Expanding Services for Injectable Contraceptives
Based on Population Reports, Series K, Number 6 Dec. 2006
Prepared by Robert Lande and Catherine Richey, MPH
More Women Are Choosing
• Worldwide use of • Injectables are
injectables more than currently the fourth
doubled over 10 years most popular
among married contraceptive method
women ages 15-49, worldwide.
increasing from 12 – In sub-Saharan Africa,
million in 1995 to over injectables are the most
popular method: among
32 million in 2005. women using modern
methods, 38% use
Levels of Use Vary Widely
• In sub-Saharan • Variations can be
Africa, Asia, and Latin attributed to a variety of
America and the factors.
Caribbean over 40% – Access to injectables
of married – Customs related to
contraceptive users contraceptive use
rely on injectables in – Government policies
some countries, while – Tolerance for side effects
5% to 7% use them in – Communication about
other countries. injectables
Numbers Expected to Grow as
Injectables Become More Available
• By 2015, worldwide
use is projected to
reach 40 million—
more than triple the
Source: Mauldin, 1994; Ross, 2005; United Nations, 2005
Two Types of Injectables Are
Progestin-Only Injectables Combined Injectables
•DMPA: Injected every three •Estrogen + Progestin (e.g.,
months Cyclofem, Mesigyna)
•NET-EN: Injected every two •Injected every month (also
months called ―monthly injectables‖)
Injectables Are a Popular
• Highly effective
– Used correctly, injectables are more effective than female
• Long acting
– No action required every day or at time of intercourse.
– Fertility returns after a woman stops using an injectable.
– Women can use injectables without anyone else knowing.
– No supplies must be kept around the house.
Injectables Are Not For
• Side effects may deter use or lead to
– Common side effects include irregular bleeding,
no monthly bleeding, and weight gain.
– In a large WHO trial, half of women stopped using
DMPA and NET-EN within 12 months (WHO, 1983).
• Some women have trouble returning to the clinic for
• Counseling helps women continue using injectables
(Canto de Cetina, 2001; Lei, 1996).
A Strategy to Meet Rising Demand
for Injectables Includes:
• Maintaining adequate supplies;
• Increasing efficiency;
• Providing training and supervision;
• Ensuring safe injections;
• Disposing of waste safely;
• Considering community provision of
• Helping women who need more information
about side effects or safety.
Supply Meets Demand With
Forecasting and Ingenuity
Programs Can Maintain
Adequate Stock Levels by…
• Keeping necessary supplies on
– Needles and syringes
– Vials of injectable contraceptives
– Sharps disposal containers
• Properly storing supplies to
– Store vials upright between 20°
and 25°C (68° and 77°F)
away from direct sunlight.
• Avoiding loss of expired stock.
– Use supplies with the earliest
expiration date first.
Forecasting Is Important When
Demand Is Rising
• Good forecasting takes into account:
– Expected increases in use of injectables;
– Past trends in use of injectables;
– Numbers of new and returning injectables clients;
– Changes in population.
• Software tools help monitor injectables stock
and plan procurement.
– E.g. Pipeline Software Tool (John Snow, Inc.)
If Stockouts Do Occur…
• Order an emergency shipment.
– USAID* and UNFPA can facilitate a fast shipment.
• Borrow supplies from nearby facilities.
• Mobilize suppliers, volunteers, and shippers.
– During a national stockout in Nepal, supplies were
procured, packaged, and delivered to every MOH
health facility within 60 days.
• Share clients.
– Facilities with low stocks of injectables can
encourage clients to go to other sources.
*for USAID-funded programs
Staffing and Training to Meet
Tailor Training to Fit Program
• Comprehensive training • Training may include:
may be needed if a – Characteristics of
program is adding injectables;
injectables as a new
– Giving safe injections;
method or training new
workers. – Counseling;
– Screening clients using
• Focused training may be medical eligibility criteria;
used to strengthen a – Correcting misperceptions;
specific component of – Conducting return visits;
– Managing side effects.
A Range of Providers Can Give
• With training, any health care provider can
give contraceptive injections.
– Such providers may include pharmacists, auxiliary
nurses, midwives, medical assistants, and
• Training a wider range of providers can
expand access to injectables.
– In Honduras, allowing auxiliary nurses to provide
injectables increased use by 19-35% in the rural
clinics where the nurses were posted (Mendoza,
Safe Injections Protect Clients,
Clinic Staff, and the Community
Auto-Disable (AD) Syringes
• WHO recommends
ideally AD syringes—for
• AD syringes inactivate
after a single use,
eliminating the risk of
infection due to reuse.
Safe Injection Practices
Prevent Infection Transmission
• Rules for safe injections:
– Prepare each injection in a clean,
– Use a sterile syringe and needle
for each injection;
– Discard disposable needles and
syringes in a sharps container
immediately after use;
– Safely dispose of waste according
to local or environmental
Choose an Appropriate Method
of Waste Disposal
• Programs should choose the disposal method
that is most appropriate for their local
conditions, taking into account cost, safety
risks, and environmental regulations.
– Burying waste in a protected pit at least two meters
– Incineration, at temperatures above 800°C.
