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Bado AR. Determinants of DMPA-SC self-care/self-injectable contraceptive uptake among modern contraceptive users in Burkina Faso: findings from the 2021 demographic and health survey. Front Glob Womens Health 2024; 5:1385446. [PMID: 39301506 PMCID: PMC11410774 DOI: 10.3389/fgwh.2024.1385446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 08/13/2024] [Indexed: 09/22/2024] Open
Abstract
Introduction This study aimed to identify the determinants that influence the use of DMPA-SC/Sayana Press among women who use modern contraceptive methods in Burkina Faso. Methods This study used secondary data obtained from the 2021 Burkina Faso Demographic and Health Survey (EDSBF). The dependent variable is the use of DMPA-SC among women aged 15-49 who employ modern contraceptive methods. The descriptive analysis used percentages to describe the study variables. The Pearson chi-square test was used to assess the associations between the explanatory variables and the study variable of interest. Bivariate logistic regression was used to examine the crude odds ratios of each explanatory variable with respect to the dependent variable. The multivariate model was used to determine the net effect of each independent variable on the dependent variable. The significance levels were defined at p < 0.05, with corresponding confidence intervals. Results The study revealed significant differences in the use of DMPA-SC according to age, marital status, region of residence, level of education, number of children, and involvement in contraceptive decision-making within the couple. Younger women (aged 15-29 aOR = 2.12, p < 0.001)) and women aged 30-39 (aOR = 1.51, p = 0.02) are also more likely to use DMPA-SC compared to those aged 40-49. Married women or those living with a partner [aOR = 1.93 (1.22, 3.05)] are more likely to use DMPA-SC. Women with 1-3 children are twice as likely to use DMPA-SC as those without children (aOR = 1.97, p = 0.02). Region and Wealth Index were significantly associated with DMPA-SC use. The Boucle du Mouhoun region showed a significantly higher likelihood of DMPA-SC use (aOR = 8.10) and women in the highest wealth group are significantly less likely to use DMPA-SC (aOR = 0.59, p = 0.001). Conclusion These results demonstrated the importance of adapting interventions to account for socio-demographic, regional, and cultural differences. This will enable the provision of services to the entire female population in a fair and equitable manner, while also addressing the limitations and enhancing the understanding of the underlying factors influencing the use of DMPA-SC.
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Affiliation(s)
- Aristide Romaric Bado
- Département Biomedical et Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS), Centre National de la Recherche Scientifique et Technologique (CNRST), Ouagadougou, Burkina Faso
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Hill A, Levi J, Fairhead C, Pilkington V, Wang J, Johnson M, Layne J, Roberts D, Fortunak J. Lenacapavir to prevent HIV infection: current prices versus estimated costs of production. J Antimicrob Chemother 2024:dkae305. [PMID: 39225016 DOI: 10.1093/jac/dkae305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Despite improvements in treatment and oral pre-exposure prophylaxis (PrEP) access, 1.3 million people acquired HIV in 2022. Six-monthly lenacapavir PrEP could benefit tens of millions of people at high risk of infection. However, prices are currently up to $44 819 per person per year (pppy). OBJECTIVES We projected minimum lenacapavir pricing based on generic mass production and a Cost-Plus (Cost+) model. METHODS Current active pharmaceutical ingredient (API) and key starting materials (KSMs) costs were obtained from export databases. The routes of synthesis (ROS) were analysed to project a cost of goods (COGs). Formulation, vials and profit margin costs were included using standardized algorithms and Cost+ pricing. We estimated prices with scale-up to supply 1 million then 10 million treatment-years, comparing this with national list prices. RESULTS The lenacapavir API is currently exported from India for $64 480/kg on 1 kg scale. Based on the ROS and KSMs, API COGs of $25 000/kg and $10 000/kg are achievable for a committed demand of 1 million (2 million tonnes/annum of API) and 10 million treatment-years, respectively. Including formulation steps, injectable lenacapavir could be mass produced for approximately $94 pppy for 1 million and $41 for 10 million treatment-years, if voluntary licences are in place and competition between generic suppliers substantially improves. Greater scale-up with improvements in manufacturers' ROS could reduce prices further. Currently lenacapavir costs $25 395-44 819 pppy. CONCLUSIONS Lenacapavir could be mass produced for <$100 pppy at launch. Voluntary licensing and multiple suppliers are required to achieve these low prices. This mechanism is already in place for other antiretrovirals. To date, Gilead has not agreed lenacapavir voluntary licences with the Medicines Patent Pool.
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Affiliation(s)
- Andrew Hill
- Department of Pharmacology and Therapeutics, Liverpool University, Liverpool, UK
| | - Jacob Levi
- Charité University Hospital, Institute of Tropical Medicine and International Health, Südring 2-3, Berlin, Germany
| | - Cassandra Fairhead
- Charité University Hospital, Institute of Tropical Medicine and International Health, Südring 2-3, Berlin, Germany
| | - Victoria Pilkington
- Postgraduate Medical Education Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Junzhen Wang
- Medical Sciences Office, Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Madison Johnson
- Chemistry and Pharmaceutical Sciences, Howard University, Washington, D.C., USA
| | - Jevon Layne
- Chemistry and Pharmaceutical Sciences, Howard University, Washington, D.C., USA
| | - David Roberts
- Chemistry and Pharmaceutical Sciences, Howard University, Washington, D.C., USA
| | - Joseph Fortunak
- Chemistry and Pharmaceutical Sciences, Howard University, Washington, D.C., USA
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Aderoba AK, Steyn PS, Kiarie JN. Implementation strategies to scale up self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception: a scoping review. Syst Rev 2023; 12:114. [PMID: 37403147 PMCID: PMC10318699 DOI: 10.1186/s13643-023-02216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/06/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) is registered in many countries. It shows great potential for improving contraceptive access, continuation, and autonomy. However, there are challenges in rolling out this new efficacious intervention, and major implementation problems have been encountered during scale-up. OBJECTIVE To describe the implementation strategies to scale up self-administered DMPA-SC and the barriers, facilitators, and outcomes of these programs. METHOD Recent guidelines, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews, were used to design and report this review. An article or report was eligible for inclusion if it reported interventions that could scale up self-administered DMPA-SC implementation or its facilitators, barriers, or outcomes. We searched six electronic databases and the grey literature for eligible articles and reports. Two reviewers independently screened the document titles, abstracts, and full texts to identify eligible documents. Data were extracted using structured forms. Using the Effective Practice and Organization of Care (EPOC) taxonomy of health systems framework for thematic analysis, data were presented in a narrative approach. RESULTS Of the 755 retrieved documents, 34 were included in this review. Most of the documents included were multi-country reports (n = 14), and all documents were published within the last 5 years (2018-2021). This review identified documents that reported interventions in all EPOC domains. The most-reported interventions were: task-sharing amongst health workforce cadres, engaged leadership, encouraging policies, training and education, DMPA-SC demand generation, integration into existing programs, improved funding mechanisms, collaboration with development partners, and supply chain strengthening. The main barriers were suboptimal funding, inadequate human resources, and poor logistics supply of DMPA-SC. There was minimal evidence of scale-up outcomes. CONCLUSION This scoping review reported a wide range of interventions employed by countries and programs to scale up DMPA-SC self-administration but minimal evidence of the scale-up outcomes. Evidence from this review can help design better programs that improves access to quality family planning services to achieve the Sustainable Development Goals (SDG) targets 3.7. However, efforts should focus on rigorous implementation research that assess scaled up self-administered DMPA-SC interventions and report their outcomes. REGISTRATION The protocol for this review was registered in the protocols.io repository ( https://www.protocols.io/view/a-protocol-for-a-scoping-review-of-implementation-x54v9yemmg3e/v1 ).
