DMPA-SC Self-injection Pilot Findings

Client and Provider Experiences of DMPA-SC Self-injection in select sub-cities of Addis Ababa, Ethiopia

Background

Injectable contraceptives, including DMPA, are the most popular modern contraceptive method in sub-Saharan Africa and the most widely used modern method in Addis Ababa, Ethiopia. DMPA-SC is a formulation of DMPA delivered subcutaneously in an easy-to-use, prefilled auto disabled injection system. The self-injection of DMPA-SC is a globally endorsed evidence-based practice that is approved in a growing number of countries. In 2019, the World Health Organization (WHO) added DMPA-SC self-injection (SI) as a “strong recommendation” to their consolidated guidelines on self-care interventions for health1.

To support the Ethiopian Ministry of Health to determine the safety, acceptability, and feasibility of introducing DMPA-SC self-injection in Ethiopia, Population Services International with support from the Ethiopian Public Health Institute (EPHI) and FHI 360, developed a mixed methods pilot study that sampled 400 women 18–49 years in six sub-cities of Addis Ababa. Interviews were also conducted with family planning providers who trained clients on DMPA-SC self-injection to explore their perceptions of the acceptability and feasibility of introducing the method. The study objectives were co-developed with the Ministry of Health (MOH). The MOH also provided technical support with the development of the study protocol and two representatives were included as co-investigators. The purpose of this pilot study was to generate evidence for the Ministry of Health on the feasibility of DMPA-SC self-injection within the context of Ethiopia.

1 World Health Organization (WHO). WHO consolidated guideline on self-care interventions for health: sexual and reproductive health and rights. Geneva: World Health Organization: WHO; 2019

Specific study objectives included:

1. Determine the competence of clients to self-inject DMPA-SC,
2. Assess the experience of DMPA-SC self-injection users, and
3. Document the experience of family planning providers who train women to self-inject.

The study was implemented from August 2021 through April 2022 and included an enrollment period and follow-up phase. Once the study protocol received the necessary Institutional Review Board (IRB) approvals from Ethiopian Public Health Institute(EPHI) and Population Services International (PSI), Training of Trainers (ToT) was given to selected master trainers from Addis Ababa Health Bureau (AAHB), sub-cities and health facilities by Marie Stopes International Ethiopia (MSIE) and cascaded to family planning providers from the study sites in two rounds. The training included theoretical and practical sessions at MSIE clinics to allow trainees to better understand the counseling, steps to be followed, tools to be used, infection prevention and waste management, and quality of care standards.

During the enrollment period, interested clients between 18–49 years who were medically eligible for injectable contraception were invited to learn about the study. Family planning providers from six public health facilities trained clients who provided written informed consent and met study eligibility to self inject DMPA-SC. Through the data collection period, representatives from MOH, AAHB, EPHI and PSI supervised the implementation of the study according to the approved study protocol. PSIE Quality of Care Manager also conducted supervisory visits with family planning providers to observe the counseling and to ensure that standards and protocols were adhered to.

Key Findings:

1. The majority of participants demonstrated ability to safely and properly self-inject DMPA-SC during the enrollment (95.3%) and follow-up observations (83.1%).
2. There was no statistically significant difference in competence at 3-month reinjection by participant characteristics, including age, education, marital status and employment status. In line with this, providers said that nearly all participants were able to learn self-injection regardless of educational status and age.
3. The majority of women were satisfied or very satisfied (84%) with DMPA-SC self-injection, would recommend it to a friend or family member (85%) and would like to continue using the method if available (78%).
4. Providers widely recommended DMPA-SC self-injection be added to the method mix and agreed that health extension workers could effectively offer DMPA-SC self-injection training to clients.

Results

Competency: Through observation and evaluation using a standardized observation checklist adapted from the Access Collaborative, participants demonstrated a high level of competence to self-inject DMPA-SC after initially learning how to do so at enrollment and at the time of follow-up, 3-months later.

Figure 1: Competency level of clients at enrollment and follow-up

Sociodemographic characteristics: Competency at 3-months was compared across various sociodemographic indicators such as participants’ age group, marital status, employment status and educational attainment. There was no statistically significant difference in competency across any of the groups compared (p>0.05 for all). This suggests that expansion of DMPA-SC self-injection to areas of Ethiopia with less educated populations would likely find that most clients are able to safely and effectively self-inject.

Confidence and comfort to self-inject DMPA-SC: At the 3-month follow-up visit, participants were asked separate questions about how confident and comfortable they were self-injecting at enrollment and at the time of re-injection. Compared to enrollment, participants reported feeling more confident and comfortable self-injecting at follow-up. Participants reported similarly high rates of confidence and certainty about being able to handle self-injection in the future.

