One on One — Beth Fredrick of Advance Family Planning and Scott Radloff of Performance Monitoring and Accountability 2020 on Trends in Contraceptive Use and Increasing Access to Family Planning

Millions of women worldwide rely on injectable contraceptives as their primary method of contraception. Trends in contraceptive use show that in various low and middle-income countries, injectables account for about 50% of the modern methods used.

In the past few years, a new version of injectable contraception has gained traction among family planning providers and women, and with good reason. The new formulation, depot medroxyprogesterone acetate that can be delivered subcutaneously (DMPA-SC), comes in a prefilled Uniject™ injection system which is small and light and has an easier injection method than the existing formulation of intramuscular DMPA (DMPA-IM). With this advancement, there is potential for more types of health providers to be trained and provide the method as well as self-injection by women at home. DMPA-SC is heat-insensitive, allowing women to keep two or three future doses easily in their homes, cutting down the inconvenience, time cost, and opportunity cost of having to visit a health facility every three months for their next injection.

Advance Family Planning's Beth Fredrick and Performance Monitoring and Accountability 2020's (PMA2020) Scott Radloff, talk about DMPA-SC in Uganda and the broader potential for improving access to and use of family planning.

(Transcript has been edited for clarity and length)

Beth: PMA2020 and its partner Makerere University recently released new findings on contraceptive service provision and use from your surveys in Uganda. Uganda has been a frontrunner in introducing and providing DMPA-SC. What trends are you noticing in terms of DMPA-SC's use and availability in Uganda and in other countries where PMA2020 is active?

Scott: In recent rounds of surveys, PMA2020 has been able to shed light on DMPA-SC availability and use. In Uganda, about half of the public facilities in our sample are offering this method with a smaller share offering among private facilities.  And we’re seeing remarkable uptake. Among modern contraceptive users in our sample, the proportion using DMPA-SC nearly doubled (from about 6% of the method mix in 2017 to 11% a year later).  About 60% of these women are receiving this method from the public sector.  And, Uganda is not alone.  Where DMPA-SC is being made available, it is quickly becoming a measurable and significant share of the method mix as we have seen in Burkina Faso, Niger, and in some sub-geographies in Nigeria and the Democratic Republic of Congo.

Beth: I know that PMA2020 and Advance Family Planning share a desire to have a better contraceptive method mix and have DMPA-SC as just one part of that. PMA2020’s findings in Uganda also show progress in improving method mix. Not only is DMPA-SC use increasing, but there is an increasing use of implant. What else are you seeing?

Scott: A strong family planning program is one that offers a wide range of choice that can better meet women’s contraceptive needs as they change throughout their reproductive life cycle. As method options expand, we’re seeing, in Uganda in particular, a decrease in use of intramuscular DMPA (DMPA-IM) among women in our sample, as more women access and use DMPA-SC and implants. DMPA-IM had been the fastest growing method in Uganda as in other countries in Africa.

Scott: Advance Family Planning is working alongside several civil-society and government partners to make DMPA-SC more widely accessible to women. What kinds of policy gains have you made and what is your focus now?

Beth:  From the start, Advance Family Planning’s advocacy in Africa and Asia has aimed to improve contraceptive method mix and ensure that women have a choice of a number of contraceptive methods. Specific to DMPA-SC, we and our partners have worked to ensure a conducive policy environment.  One of the more notable advocacy wins was in collaboration with FHI360 in Uganda. The effort focused on government approval of pharmacy provision of injectable contraceptives. In July 2017, the Ugandan National Drug Authority Board authorized the stocking of injectable contraception in private drug shops, in 20 select districts. Until then, local drug shops—often women’s closest healthcare establishment—offered only a limited range of family planning methods: pills, condoms, and emergency contraception. Evidence from Uganda and elsewhere indicated that drug shop operators could provide it safely and effectively. With nearly 10,000 drug shops registered throughout the country, advocates saw potential to expand service offerings to include injectable contraception. As the pilot has been rolling out, the next step will be to see if we can make sure that all 10,000 of those drug shops are able to provide DMPA-SC, and that women will have easier access to it.

Scott: What are the advocacy opportunities for self-administration of DMPA-SC?

Beth: The advocacy win in Uganda opens the door not only for nationwide provision of injectable contraceptives, but also for specific provision of DMPA-SC. It also presents an avenue for advocacy in other countries where pharmacists could play a role in improving family planning access. The advocacy opportunities don’t stop there. Many advocates, including Advance Family Planning, are looking at a total market approach to see how the public and private sector and individuals themselves can better meet the need for family planning. We are working to include DMPA-SC provision, including self-administration, in official government guidance. Our advocacy partners are keeping watch on levels of contraceptive stocks, including findings from PMA2020. They are specifically interested in ensuring that enough DMPA-SC is available to keep pace with demand. We are also providing the rationale for governments to put their own funding behind contraception in general, and for DMPA-SC. Though we don’t yet know whether DMPA-SC relieves burdens on women themselves or the health service, there are indications that it will, and governments are paying attention.

Beth: One of the biggest benefits of DMPA-SC is its potential as a method that a woman can administer it to herself after she’s been trained to do so by a health provider. The World Health Organization is starting the process of developing normative guidance around self-interventions for health. Do you foresee PMA2020 looking at self-initiated care?

Scott: Once DMPA-SC self-injection is approved in the countries where we are active, PMA2020 can introduce questions relating to this practice. When you look at the array of contraceptive methods available, each have attributes that make them more or less accessible. One that is important is whether a method can be self-administered or woman-controlled.  In other words, women are able to determine when they will use it and when to stop without going to a provider. They need to be sufficiently counseled to know when and how to seek information so the normative guidance is important.  With self-administration a new possibility, DMPA-SC has the potential to join methods like the condom, pill, and emergency contraception. The easier it is for a woman to access and safely use the method of her choice, the better.  

Beth: Our experience, as advocates working in countries where DMPA-SC has been introduced, is that women and providers like it and scale-up is happening very quickly. We see PMA2020 as being an essential part of figuring out exactly how much it’s taking hold and whether it’s generating new use of contraception or displacing DMPA-IM, whether DMPA-SC is more attractive to young people versus older women. It will be one of the critical tools for advocates and for governments to keep track of the changes. We must be careful women aren’t pushed into self-injection. If they feel they need medical help or health professionals to provide confidence in using or switching methods, they should have access to that, as well.

Scott: We agree. Like you, we also have found a great deal of support within governments for helping women and couples to delay, space and prevent pregnancy. Sound research—like that of PMA2020 and others—has proven critical to track progress in making various contraceptives more widely available and used. Let me end by saying that every research enterprise needs a wider network to make sure that evidence drives policy and program change. We feel fortunate to have such a strong partnership. We rely on Advance Family Planning, and other advocates, to spark program and policy action.


Friday, July 27, 2018 - 17:15