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Affiliation(s)
- Adeniyi Kolade Aderoba
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Centre for Population Health and Interdisciplinary Research, Box 603, HealthMATE 360, Ondo Town, Ondo State, 350001, Nigeria.
| | - Petrus Schoken Steyn
- UNDP/UNFPA, UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization Headquarters, Geneva, Switzerland
| | - James Njogu Kiarie
- UNDP/UNFPA, UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization Headquarters, Geneva, Switzerland
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Lydon MM, Vilanculos J, Martinez A, Barata A, Keyes E. Effects of the COVID-19 pandemic on maternal and perinatal health service utilisation and outcomes in Mozambique: an interrupted time series analysis. BMJ Open 2022; 12:e062975. [PMID: 36385027 PMCID: PMC9670093 DOI: 10.1136/bmjopen-2022-062975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To measure the effects of the COVID-19 pandemic on maternal and perinatal health services and outcomes in Mozambique. DESIGN This is an observational study analysing routine service delivery data using interrupted time series analysis. We used 43 months of district-level panel data with April 2020 as the point of interruption, adjusting for seasonality and population growth to analyse service utilisation outcomes. SETTING The 222 public health facilities in Nampula Province, Mozambique, from January 2018 to July 2021. OUTCOME MEASURES The change in the number of antenatal care (ANC) visits and facility deliveries, and the change in the rate of adverse birth outcomes at pandemic onset and over time compared with expected levels and trends, respectively. RESULTS There were no significant disruptions to ANC at pandemic onset. Following this, there was a significant monthly increase of 29.8 (18.2-41.4) first ANC visits and 11.3 (5.5-17.2) ANC visits within the first trimester per district above prepandemic trends. There was no significant change in the number of fourth ANC visits completed. At the onset of COVID-19, districts experienced a significant decrease of 71.1 (-110.5 to -31.7) facility deliveries, but the rate then increased significantly above prepandemic trends. There was no significant increase in any adverse birth outcomes during the pandemic. Conversely, districts observed a significant monthly decrease of 5.3 uterine rupture cases (-9.9 to -0.6) and 19.2 stillbirths (-33.83 to -4.58) per 100 000 facility deliveries below prepandemic trends. There was a significant drop of 23.5 cases of neonatal sepsis/100 000 facility deliveries per district at pandemic onset. CONCLUSION Despite pandemic interference, Nampula Province saw no disruptions to ANC, only temporary disruptions to facility deliveries and no increases in adverse birth outcomes. ANC visits surprisingly increased, and the rates of uterine rupture, stillbirth and neonatal sepsis decreased, suggesting that Nampula Province may offer insights about health system resilience.
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Affiliation(s)
- Megan M Lydon
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, Durham, North Carolina, USA
| | | | - Andres Martinez
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, North Carolina, USA
| | | | - Emily Keyes
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, Durham, North Carolina, USA
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Morozoff C, Cover J, Namagembe A, Nsangi D, Komunyena Tumusiime J, Stout A, Kidwell Drake J. Contraceptive self-injection through routine service delivery: Health worker perspectives from Uganda. Front Glob Womens Health 2022; 3:890017. [PMID: 36204255 PMCID: PMC9531016 DOI: 10.3389/fgwh.2022.890017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022] Open
Abstract
Self-care reproductive health innovations are increasingly valued as practices that enable women to manage their fertility with greater autonomy. While self-care, by definition, takes place beyond the clinic walls, many self-care practices nonetheless require initial or follow up visits to a health worker. Access to self-care hinges on the extent to which health care workers who serve as gatekeepers find the innovation appropriate and practical. Self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is being introduced and scaled in many countries. In late 2018, health workers in Uganda began offering self-injection of DMPA-SC in the public sector, and this study examines health workers' views on the acceptability and feasibility of training women to self-inject. We conducted in-person interviews with 120 health workers active in the self-injection program to better understand provider practices, program satisfaction, and their views on feasibility. A subset of 77 health workers participated in in-depth interviews. Quantitative data was analyzed using Stata (v14) software, and chi square and student t tests used to measure between group differences. Qualitative data was analyzed using Atlas.ti, employing an iterative coding process, to identify key themes that resonated. The majority of health workers were very satisfied with the self-injection program and reported it was moderately easy to integrate self-injection training into routine service delivery. They identified lack of time to train clients in the clinic setting, lack of materials among community health workers, and client fear of self-injection as key challenges. Community health workers were less likely to report time challenges and indicated higher levels of satisfaction and greater ease in offering self-injection services. The relatively high acceptability of the self-injection program among health workers is promising; however, strategies to overcome feasibility challenges, such as workload constraints that limit the ability to offer self-injection training, are needed to expand service delivery to more women interested in this new self-care innovation. As self-injection programs are introduced and scaled across settings, there is a need for evidence regarding how self-care innovations can be designed and implemented in ways that are practical for health workers, while optimizing women's successful adoption and use.
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Cover J, Namagembe A, Morozoff C, Tumusiime J, Nsangi D, Drake JK. Contraceptive self-injection through routine service delivery: Experiences of Ugandan women in the public health system. Front Glob Womens Health 2022; 3:911107. [PMID: 36060608 PMCID: PMC9433546 DOI: 10.3389/fgwh.2022.911107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Contraceptive self-injection (SI) is a new self-care practice with potential to transform women's family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women's experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10-17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.
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Ruderman LW, Packer C, Zingani A, Moses P, Burke HM. "Men can take part": examining men's role in supporting self-injectable contraception in southern Malawi, a qualitative exploration. Reprod Health 2022; 19:174. [PMID: 35945601 PMCID: PMC9361263 DOI: 10.1186/s12978-022-01476-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The male engagement framework for reproductive health, which presents men as family planning users, supportive partners, and agents of change, is being increasingly incorporated into family planning strategies worldwide. We applied this framework to understand the perspectives of and role that men play in supporting the use of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC). METHODS We conducted a qualitative analysis using data from a study conducted in southern Malawi to develop and test a counseling message to introduce DMPA-SC and self-injection. We conducted 4 focus group discussions (FGD) with male community leaders and partners of DMPA-SC users, 13 interviews and FGDs with public and private sector family planning providers, and 30 interviews with female clients. We explored all participant groups' perspectives on what could facilitate or prevent women from choosing self-injection, including views on men's attitudes towards DMPA-SC and self-injection. RESULTS Overall, participants expressed ways that men could be engaged as cooperative users, supportive partners, and agents of change, and felt that this would help build a more supportive environment for DMPA-SC self-injection use. Men held favorable opinions of DMPA-SC self-injection: they felt that it is useful, described ways they could actively and emotionally support their partners in its use, and described their role in normalizing it. CONCLUSIONS We suggest that DMPA-SC self-injection has the potential to be both a female-controlled and a cooperative method, based on the ability for women to use it autonomously and the option to encourage male partner involvement (only where the woman welcomes this). Shifting the conversation from viewing men as a barrier to men as a resource may allow us to harness the social capital of men and transform traditional power dynamics, therefore establishing more enabling environments to support autonomy and choice for DMPA-SC and self-injection use.
