While there is widespread interest in improving access to self-injection, implementation science is needed to better understand this new delivery approach, particularly around storage and disposal. The WHO provides recommendations for facility- and community-based use, with some guidance on household-level sharps disposal (PATH & JSI 2019). Existing evidence indicates that without specific guidance, women will likely dispose of DMPA-SC sharps in pit latrines and open spaces, which poses safety and environmental risks (Cover et al. 2016, Cover et al. 2017, PATH & JSI 2019).
Piloting DMPA-SC self-injection in Ghana
To reach its FP2020 goals, Ghana has focused on introducing and scaling DMPA-SC provision in public and private health facilities. To inform national planning efforts, the Ghana Health Service (GHS) prioritized research on home-based self-injection to better understand storage and disposal practices in a context where at-home disposal in pit latrines and open spaces is explicitly not allowed. The Evidence Project, led by the Population Council with support from the United States Agency for International Development (USAID) Mission in Ghana, collaborated with the GHS to conduct a feasibility and acceptability study introducing DMPA-SC and self-injection.
The DMPA-SC and self-injection introduction process through this study were conducted in rural, peri-urban, and urban areas within two regions of Ghana— Ashanti and Volta. Across these two regions, a cascade training approach was used to train a total of 150 FP providers at eight public health facilities through three-day training workshops on DMPA-SC counseling and administration, including how to teach clients to self-inject correctly. Following the trainings, DMPA-SC was incorporated into comprehensive FP counseling and services at these facilities. Those clients who voluntarily chose DMPA-SC as their contraceptive method were offered the option to be trained by the provider on self-injection. After self-injection instruction and assessment by the provider, the client was then permitted to self-inject under provider supervision and given two doses of DMPA-SC to take home for future self-injections.
Self-injection clients were also given information on DMPA-SC safe storage and disposal, which included instructions to: 1) store the Uniject™ devices in a cool, dry area at room temperature; 2) dispose of them in a puncture-proof container; and 3) return that container to a facility when it was full or when then woman needed a refill of DMPA-SC. In addition, each client was provided a puncture-proof container that could hold up to 5 used Uniject™ devices (Figure 1). To understand women’s experiences with DMPA-SC and self-injection practices, we conducted quantitative interviews with 568 women (18-49 years) following their initial, second and third injections as well as in-depth qualitative interviews with 58 women after their scheduled third injection. A full description of the intervention and study methods can be found at Nai et al. 2020.
Safe and private home storage of DMPA-SC is feasible and “easy”: Nearly all women reported storing the Uniject™ devices as instructed in a cool, dry area at room temperature (96% after third injection) and found this easy to do (94%). These findings held across age groups, new and previous FP users, and women of all education levels. Women were able to keep DMPA-SC out of reach of children, and they were successful in keeping the devices away from family members for privacy, if desired.