Introducing the subcutaneous depot medroxyprogesterone acetate injectable contraceptive via social marketing: lessons learned from Nigeria's private sector

How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria

BACKGROUND

Inconsistent provision of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection (SI) undermines efforts to improve women's reproductive health agency and access to self-care. In Nigeria, providers feel pro-social responsibility as frontline health workers to support their clients' wellbeing. However, their pronatalist beliefs censure premarital sexual activity and inhibit access to contraceptives for young, unmarried women. How pro-social tendencies and provider biases interact to affect service delivery is a critical but underexplored question.

METHODS

We conducted a mixed-methods study comparing stated pro-social tendencies and intentions to dispense DMPA-SC for SI (N = 81 in-depth interviews (IDIs)) with actual dispensing behavior during mystery client (MC) visits (N = 162 post-interaction surveys) across private and public facilities in Lagos, Enugu and Plateau. Qualitative analysis of providers' pro-social tendencies, biases, and reasons for not offering DMPA-SC for SI complemented quantitative analysis exploring the associations between pro-social tendencies and dispensing behavior.

RESULTS

Providers showed substantial levels of both pro-social tendencies and bias against young, unmarried women. High levels of stated intentions to dispense in IDIs (91% to older, married women vs 78% to young, unmarried women) did not translate to actual willingness to dispense in MC visits (30% to older, married women vs 27% to young, unmarried women). Young, unmarried actors were twice as likely to perceive differential treatment from providers (33%) relative to older, married women actors (17%). From IDIs, providers expressed biases about the appropriateness of family planning and SI specifically based on a client's age, marital status, parity, and covert use. In some cases, pro-social tendencies reinforced bias when providers sought to uphold social norms as a gatekeeper; in other cases, pro-social tendencies on self-defined client needs helped overcome bias. Providers described other factors that deterred them from dispensing DMPA-SC for SI, including elements of self-care that posed risks to their practice or business.

CONCLUSIONS

Provider biases may limit provision of DMPA-SC for SI, which could affect contraceptive equity and women's control over their own fertility, especially for younger, unmarried women. Targeted interventions that effectively address provider biases against young, unmarried women, potentially leveraging providers' underlying pro-social tendencies, may help ensure equity in client access to contraceptive self-care.

Scale-up of the DMPA-SC in Nigeria: Why policy matters

BACKGROUND

Injectable contraceptives have contributed substantially to Nigeria's rise in modern family planning methods usage. They are one of the most commonly used and preferred means of contraception among women in the country. Enabling policies are required to assure contraceptive access, security, and use. This study aimed to investigate the policy environment and how it supports or limits Nigeria's introduction and scale-up of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC).

METHODS

The design of this mixed-methods study was cross-sectional. Desk reviews of policy papers, key informant interviews, and in-depth interviews were used to obtain information from respondents about the introduction of DMPA-SC in Nigeria and how existing policies influenced its scale-up. Data on DMPA-SC and other injectables were gathered from Nigeria's national electronic logistics management information system.

RESULTS

The findings suggest that policies such as task-shifting and task-sharing, cost-free policies, reproductive health policies, and others created an enabling environment for the scale-up of DMPA-SC adoption in Nigeria. The inclusion of DMPA-SC on the essential medicines list and the approved patent medicines list facilitated the scale-up process by ensuring private sector participation, removing economic barriers to access, fostering greater collaboration among health worker cadres, improving intersectoral partnerships, and improving logistics and client access. Despite significant anomalies in some implementing policies, injectable contraceptive consumption data demonstrate a progressive increase in DMPA-SC use during the study period. The results also indicate that policy initiatives have a favorable impact on the use of DMPA-SC throughout the country.

CONCLUSION

The existence of policies, the active participation of stakeholders, and the political will of the Nigerian health system's leadership have all aided in the scaling-up of the DMPA-SC. Understanding how to build an enabling policy climate is critical for providing women with family planning options. These lessons from Nigeria emphasize the importance of these levers, which should be considered by teams intending to introduce innovative health products, particularly in developing countries.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Self-injected contraceptives: does the investment reflect women's preferences?

