Community-based Provision of Contraceptive Injectables: Home and Self Injection Study in Malawi

As we commemorate World Contraception Day 2016, we must note that approximately 225 million women worldwide still lack access to a modern method of contraception. Increasing access to family planning was a premier goal of the Millennium Development Goals, and if we are to achieve the ambitious Sustainable Development Goals and the FP2020 goal of reaching 120 million new users of contraception in the world’s poorest 69 countries, we must provide people with readily available contraception.

Malawi, in particular, has made a commitment to increase their contraceptive prevalence rate for married and sexually active women from 33 percent to 60 percent by 2020. According to the Malawi Demographic and Health Survey, 42 percent of married women used family planning methods, while only 33 percent of all women of childbearing age did. Bringing family planning to all women of childbearing age is fundamental to achieving Malawi’s development goals.  

Community-based services and commodity distribution increases access to family planning. Sayana® Press, a three-month progestin-only injectable contraceptive is small, prefilled, easy to use, and can be distributed through community-based family planning services. Additionally, the potential for self-injection of Sayana Press offers users—particularly adolescent girls, and women and couples who live in hard-to-reach areas—autonomy. Government approval of self-injection could prove to be a major milestone in Malawi, ultimately leading to healthier lives.  

A one-year randomized clinical trial is underway in Malawi, spearheaded by FHI 360 in partnership with the Malawi Ministry of Health (MOH) and USAID/Malawi, through the Advancing Partners & Communities (APC) project and co-funded by Children’s Investment Fund Foundation. The study will assess whether adult women residing in a rural, resource-poor district in Malawi are able to self-inject Sayana Press every three months for one year following enrollment. Study enrollment began in September 2015 and completed in February 2016. Study staff trained master trainers from the College of Medicine on the protocol and Sayana Press, who in turn trained the public sector MOH clinic-based providers and community health workers, known as health surveillance assistants (HSA).

More than 700 women were randomized to two study arms by the health care provider cadres (e.g. clinic-based provider, HSA). One arm receives provider-administered injections and the other arm is trained to self-inject and given three doses of Sayana Press to take home. Approximately 70 percent of the study participants were enrolled by an HSA. Participants will be monitored for 12 months or until they discontinue use of Sayana Press, whichever comes first. The study will be the first to ascertain if continuation rates among women who self-inject Sayana Press are higher than for those who receive injections from a provider.

Results from the study, which are anticipated in mid-2017, will inform decision-making for Sayana Press procurement and distribution through Malawi’s health system. This study also contributes to the growing body of knowledge on community-based access to injectables (CBA2I), and is the first to provide evidence on the safety and feasibility of community-based provision of injectables for home and self-injection. It is also anticipated that results will be used to inform the World Health Organization’s guidelines on self-injection of contraceptive injectables.

Scaling up community-based distribution of Sayana Press and enabling home and self-injection has the potential to dramatically increase the number of contraceptive users in Malawi, helping the country reach its target contraceptive prevalence rate by 2020, and eventually reducing the percentage of women and couples who have an unmet need for contraception.

To learn more about the Sayana Press self-injection study, CBA2I, or the APC project, visit https://www.advancingpartners.org/.

Written by APC staff