By Rebecca Bowers

EXECUTIVE SUMMARY

New research indicates that use of subcutaneous depot medroxyprogesterone (DMPA-SC, marketed as Sayana Press, Pfizer Inc.) may help women to continue using injectable contraception longer than women who receive traditional intramuscular injections.

  • Data collected during a 12-month study period in Uganda suggest that 81% of 561 DMPA self-injection participants continued to use the product, compared to 65% of the 600 women who received DMPA injections administered by a health worker.
  • In a separate study, self-administration led to a more than 50% increase in continuous DMPA-SC pregnancy protection through 12 months, compared with provider-administered injection.

New research indicates that use of subcutaneous depot medroxyprogesterone (DMPA-SC, marketed as Sayana Press) may help women to continue using injectable contraception longer than women who receive traditional intramuscular injections.1 Data collected during a 12-month study period in Uganda suggest that 81% of 561 DMPA self-injection participants continued to use the product, compared to 65% of the 600 women who received DMPA injections administered by a health worker.1

The study, conducted by PATH, a Seattle-based international nonprofit global health organization, was designed to evaluate use of the device, which combines the drug and needle in the PATH-developed BD Uniject injection system. The small, prefilled device offers ease of use not only for providers with minimal training, but also for women themselves to administer via self-injection. Sayana Press is approved for use in more than 40 countries around the world.

The research, supported by the Bill & Melinda Gates Foundation and the Children’s Investment Fund Foundation, gives impetus to expanding use of self-injection in Uganda. Since national regulatory approval of self-injection was issued in Uganda in 2017, self-injection now is available in four districts of Uganda outside of a research setting. Plans are in process for a national rollout of the practice.

“Our vision for Uganda: any woman can go to any service delivery site to receive quality information about a range of contraceptive methods,” says Dinah Nakiganda, MD, MPH, assistant commissioner of reproductive health, Uganda Ministry of Health. “And self-injection will be one of them.”

Review the Data

To conduct the non-randomized cohort study, researchers enrolled 1,161 women ages 18-45 who were seeking injectable contraception at 14 public sector health facilities. Patients were offered the option of injecting DMPA-SC themselves or receiving an injection of the intramuscular form of DMPA from a health worker. Women who selected to self-inject were provided training and given three units of the drug, an instruction guide, and a reinjection calendar to take home.

Data indicate that at the end of 12 months, significantly more women who self-injected DMPA-SC continued to use the product compared to those who returned to a facility every three months to receive DMPA-IM from a health worker. In an analysis that controlled for multiple factors, data indicate that self-injection reduced the risk of discontinuing by 46%. Researchers note that while younger women exhibited a higher risk of discontinuation in general, self-injection appeared to help them continue. In the analysis, women 18 to 24 years of age who were self-injecting had a 40% reduced risk of discontinuing, compared with a 25% reduced risk for those women 25 years of age and older.1

“Women and girls have the ability and the right to manage their own sexual and reproductive health needs, and contraceptive self-injection is one new way to make this possible,” notes Martha Brady, MS, reproductive health program leader at PATH. “Supporting them to have greater control and decision-making through evidence-based ‘self-care’ approaches like this can benefit not only women and girls themselves, but health systems overall.”

Data Confirm Safety, Effectiveness

Research released earlier in 2018 indicates that DMPA-SC may be a new way to help increase continued contraception use among women in low-resource settings.2

FHI 360 conducted a one-year, randomized controlled trial in Malawi with more than 700 women who opted into the study after seeking family planning services at six Ministry of Health clinics or from community health workers. Those who were enrolled were randomized to receive either DMPA-SC from providers, including community health workers, or were given training on how to self-inject DMPA-SC. Women who received DMPA-SC were sent home with three doses, while those in the provider-administered group were asked to return for subsequent injections. Researchers reported that self-administration led to a more than 50% increase in continuous DMPA-SC pregnancy protection through 12 months, compared with provider-administered injection. Researchers observed similar rates of pregnancies, adverse events, and overall side effects in the self-administered and provider-administered groups.2

The study results will be used to inform decision-making on the procurement and distribution of DMPA-SC through the Malawi national health system. The study, funded by USAID and the Children’s Investment Fund Foundation, was conducted under the Advancing Partners & Communities project in partnership with the University of Malawi College of Medicine.

“These results have implications for other areas of global health, especially as new drug delivery technologies allow for self-administration,” says Holly Burke, PhD, MPH, FHI 360 scientist and principal investigator. “Self-injection of other medications may improve other health conditions affecting disadvantaged populations around the world. Adherence to medication is a global health problem that affects the entire medical field.”

Collaboration Expands Access

In 2017, Pfizer Inc., the Bill & Melinda Gates Foundation, and the Children’s Investment Fund Foundation enacted a multi-year extension of their collaboration to further broaden access to DMPA-SC. Through the collaboration, DMPA-SC has been made available to qualified purchasers at a guaranteed price of US $0.85 per dose, a reduction from the previous price of US $1 per dose.

The aim is to aid women who are most in need of contraception. Research estimates that approximately 225 million women in developing countries would like to prevent or delay pregnancy but they are not currently using any contraception.3 Barriers such as travel to health facilities, social barriers, and lack of knowledge about available contraceptive methods prevent women from accessing contraception. By expanding access to DMPA-SC, more women can have access to a method that is safe, effective, and self-administered, advocates say.

REFERENCES

  1. Cover J, Namagembe Al, Tumusiime J, et al. Continuation of injectable contraception when self-injected v. administered by a facility-based health worker: A non-randomized, prospective cohort study in Uganda. Contraception 2018; doi:10.1016/j.contraception.2018.03.032.
  2. Burke, 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; doi:10.1016/S2214-109X(18)30061-5.
  3. World Health Organization. Family planning/contraception fact sheet. Available at: https://bit.ly/1YIkQjP. Accessed May 14, 2018.