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Reflections on advances in DMPA-SC and self-injection

FHI 360’s Catherine Packer shares a personal perspective on the rapid progress of DMPA-SC over the past ten years, from early research to recent workshops. Since its introduction—and particularly since it became available for self-injection—DMPA-SC has become an important part of the global family planning and reproductive health landscape.

“Sayana is easy to use, and [there is] no need to spend time coming to the hospital to be injected. When it’s your date, you just help yourself at home.” – Participant in the randomized controlled trial of DMPA-SC self-injection in Malawi, 2017

I joined FHI 360 as a Research Assistant in 2011. I was delighted when I found out that I would get to work on two research studies about a new family planning method called DMPA-SC* (often known by its brand name, Sayana® Press). The goal of these studies was to explore the acceptability of this new contraceptive injectable in Uganda and Senegal. We wanted to answer the questions: Can facility- and community-based healthcare providers safely administer DMPA-SC (give injections)? How do family planning clients and providers feel about this method?

J’ai rejoint FHI 360 en tant qu’assistant de recherche en 2011. J’ai été ravie d’apprendre que j’allais travailler sur deux études de recherche sur une nouvelle méthode de planification familiale appelée DMPA-SC* (souvent connu sous son nom de marque, Presse Sayana®). Le but de ces études était d’explorer l’acceptabilité de ce nouveau contraceptif injectable en Ouganda et au Sénégal.. Nous voulions répondre aux questions: Peuvent les prestataires de soins de santé basées aux formation sanitaires ainsi qu’à la communauté administrent en toute sécurité le DMPA-SC (faire des injections)? Que pensent les clients et les prestataires de planification familiale de cette méthode?

I had studied abroad in Senegal, so I was excited to return there and train the people collecting data for the studies. The data collectors interviewed clients who had used DMPA-SC as a contraceptive method and the healthcare providers who administered it. We found that facility- and community-based health providers could safely administer DMPA-SC to clients. All of the clients and providers interviewed had previously used or administered another form of injectable contraception called intramuscular DMPA (or DMPA-IM). We asked clients what they liked and did not like about DMPA-SC, and whether they preferred DMPA-SC or DMPA-IM (most said they preferred DMPA-SC). We also asked providers about their experiences administering DMPA-SC, and most said they preferred to administer DMPA-SC compared to DMPA-IM.

These were the first studies to measure the feasibility (“Can we deliver it?”) and acceptability (“Do clients feel positive about it?”) of DMPA-SC in sub-Saharan Africa. At that time, the product was not registered in either Senegal or Uganda, so we needed to get special permission to bring in DMPA-SC for use in our studies. For decades, FHI 360 has generated and used evidence to advocate for more family planning access and to improve quality of care (including through task sharing). For example, these efforts led to scaling up community-based provision of injectable contraception, which is now well-recognized as the standard of practice.

J’avais étudié à l’étranger au Sénégal, J’étais donc ravi d’y retourner et de former les personnes qui collectent des données pour les études. Les collecteurs de données interrogés clients qui avaient utilisé le DMPA-SC comme méthode contraceptive et fournisseurs de soins de santé qui l’ont administré. Nous avons trouvé que les prestataires de soins basées aux formations sanitaires et à la communauté pourraient administrer en toute sécurité le DMPA-SC aux clients. Toutes les clientes et prestataires interrogés avaient déjà utilisé ou administré une autre forme de contraception injectable appelée DMPA intramusculaire (ou DMPA-IM). Nous avons demandé aux clients ce qu’ils aimaient et n’aimaient pas à propos du DMPA-SC, et s’ils préféraient le DMPA-SC ou le DMPA-IM (la plupart ont dit qu’ils préféraient le DMPA-SC). Nous avons également interrogé les prestataires sur leurs expériences d’administration du DMPA-SC, et la plupart ont dit qu’ils préféraient administrer le DMPA-SC par rapport au DMPA-IM.

Ce sont les premières études à mesurer la faisabilité (“Pouvons-nous le livrer?”) et acceptabilité (“Les clients sont-ils positifs à ce sujet?”) du DMPA-SC en Afrique subsaharienne. À ce moment-là, le produit n’a été enregistré ni au Sénégal ni en Ouganda, nous devions donc obtenir une autorisation spéciale pour utiliser le DMPA-SC dans nos études. Depuis des décennies, FHI360 a généré et utilisé des preuves pour plaider en faveur d’un plus grand accès à la planification familiale et pour améliorer la qualité des soins (y compris via La délégation des tâches). Par exemple, ces efforts ont conduit à une intensification fourniture communautaire de contraceptifs injectables, qui est maintenant bien reconnu comme la norme de pratique.

