IntroductionMalawi has made progress in expanding access to modern contraceptive methods over the last decade, including the introduction of depot-medroxyprogesterone acetate subcutaneous (DMPA-SC) in 2018. DMPA-SC offers women the option to self-inject at home and may benefit adolescents with unmet need for contraception due to its discretion. This qualitative study was conducted to assess perspectives and preferences of adolescents with unmet need for contraception regarding the self-injection option of DMPA-SC in Malawi.MethodsSix focus group discussions were conducted involving 36 adolescents with unmet need for contraception (aged between 15 and 19 years, married and never-married) in October 2021 in three districts in Malawi. Data were coded inductively and analyzed thematically, using Dedoose software. Two validation workshops were conducted with other adolescents with unmet need in February 2022 to elucidate the preliminary findings.ResultsDMPA-SC attributes such as discretion and reduced facility visits were ranked most appealing by both married and never-married adolescents, particularly for adolescents needing covert contraception use. Concerns about self-injection included fear of pain, injury, and doubt in ability to self-inject. Never-married adolescents had additional concerns around privacy at home if using covertly, and fears of affecting long-term fertility. Overall, health surveillance assistants (community-based healthcare workers) were voted to be the most private, convenient, and affordable sources for potential DMPA-SC self-injection training.ConclusionSelf-injection of DMPA-SC may offer an appealing option for adolescents in Malawi, aligning most closely to the needs of married adolescents who may wish to delay or space pregnancies conveniently and discreetly, and who also may face fewer access barriers to receiving self-injection training from health care providers. Access barriers including stigma and concerns about privacy at home for adolescents needing to use contraception covertly would need to be adequately addressed if never-married adolescents were to consider taking up this option.

Since the introduction of depot medroxyprogesterone acetate (DMPA-SC) in 2018, Malawi has achieved national coverage of trained providers in the public sector and steady increases in uptake of DMPA-SC. However, the rate of clients opting to self-inject DMPA-SC has remained lower than early acceptability studies suggested. Providers play an instrumental role in building client confidence to self-inject through counselling. This cross-sectional qualitative study explored the perspectives of providers and injectable clients on the integration of self-injection into contraceptive counselling, to identify best practices and gaps. The study was conducted at public sector sites in three districts (Nkhotakota, Mzimba South, Zomba) in Malawi. In-depth interviews were conducted with provider-administered injectable clients, self-injecting clients, and DMPA-SC trained providers. All providers interviewed reported successfully integrating self-injection into their approach. During health education sessions, providers tended to focus mainly on benefits of self-injection to spark interest in the method, and then follow that up with more in-depth information in individual counselling.  Due to time pressures, a minority of providers reported replacing individual counselling with small-group counselling and limited their use of peer testimonials, visualizations, and demonstrations. Most providers skipped client practice on inanimate objects, feeling this was either not necessary or not appropriate given stock or resource constraints. Current self-injecting clients showed the best recall for self-injection steps and tended to report having received comprehensive, supportive counselling including aspects such as peer testimonials, visualizations, and demonstrations to build confidence. Injectable clients who had declined self-injection tended to demonstrate less detailed recall of key self-injection messages and report receiving incomplete information, and lack of peer testimonials, visualization, or demonstrations. Comprehensive counselling and training from supportive providers, including best practices identified in this study, are vital to improving client confidence to self-inject. Providers should be supported to overcome time- and resource-pressures to invest in these best practices.