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Affiliation(s)
- Lucy W Ruderman
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Catherine Packer
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA.
| | - Akuzike Zingani
- Centre for Health, Agriculture Development Research and Consulting (CHAD), Blantyre, Malawi
| | - Philemon Moses
- Centre for Health, Agriculture Development Research and Consulting (CHAD), Blantyre, Malawi
| | - Holly M Burke
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
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Burke HM, Packer C, Fuchs R, Brache V, Bahamondes L, Salinas A, Veiga N, Miller A, Deese J. Acceptability of the contraceptive Sayana® Press when injected every four months: Results from a 12-month trial in Brazil, Chile and the Dominican Republic. Contraception 2022; 113:95-100. [PMID: 35483431 DOI: 10.1016/j.contraception.2022.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We assessed the acceptability of subcutaneous depot-medroxyprogesterone acetate 104 mg (Sayana® Press) when injected every four months for 12 months. STUDY DESIGN We assessed acceptability using questionnaires within a clinical trial to evaluate contraceptive effectiveness of Sayana® Press when the reinjection interval was extended from three to four months. We enrolled 750 women aged 18 to 35 years and at risk of pregnancy at three centers in Brazil, Chile, and the Dominican Republic who agreed to use Sayana® Press every four months for 12 months. Acceptability outcomes included responses to questions about perception of bleeding patterns and side effects, likes, and dislikes about the regimen. We descriptively compared outcomes across study centers and between those who completed the study and those who discontinued early. RESULTS Across the three centers, participants differed in age, marital status, years of schooling, and race. At the final visit, 90% reported being satisfied with Sayana® Press and 75% reported preferring to use this contraceptive every four months. The most common reasons women liked using Sayana® Press were for its duration of effectiveness, followed by amenorrhea. The most common dislike, when a reason was identified, was its effect on uterine bleeding, including amenorrhea reported by some participants. We also observed center-level differences in the proportion of women who liked amenorrhea. CONCLUSIONS Satisfaction with Sayana® Press injected every four months was high across the three demographically diverse Latin-American centers. However, participants had varied feelings towards contraceptive-induced amenorrhea.
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Affiliation(s)
- Holly M Burke
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA.
| | | | - Rachael Fuchs
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA
| | | | - Luis Bahamondes
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Caixa Postal 6181; 13084-971, Campinas, SP, Brazil
| | - Abril Salinas
- Instituto Chileno de Medicina Reproductiva, Universidad de Chile
| | - Nelio Veiga
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Caixa Postal 6181; 13084-971, Campinas, SP, Brazil
| | - Ashley Miller
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA
| | - Jennifer Deese
- Global Public Health Impact Center, RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27709, United States (formerly FHI 360)
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Hémono R, Packel L, Gatare E, Baringer L, Ippoliti N, McCoy SI, Hope R. Digital self-care for improved access to family planning and reproductive health services among adolescents in Rwanda: preliminary findings from a pilot study of CyberRwanda. Sex Reprod Health Matters 2022; 29:2110671. [PMID: 36083099 PMCID: PMC9467528 DOI: 10.1080/26410397.2022.2110671] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Adolescents experience significant barriers, including stigma and discrimination, to accessing voluntary family planning and reproductive health (FP/RH) services in Rwanda. Self-care interventions have been shown to reduce social barriers to FP/RH care, but little is known about the effectiveness of digital self-care for adolescents, particularly in low-resource settings. This paper presents findings from a pilot study of CyberRwanda, a digital self-care intervention providing comprehensive sexuality education and confidential online ordering of contraceptives for school-aged youth in Rwanda through a rights-based approach. A mixed-methods pilot study was conducted from November 2019 to February 2020 to assess feasibility, acceptability, and engagement and to inform a future impact evaluation. Surveys were administered to a random sample of 158 students aged 12–19 years in three secondary schools. In-depth interviews were conducted with students, parents, teachers, pharmacists, district-level administrators, and youth centre staff. Descriptive statistics were calculated and qualitative data were analyzed using a thematic coding approach. One hundred and fifty-eight surveys and 28 interviews were conducted. Results revealed high demand for CyberRwanda in schools. Students were interested in engaging with the program and found the FP/RH content relevant to their needs. However, few purchased contraceptive products through the online ordering system. There are preliminary indications that CyberRwanda may improve access to FP/RH information. An extended implementation period and further research are needed to measure the long-term impacts of the program and evaluate whether this digital self-care intervention can increase uptake of contraceptive methods and reduce adolescent pregnancy among school-aged youth.
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Affiliation(s)
- Rebecca Hémono
- Research Manager, Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Laura Packel
- Research Director, Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Emmyson Gatare
- Research Lead, YLabs Rwanda, 2nd Floor, Golden Plaza, KG 546 St. Kacyiru, Kigali, Rwanda
| | - Laura Baringer
- Project Director, YLabs Rwanda, 2nd Floor, Golden Plaza, KG 546 St. Kacyiru, Kigali, Rwanda
| | | | - Sandra I. McCoy
- Evaluation Principal Investigator, Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Rebecca Hope
- Chief Executive Officer, YLabs Rwanda, Berkeley, CA, USA
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Marx M. Evidence-Based Guidance for Self-Administration of Injectable Contraception. J Midwifery Womens Health 2020; 66:108-112. [PMID: 33369137 DOI: 10.1111/jmwh.13190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/13/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
The requirement of in-person visits every 3 months for a health care provider to administer intramuscular depot medroxyprogesterone acetate (DMPA-IM) is a significant barrier to its use, particularly in the wake of the coronavirus pandemic. Time and travel costs as well as scheduling conflicts also negatively impact the receipt of subsequent contraceptive injections, which can result in unintended pregnancies. Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) can be self-administered by individuals at home, expanding contraceptive access, convenience, and reproductive autonomy. With 30% less progestin, DMPA-SC improves upon the DMPA-IM formulation while retaining efficacy. As part of comprehensive contraceptive counseling, health care providers should consider offering DMPA-SC to eligible individuals interested in self-administration. Using a case study approach, evidence-based recommendations are reviewed for the off-label use of self-administered DMPA-SC in the United States.
