Implementation strategies to scale up self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception: a scoping review

Abstract

Background: Self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) is registered in many countries. It shows great potential for improving contraceptive access, continuation, and autonomy. However, there are challenges in rolling out this new efficacious intervention, and major implementation problems have been encountered during scale-up.

Objective: To describe the implementation strategies to scale up self-administered DMPA-SC and the barriers, facilitators, and outcomes of these programs.

Method: Recent guidelines, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews, were used to design and report this review. An article or report was eligible for inclusion if it reported interventions that could scale up self-administered DMPA-SC implementation or its facilitators, barriers, or outcomes. We searched six electronic databases and the grey literature for eligible articles and reports. Two reviewers independently screened the document titles, abstracts, and full texts to identify eligible documents. Data were extracted using structured forms. Using the Effective Practice and Organization of Care (EPOC) taxonomy of health systems framework for thematic analysis, data were presented in a narrative approach.

Results: Of the 755 retrieved documents, 34 were included in this review. Most of the documents included were multi-country reports (n = 14), and all documents were published within the last 5 years (2018-2021). This review identified documents that reported interventions in all EPOC domains. The most-reported interventions were: task-sharing amongst health workforce cadres, engaged leadership, encouraging policies, training and education, DMPA-SC demand generation, integration into existing programs, improved funding mechanisms, collaboration with development partners, and supply chain strengthening. The main barriers were suboptimal funding, inadequate human resources, and poor logistics supply of DMPA-SC. There was minimal evidence of scale-up outcomes.

Conclusion: This scoping review reported a wide range of interventions employed by countries and programs to scale up DMPA-SC self-administration but minimal evidence of the scale-up outcomes. Evidence from this review can help design better programs that improves access to quality family planning services to achieve the Sustainable Development Goals (SDG) targets 3.7. However, efforts should focus on rigorous implementation research that assess scaled up self-administered DMPA-SC interventions and report their outcomes.

Registration: The protocol for this review was registered in the protocols.io repository ( https://www.protocols.io/view/a-protocol-for-a-scoping-review-of-implementation-x54v9yemmg3e/v1 ).

Keywords: Implementation strategies; Injectable contraception; Scale-up; Scoping review; Self-care; Subcutaneous depot medroxyprogesterone acetate.

Fig. 1

PRISMA flow diagram for the DMPA-SC Self-Administration Scoping Review

Fig. 2

Delivery arrangements to scaling up DMPA-SC self-administration programs *How, when, and where DMPA-SC client self-administration was organized and delivered, and who delivered DMPA-SC client self-administration activities, **Self-administration of depot medroxyprogesterone acetate subcutaneous injectable contraception

Fig. 3

Financial arrangements to scaling up DMPA-SC self-administration programs *Insurance schemes, how funds were collected, how services were purchased, and the use of targeted financial incentives or disincentives for DMPA-SC client self-administration, **Self-administration of depot medroxyprogesterone acetate subcutaneous injectable contraception

Fig. 4

Governance arrangements to scaling up DMPA-SC self-administration programs *Rules or processes that affect how powers were exercised, particularly regarding authority, accountability, openness, participation, and coherence of DMPA-SC client self-administration programs, **Self-administration of depot medroxyprogesterone acetate subcutaneous injectable contraception

Fig. 5

Implementation strategies to scaling up DMPA-SC self-administration programs *Interventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals, and the use of health services by healthcare recipients **Self-administration of depot medroxyprogesterone acetate subcutaneous injectable contraception

Fig. 6

Implementation barriers to scaling up DMPA-SC self-administration programs **Self-administration of depot medroxyprogesterone acetate subcutaneous injectable contraception