Introduction
Innovations in contraceptive technology and delivery are needed to meet the unique needs and circumstances of women, men, and couples. One recent contraceptive innovation offers promise: subcutaneous depot medroxyprogesterone acetate (DMPA-SC), which is often known by its brand name, Sayana Press.1 Since 2014–2015, DMPA-SC has been gradually rolled out across sub-Saharan Africa; as of April 2022, approximately 50 countries offer DMPA-SC, and approximately 30 countries are currently piloting or scaling up self-injection of DMPA-SC.2
DMPA-SC is positioned to become a leading contraceptive method in sub-Saharan Africa because it offers several advantages over other contraceptive methods, particularly intramuscular depot medroxyprogesterone acetate (DMPA-IM).3 One particularly noteworthy attribute of DMPA-SC is that it comes in an easy-to-use, all-in-one injection system and can be used without a provider, making it a viable option for women in sub-Saharan Africa to self-inject.4 5
Self-injection has several important features for sub-Saharan women seeking to use contraception. First, there is an emphasis in the family planning field towards expanding access to self-care methods of contraception, that is, methods that women can use on their own or with minimal assistance from the healthcare system.6 The self-care approach is further embedded within the broader goal of contraceptive empowerment, in which a woman has the ability to decide for herself what she wants in relation to contraception and then acts on these preferences.4 7 Findings from qualitative studies investigating the preference for or acceptability of self-injection found that users appreciated the time and money savings, being able to bring units home for future use and not having to worry about stockouts, and increased privacy and confidentiality.8 9 Expansion of self-injection is also poised for broader health system benefits, including alleviation of time and resource burdens on healthcare providers, including task-shifting family planning services to community-level providers to expand access.4 10 11 With the onset of the COVID-19 pandemic, advocacy efforts surrounding self-care methods of contraception, including DMPA-SC, have intensified.12
Many reproductive health advocates and policymakers believe that self-injection represents the future of contraception within sub-Saharan Africa, and this promise appears to be reinforced by initial evidence showing increased prevalence of DMPA-SC in several sub-Saharan African settings.13 This promise has led to substantial donor funding and enthusiasm to roll-out DMPA-SC as a method of self-care,3 14 as well as a promising contraceptive method regardless of its self-injection capability, recognising the benefits of a lower hormone dose, smaller needle, and all-in-one application. Furthermore, large donors, supply coalitions, and governments are heavily invested in successful implementation of DMPA-SC given its potential to ease overburdened healthcare systems given the COVID-19 pandemic.
Despite the prominent advantages of self-injection for individuals and health systems, little is known about women’s attitudes towards self-injection. Yet, this information is critical, because for uptake and continuation of self-injection to accelerate in sub-Saharan Africa and globally, there must be demand for it. In this analysis, we present the first nationally and regionally representative findings on women’s knowledge and attitudes towards self-injection in Burkina Faso, Democratic Republic of Congo (DRC), Kenya and Nigeria, contextualising the results and weighing whether women’s preferences in these settings are reflected in current advocacy efforts.
Our data for this analysis come from Performance Monitoring for Action (PMA), which monitors reproductive health behaviours across eight countries in sub-Saharan Africa through annual surveys.15 Since 2016, PMA has included questions on DMPA-SC to help governments and donors understand prevalence of and patterns in uptake. Given the increasing use of DMPA-SC in many settings,13 the most recent PMA survey (PMA Phase 2) added questions to better understand women’s preferences, including knowledge of and attitudes towards self-injection. Full details of PMA, the study and sampling design, questionnaires and data are available from www.pmadata.org and Zimmerman et al.15 Further, we present data collected in winter 2020–2021 from four countries: Burkina Faso, DRC, Kenya, and Nigeria. Data collection in the DRC and Nigeria was limited to the provinces of Kinshasa and Kongo Central and the states of Kano and Lagos, respectively, and data are presented separately for each setting.