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Affiliation(s)
- Megan Marx
- Columbia University School of Nursing, New York, New York
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Burke HM, Packer C, Wando L, Wandiembe SP, Muwereza N, Pradhan S, Zingani A, Ngwira B. Adolescent and covert family planning users' experiences self-injecting contraception in Uganda and Malawi: implications for waste disposal of subcutaneous depot medroxyprogesterone acetate. Reprod Health 2020; 17:117. [PMID: 32746860 PMCID: PMC7396890 DOI: 10.1186/s12978-020-00964-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is poised to increase access to contraception; however, governments are concerned about the waste management of used units. Self-injectors in Malawi and Uganda are currently instructed to store used units in containers and return them to health workers for disposal. However, this may not be feasible in low-resource settings, especially for younger or covert self-injectors. We describe adolescent (15–19 years) and adult (20–49 years) self-injectors’ disposal experiences in Uganda and Malawi. When possible, we compare covert and overt users’ experiences. Methods We conducted cross-sectional qualitative studies in 2019 with 50 self-injectors in Uganda and 60 in Malawi. We purposively selected approximately half adolescents and included those trained by clinic-based providers and community health workers. We conducted semi-structured interviews and thematic data analysis and compared the findings across settings. Results Just under half of both samples were adolescents, substantially more of whom were covert users in Uganda (68%) than Malawi (~ 10%). Most participants reported being told to store used units in a container and return them to health workers. About two-thirds of Uganda participants had disposed of at least one unit by the interview, most commonly returning them to health workers. Over one-third of Malawi participants had disposed of at least one unit by the interview, slightly more disposed into latrines compared to returning to health workers. Participants in both settings reported compliance with health workers’ disposal instructions as a primary reason for their disposal method. One-fifth of Uganda participants, mostly adolescent covert users, and one-quarter in Malawi said they were told they could dispose into latrines, and often did so. The majority in both settings said they would prefer to dispose units in latrines because they worried about needlestick injuries to others and because it was convenient. Some Uganda adolescent covert users felt returning units to health workers was challenging due to privacy concerns. Conclusions While most self-injectors disposed of used units as instructed, findings from both studies suggest that returning units to health workers is not preferred and may not be feasible for some adolescent covert users. More convenient disposal solutions should be identified.
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Affiliation(s)
- Holly M Burke
- Reproductive, Maternal, Newborn and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, North Carolina, 27701, USA.
| | - Catherine Packer
- Reproductive, Maternal, Newborn and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, North Carolina, 27701, USA
| | - Laura Wando
- WellShare International, PO Box 35514, Kampala, Uganda
| | | | - Nelson Muwereza
- N&E Consult International Limited, PO Box 75686, Makerere Hill Kampala, Uganda
| | - Subarna Pradhan
- Reproductive, Maternal, Newborn and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, North Carolina, 27701, USA
| | - Akuzike Zingani
- University of Malawi, Polytechnic, PO Box 303, Chichiri, Blantyre 3, Malawi
| | - Bagrey Ngwira
- University of Malawi, Polytechnic, PO Box 303, Chichiri, Blantyre 3, Malawi
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Brady M, Drake JK, Namagembe A, Cover J. Self-care provision of contraception: Evidence and insights from contraceptive injectable self-administration. Best Pract Res Clin Obstet Gynaecol 2020; 66:95-106. [PMID: 32199705 DOI: 10.1016/j.bpobgyn.2020.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
As new reproductive health products become available, women increasingly want to take a participatory role in their health. New developments and formulations of contraceptive products provide an opportunity to support this evolving trend toward self-care. Self-care, as defined by the World Health Organization (WHO), highlights the ability of individuals to promote health, prevent disease, and manage their own health with or without the support of a health care provider. The recently released WHO Guidelines on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights included new self-care recommendations related to use of family planning, including self-injection of injectable contraceptives and over-the-counter provision of oral contraceptive pills. This paper focuses on the research evidence of self-administration (self-injection) of subcutaneous depot medroxyprogesterone acetate (DMPA-SC), and the practical experience of providers, women, and family planning programs adopting self-injection practices. We also explore the role of self-care in the provision of other contraceptives.
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Affiliation(s)
- Martha Brady
- PATH DC Office, 455 Massachusetts Ave NW, 20001, Washington, DC, USA.
| | | | - Allen Namagembe
- PATH Uganda Office, Plot 17, Golf Course Road, Kololo, Kampala, Uganda.
| | - Jane Cover
- PATH, 2201 Westlake Ave Suite 200, Seattle, 98121, WA, USA.
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Cartwright AF, Otai J, Maytan-Joneydi A, McGuire C, Sullivan E, Olumide A, Baye Easton C, Speizer IS. Access to family planning for youth: perspectives of young family planning leaders from 40 countries. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.13045.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: With growing populations of young people, low and middle-income countries have renewed focus on reaching both unmarried and married youth with family planning (FP) services. Young people themselves bring an important perspective to guide future programmatic directions. Methods: In October 2018, 207 youth leaders in FP from around the world completed an online survey prior to their participation at the International Conference on Family Planning (ICFP). These youth leaders provided their perspectives on the most important influencers for youth FP use, how easy or hard it is for youth to obtain FP, preferred sources of FP methods for youth, and perceptions of commonly used terms in FP programming. We examined differences in perceptions of unmarried and married youth’s access to and use of FP using bivariate analyses. Results: Respondents reported that peers/friends were the most important influencer on use of FP among unmarried youth (80.2%), while spouse/partner was the most important for married youth (80.4%). Oral contraceptive pills, injectable contraception, and contraceptive implants were perceived as significantly harder for unmarried youth to access. Privacy, confidentiality, and anonymity were all important factors for the locations to access FP for unmarried youth, while married youth were more influenced by cost. None of the commonly used terms for FP were perceived positively by a majority of respondents, with the exception of ‘birth spacing’ by African respondents (51.0%). Conclusions: These findings indicate that the preferences and needs of unmarried youth are different than married youth, but that all young people face barriers accessing FP. Unmarried youth seeking family planning are more influenced by peers and friends and continue to face difficulty accessing methods compared to married youth. These findings indicate the importance of including youth perspectives in development of youth-focused family planning programs.
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Cartwright AF, Otai J, Maytan-Joneydi A, McGuire C, Sullivan E, Olumide A, Baye Easton C, Speizer IS. Access to family planning for youth: perspectives of young family planning leaders from 40 countries. Gates Open Res 2019; 3:1513. [PMID: 32025630 PMCID: PMC6978846 DOI: 10.12688/gatesopenres.13045.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2019] [Indexed: 11/22/2022] Open
Abstract
Background: With growing populations of young people, low and middle-income countries have renewed focus on reaching both unmarried and married youth with family planning (FP) services. Young people themselves bring an important perspective to guide future programmatic directions. Methods: In October 2018, 207 youth leaders in FP from around the world completed an online survey prior to their participation at the International Conference on Family Planning (ICFP). These youth leaders provided their perspectives on the most important influencers for youth FP use, how easy or hard it is for youth to obtain FP, preferred sources of FP methods for youth, and perceptions of commonly used terms in FP programming. We examined differences in perceptions of unmarried and married youth’s access to and use of FP using bivariate analyses. Results: Respondents reported that peers/friends were the most important influencer on use of FP among unmarried youth (80.2%), while spouse/partner was the most important for married youth (80.4%). Oral contraceptive pills, injectable contraception, and contraceptive implants were perceived as significantly harder for unmarried youth to access. Privacy, confidentiality, and anonymity were all important factors for the locations to access FP for unmarried youth, while married youth were more influenced by cost. None of the commonly used terms for FP were perceived positively by a majority of respondents, with the exception of ‘birth spacing’ by African respondents (51.0%). Conclusions: These findings indicate that the preferences and needs of unmarried youth are different than married youth, but that all young people face barriers accessing FP. Unmarried youth seeking FP are more influenced by peers and friends and continue to face difficulty accessing methods compared to married youth. These findings indicate the importance of including youth perspectives in development of youth-focused family planning programs.
