Self-administration of injectable contraception: a systematic review and meta-analysis

Abstract

IntroductionDepot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) may facilitate self-administration and expand contraceptive access. To inform WHO guidelines on self-care interventions, we conducted a systematic review and meta-analysis comparing self-administration versus provider administration of injectable contraception on outcomes of pregnancy, side effects/adverse events, contraceptive uptake, contraceptive continuation, self-efficacy/empowerment and social harms.MethodsWe searched PubMed, Cumulative Index to Nursing and Allied Health Literature, LILACS and EMBASE in September 2018 for peer-reviewed studies comparing women who received injectable contraception with the option of self-administration with women who received provider-administered injectable contraception on at least one outcome of interest. Risk of bias was assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for non-randomised studies. Meta-analysis was conducted using random-effects models to generate pooled estimates of relative risk (RR).ResultsSix studies with 3851 total participants met the inclusion criteria: three RCTs and three controlled cohort studies. All studies examined self-injection of DMPA-SC; comparison groups were either provider-administered DMPA-SC or provider-administered intramuscular DMPA. All studies followed women through 12 months of contraceptive coverage and measured (dis)continuation of injectable contraception. Meta-analysis found higher rates of continuation with self-administration compared with provider administration in three RCTs (RR: 1.27, 95% CI 1.16 to 1.39) and three controlled cohort studies (RR: 1.18, 95% CI 1.10 to 1.26). Four studies reported pregnancies; all showed no difference across study arms. Four studies reported side effects/adverse events; while two controlled cohort studies showed increased injection site reactions with self-administration, no other side effects increased with self-administration. One study found no difference in social harms. No studies reported measuring uptake or self-efficacy/empowerment.ConclusionA growing evidence base suggests that self-administration of DMPA-SC can equal or improve contraceptive continuation rates compared with provider administration. This benefit comes without notable increases in pregnancy or safety concerns. Self-injection of DMPA-SC is a promising approach to increasing contraceptive use.

Contraception in the Era of COVID-19

“…Train for and offer self-injection of Sayana Press (DMPA-SC), where available, for women desiring injectable contraception. 9 Continue to offer insertion of LARC methods, such as intrauterine devices and contraceptive implants, to new users where possible with adequate safety preparations for the procedure. Make arrangements to avoid having too many clients in the waiting area.…”

Adolescent and covert family planning users’ experiences self-injecting contraception in Uganda and Malawi: implications for waste disposal of subcutaneous depot medroxyprogesterone acetate

“…A subcutaneous (SC) version of depot medroxyprogesterone acetate (DMPA-SC) in a prefilled, Uniject™ injection system (Sayana Press with 104 mg of medroxyprogesterone acetate in 0.65 mL suspension for injection), is an easy-to-use, self-injectable contraceptive option. Research has demonstrated DMPA-SC selfinjection to be acceptable, feasible, safe and improve continuation rates [12][13][14][15][16][17][18][19][20][21][22], however, the need to dispose of used product after injecting themselves outside of clinical settings might present problems for adolescent and covert self-injectors.…”

Prioritising gender, equity, and human rights in a GRADE-based framework to inform future research on self care for sexual and reproductive health and rights

“…We adopted a similar methodological approach to research formulation used in two previously published WHO guidelines 11 12. Prior to the GDG meeting, a systematic review, including meta-analysis where appropriate, was conducted for each of the five selected PICO questions 13–17. The overall certainty of evidence was rated as high, moderate, low or very low according to the Grading of Evidence, Assessment, Development and Evaluation (GRADE) approach 18.…”