Self-administration of injectable contraception

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Self-administration of depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) can lead to improved contraceptive continuation rates and equivalent pregnancy prevention compared to provider administration. These are the findings of a literature search and meta-analysis published in BMJ Global Health.

The American and Swiss review authors wanted to illuminate the guidelines from the World Health Organization (WHO) about self-care interventions for sexual and reproductive health and rights (SRHR).

Six studies (three randomized controlled trials [RCTs] and three controlled cohort studies) published in a peer-reviewed journal between 2012 and 2019 met the inclusion criteria, which included a study design that compared women given the option of self-administering the contraceptives to those who weren’t offered that method of use.

The location of two of the studies was the United States, and one study each was in Scotland, Uganda, Senegal and Malawi. Individual studies ranged between 128 and 1,299 participants, with an aggregate of 3,851 women.

All studies included an arm with women who self-injected DMPA-SC. However, in three studies, the comparison arm was provider-administered DMPA-SC, while in the other three studies the comparison arm was a provider-administered intramuscular product (DMPA-IM).

All six studies followed participants through 12 months of contraceptive coverage, for which discontinuation and continuation of injectable contraception were recorded. Rates of continuation were higher with self-administration than with provider administration in both the three RCTs (RR 1.27; 95% CI: 1.16 to 1.39) and the three controlled cohort studies (RR 1.18; 95% CI: 1.10 to 1.26). Four of the six studies reported pregnancies, with no difference across study arms.

Four studies also reported side effects/adverse events. “While two controlled cohort studies showed increased injection site reactions with self-administration, no other side effects increased with self-administration,” wrote the review authors. “One study found no difference in social harms. No studies reported measuring uptake or self-efficacy/empowerment.”

DMPA-SC is produced and marketed as a prefilled needle and drug combination, with availability in at least 20 Family Planning 2020 (FP2020) countries and regulatory approval in over 40 countries.

“Allowing women to self-inject DMPA may remove barriers to DMPA continuation, specifically challenges around returning to a healthcare facility every 3 months for a new injection,” the authors wrote. “There is hope that self-injection of DMPA-SC, or other injectable contraceptives, could expand access to contraception for women facing challenges to regular access to healthcare settings or where provider shortages limit availability.”

One study each from Scotland and the United States offered self-administration support by text messages and/or emails to remind participants of their next injection. The remaining four studies provided a calendar to remind women of their reinjection window. However, there were no distinct differences in outcomes based on the reminder method.

Concerning age, the Uganda controlled cohort study concluded that in women 25 and older, self-injecting reduced the risk of discontinuation by 25%, while for women 18 to 24, self-injecting reduced the risk by 40%.

The two studies that showed no statistically significant difference in continuation across study arms were from high-income countries. But these were the two studies with the least number of participants.

“Self-injection of DMPA-SC is a promising approach to increasing contraceptive use,” the authors wrote. “This benefit comes without notable increases in pregnancy or safety concerns.”