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Affiliation(s)
- Alice F Cartwright
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Jane Otai
- Jhpiego, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Amelia Maytan-Joneydi
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27516, USA
| | - Courtney McGuire
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27516, USA
| | - Emily Sullivan
- Family Planning 2020, UN Foundation, 1750 Pennsylvania Avenue, Washington, D.C., 20006, USA
| | - Adesola Olumide
- Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria.,University College Hospital, Queen Elizabeth Road, Ibadan, Oyo State, Nigeria
| | - Catherine Baye Easton
- International Youth Alliance for Family Planning (IYAFP), 1750 Harvard Street NW, Washington, D.C., 20009, USA
| | - Ilene S Speizer
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27516, USA
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Liu J, Shen J, Schatzkin E, Adedeji O, Kongnyuy E, Onuoha C, Fajemisin M, Ayodeji K, Omoluabi E. Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.12890.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.
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Remme M, Narasimhan M, Wilson D, Ali M, Vijayasingham L, Ghani F, Allotey P. Self care interventions for sexual and reproductive health and rights: costs, benefits, and financing. BMJ 2019; 365:l1228. [PMID: 30936210 PMCID: PMC6441864 DOI: 10.1136/bmj.l1228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Michelle Remme
- United Nations University-International Institute for Global Health, Kuala Lumpur, Malaysia
| | - Manjulaa Narasimhan
- Department of Reproductive Health and Research, and UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | | | - Moazzam Ali
- Department of Reproductive Health and Research, and UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Lavanya Vijayasingham
- United Nations University-International Institute for Global Health, Kuala Lumpur, Malaysia
| | - Fatima Ghani
- United Nations University-International Institute for Global Health, Kuala Lumpur, Malaysia
| | - Pascale Allotey
- United Nations University-International Institute for Global Health, Kuala Lumpur, Malaysia
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17
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Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, Santo LD, Ngwira B. Factors Affecting Continued Use of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC): A Secondary Analysis of a 1-Year Randomized Trial in Malawi. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:54-65. [PMID: 30894394 PMCID: PMC6538126 DOI: 10.9745/ghsp-d-18-00433] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/16/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the supply- and demand-side factors influencing continued use of the injectable contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC). METHODS We conducted a 12-month randomized controlled trial in Malawi to measure DMPA-SC continuation rates. A total of 731 women presenting to clinic-based providers (CBPs) at 6 Ministry of Health clinics or to community health workers (CHWs) in rural communities were randomized to receive DMPA-SC administered by a provider or be trained to self-inject DMPA-SC. Data collectors contacted women after the reinjection window at 3, 6, and 9 months to collect data on discontinuation and women's experiences. Twelve months after enrollment or at early discontinuation, women had their final interview, including pregnancy testing. We compared continuation, pregnancy, and safety by whether DMPA-SC or self-injection training was provided by CHWs versus CBPs. We also conducted an exploratory analysis assessing the association between women's sociodemographic factors and the risk for discontinuation using stratified Cox proportional hazards models. FINDINGS The type of provider did not seem to influence continuation, pregnancy, or safety. As reported previously, women in the self-injection group were significantly less likely to discontinue the method compared with women in the provider-administered group (hazard ratio, 0.43; P<.001). The risk for discontinuation was also different among health facility catchment sites (P<.001). No other assessed sociodemographic factors were found to significantly influence the risk for discontinuation. CONCLUSIONS Public-sector CHWs can safely and effectively provide DMPA-SC and train women to self-inject DMPA-SC in low-resource settings. DMPA-SC continuation did not seem to be influenced by the type of provider, whether CBP or CHW, or women's sociodemographic characteristics.
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Affiliation(s)
| | | | - Mercy Buluzi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | | | | | - Bagrey Ngwira
- College of Medicine, University of Malawi, Blantyre, Malawi
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18
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Mvundura M, Di Giorgio L, Morozoff C, Cover J, Ndour M, Drake JK. Cost-effectiveness of self-injected DMPA-SC compared with health-worker-injected DMPA-IM in Senegal. Contracept X 2019; 1:100012. [PMID: 32494776 PMCID: PMC7252428 DOI: 10.1016/j.conx.2019.100012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/26/2019] [Accepted: 09/29/2019] [Indexed: 11/25/2022] Open
Abstract
Objectives To evaluate the cost-effectiveness of self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to health-worker-administered intramuscular DMPA (DMPA-IM) in Senegal and to assess how including practice or demonstration injections in client self-injection training affects estimates. Study design We developed a decision-tree model with a 12-month time horizon for a hypothetical cohort of 100,000 injectable contraceptive users in Senegal. We used the model to estimate incremental costs per disability-adjusted life year (DALY) averted. The analysis derived model inputs from DMPA-SC self-injection continuation and costing research studies and peer-reviewed literature. We evaluated the cost-effectiveness from societal and health system perspectives and conducted one-way and probabilistic sensitivity analyses to test the robustness of results. Results Compared to health-worker-administered DMPA-IM, self-injected DMPA-SC could prevent 1402 additional unintended pregnancies and avert 204 maternal DALYs per year for this hypothetical cohort. From a societal perspective, self-injection costs less than health worker administration regardless of the training approach and is therefore dominant. From the health system perspective, self-injection is dominant compared to health worker administration if a one-page instruction sheet is used and one additional DMPA-SC unit is used for training and is cost-effective at $208 per DALY averted when two additional DMPA-SC units are used. Sensitivity analysis showed estimates were robust. Conclusions Self-injected DMPA-SC averted more pregnancies and DALYs and cost less from the societal perspective compared to health-worker-administered DMPA-IM and hence is dominant. Using fewer DMPA-SC units for practice or demonstration improves cost-effectiveness of self-injection from the health system perspective. Implications Evidence from Senegal shows that self-injection of DMPA-SC can be dominant or cost-effective from both health system and societal perspectives relative to DMPA-IM from health workers even if women practice injecting or health workers demonstrate with one or two DMPA-SC units. Evidence on whether practice or demonstration is required for client training would be useful.
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Affiliation(s)
- Mercy Mvundura
- PATH, PO Box 900922, Seattle, WA 98109, USA
- Corresponding author at: PO Box 900922, Seattle, WA, 98109 USA. Tel.: + 1 206 302 4714.
| | | | | | - Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA
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Liu J, Shen J, Schatzkin E, Adedeji O, Kongnyuy E, Onuoha C, Fajemisin M, Ayodeji K, Omoluabi E. Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12890.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.