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an innovative contraceptive method aimed at meeting women's unique circumstances and needs, largely due to its ability to be self-injected. Substantial research and advocacy investments have been made to promote roll-out of DMPA-SC across sub-Saharan Africa. To date, research on the demand for DMPA-SC as a self-injectable method has been conducted largely with healthcare providers, via qualitative research, or with highly specific subsamples that are not population based. Using three recent rounds of data from Performance Monitoring for Action, we examined population-representative trends in demand, use, and preference for self-injection among current non-users in Burkina Faso, the Democratic Republic of Congo (Kinshasa and Kongo Central regions), Kenya, and Nigeria (Lagos and Kano States). We found that while over 80.0% of women had heard of injectables across settings, few women had heard of self-injection (ranging from 13.0% in Kenya to 24.8% in Burkina Faso). Despite initial increases in DMPA-SC prevalence, DMPA-SC usage began to stagnate or even decrease in all settings in the recent three years (except in Nigeria-Kano). Few (0.0%-16.7%) current DMPA-SC users were self-injecting, and the majority instead were relying on a healthcare provider for administration of DMPA-SC. Among current contraceptive non-users wishing to use an injectable in the future, only 1.5%-11.4% preferred to self-inject. Our results show that self-injection is uncommon, and demand for self-injection is very limited across six settings, calling for further qualitative and quantitative research on women's views on DMPA-SC and self-injection and, ultimately, their contraceptive preferences and needs.

Resilient and Accelerated Scale-Up of Subcutaneously Administered Depot-Medroxyprogesterone Acetate in Nigeria (RASuDiN): A Mid-Line Study in COVID-19 Era

Background

Injectable contraceptives are fast becoming the method of choice among women in sub-Saharan Africa (SSA). Specifically, the subcutaneously administered depot–medroxyprogesterone acetate (DMPA-SC) is gaining traction as a convenient, private and effective method to address unmet need for family planning (FP). The objective of this study was to determine the trend in DMPA-SC use in Nigeria.

Methods

Data was extracted from the National Health Management Information System (NHMIS) FP register on DMPA-SC uptake in public health facilities and through community-oriented resource providers (CORPS) in 10 Nigerian states. The linear trend model was adopted in data analysis based on lowest measure of dispersion and/or highest adjusted coefficient of determination (R²). The statistical significance was determined at 5%.

Results

There was an upward trend in the use of DMPA-SC among clients who received the service through health providers, CORPS and self-injection in the 10 project states over a period of 12 months (August 2019–July 2020). In addition, the linear trend model showed that for every unit increase in months, the average number of women expected to use DMPA-SC through health providers, CORPS and self-injection will increase by 1308.3 (Yt = 3799.7 +1308.3*t), 756.73 (Yt = −1030.8 +756.73*t) and 77.864 (Yt = −159.7 +77.864*t) respectively. In all models, the adjusted coefficient of determination was 99.9% which showed good model fitness. The results also showed that the number of DMPA-SC clients varied across the project states with Niger (32,988) and Oyo (31,511) states reporting the highest number of clients over the period of 12 months.

Conclusion

There was an increasing use of DMPA-SC and self–injection among clients over time. Health facility and community-based FP programs should be strengthened to ensure improved access to FP services.

Thoracic Visceral Adipose Tissue Area and Pulmonary Hypertension in Lung Transplant Candidates. The Lung Transplant Body Composition Study

Rationale: Obesity is associated with an increased risk of pulmonary hypertension (PH); however, regional adipose tissue deposition is heterogeneous with distinct cardiovascular phenotypes.Objectives: To determine the association of body mass index (BMI) and thoracic visceral and subcutaneous adipose tissue areas (VAT and SAT, respectively) with PH in patients with advanced lung disease referred for lung transplantation.Methods: We studied patients undergoing evaluation for lung transplantation at three centers from the Lung Transplant Body Composition Study. PH was defined as mean pulmonary artery pressure >20 mm Hg and pulmonary vascular resistance ≥3 Wood units. VAT and SAT were measured on chest computed tomography and normalized to height squared.Results: One hundred thirty-seven (34%) of 399 patients included in our study had PH. Doubling of thoracic VAT was associated with significantly lower pulmonary vascular resistance (β, -0.24; 95% confidence interval [95% CI], -0.46 to -0.02; P = 0.04), higher pulmonary arterial wedge pressure (β, 0.79; 95% CI, 0.32 to 1.26; P = 0.001), and decreased risk of PH (relative risk, 0.86; 95% CI, 0.74 to 0.99; P = 0.04) after multivariate adjustment. Vaspin levels were higher in patients without PH (median, 101.8 vs. 92.0 pg/ml; P < 0.001) but did not mediate the association between VAT and the risk of PH. SAT and BMI were not independently associated with risk of PH.Conclusions: Lower thoracic VAT was associated with a higher risk of PH in patients with advanced lung disease undergoing evaluation for lung transplantation. The role of adipokines in the pulmonary vascular disease remains to be evaluated.

Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences

Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.

Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria

Background: From August 2016 to December 2017, the United Nations Population Fund (UNFPA) in Nigeria, through three implementing partners, scaled up the public sector delivery of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) across 10 states. The public sector program featured a proactive community-based distribution (CBD) model, led by community health extension workers (CHEWs) and supported by community health volunteers (CHVs). Methods: We conducted monitoring and evaluation (M&E) alongside program implementation to understand the program’s reach, particularly in terms of clients served, and their proportions of new users of modern contraception and younger women. Key performance indicators (KPIs) were calculated from end-user data digitized from client registers. To evaluate performance trends over time and understand geographic variation, we analyzed quarterly data in Excel and Stata 15, and complemented these analyses with data from interviews conducted periodically with program staff and performance documentation submitted by implementing partners. Results: The program reached 144,505 clients, of whom 88% (n=127,315) were women. Among women reached, 92% (n=116,614) chose DMPA-SC. The program reached a high percentage of new users of modern contraception: 80% (n=93,075) of DMPA-SC clients were new users, as were 80% (n=111,350) of overall clients. However, only 26% (n=36,313) of clients were under 25. From performance reports and interviews with program staff, many involved credited the CBD model with reaching a client base largely comprised of new users of modern contraception. Conclusions: Our analysis of the Nigeria public sector DMPA-SC program suggests that the combination of DMPA-SC and proactive CBD may accelerate contraceptive uptake and reduce unmet need in Nigeria. While some strategies for increasing the cost-efficiency of the CBD emerged, future research on this delivery model should focus on key concerns about the modality’s sustainability.

Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences

Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.

Predictors of DMPA-SC continuation among urban Nigerian women: the influence of counseling quality and side effects

Objectives

In 2015, private healthcare providers in Nigeria introduced DMPA-SC (depot medroxyprogesterone acetate administered subcutaneously) into the method mix. We aimed to [1] examine the sociodemographic predictors of continued DMPA-SC use after 3 months, and [2] characterize the additional influences of contraceptive counseling quality and experiences of side effects on continuation.

Study design

From March to August, 2016, we conducted phone interviews with a convenience sample of women obtaining DMPA-SC from selected providers to survey them about their experience obtaining an initial dose of DMPA-SC. Study coordinators contacted women again about 3 months later after when they were due for reinjection. We used logistic regressions to examine the likelihood of having obtained a subsequent dose of DMPA-SC at follow-up as predicted by sociodemographic characteristics, a quality of counseling indicator based on responses to a 14-item scale, and reports of side effects experienced.

Results

Of the 541 DMPA-SC users who completed the first survey, 311 were reached again via phone after 3 months to conduct a second survey. Multivariate results for sociodemographic predictors of continued DMPA-SC use show that those with some college education or more (OR=2.79; 95% CI: 1.09–7.14), and those with four or more children (OR=2.89; 95% CI: 1.09 0 7.67) were more likely to obtain another dose. Our summary quality measure showed that women overall rated the quality of their initial counseling session high. Logistic regressions indicated that higher quality during the initial counseling session is related to the likelihood of getting another dose of DMPA-SC (OR=2.04; 95% CI: 1.12–3.47) whereas experiencing more bleeding reduced the likelihood of continuation after 3 months (OR=0.15; 95% CI: 0.07–0.34).

Conclusions

Among urban Nigerian women, both counseling quality and experiencing side effects were important factors in predicting continued use of DMPA-SC after 3 months. These findings are consistent with previous studies of DMPA and injectable contraception continuation.

Implications

New contraceptive methods that are designed for increased access and ease of use, combined with high quality provision, have potential to increase contraceptive use in settings with low levels of contraceptive prevalence. Higher quality counseling can help encourage women's continuation of a new injectable contraceptive method at 3 months.