Figure 2: Confidence and comfort to self-inject DMPA-SC at enrollment, follow-up and the future

Client satisfaction with DMPA-SC self-injection: Overall, 84% of participants said they were satisfied or very satisfied with DMPA-SC self-injection. In particular, they reported liking its convenience (44%), the length of the needle (43%), that it is not painful or less painful than other methods (36%) and that it is discreet (17%).

Family planning providers’ experiences with DMPA-SC self-injection: The qualitative piece of the pilot study included in-depth interviews with 15 family planning providers who trained clients to self inject DMPA-SC. Following are some quotes from the family planning providers:

“I would be very much happy if mothers use this once it passes all the necessary steps. I would be happy if I myself use it.”

“It is good to give self-injection training in the community by a health extension […] Because a health extension knows each family well, she is able to communicate freely with them because they meet every day. So, it’s good”

“The big thing is to reduce the time mothers spend here. [DMPA-SC self injection] minimizes the time they spend. It reduces our job burden. It has benefit for them and us if they use it.”

“I think it might be implemented based on the result of the study. It is nice if this is implemented continuously.”

Challenges in the study and mitigation strategies

While the results from the study are positive, there were some challenges encountered. One of the challenges of the study was tracing clients after enrollment and scheduling appointments for completing the follow-up survey which assessed clients’ experiences. As a mitigation strategy, data collectors used all the possible options stated in the study protocol including phone and in-person visits according to the locations clients gave during the enrollment. They also worked with Urban Health Extension Workers from the study sites to locate clients for follow-up. The flexibility of the data collectors to be available in the places and times of the choosing of clients was an added advantage and in alignment with the study protocol.

Challenges with training clients and strategies

Below are some of the provider-reported challenges related to initial counseling and steps of self injection linked with strategies discussed to overcome these issues. A more detailed list of challenges and strategies is stated in the full study report.

Conclusion

Ethiopia is committed to expanding women’s access to and choice of modern family planning methods. To do so, the country has given focus to ensuring a broad method mix in both public and private health care facilities. Despite the efforts made to date, unmet need for modern contraceptive methods remains high. The potential impact of DMPA-SC self-injection in a country like Ethiopia is substantial, particularly through the public sector where the overwhelming majority of women obtain their family planning methods. The need for expanded access to modern contraceptives is made even more urgent in the face of current emergencies related to conflict, drought and disease outbreaks which are straining on the health system and availability of health services. Interventions such as DMPA-SC for self-injection, promote women’s ability to exercise self-care and can lighten the burden on the health system by putting family planning directly into the hands of those who need these services most. The introduction of DMPA-SC SI can also help advance the Ministry of Health Ethiopia’s progress on reaching FP2030 goals by expanding the existing contraceptive method mix, increasing new family planning users and increasing contraceptive continuation rates. Recommendations co-developed by the Family Planning technical working group are stated below to guide the introduction of DMPA-SC for self-inject in Ethiopia.

Pilot Research Implications and Recommendations

The below recommendations were developed through close consultation with the Ministry of Health’s Family Planning technical team and with members of the Family Planning Technical Working Group, and are based on the findings of this study.

1. The findings of the study show that most clients are competent to self-inject DMPA-SC and have positive experiences with the method. Accordingly, it is recommended that the Ministry of Health authorize a phased scale-up of DMPA-SC self-injection (DMPA-SC SI) in Ethiopia. A phased approach of implementation will create opportunities for continued learning and smooth introduction of DMPA-SC SI across the different contexts in Ethiopia.
2. As part of the initial phase of scale-up of DMPA-SC SI, it is advised that the Ministry of Health allow the continuity of the provision of DMPA-SC SI in the study sites to minimize disruption of women’s preferred FP method and maintain provider’s skills. This ensures that women have the chance to use the method of their choice and empowers women to develop the practice of self-care.
3. For the successful introduction of DMPA-SC SI in Ethiopia, it is recommended to develop an introduction/strategic roll-out plan and learning agenda to guide the national phased scaleup. The Ministry of Health Family Planning Technical Working Group (MoH FP TWG) shall support the process of development of this plan that would provide clear guidance on how to address details including training, advocacy, sustainable commodity supply chain, monitoring and evaluation, resource mobilization systems, and related components that would guide the introduction and implementation process.
4. Form a task force comprised of selected FP TWG members to support the next steps in the introduction of DMPA-SC SI in Ethiopia. The task force would support the Ministry of Health to pave the way forward including the development of the strategic roll-out plan and follow-up of the introduction of the method.
5. During scale up, consider the diverse communities in urban, rural, pastoralist and agrarian areas and contextualize accordingly. In addition, plan service provision for hot spot areas such as industrial parks, mega project locations, humanitarian (IDP) settings and places with high unmet need for family planning.
6. Include DMPA-SC SI in the self-care guideline, and family planning guideline to create an enabling environment for the introduction of DMPA-SC SI.