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20
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Cover J, Ba M, Drake JK, NDiaye MD. Continuation of self-injected versus provider-administered contraception in Senegal: a nonrandomized, prospective cohort study. Contraception 2018; 99:137-141. [PMID: 30439358 PMCID: PMC6367564 DOI: 10.1016/j.contraception.2018.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 11/08/2022]
Abstract
Objectives The primary objective of this study was to compare the 12-month continuation rate for women who self-injected subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) with that for women receiving intramuscular depot-medroxyprogesterone acetate (DMPA-IM) from a provider. This research contributes to the broader goal of identifying solutions to support women to use contraception for their full desired duration. Study design Participants were clients from 13 clinics in the Dakar and Thiés regions of Senegal who had decided to use injectable contraception prior to enrollment. They chose self-injection of DMPA-SC or provider administration of DMPA-IM. Self-injectors were trained and given three units of DMPA-SC. The provider-injected group received DMPA-IM and returned to the clinics for future injections. We interviewed participants at baseline and after the second, third and fourth injections (the equivalent of 12 months of contraceptive coverage). We employed Kaplan–Meier methods to estimate continuation probabilities, with a log-rank test to compare differences between groups. A multivariate Cox regression identified factors correlated with discontinuation. Results The 12-month continuation rate for 650 women self-injecting DMPA-SC was 80.2%, while that for 649 women receiving DMPA-IM from a provider was 70.4% (p<.01). The difference in continuation between self-injectors and those receiving DMPA from a provider remained significant in a multivariate Cox regression model. The primary reason for discontinuation in both groups (44.7% self-injected; 44.5% provider-injected) was forgetting to reinject or reinjecting late. Fewer women reported side effects in the self-injection group than in the provider-administered group. Conclusions The higher 12-month continuation rate for women self-injecting DMPA-SC relative to provider-administered DMPA-IM suggests that self-injection may help prevent pregnancy more consistently and continuously. Implications Discontinuation of injectable contraception among women wishing to avoid pregnancy may increase unmet need in francophone West Africa. This study showed higher 12-month continuation rates for women who self-injected DMPA-SC, suggesting that this delivery method may improve injectable continuation.
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Affiliation(s)
- Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA.
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Di Giorgio L, Mvundura M, Tumusiime J, Morozoff C, Cover J, Drake JK. Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda. Contraception 2018; 98:396-404. [PMID: 30098940 PMCID: PMC6197841 DOI: 10.1016/j.contraception.2018.07.137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/18/2018] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to health-worker-administered intramuscular DMPA (DMPA-IM) in Uganda. STUDY DESIGN We developed a decision-tree model with a 12-month time horizon for a hypothetical cohort of approximately 1 million injectable contraceptive users in Uganda to estimate the incremental costs per pregnancy averted and per disability-adjusted life year (DALY) averted. The study design derived model inputs from DMPA-SC self-injection continuation and costing research studies and peer-reviewed literature. We calculated incremental cost-effectiveness ratios from societal and health system perspectives and conducted one-way and probabilistic sensitivity analyses to test the robustness of results. RESULTS Self-injected DMPA-SC could prevent 10,827 additional unintended pregnancies and 1620 maternal DALYs per year for this hypothetical cohort compared to DMPA-IM administered by facility-based health workers. Due to savings in women's time and travel costs, under a societal perspective, self-injection could save approximately US$1 million or $84,000 per year, depending on the self-injection training aid used. From a health system perspective, self-injection would avert more pregnancies but incur additional costs. A training approach using a one-page client instruction sheet would make self-injection cost-effective compared to DMPA-IM, with incremental costs per pregnancy averted of $15 and per maternal DALY averted of $98. Sensitivity analysis showed that the estimates were robust. The one-way and probabilistic sensitivity analyses showed that the costs of the first visit for self-injection (which include training costs) were an important variable impacting the cost-effectiveness estimates. CONCLUSIONS Under a societal perspective, self-injected DMPA-SC averted more pregnancies and cost less compared to health-worker-administered DMPA-IM. Under a health system perspective, self-injected DMPA-SC can be cost-effective relative to DMPA-IM when a lower-cost visual aid for client training is used. IMPLICATIONS Self-injection has economic benefits for women through savings in time and travel costs, and it averts additional pregnancies and maternal disability-adjusted life years compared to health-worker-administered injectable DMPA-IM. Implementing lower-cost approaches to client training can help ensure that self-injection is also cost-effective from a health system perspective.
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Affiliation(s)
| | | | | | | | - Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA.
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DMPA-SC: an emerging option to increase women's contraceptive choices. Contraception 2018; 98:375-378. [DOI: 10.1016/j.contraception.2018.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 11/17/2022]
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Women's satisfaction, use, storage and disposal of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) during a randomized trial. Contraception 2018; 98:418-422. [DOI: 10.1016/j.contraception.2018.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 11/19/2022]
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Cover J, Namagembe A, Tumusiime J, Lim J, Cox CM. Ugandan providers' views on the acceptability of contraceptive self-injection for adolescents: a qualitative study. Reprod Health 2018; 15:165. [PMID: 30285779 PMCID: PMC6169014 DOI: 10.1186/s12978-018-0611-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 09/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-injection of subcutaneous depot medroxyprogesterone acetate may offer greater discretion and increase access to injectable contraception, particularly for those who face challenges accessing clinic services. In particular, unmarried adolescents often encounter stigma when seeking services, and may also lack the financial means to travel to clinics on the quarterly basis that injectable contraception requires. Whether self-injection is offered to women on a wide scale basis, and to adolescents specifically, will depend in part upon the willingness of providers to train clients of diverse ages and educational backgrounds. This study explores the views of providers with regard to self-injection as an option for women and adolescents in Uganda. METHODS In-depth qualitative interviews were conducted with family planning providers in Gulu district, to understand their views on injectable self-injection for women, with a specific focus on unmarried adolescents ages 15 to 19 years. The in-depth interviews, which lasted up to 60 min were audio-recorded, translated and transcribed simultaneously, and analyzed using Atlas.ti software to identify key themes and common perspectives. RESULTS A total of 40 health care providers were interviewed with equal numbers of each type (public, NGO, and private clinics, pharmacies, and community-based health workers). While most providers were receptive to self-injection for adult women, fewer than half were supportive of adolescent self-injection. Their reservations focused on age, marital status and parity concerns around adolescent use of the injectable more broadly, and concerns about the ability of adolescents to self-inject safely. CONCLUSIONS Self-injection presents an opportunity to reduce the enormous burden on the public sector health system in Uganda, which is particularly compounded by the heavy reliance on injectable contraception requiring quarterly clinic visits. The results of this study reveal a level of cautious support for self-injection among providers when it comes to self-injection by adult women. With respect to adolescent clients, family planning policymakers and program implementers should design, implement, and evaluate self-injection interventions with the needs of adolescent clients uppermost in mind, recognizing that extra attention will likely be needed to reduce provider-imposed restrictions on adolescent access to this injectable delivery modality.
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Affiliation(s)
- Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109 USA
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Chin-Quee DS, Stanback J, Orr T. Family planning provision in pharmacies and drug shops: an urgent prescription. Contraception 2018; 98:379-382. [PMID: 30170029 DOI: 10.1016/j.contraception.2018.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 10/28/2022]
Abstract
Drug shops and pharmacies have long been recognized as the first point of contact for health care in developing countries, including family planning (FP) services. Drug shop operators and pharmacists should not be viewed as mere merchants of short-acting contraceptive methods, as this ignores their capacity for increasing uptake of FP services and methods in a systematic and collaborative way with the public sector, social marketing groups and product distributors. We draw on lessons learned from the rich experience of earlier efforts to promote a variety of public health interventions in pharmacies and drug shops. To integrate this setting that provides convenience, confidentiality, access to user-controlled contraceptive methods (i.e., pills, condoms and potentially Sayana Press®) and a gateway to clinic-based FP services, we propose three promising practices that should be encouraged in future interventions to increase access to quality FP services.
