Women in sub-Saharan Africa are voting with their feet. Or in the case of injectable contraceptives, they are voting with their arms.
Injectable contraceptives — which are typically administered in the upper arm and provide protection from pregnancy for 1-3 months depending on the formulation — are the most commonly used family planning method in sub-Saharan Africa, with more than one-third of contraceptive users choosing this method, according to a United Nations report. Worldwide, over 40 million women use injectable contraceptives, mainly depot medroxyprogesterone acetate — commonly known as Depo-Provera or DMPA.
Nineteen year old Masani* from Tanzania chose injectables because she wanted an effective method that was convenient and didn’t require daily action. When offered oral contraceptives at the clinic, she declined. “I will fail because I will forget,” she explained. Some women say that they appreciate injectable contraceptives because they do not require a more invasive medical procedure. For Masani, the familiarity of DMPA was appealing. “That one I can understand,” she said.
In addition, many women like injectables because they can be used covertly, an important consideration given that some women face opposition to family planning use from husbands, other family or community members.
Injectable contraceptives are also well-suited for task-shifting, a key benefit in settings where human resource constraints pose a substantial challenge and access to health clinics is limited. Increasingly, countries are introducing policies that allow lower cadre workers to offer injectables to clients at the community level. A new formulation of DMPA which is injected in the fatty layer of tissue just under the skin, known as Sayana Press, will soon be available in a prefilled, single-use syringe which may facilitate administration by community health workers or women themselves.
However, one concern is that even though injectables are popular, discontinuation rates are high. In many countries, up to half of women stop using injectables within 12 months of initiation, with discontinuation rates even higher in some settings. Masani stopped using the method after her second injection. “I [had] one injection. I was given a card, and I was told to go back after three months for another injection. I went and [got] injected. They told me to go back after another three months, but I never went [back].”
Women like Masani discontinue use for various reasons, including side effects such as changes in menstrual bleeding or opposition from family members. In addition, one of the key challenges for many clients is unintentional discontinuation due to missed follow-up appointments. Remote locations, a lack of reliable transportation, long waiting times, and associated costs contribute to missed or late clinic-based reinjection appointments. Often women who arrive late for their appointments are denied their next injection by providers in spite of being within the approved grace period.
Stock-outs also remain a major barrier in many developing countries. A long-term injectable user in Kenya described going to a clinic only to find that no supplies were available. “You can be discouraged until you stop [using injectables].”
In addition, some policymakers are concerned about injectables because they have been associated with HIV acquisition in several studies. The World Health Organization recently reviewed the evidence and still considers injectables to be a safe contraceptive but urges women at high risk of HIV acquisition to also use condoms.
How can we improve upon the design and delivery of current injectables to address these challenges while building on their popularity? FHI 360 recently launched a new initiative to support early proof-of-concept testing for research strategies that have the potential to be developed into a contraceptive injectable that lasts for six months. Because users would not have to get injections as frequently, a longer-acting injectable would likely lead to higher compliance and continuation rates. In turn, better compliance would result in higher clinical effectiveness and mean fewer unintended pregnancies. Less frequent injections would also reduce the burden on clinical facilities. This would be a win-win for women and health workers.
As the global health community works to achieve the ambitious goals laid out in the July 2012 London Summit on Family Planning, we must meet the needs of women by ensuring that sufficient supplies of injectables are available at an affordable price; that policies and programs are in place that support provision of high-quality services and that facilitate task-shifting; that service providers are well educated about the appropriate reinjection guidelines; and that continued support is invested in research and development for new and improved injectable products. When women vote with their feet — and with their arms — we have to listen.
*Names of clients changed. Quotations are from research conducted in Tanzania and Kenya by FHI 360 and partners.