Suppression of ovulation and pharmacokinetics following subcutaneous administration of various doses of Depo-Provera®: a randomized trial

Using Human-Centered Design to Explore Potential Users' and Men's Views of New Injectable Contraceptives in Kampala and Lagos

BACKGROUND

Injectable contraceptives are the most used method in sub-Saharan Africa. We conducted market research to assess potential user attitudes toward 4- and 6-month injectables. We also present user suggestions for marketing these new injectables once they are available.

METHODS

We implemented a 2-phase market research study from October through December 2021 in Kampala, Uganda, and Lagos, Nigeria. We conducted 11 focus group discussions (FGDs) with 51 participants in Kampala and 12 FGDs with 67 participants in Lagos. FGDs included current and potential injectable users and men stratified by marital status and age. Next, 23 women in Kampala and 24 in Lagos participated in cocreation workshops using human-centered design methods to explore marketing and communications strategies for each injectable. Data collection teams completed semistructured data extraction tables that were then analyzed thematically.

RESULTS

Participants liked both injectable options due to the reduced number of facility visits that would save time and money and increase privacy. Primary concerns included side effects, delayed return to fertility, cost, self-efficacy to self-inject, and stock-outs. Participants in Kampala preferred a shorter reinjection window (or "grace period") because it is easier to remember and they assumed it meant a quicker return to fertility, but participants in Lagos preferred a longer window because it provides extra time for reinjection. Citing norms around women needing to get pregnant quickly after marriage, participants in both sites felt that the 4-month injectable would benefit young people with busy lifestyles or limited access to facilities, whereas the 6-month injectable would benefit women who already had children.

CONCLUSIONS

We found that participants in Kampala and Lagos would prefer additional injectable options to meet the wide-ranging needs of users in different stages of their reproductive lives. Family planning program planners can apply the marketing insights we identified when these new injectables become available.

Another Best Practice: Leveraging User and Stakeholder Perspectives to Improve and Refine Existing Medical Products

Refinement of existing medical products, which may already have an established evidence base, robust market, and experienced users, may better meet user and potential user needs, if feedback from key stakeholders is solicited and incorporated early in the refinement process.

Service Delivery Considerations for Introducing New Injectable Contraceptives Lasting 4 and 6 Months in Nigeria and Uganda: A Qualitative Study

BACKGROUND

New family planning (FP) product introduction requires understanding the target market and support from stakeholders from across the health sector. We aimed to understand the perspectives of FP providers and other stakeholders on the potential introduction of new subcutaneous (SC) depot medroxyprogesterone acetate (DMPA) injectable contraceptives lasting 4 and 6 months in Nigeria and Uganda.

METHODS

Between July 2021 and February 2022, we conducted 48 in-depth interviews (IDIs) and 11 focus group discussions (FGDs) with FP providers and other stakeholders involved with service delivery, program management, and policymaking in Lagos and Abuja in Nigeria and Kampala and Luwero in Uganda. IDIs and FGDs explored respondents' reactions to and preferences for the new injectables lasting 4 and 6 months.

RESULTS

Most respondents liked the idea of longer-acting DMPA-SC products, noting the potential for reduced facility visits for clients and workloads for providers, cost savings for users and the health system, and potential for improved commodity logistics. Some nonproviders raised concerns about confusion among providers and clients with the availability of multiple injectable products; however, providers did not share this concern. The greatest interest among all groups was for the 6-month injectable, even without the option for self-injection. Several respondents reported that self-injection is not widespread in either context, and some noted that contact with a provider would be important for products with longer durations. Respondents' acceptability of the new injectables assumed that side effects would be no worse than the existing 3-month product.

CONCLUSIONS

Family planning stakeholders in Nigeria and Uganda are supportive of expanding the method mix with new injectables, which they see as having the potential to meet the needs of more users. Concerted engagement of health providers, policymakers, and the community will be necessary for successful introduction once these new contraceptive products are available.

Return to ovulation after Sayana Press is injected every 4 months for one year: Empirical and pharmacokinetic/pharmacodynamic modeling results

Objective

To characterize return to ovulation after injecting Sayana Press (104 mg/0.65 mL medroxyprogesterone acetate [MPA] in the Uniject device) every 4 months for 1 year of treatment.

Study design

We followed a subset of women for return to ovulation in a trial that demonstrated Sayana Press remains highly effective when the subcutaneous reinjection interval is extended from 3 to 4 months. We measured serum progesterone in weeks 38 to 42 and 46 to 50 after a final (third) injection and used a concentration ≥4.7 ng/mL as a surrogate for ovulation. We also performed pharmacokinetic and pharmacodynamic modeling to predict differences in MPA accumulation and return to ovulation had - contrary to fact - injections been given every 3 months.

Results

Ten of 19 women (53%; 95% confidence interval: 29–76) ovulated within 50 weeks of their last injection. We predicted that typical 12-month trough MPA concentrations are 34% lower (0.46 vs 0.69 ng/mL) and the median time from last dose to ovulation is 1.1 months shorter (13.1 vs 14.2 months) when injections are given every four months for 1 year.

Conclusion

Extending the Sayana Press reinjection interval from 3 to 4 months leads to less drug accumulation, without a noticeable loss in efficacy. Although the Sayana Press patient leaflet specifies that over 80% of women desiring pregnancy will conceive within a year of stopping the method (independent of treatment duration), our empirical and modeling results indicate women should anticipate waiting a year or more for fertility to return after repeat dosing, with a somewhat shorter delay were the reinjection interval extended to four months.

Implications

Providers should counsel women regarding the distinct possibility that return to fertility will take a year or longer following repeat use of Sayana Press. Extending the dosing interval from 3 to 4 months would result in approximately a 1-month shorter delay, without any appreciable reduction in contraceptive efficacy.