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Affiliation(s)
- Dawn S Chin-Quee
- FHI 360, Division of Health Services Research, 359 Blackwell Street, Suite 200, Durham, North Carolina, USA.
| | - John Stanback
- FHI 360, Division of Health Services Research, 359 Blackwell Street, Suite 200, Durham, North Carolina, USA
| | - Tracy Orr
- FHI 360, Division of Health Services Research, 359 Blackwell Street, Suite 200, Durham, North Carolina, USA
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An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa. Contraception 2018; 98:411-417. [PMID: 30120925 PMCID: PMC6197832 DOI: 10.1016/j.contraception.2018.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 12/02/2022]
Abstract
Objectives Given the promise of DMPA-SC to increase community-level access to modern contraception in developing countries, we conducted an observational study to assess the acceptability and feasibility of DMPA-SC self-injection among women in Kinshasa, Democratic Republic of the Congo, and of medical/nursing (M/N) students as instructors for self-injection. Study design Women who selected DMPA-SC at a community outreach event adjacent to a health center were interviewed upon acceptance (baseline) and then 3, 6 and 12 months later. Results Of 850 clients selecting DMPA-SC at baseline, 640 (75.3%) opted for self-injection over being injected by the M/N students for reasons of convenience and personal agency. Among these 640 self-injectors, 47.5% were anxious at baseline (for fear of needles or injecting incorrectly). Over 80% reported feeling very ready after training, confident that they knew how to self-inject and confident that they would remember the next injection date. By 3 months, 97% described it as easy. Half (54%) experienced side effects, mainly menstrual irregularities, the main reason for discontinuation. At 6-month follow-up, self-injectors cited effectiveness and ease of use as positive elements, though one quarter reported side effects. Their impressions of M/N students as instructors were highly positive. Conclusions Where DMPA-SC was free and easily accessible, the majority of women interested in DMPA-SC opted to learn self-injection. The M/N students performed well in instructing women to self-inject. Clients were highly satisfied with the services received, yet many did not recognize their student status, possibly because outreach occurred near a health facility. Once told, clients remained very favorable, suggesting strong motivation to receive their preferred contraceptive free, whoever the provider. Implication statement This study provides additional evidence on the acceptability and the feasibility of the self-injection of DMPA-SC by users from a resource-limited setting.
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Di Giorgio L, Mvundura M, Tumusiime J, Namagembe A, Ba A, Belemsaga-Yugbare D, Morozoff C, Brouwer E, Ndour M, Drake JK. Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal. Contraception 2018; 98:389-395. [PMID: 29859148 PMCID: PMC6197836 DOI: 10.1016/j.contraception.2018.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 12/04/2022]
Abstract
Objective To evaluate the 12-month total direct costs (medical and nonmedical) of delivering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) under three strategies — facility-based administration, community-based administration and self-injection — compared to the costs of delivering intramuscular DMPA (DMPA-IM) via facility- and community-based administration. Study design We conducted four cross-sectional microcosting studies in three countries from December 2015 to January 2017. We estimated direct medical costs (i.e., costs to health systems) using primary data collected from 95 health facilities on the resources used for injectable contraceptive service delivery. For self-injection, we included both costs of the actual research intervention and adjusted programmatic costs reflecting a lower-cost training aid. Direct nonmedical costs (i.e., client travel and time costs) came from client interviews conducted during injectable continuation studies. All costs were estimated for one couple year of protection. One-way sensitivity analyses identified the largest cost drivers. Results Total costs were lowest for community-based distribution of DMPA-SC (US$7.69) and DMPA-IM ($7.71) in Uganda. Total costs for self-injection before adjustment of the training aid were $9.73 (Uganda) and $10.28 (Senegal). After adjustment, costs decreased to $7.83 (Uganda) and $8.38 (Senegal) and were lower than the costs of facility-based administration of DMPA-IM ($10.12 Uganda, $9.46 Senegal). Costs were highest for facility-based administration of DMPA-SC ($12.14) and DMPA-IM ($11.60) in Burkina Faso. Across all studies, direct nonmedical costs were lowest for self-injecting women. Conclusions Community-based distribution and self-injection may be promising channels for reducing injectable contraception delivery costs. We observed no major differences in costs when administering DMPA-SC and DMPA-IM under the same strategy. Implications Designing interventions to bring contraceptive service delivery closer to women may reduce barriers to contraceptive access. Community-based distribution of injectable contraception reduces direct costs of service delivery. Compared to facility-based health worker administration, self-injection brings economic benefits for women and health systems, especially with a lower-cost client training aid.
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Affiliation(s)
| | | | | | | | - Amadou Ba
- Independent consultant, Cite Menthor Diouf Villa N. 02 Zac Mbao, Dakar, Senegal.
| | | | | | - Elizabeth Brouwer
- University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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Liu J, Shen J, Diamond-Smith N. Predictors of DMPA-SC continuation among urban Nigerian women: the influence of counseling quality and side effects. Contraception 2018; 98:430-437. [PMID: 29733817 PMCID: PMC6197834 DOI: 10.1016/j.contraception.2018.04.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 11/26/2022]
Abstract
Objectives In 2015, private healthcare providers in Nigeria introduced DMPA-SC (depot medroxyprogesterone acetate administered subcutaneously) into the method mix. We aimed to [1] examine the sociodemographic predictors of continued DMPA-SC use after 3 months, and [2] characterize the additional influences of contraceptive counseling quality and experiences of side effects on continuation. Study design From March to August, 2016, we conducted phone interviews with a convenience sample of women obtaining DMPA-SC from selected providers to survey them about their experience obtaining an initial dose of DMPA-SC. Study coordinators contacted women again about 3 months later after when they were due for reinjection. We used logistic regressions to examine the likelihood of having obtained a subsequent dose of DMPA-SC at follow-up as predicted by sociodemographic characteristics, a quality of counseling indicator based on responses to a 14-item scale, and reports of side effects experienced. Results Of the 541 DMPA-SC users who completed the first survey, 311 were reached again via phone after 3 months to conduct a second survey. Multivariate results for sociodemographic predictors of continued DMPA-SC use show that those with some college education or more (OR=2.79; 95% CI: 1.09–7.14), and those with four or more children (OR=2.89; 95% CI: 1.09 0 7.67) were more likely to obtain another dose. Our summary quality measure showed that women overall rated the quality of their initial counseling session high. Logistic regressions indicated that higher quality during the initial counseling session is related to the likelihood of getting another dose of DMPA-SC (OR=2.04; 95% CI: 1.12–3.47) whereas experiencing more bleeding reduced the likelihood of continuation after 3 months (OR=0.15; 95% CI: 0.07–0.34). Conclusions Among urban Nigerian women, both counseling quality and experiencing side effects were important factors in predicting continued use of DMPA-SC after 3 months. These findings are consistent with previous studies of DMPA and injectable contraception continuation. Implications New contraceptive methods that are designed for increased access and ease of use, combined with high quality provision, have potential to increase contraceptive use in settings with low levels of contraceptive prevalence. Higher quality counseling can help encourage women's continuation of a new injectable contraceptive method at 3 months.
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Affiliation(s)
- Jenny Liu
- Institute for Health and Aging, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 340, San Francisco, CA 94118, USA.
| | - Jennifer Shen
- Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 266D, San Francisco, CA 94101, USA.
| | - Nadia Diamond-Smith
- Global Health Sciences, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street Mission Hall, San Francisco, CA 94158, USA.
