, and reversibility.1x1Staveteig, S, Mallick, L, and Winter, R. Uptake and discontinuation of long-acting reversible contraceptives (LARCS) in low-income countries. DHS analytical studies No. 54. ICF International, Rockville; 2015
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Evidence before this study

We conducted a literature search, and found that evidence to date suggests that, although side-effects are the most commonly reported reason for discontinuation of depot medroxyprogesterone acetate (DMPA) among women still in need of family planning, access to services is also an important factor in low-income and middle-income countries (LMICs) in sub-Saharan Africa. Subcutaneous DMPA (DMPA-SC) offers a potential solution to the access issue because its simplified delivery system and subcutaneous administration route enable DMPA to be delivered by health workers with less training and potentially by women themselves. Existing evidence shows that self-administration of DMPA-SC is safe, acceptable, and feasible, and in high-income countries is associated with continuation rates similar to those of provider-administered DMPA. However, the potential for self-injection to increase DMPA continuation rates had never been assessed in LMIC settings, and the safety and feasibility of self-injection had never been assessed in the context of community-based distribution of injectable contraceptives, which is the current standard practice in Malawi and many other countries in sub-Saharan Africa.

Added value of this study

Our study is, to our knowledge, the first to provide evidence on the important global public health question of whether self-injection improves DMPA continuation rates in an LMIC setting and we used the gold-standard design (a randomised controlled trial) to do so. We noted a strong effect of self-administration of DMPA-SC on continuation rates compared with administration by a provider. The effect was robust to a more lenient different definition of continuation in a sensitivity analysis, increasing our confidence in the findings. Moreover, since the study took place in a real-world setting, with Ministry of Health providers and community health workers, this study will contribute to the growing body of knowledge around community-based access to injectable contraceptives. It is also the first study to provide evidence on the safety and feasibility of community-based provision of injectable contraceptives for home and self-injection.

Implications of all the available evidence

Other studies have found self-administration of DMPA-SC to be safe, acceptable, and feasible in LMIC settings. Our findings contribute by showing that self-administration can improve continuation rates compared with provider-administered DMPA-SC and provide evidence that community health workers can safely and effectively train women to self-inject DMPA-SC in LMIC settings. A barrier to the rapid programmatic uptake of DMPA-SC is its anticipated higher cost relative to intramuscular DMPA; however, costs might be substantially reduced if DMPA-SC is self-administered. Self-administration might attract new users of family planning, including through the private sector, pharmacies, and drug shops and could reduce the cost of serving existing DMPA users by decreasing operational costs and more efficiently using resources such as the providers’ time. Moreover, the opportunity costs for women would be reduced through the removal of the need to travel as often to receive re-injections from health-care providers. Given the advantages we and others have found, DMPA-SC self-administration could be adopted by a substantial number of users which, in turn, might drive down the cost, a key factor in adoption of any contraception in LMICs.

Although many women start to use them, discontinuation rates are high, placing women at risk of unintended pregnancy and adverse maternal health outcomes. In a study of discontinuation rates in 19 countries, including five in sub-Saharan Africa, injectables had the shortest duration of use compared with other modern methods.5x5Castle, S and Askew, I. Contraceptive discontinuation: reasons challenges and solutions. Population Council, New York; 2015
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Malawi has made great strides in increasing the prevalence of modern contraceptive use, from 7% in 1992 to 58% in 2015–16, primarily through increased use of injectable contraceptives.8x8National Statistical Office [Malawi] and ICF. Malawi demographic and health survey 2015–16. National Statistical Office [Malawi] and ICF, Zomba and Rockville; 2017
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Although method-related concerns, such as side-effects, are the most commonly reported reasons for discontinuation of modern contraceptives among women still in need of family planning, access to services is also an important factor in low-income and middle-income countries (LMICs) in sub-Saharan Africa.5x5Castle, S and Askew, I. Contraceptive discontinuation: reasons challenges and solutions. Population Council, New York; 2015
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A 2013 Cochrane review of interventions to increase continuation rates of hormonal methods of contraception15x15Halpern, V, Lopez, LM, Grimes, DA, Stockton, LL, and Gallo, MF. Strategies to improve adherence and acceptability of hormonal methods of contraception. Cochrane Database Syst Rev. 2013; 10 ()
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To overcome challenges to accessibility that result in discontinuation of injectables, there has been an increase in efforts to explore the feasibility of self-injection of DMPA-SC in the form of both Sayana Press and depo-subQ provera 104 (medroxyprogesterone acetate injectable suspension 104 mg in 0·65 mL in a prefilled glass syringe; Pfizer). As of August, 2017, Sayana Press was registered for self-injection in 18 countries, including seven in sub-Saharan Africa (Radola A, Pfizer, personal communication). Proponents of self-injection cite the potential for improved contraceptive use due to increased timeliness of re-injection;16x16Kim, CR, Fønhus, MS, and Ganatra, B. Self-administration of injectable contraceptives: a systematic review. BJOG. 2017; 124: 200–208
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We did the first study in an LMIC setting to investigate whether self-administration of DMPA-SC could improve continuation rates and whether community-based provision of injectable contraceptives for self-injection is safe and feasible. Our primary objective was to compare continuation rates between women who self-inject DMPA-SC and women who receive DMPA-SC from a provider, including CHWs, within the context of family planning in Malawi’s public sector.

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