ObjectivesGiven the promise of DMPA-SC to increase community-level access to modern contraception in developing countries, we conducted an observational study to assess the acceptability and feasibility of DMPA-SC self-injection among women in Kinshasa, Democratic Republic of the Congo, and of medical/nursing (M/N) students as instructors for self-injection.Study designWomen who selected DMPA-SC at a community outreach event adjacent to a health center were interviewed upon acceptance (baseline) and then 3, 6 and 12 months later.ResultsOf 850 clients selecting DMPA-SC at baseline, 640 (75.3%) opted for self-injection over being injected by the M/N students for reasons of convenience and personal agency. Among these 640 self-injectors, 47.5% were anxious at baseline (for fear of needles or injecting incorrectly). Over 80% reported feeling very ready after training, confident that they knew how to self-inject and confident that they would remember the next injection date. By 3 months, 97% described it as easy. Half (54%) experienced side effects, mainly menstrual irregularities, the main reason for discontinuation. At 6-month follow-up, self-injectors cited effectiveness and ease of use as positive elements, though one quarter reported side effects. Their impressions of M/N students as instructors were highly positive.ConclusionsWhere DMPA-SC was free and easily accessible, the majority of women interested in DMPA-SC opted to learn self-injection. The M/N students performed well in instructing women to self-inject. Clients were highly satisfied with the services received, yet many did not recognize their student status, possibly because outreach occurred near a health facility. Once told, clients remained very favorable, suggesting strong motivation to receive their preferred contraceptive free, whoever the provider.Implication statementThis study provides additional evidence on the acceptability and the feasibility of the self-injection of DMPA-SC by users from a resource-limited setting.

Formidable challenges: uncertain political situation, cultural norms favoring high fertility, a thin patchwork of service delivery institutions, logistical issues in a vast country with weak infrastructure, and low capacity of the population to pay for contraceptive services. Encouraging progress: increasing government and donor support, openness to progressive service delivery policies, innovative programming including robust social marketing and initiatives with nursing schools and the military, strong collaboration among stakeholders, high unmet need suggesting strong latent demand for family planning, and an increasingly balanced method mix including long-acting methods.

In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools.

BackgroundAn estimated 214 million women have unmet need for family planning in developing regions. Improved utilization of the private sector is key to achieving universal access to a range of safe and effective modern contraceptive methods stipulated by FP2020 and SDG commitments. Until now, a lack of market data has limited understanding of the private sector’s role in increasing contraceptive coverage and choice.MethodsIn 2015, the FPwatch Project conducted representative outlet surveys in Ethiopia, Nigeria, and DRC using a full census approach in selected administrative areas. Every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, availability, and price.FindingsExcluding general retailers, 96% of potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods available. In Ethiopia, 41% of modern contraceptive stocking outlets were in the private sector compared with approximately 80% in Nigeria and DRC where drug shops were dominant. Ninety-five percent of private sector outlets in Ethiopia had modern contraceptive methods available; 37% had three or more methods. In Nigeria and DRC, only 54% and 42% of private sector outlets stocked modern contraceptives with 5% and 4% stocking three or more methods, respectively. High prices in Nigeria and DRC create barriers to consumer access and choice.DiscussionThere is a missed opportunity to provide modern contraception through the private sector, particularly drug shops. Subsidies and interventions, like social marketing and social franchising, could leverage the private sector’s role in increasing access to a range of contraceptives. Achieving global FP2020 commitments depends on the expansion of national contraceptive policies that promote greater partnership and cooperation with the private sector and improvement of decisions around funding streams of countries with large populations and high unmet need like Ethiopia, Nigeria, and DRC.

Building on expressed support from the Prime Minister to the Ministries of Health and Planning, the country’s new family planning commitment grew out of: (1) recognition of the impact of family planning on maternal mortality and economic development; (2) knowledge sharing of best practices from other African countries; (3) participatory development of a national strategic plan; (4) strong collaboration between stakeholders; (5) effective advocacy by champions including country and international experts; and (6) increased donor support. The question becomes: Will the favorable policy environment translate into effective local programming?