A new study revealed that women can engage in self-care reproductive health through the use of subcutaneous injectable contraception.1

Adherence has long been a barrier to use of injectable contraceptives. Could the women administer the medication at the correct time and in the correct way? The authors of a new study answer that question affirmatively.

“Women are able to learn how to do this with appropriate training and support,” says Martha Brady, MS, director of sexual and reproductive health with PATH in Washington, DC.

The study focused on self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and the experience of women, providers, and family planning programs that adopted self-injection practices.

PATH investigators have been studying various self-care reproductive health methods employed by women who live in low-resource countries. (See Q&A on reproductive self-care worldwide in this issue.)

“We work in low-income countries, where a woman getting back to the clinic is challenging,” Brady says. “It’s a longer distance, and women have multiple daily tasks.”

This barrier is more prominent in developing countries, but women in high-income countries could benefit from reproductive health self-care as well — particularly in the midst of the COVID-19 pandemic.

“In this new, COVID-19 world we’re living in, we will see shifts in how health services are delivered,” Brady says. “It’s not just in reproductive health.”

When Brady and co-authors first wrote the paper on self-care, it was based on women’s empowerment. “Now, it’s in a new light, given COVID,” she says.

“There are a lot of blogs around this,” Brady adds. “What is the impact of COVID-19 on various health services? How can you maintain quality services when people can’t have access and have to do social distancing, and providers have to do other services related to COVID-19?”

In this context, the idea of self-care and self-injectable contraception is increasingly important, Brady says. Some women prefer self-injectables, rather than being given a shot by a provider.

“Individual choice has always been part of any work we do in family planning,” Brady says. “Choice is the answer to every problem.”

Also, there is precedent for people self-injecting medication. For example, people with diabetes self-inject insulin, she notes.

Adherence is important. Investigators have studied how well women adhere to provider instructions on how and when to self-inject.

“We’ve done studies in different countries,” Brady says. “Women need to be trained on how to do this by a provider, and they need to understand how often they need to inject.”

With a self-injection contraceptive, researchers focused on DMPA-SC, also called Sayana Press, because it can be injected subcutaneously. An alternative DMPA injectable, as well as norethisterone enanthate, must be injected into muscle, typically in the arm or buttocks. (More information is available at: https://www.ncbi.nlm.nih.gov/pubmed/6781816.) DMPA-SC is a game-changer because it can be injected subcutaneously, Brady says.

“Its self-injection device is an auto device that you can’t reuse,” she adds. This feature helps to protect women from infection.

“The percentage of women continuing to use the intramuscular Depo-Provera shot at one year is 56% — the lowest adherence of all modern contraceptives, including pills, patches, rings, IUDs, and implants,” says Robert Hatcher, MD, MPH, professor emeritus of obstetrics and gynecology at the Emory University School of Medicine in Atlanta. “This underscores the need for subcutaneous Depo-Provera. This technique can be taught to women themselves.”

Women who agree to use self-injectable contraception are trained by a provider. They are instructed to give themselves a dose of DMPA-SC every three months. Training materials are provided as reminders.

“It’s doable, but women will need a lot of information and support,” Brady says. “The fact that it’s subcutaneous allows for a lower dose and allows for self-injection.”

Intramuscular injections are physically hard for someone to do to themselves, Brady notes.

One of the chief challenges of self-care contraception is the willingness of nations to allow this practice. “We work with countries and ministries of health, and they decide whether country X will say they’ll allow this idea of self-injection or not,” she says. “Some say, ‘Not yet.’”

From a patient’s perspective, it is convenient. They do not have to return to a clinic every three months, so that obstacle is removed. And, it is empowering: “Women say, ‘I can do this,’” she adds.

The challenges include ensuring people are well-trained and have access to counseling, information, and support to continue the correct behavior.

When possible, women could contact a provider online or by phone to describe issues they are experiencing or to ask questions about what they should do in a given situation, Brady says. Back-up support is important for any self-care medical practice, she adds.

“When you allow people to do things at home, if they have a question, can they have virtual contact with a provider to say, ‘I’m experiencing this, and what do you say?’” Brady says. “There needs to be a mechanism to have a hotline.”

Reproductive health providers always have been focused on quality of care and empowering women. Providing self-injectable contraceptives is part of this tradition.

“My feeling is that in the history of medical care, people say, ‘Women can’t do this,’ but wait a minute — I’m going to vote for women,” Brady says.

REFERENCE

  1. Brady M, Drake JK, Namagembe A, et al. Self-care provision of contraception: Evidence and insights from contraceptive injectable self-administration. Best Pract Res Clin Obstet Gynaecol 2020. doi: 10.1016/j.bpobgyn.2020.01.003.