Self-injection (SI) of DMPA-SC has been a hot topic in the contraception field since pilot projects began about a decade ago. Early studies showed acceptability among providers and clients alike, contributing to mounting anticipation about its potential to influence women’s autonomy and control over contraception. Researchers and donors hoped self-injection could expand access to contraception for women who are typically more susceptible to structural barriers and the constraints of societal norms, such as unmarried adolescents or married women with unsupportive partners. With implementation currently in a more evolved state in many settings, we endeavored to understand how this contraceptive innovation is sitting with women—both those who have opted to use it themselves and others who have never tried SI.
In our study, published in Studies in Family Planning, we explored this topic through in-depth interviews with 241 women of reproductive age in Kenya, Nigeria, Malawi and Uganda. Women in our sample had diverse experience with contraception, offering a range of perspectives on the idea of and experience of SI. We were able to home in on the benefits of this novel method in the context of women’s lives.
What do women like about self-injection?
Among women who opted for SI as their method of contraception, their impressions were overwhelmingly positive. Within the identified benefits of privacy, eased access barriers, and self-management, women spoke of specific ways self-injecting impacted their lives for the better. Many women who had not tried SI echoed these same benefits as they described their interest in the method and why it was a desirable option for them. Women felt that administering the method within their home was advantageous because contraception was indeed a family matter, and the experience of traveling to and waiting in line at the health center had previously left them feeling exposed. Women in Malawi appreciated the bodily privacy and knowing they would not have to encounter a male provider as sometimes happened with other methods. Eased access was the most profound benefit; having the method at home helped women avert numerous common barriers to contraception, for example, stockouts, transportation costs, and provider bias. Finally, through self-management, women described making the injection experience more comfortable and less painful, as compared to provider-administered injections, and managing their own schedules and supply offered reassurance that the method would have the efficacy they desired.
How are implementation efforts falling short?
While positive experiences among SI users were the norm, our findings also revealed important limitations in the method that may be ameliorated with enhancements to implementation efforts. Despite the method’s early promise, adolescent women and those with partners disapproving of contraception were not well-represented in our sample of SI users, and women using other methods or no method that fit this description were often hesitant to try SI. For them, the method did not offer enough in the way of privacy or avoiding provider bias. Additionally, fear was a prominent theme among women who had never tried SI; fear of needles, fear of injecting incorrectly, and fear of adverse effects were all reasons women cited for not wanting to self-inject. Interestingly, many SI users spoke about such fears when they initiated use of the method but had experienced a steady dissipation of these feelings with continued use.
How can SI implementation better meet women’s needs?
To reach women who require the greatest discretion when using contraception, we need to see more innovation around accessing SI units and training. Technology—when available—may be a key resource to expand avenues for communication, support, training, and even delivery of units. Well-trained providers may be able to reduce some women’s fear through supportive counseling. Perhaps more so, peer support networks show great promise in getting women to see themselves as capable self-injectors. Utilizing experienced SI users in such interventions offers relatability for the beneficiaries and potential cost-effectiveness for programs.
To conclude, “Women’s perspectives on the unique benefits and challenges of self-injectable contraception: A four-country in-depth interview study in sub-Saharan Africa,” offers a rich exploration of how women experience and perceive SI in various countries. While the many women who are using SI celebrate its advantages, its early promise has fallen short in terms of offering a path to greater autonomy for women who typically face the most barriers to contraceptive use. Our findings highlight where to focus energy in this next iteration of SI implementation to optimize its potential as a self-care contraceptive method.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Emily Himes, Department of Family and Community Medicine, University of California San Francisco