A prospective cohort study of the feasibility and acceptability of depot medroxyprogesterone acetate (DMPA) administered subcutaneously through self-injection

Objective: Evidence on contraceptive self-injection from the United States and similar settings is promising, and the practice may increase access. There are no published studies on the feasibility of contraceptive self-injection in sub-Saharan Africa to date. The purpose of this study was to assess feasibility of DMPA-SC self-injection in Uganda, with specific objectives to: 1) measure the proportion of participants who self-injected competently; 2) measure the proportion who self-injected on time three months after training (defined conservatively as within seven days of their reinjection date); and 3) assess acceptability.

Study design: In this prospective cohort study, 380 18 to 45 year old participants completed self-injection training by licensed study nurses, guided by a client instruction booklet, and practiced injection on prosthetics until achieving competence. Nurses supervised participants' self-injection and evaluated injection technique using an observation checklist. Those judged competent were given a Sayana® Press unit, instruction booklet, and reinjection calendar for self-injection at home three months later. Participants completed an interview before and after self-injection. Nurses visited participants at home following reinjection dates; during the follow-up visit, participants demonstrated self-injection on a prosthetic, injection technique was re-evaluated, and a post-reinjection interview was completed.

Results: Of 368 participants followed up three months post-training, 88% [95% confidence interval (CI)=84-91] demonstrated injection competence, and 95% (95% CI=92-97) reinjected on time, while 87% (95% CI=84-90) were both on-time and competent. Nearly all (98%) expressed a desire to continue.

Conclusions: Self-injection is feasible and highly acceptable among most study participants in Uganda.

Implications: The first research results on contraceptive self-injection in sub-Saharan Africa indicate initial feasibility and acceptability of the practice three months after women receive one-on-one training and a highly visual training and memory aid. Results can inform self-injection programs which aim to increase women's autonomy and access to injectable contraception.

Comment: Subcutaneous self-injection of DMPA for contraception has been very effective in popular in a number of high-income countries. This study shows that also in lower income countries this method can increase the choices and the independence of women when finding a suitable contraceptive. A good one-on-one training, however, is essential. (HMV)