Catherine Packer (FHI 360) and Ibrahima Mall (Centre de Formation et de Rercherche en Santé [CEFOREP]) carry DMPA-SC and DMPA-IM to study sites in Senegal in 2012. Image credit: Daouda Mbengue
Catherine Packer (FHI 360) and Ibrahima Mall (Centre de Formation et de Rercherche en Santé [CEFOREP]) carry DMPA-SC and DMPA-IM to study sites in Senegal in 2012. Image credit: Daouda Mbengue

Evidence to Support Scale-up

During the past decade, FHI 360, PATH, and other groups have generated strong evidence showing that DMPA-SC is safe and acceptable to clients and providers. DMPA-SC was soon made available for self-injection: Clients could take the product home with them to use themselves. Since then, studies have also shown that DMPA-SC and self-injection can increase access to contraception and continued use among adolescent girls and women around the world. Thanks to the resulting endorsement by the World Health Organization (WHO) and advocacy efforts, countries have introduced and scaled up DMPA-SC and self-injection in the past several years. For example, Malawi was one of the first countries to introduce DMPA-SC and self-injection at the same time (it is more common to introduce provider-administered DMPA-SC first, and introduce self-injection later). This was based on evidence from a randomized controlled trial conducted by FHI 360 and the University of Malawi. This trial showed that those who self-injected DMPA-SC were more likely to continue using it compared to those who received their injection from a healthcare provider. In 2018, Malawi’s Ministry of Health (MOH) approved the introduction of DMPA-SC self-injection into the family planning method mix and began offering it in seven districts. Malawi was a pioneer in sub-Saharan Africa in offering DMPA-SC self-injection as part of routine family planning delivery. The MOH approved the national rollout of self-injection in 2020.

A “sous-verre” painting (specific type of reverse glass painting technique, popular in Senegal) promoting family planning from Dakar. Photo credit: Catherine Packer
A “sous-verre” painting (specific type of reverse glass painting technique, popular in Senegal) promoting family planning from Dakar. Photo credit: Catherine Packer

Workshops Expand Knowledge

In 2019, I was fortunate to attend the DMPA-SC Evidence to Practice meeting. This meeting was convened by the DMPA-SC Access Collaborative and took place over four days in Dakar, Senegal. It was amazing to see the progress achieved through the introduction and availability of this product and the hard work of people around the world. During that meeting, countries shared and learned from one another’s experiences introducing and scaling up DMPA-SC and self-injection. Based on these learnings, the meeting supported more countries to make action plans to introduce DMPA-SC and self-injection.

Participants gather for the DMPA-SC Evidence to Practice meeting in Dakar, Senegal in 2019. Image credit: Catherine Packer
Participants gather for the DMPA-SC Evidence to Practice meeting in Dakar, Senegal in 2019. Image credit: Catherine Packer

In March 2021, the DMPA-SC Access Collaborative organized the virtual Making Self-Injection Count workshop. The eight sessions focused on how to integrate self-injection data into routine health management information systems (HMIS). Sessions also focused on how to use public and private sector data to inform policy and practice. I helped to support the session, “Integrating Self-Care Methods into the National Health Information System: Experiences and Lessons Learned from Malawi.” This session was based on the Malawi Ministry of Health’s (MOH) integration of DMPA-SC and self-injection into their HMIS and the effective partnership that enabled the successful rollout of DMPA-SC. In addition to the Malawi MOH, this partnership included ten other organizations:

  • FHI 360
  • The Centre for Health, Agriculture, Development Research and Consulting (CHAD);
  • Youth Net and Counseling (YONECO);
  • 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).

The workshop also featured a great hands-on session about HMIS data visualization and another on the opportunities and challenges related to the use of private sector data.

A Look Ahead

We are now more than one year into the COVID-19 pandemic. Self-injection of DMPA-SC allows adolescent girls and women to avoid traveling to crowded health facilities every three months to be injected by a provider. Self-injection enables adolescent girls and women to prevent pregnancy in a private and convenient manner for up to one year. Throughout the pandemic and beyond, this method has the potential to help adolescent girls and women prevent pregnancy.

Today, more than 40 countries have introduced or scaled up DMPA-SC as a family planning method. Half of these countries have also introduced or are planning to introduce self-injection. When I think back to my trip to Senegal nine years ago to begin working on DMPA-SC research, I am awed by how far we have come. I am excited to see where we go from here.

* DMPA-SC: Subcutaneous depot medroxyprogesterone acetate. Sayana® Press is a registered trademark of Pfizer Inc. Uniject™ is a trademark of BD (Becton, Dickinson and Company).

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Catherine Packer

Technical Advisor - RMNCH Communications and Knowledge Management, FHI 360

Catherine is passionate about promoting the health and well-being of under-served populations around the world. She is experienced in strategic communications, knowledge management, project management; technical assistance; and qualitative and quantitative social and behavioral research. Catherine's recent work has been in self-care; DMPA-SC self-injection (introduction, scale-up, and research); social norms related to adolescents’ reproductive health; postabortion care (PAC); advocacy for vasectomy in lower- and middle-income countries; and retention in HIV services of adolescents living with HIV. Now based in North Carolina, USA, her work has taken her to many countries including Burundi, Cambodia, Nepal, Rwanda, Senegal, Vietnam, and Zambia. She holds a Master of Science in Public Health degree specializing in international reproductive health from Johns Hopkins Bloomberg School of Public Health.