– Burning waste at low temperatures and burying
remaining ash and noncombustible material in a
Expands Access to Injectables
Expands Access to Injectables
• Programs in several countries offer
injectables in community outlets:
– Mobile clinics, village clinics, periodic
temporary outreach clinics, or at the homes
of clients or community health workers
• Community provision has dramatically
increased use of injectables in some areas
– In the Navrongo Initiative in Ghana, 92% of
contraceptive users chose injectables from a
community provider (Debpuur, 2002; Phillips, 2005).
Community and Clinic
Provision Are Comparable
• A 2005 study in Uganda compared the quality of injectables
services in the community and in the clinic.
– Screening for medical eligibility: No reported screening
mistakes in either group.
– Counseling: Levels of client knowledge were the same in both
groups, but both needed improvement.
– Injection safety: No reported infections or needlestick injuries.
– Disposal of waste: Disposal practices in both groups needed
– Continuation rates: 88% of community clients and 85%
among clinic clients had a second injection.
– On-time repeat injections: 94% of clients in both groups
received their second injections on time (Stanback 2005) .
Challenges of Scaling-Up
• Retaining community providers
– To improve morale, the Ghana Health Service increased
incentives for community nurses to stay on the job and
allowed them to work in their home areas.
• Ensuring quality of care
– Training and supervision must cover screening for medical
eligibility, counseling, and waste disposal.
• Cost of offering household visits
– Encouraging women to visit community clinics can reduce
costs but may decrease access for some poor or
uneducated women who depend on household visits.
Meeting Rising Demand
Programs Can Avoid Large
Increases in Costs By…
• Organizing work better
– Improve the flow of clients through clinics by
reducing waiting time or setting up an ―express‖
line for routine repeat injections.
• Reducing the costs of supplies and facilities
– Buy injectables supplies and equipment in bulk at
the lowest available price.
• Increasing productivity
– In some clinics providers can be encouraged to
spend less time on administrative duties and more
time seeing clients.
Programs Can Recover Some
Costs by Encouraging Clients
to Pay if They Can
• Charging clients for services does not always
decrease demand substantially.
– Doubling the price of contraceptives has reduced
demand by no more than 15%, according to studies in
Bangladesh, Indonesia, and Nigeria.
• A willingness-to-pay survey can help gauge
what people are willing to pay for injectables
and other contraceptives.
Communication Helps Women
Try and Use Injectables
Tailor Messages For Specific
• Potential users
– May know about injectables but hesitate to try them.
– Seeing satisfied users and receiving correct information can help
women make informed choices about injectables.
• Current users
– May have questions or concerns about side effects.
– Interacting with a trusted source of information helps women cope
with changes if they occur.
• Partners and husbands
– Can help women use injectables effectively.
– A 1995 study in the Philippines found that women whose husbands
approved of injectables were more than twice as likely to continue
using the method (Population Council, 1996).
Interactive Sources Help
Inform About Injectables
• Telephone Hotlines
– Offer a private connection with a trained family planning
– In Turkey injectables users called with questions about side
effects (Berg, 1998).
• Discussions with providers
– Gives women a chance to interact directly with a trusted
• Community meetings
– An interactive and public way to improve knowledge and
answer questions about injectables.
Key Points for Clients to Make a
Well-Informed Choice of Injectables
Progestin-Only Injectables Combined Injectables
(DMPA and NET-EN)
•One of the most effective •One of the most effective
•Important to try to be on time for •Important to try to be on
next injection. time for next injection.
•Frequent or irregular bleeding at
•Likely to change bleeding
first, then little or no monthly
bleeding. This is not harmful.
during the first 3 months of
•Gradual weight gain is common
and not harmful.
use. This is not harmful.
•Delay in return to fertility (DMPA)
Providers Can Help Clients be
Informed Users of Injectables
• To support a client using injectables, tell her:
– When to return for her next injection and what to
do if she is late.
– That side effects are not harmful; providers can
help women manage some bothersome side
• If a client is dissatisfied with injectables, help
her choose a different method.
Women with HIV/AIDS Can Use
• Injectables are safe and effective for women with
HIV/AIDS, and for those taking ARV medications.
– The few studies available find that DMPA has little effect on
ARV medications and ARV medications do not reduce
effectiveness of DMPA (Chu, 2005; Cohn, 2005; WHO, 2004).
– Women on ARV medications can use the same injection
schedule as other women. They do not need to come back
• Injectables offer no protection against transmission
of STIs; male or female condoms can be used with
injectables to protect against STIs.
New Options Offer Women
• Subcutaneous Injection
– The low-dose depo-subQ provera
104 (DMPA-SC) is injected under
the skin every 3 months.
– Currently approved in the U.S. and
U.K.; may be available in
developing countries by 2008.
– In trials many women preferred
giving themselves injections
– May avoid repeated visits and
increase continuation rates
Photo and Illustration Credits
• Slide 1 Bangladesh/CCP
• Slide 5: JSI/DELIVER and Schering AG
• Slide 9: JSI/DELIVER
• Slide 10: JSI/DELIVER
• Slide 13: John Stanback/FHI
• Slide 16: John Stanback/FHI
• Slide 17: Dr. Sanjeev Badiger, Courtesy of Photoshare
• Slide 18: Rafael Avila/CCP
• Slide 20: Kingson Namun/Mark Munguas, Courtesy of Photoshare
• Slide 24: Population Services International
• Slide 27: Sarah A. Holtz, Courtesy of Photoshare
• Slide 33: Rafael Avila/CCP
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