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. 2018 Nov;98(5):423-429.
doi: 10.1016/j.contraception.2018.08.007. Epub 2018 Aug 17.

Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda

Ellen MacLachlan  1 , Lynn M Atuyambe  2 , Tieba Millogo  3 , Georges Guiella  4 , Seydou Yaro  5 , Simon Kasasa  2 , Justine Bukenya  2 , Agnes Nyabigambo  2 , Fredrick Mubiru  6 , Justine Tumusiime  7 , Yentéma Onadja  4 , Lonkila Moussa Zan  4 , Clarisse Goeum/Sanon  5 , Seni Kouanda  8 , Allen Namagembe  9
Affiliations

Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda

Ellen MacLachlan et al. Contraception. 2018 Nov.

Abstract

Objective: The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda.

Study design: Participants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product.

Results: Twelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda.

Conclusions: There is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso.

Implications: The subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users.

Keywords: Community-based distribution; DMPA-IM; DMPA-SC; Injectable contraception; Sayana Press.

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Figures

Fig. 1
Fig. 1
Participant flow diagram for DMPA-SC and DMPA-IM users enrolled in the study, and injectable continuation rates in Burkina Faso and Uganda.
Fig. 2
Fig. 2
Kaplan–Meier cumulative probability of DMPA-SC and DMPA-IM continuation in (A) Burkina Faso and (B) Uganda. Log-rank test for equality of survivor function, p value=.31 (Burkina Faso) and .88 (Uganda).
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