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Kohn JE. DMPA self-administration can improve contraceptive access, continuation, and autonomy. LANCET GLOBAL HEALTH 2018. [DOI: 10.1016/s2214-109x(18)30077-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, Dal Santo L, Ngwira B. Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial. LANCET GLOBAL HEALTH 2018. [DOI: 10.1016/s2214-109x(18)30061-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Burke HM, Packer C, Buluzi M, Healy E, Ngwira B. Client and provider experiences with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in Malawi. Contraception 2018; 98:405-410. [PMID: 29706227 DOI: 10.1016/j.contraception.2018.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/20/2018] [Accepted: 02/21/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE As low- and middle-income countries (LMICs) consider adding self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) to their contraceptive method mix, learning about family planning clients' and providers' experiences with self-injectable DMPA-SC during trials will inform introduction and scale-up efforts. STUDY DESIGN We conducted semistructured interviews with 30 randomly selected adult women enrolled in the self-administration group of a 12-month randomized controlled trial studying DMPA-SC continuation rates in rural Malawi. We asked about their experiences learning to self-inject, self-injecting, remembering when to reinject, and storing and disposing of DMPA-SC. We also interviewed 12 providers - clinic-based providers (CBPs) and community-based health surveillance assistants (HSAs) - who trained clients to self-inject DMPA-SC during the trial. We asked about their experiences training and supporting women to self-inject DMPA-SC during the trial and their recommendations for scale-up of self-administered DMPA-SC. RESULTS Clients and providers reported positive experiences with DMPA-SC self-injection. Clients felt that DMPA-SC self-injection saved them time and money, and providers felt that it reduced their workload and saved them time. We found that both CBPs and HSAs successfully trained clients to self-inject DMPA-SC and that clients safely and appropriately stored and disposed of DMPA-SC. CONCLUSIONS Our findings contribute to the growing body of evidence of the feasibility of DMPA-SC self-injection in LMIC settings. We recommend that providers plan to train clients for at least 30min, emphasize the activating and injecting steps during training, use up to four practice injections per client trained and give self-injectors calendars to help them remember when to reinject. IMPLICATIONS DMPA-SC self-administration should be made available in LMIC settings, but because it is a new practice, implementation guidance is needed. We offer practical recommendations for introducing and scaling up DMPA-SC self-administration based on clients' and providers' experiences during a trial investigating this practice in Malawi.
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Affiliation(s)
- Holly M Burke
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA.
| | - Catherine Packer
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA.
| | - Mercy Buluzi
- College of Medicine, University of Malawi, P/Bag 360 Chichiri Blantyre 3, Malawi.
| | - Elise Healy
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA.
| | - Bagrey Ngwira
- College of Medicine, University of Malawi, P/Bag 360 Chichiri Blantyre 3, Malawi.
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Cover J, Namagembe A, Tumusiime J, Nsangi D, Lim J, Nakiganda-Busiku D. Continuation of injectable contraception when self-injected vs. administered by a facility-based health worker: a nonrandomized, prospective cohort study in Uganda. Contraception 2018; 98:383-388. [PMID: 29654751 PMCID: PMC6197833 DOI: 10.1016/j.contraception.2018.03.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/21/2018] [Accepted: 03/25/2018] [Indexed: 11/25/2022]
Abstract
Objective The purpose of this study was to compare 12-month continuation rates for subcutaneous depot medroxyprogesterone acetate (DMPA-SC) administered via self-injection and DMPA-IM administered by a health worker in Uganda. Study design Women seeking injectable contraception at participating health facilities were offered the choice of self-injecting DMPA-SC or receiving an injection of DMPA-IM from a health worker. Those opting for self-injection were trained one-on-one. They self-injected under supervision and took home three units, a client instruction guide and a reinjection calendar. Those opting for DMPA-IM received an injection and an appointment card for the next facility visit in 3 months. We interviewed participants at baseline (first injection) and after 3 (second injection), 6 (third injection) and 9 (fourth injection) months, or upon discontinuation. We used Kaplan–Meier methods to estimate continuation probabilities, with a log-rank test to compare differences between groups. A multivariate Cox regression identified factors correlated with discontinuation. Results The 12-month continuation rate for the 561 women self-injecting DMPA-SC was .81 [95% confidence interval (CI) .78–.84], and for 600 women receiving DMPA-IM from a health worker, it was .65 (95% CI .61–.69), a significant difference at the .05 level. There were no differences in pregnancy rates or side effects. The multivariate analysis revealed that, controlling for covariates, self-injecting reduced the hazard for discontinuing by 46%. A significant interaction between injection group and age suggests that self-injection may help younger women continue injectable use. Conclusions The significant difference in 12-month continuation between women self-injecting DMPA-SC and women receiving DMPA-IM from a health worker — which remains significant in a multivariate analysis — suggests that self-injection may improve injectable contraceptive continuation. Implications While injectable contraceptives are popular throughout much of sub-Saharan Africa, they have high rates of discontinuation. This study is the second from an African country to demonstrate that self-injection may improve injectable continuation rates and may do so without increasing the risk of pregnancy or adverse events.
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Affiliation(s)
- Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA.
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Cover J, Ba M, Lim J, Drake JK, Daff BM. Evaluating the feasibility and acceptability of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA) in Senegal: a prospective cohort study. Contraception 2017; 96:203-210. [PMID: 28673645 PMCID: PMC6381449 DOI: 10.1016/j.contraception.2017.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 11/27/2022]
Abstract
Objectives Expanding contraceptive options through self-injection may improve access and confidentiality. There are few published studies on contraceptive self-injection in sub-Saharan Africa and none in West Africa, a region with high unmet need. This study was performed to assess feasibility of subcutaneous DMPA self-injection in Senegal; objectives were to (1) measure the proportion of participants who self-injected competently 3 months after training, (2) measure the proportion who self-injected on time (defined conservatively as within 7 days of reinjection date), and (3) assess acceptability of self-injection. Study design In this prospective cohort study, 378 women aged 18–49 years were trained to self-inject by study nurses. Three months later, women returned unprompted to the clinic to self-inject, and technique and visit timing were evaluated. Women continuing with a third self-injection were followed up at home after their next scheduled injection date. At each interaction, participants were interviewed to learn about their experience; additional questions during the final home visit focused on storage and disposal practices, and acceptability. Results Among the 337 participants followed up 3 months post-training, 310 self-injected, and 87% did so competently. Factoring in women who declined to self-inject, electing to have the provider administer the injection instead, a total of 80% [95% confidence interval (CI) = 75–84%] self-injected competently 3 months post-training, and 84% [95% CI=80–88%] reinjected on time, while 72% [95% CI=67–77%] were both on time and competent. The vast majority (93%) expressed a desire to continue. Conclusions Self-injection is feasible and acceptable among most study participants in Senegal. Implications These first research results on contraceptive self-injection in West Africa indicate initial feasibility and acceptability of the practice. Results underscore the importance of designing self-injection programs that empower and support women, including those with limited education.
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Affiliation(s)
- Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA.
| | | | | | | | - Bocar M Daff
- Senegal Ministry of Health and Social Action, DSRSE, VDN, Cite Keur Gorgui, BP 4024, Dakar, Dakar, Senegal.
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