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Malawi’s Self-Care Success Story: Rapid Introduction of Self-Injectable Contraception

The chronicle of Malawi’s rapid, efficient introduction of self-injected subcutaneous DMPA (DMPA-SC) into the method mix is a model of teamwork and coordination. Although this process typically takes about 10 years, Malawi achieved it in fewer than three. Self-injected DMPA-SC epitomizes the ideal of self-care by empowering women to learn how to inject themselves, and has the added benefit of helping clients avoid busy clinics during the COVID-19 pandemic.

As the public health world celebrates Self-Care Month, the extraordinary research-to-practice journey of self-injected subcutaneous DMPA (DMPA-SC, brand name Sayana Press) in Malawi has revolutionized womens ability to achieve their own reproductive intentions. The World Health Organization defines self-care as the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health care provider. In terms of family planning, self-injected DMPA-SC epitomizes the ideal of self-care by empowering women to learn how to inject themselvesat home, at their convenience—and when to reinject themselves.

Putting Results into Policy and Practice

The average time required to institutionalize new research findings into policy and practice is about 10 years, but Malawi reached this milestone in fewer than three. Just eight months after the release of positive results from a randomized controlled trial (RCT) about DMPA-SC in 2017 (1) the Ministry of Healths (MOH) Senior Management Team (SMT) approved the introduction of DMPA-SCboth provider-injected (PI) and self-injection (SI)into the family planning methods mix. This followed a phased introduction in seven districts and recently culminated in the MOH approving the national rollout. The story of this rapid, efficient introduction is a model of teamwork among a multitude of stakeholders working toward a common goal.

National Rollout Timeline

Task Forceto BReckoned With

Raise your hand if you have ever served on a task force that was more of a task and less of a forcewhere, despite members’ good intentions, accomplishments were few. Recognizing that successful introduction and scale-up of DMPA-SC would require widespread buy-in, intense cooperation, and tangible results, the MOH created and led a dynamic task force (2) of government agencies, local implementing partners, and international nongovernmental organizations.  In meetings held quarterly, to start, and later monthly, the task force selected Phase One districts and identified partners to lead the rollout; updated the service delivery guidelines to include DMPA-SC and self-injection; updated training curricula and job aids; and successfully advocated for DMPA-SC to be available in private franchised clinics and pharmacies. Task force members also led the revision and printing of the family planning registers, reporting booklets, and self-injection leaflets and supported updates to national electronic and paper reporting forms to include DMPA-SC so that data can be disaggregated by provideradministered and self-injection. The attention paid to these kinds of details, at every level, is what differentiates this task force from so many others.

The Latest DMPA-SC Self-Injection Research

The MOH requested that FHI 360 and the University of Malawi‒Polytechnic explore how people who self-inject dispose of used DMPA-SC units, in order to inform the anticipated national scale-up. The goal of the study, which was funded by the Children’s Investment Fund Foundation (CIFF), was to identify which waste disposal methods and training approaches are acceptable and feasible and can help address method discontinuation, as injectables are one of the most common methods discontinued within a year. This research also captured youth experiences with self-injection, as nearly half of the self-injectors interviewed were youth (ages 15‒19 years).

The study’s results showed that most participants planned to dispose of used units according to instructions, which advised storing used units in puncture-proof containers and returning them to health workers at facilities or in the community. However, despite their desire to follow directions, most participants said they would have preferred to dispose of units in latrines because they worried about needlestick injuries to others, and because it was convenient. Despite their concerns about needles, no participants reported that either they or others experienced such an injury. The study also found that very few clients practiced before self-injecting for the first time, though most youth and half of adults said they would have liked to. Sometimes, informational self-injection leaflets—which included a calendar—were not provided during training, which affected clients’ ability to remember when to re-inject. Youth found self-injection acceptable, feasible, and beneficial; most preferred the privacy of individual versus group training.

Among other recommendations, researchers suggested that youth-friendly waste management options should be considered, and all clients should be offered the opportunity to practice injecting on something, such as a condom filled with salt or sugar, before they self-inject for the first time. Offering those trained in a group the opportunity to self-inject privately should be considered out of respect for privacy, especially for youth. For more information, review an in-depth description of the study results and recommendations.

WhatNext?

The MOH and partners are keen to regularly collect data from clients on their long-term satisfaction with both self- and provider-injected DMPA-SC. As funding allows, this information will be gathered through focus group discussions and interviews with clients as part of the supportive supervision visits to inform programming. Also, some indicators on long-term satisfaction are being considered for the annual family planning client satisfaction surveys.

Finally, both public- and private-sector providers will ramp up efforts to raise awareness about DMPA-SC and self-injection, particularly now, as a self-care family planning method that can help women avoid busy clinics during the COVID-19 pandemic. For more details on this phenomenal self-care success story, listen to the journey from research to practice for self-injectable contraception in Malawi webinar (password: Malawi5.4). FHI Partners, a subsidiary of FHI 360, is currently conducting a study to develop and test counseling messages for DMPA-SC self-injection with funding from CIFF. 

FOOTNOTES

  1. A study by FHI 360, University of Malawi, and the MOH showed that self-administration led to a more than 50 percent increase in continuous DMPA-SC pregnancy protection over 12 months compared with provider-administered injection. See Effect of self-administration of subcutaneous depot medroxyprogesterone acetate versus provider-administered injection on continuation rates: results from a one-year randomized controlled trial in Malawi.
  2. The MOH-led task force members were the Center for Health Agriculture, Development Research and Consulting (CHAD), which served as secretariat; Youth Net and Counselling (YONECO); FHI 360; Banja La Mtsogolo (BLM); Population Services International (PSI); Clinton Health Access Initiative (CHAI); Management Sciences for Health (MSH); United States Agency for International Development (USAID); and United Nations Population Fund (UNFPA).

Cover photo credit: Melissa Cooperman/IFPRI

Leigh Wynne

Technical Advisor, Global Health, Population and Nutrition

Leigh Wynne, MPH is a Technical Advisor in the Global Health, Population and Nutrition (GHPN) department at FHI 360. Her areas of specialization include research utilization, family planning, reproductive health and gender. Her tasks include synthesizing research results and programmatic experience into materials that meet global needs and promote evidence-based practices, building and maintaining partnerships; facilitating dissemination meetings, trainings and technical consultations; and supporting strategic advocacy, scale-up and institutionalization activities.

Suzanne Fischer

Suzanne Fischer, MS, joined FHI 360 in 2002 and is now an Associate Director of Knowledge Management in the Research Utilization division, where she supervises a team of writers, editors, and graphic designers. In addition, she conceptualizes, writes, revises, and edits curricula, provider tools, reports, briefs, and social media content. She also trains international researchers on writing scientific journal articles and has co-facilitated writing workshops in eight countries. Her technical areas of interest include youth sexual and reproductive health and HIV programs for key populations. She is the co-author of Positive Connections: Leading Information and Support Groups for Adolescents Living with HIV.

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