DMPA self-administration can improve contraceptive access, continuation, and autonomy
Authors: Julia E Kohn
Journal: The Lancet Global Health (2018)

In their Article in The Lancet Global Health, Holly Burke and colleagues1Burke HM Chen M Buluzi M et al.Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial.Lancet Glob Health. 2018; (published online March 8.)http://dx.doi.org/10.1016/S2214-109X(18)30061-5Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar make an important contribution to the literature on the self-administration of the injectable contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC). In this large randomised controlled trial done in Malawi, the investigators used robust methods and frequent participant follow-up and found a significantly higher rate of 1 year DMPA-SC continuation among women who self-administered injections compared with those assigned to return to a provider for the injections, as is usual. The overall findings show great potential for self-administration to improve contraceptive access, continuation, and autonomy, including in low-income and middle-income countries. Data from previous research with the DMPA formulation depo-subQ provera 104 showed that self-administration of DMPA-SC was feasible, safe, and effective.2Beasley A White KO Cremers S Westhoff C Randomized clinical trial of self versus clinical administration of subcutaneous depot medroxyprogesterone acetate.Contraception. 2014; 89: 352-356Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 3Prabhakaran S Sweet A Self-administration of subcutaneous depot medroxyprogesterone acetate for contraception: feasibility and acceptability.Contraception. 2012; 85: 453-457Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 4Williams RL Hensel DJ Fortenberry D Self-administration of subcutaneous depot medroxyprogesterone acetate by adolescent women.Contraception. 2013; 88: 401-407Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 5Cameron ST Glasier A Johnstone A Pilot study of home self-administration of subcutaneous depo-medroxyprogesterone acetate for contraception.Contraception. 2012; 85: 458-464Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar Studies of the feasibility and acceptability of Sayana Press, the DMPA formulation used by Burke and colleagues, in west Africa and sub-Saharan Africa had similarly positive results.6Cover 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: 203-210Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 7Cover J Namagembe A Tumusiime J Lim J Drake JK Mbonye AK A prospective cohort study of the feasibility and acceptability of depot medroxyprogesterone acetate administered subcutaneously through self-injection.Contraception. 2017; 95: 306-311Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 8Burke HM Mueller MP Perry B et al.Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal.Contraception. 2014; 89: 361-367Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar Until very recently, however, no studies had sufficient sample sizes to detect improved continuation. In a recently published randomised controlled trial of 400 women done by researchers at Planned Parenthood in the USA,9Kohn JE Simons HR Della Badia L et al.Increased 1-year continuation of DMPA among women randomized to self-administration: results from a randomized controlled trial at Planned Parenthood.Contraception. 2017; (published online Dec 12.)http://dx.doi.org/10.1016/j.contraception.2017.11.009Summary Full Text Full Text PDF PubMed Google Scholar continuation was significantly improved among women randomised to self-administration of depo-subQ provera 104; Sayana Press is not available in the USA so was not used in that study. The study by Burke and colleagues is thus the second published randomised study to show improved continuation—and the largest one to date. Taken together, the findings of these studies show the clear potential of this new, patient-centred option across diverse settings. Although more research in other settings could bolster the evidence base, it seems that the results are in. Self-administration of DMPA-SC is feasible, acceptable, effective, and improves continuation. Therefore, I suggest that what is most needed is implementation research to analyse how self-administration is implemented in practice and to understand the barriers and facilitators to successful implementation. Such research should be informed by stakeholders, taking into account the needs and preferences of DMPA users, as well as the perspectives of health-care administrators, providers, and payers who will affect the true availability of this option across differently resourced countries with all of the associated complexities of health-care systems and financing. What additional information is needed, if any, to ensure that all countries have an injectable contraceptive that is specifically labelled for self-administration? What additional information is needed, if any, to convince insurers or health-care administrations to provide women with (and pay for) multiple doses at a time—to trust women and dispense with concerns about wasted supplies? These are just some of the questions that will need to be answered, in short order, to make this option a reality for women. I suspect that the answers might be different across countries and even states or provinces within countries. Furthermore, for the purposes of studying uninterrupted DMPA continuation—the primary study outcome—Burke and colleagues applied an admittedly strict definition of continuation. Such was true for the Planned Parenthood study9Kohn JE Simons HR Della Badia L et al.Increased 1-year continuation of DMPA among women randomized to self-administration: results from a randomized controlled trial at Planned Parenthood.Contraception. 2017; (published online Dec 12.)http://dx.doi.org/10.1016/j.contraception.2017.11.009Summary Full Text Full Text PDF PubMed Google Scholar as well. Although such strict definitions were necessary for the purposes of these studies, a subsequent real-world exploration of self-administration could take into account women's sexual activity or periods of abstinence; in other words, their ability to assess their own pregnancy risk and administer DMPA accordingly. Such an approach is not typical in examinations of contraceptive continuation—understandably so. But one could imagine a more nuanced exploration of women's use of DMPA that takes into account periodic abstinence or changes in relationship status. Having DMPA on hand to restart a week before a partner's return from a long absence or when beginning a new relationship would likely be valuable as well. Again, this would require trusting women to assess their own needs, risks, and preferences in a more dynamic fashion. Birth control is not one size fits all and perhaps DMPA is not either. Finally, as Burke and colleagues point out, self-administration of DMPA has the potential to reduce costs—to women, to providers, and to health-care systems more broadly. Although, to my knowledge, no formal cost-effectiveness studies of this have been published, the potential for reduced costs is a reasonable assumption. That said, it is crucial that the option of self-administration always remains just that—an option—and that those women who prefer to receive injections from a provider due to privacy or other reasons do not face reduced access in light of this new option. DMPA self-administration has great potential to improve contraceptive access, continuation, and autonomy, but only if it is made widely available and remains a true choice for women interested in this option. I have previously received investigator-initiated research support from Pfizer, who provided study drug for a randomised trial on DMPA self-administration in 2015. Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trialWomen who self-injected DMPA-SC had significantly higher rates of continuation than those receiving provider-injected DMPA-SC. Community-based provision of injectable contraception for self-injection in low-resource settings seems to be safe and feasible. Self-administration of DMPA-SC should be made widely available. Full-Text PDF Open Access