Family Health Intl Brief 3- Effectiveness of Community-based Distribution of DMPA

Publication date: 2007

KEY POINTS n DMPA is among the most effective contraceptive methods available as long as women receive their injections every three months. n CBD workers should have solid links to clinics to ensure that they do not run out of DMPA supplies. n Full and proper counseling helps ensure that new clients are not alarmed by bleeding changes, can manage side effects, and thus are less likely to discontinue use. The injectable depot-medroxyprogesterone acetate (DMPA or Depo-Provera) is considered to be one of the most effective contraceptives available (three pregnancies per 1,000 women during the first year of use) if women always receive their injections at the scheduled time.1 However, some program managers may worry that community-based distribution (CBD) of DMPA could increase the possibility that clients will not consistently receive scheduled reinjections, thus potentially reducing the method’s effectiveness. Consistent, scheduled reinjections Correct and consistent use of DMPA requires that a woman receive a reinjection once every three months (or 90 days), with a “window” or “grace period” of two weeks before and two weeks after each scheduled reinjection date.2 If a woman returns more than two weeks late, she can receive an injection if the provider is reasonably sure she is not pregnant. The use of back-up contraception for seven days should be considered, and the woman should be counseled that delaying injections increases the risk of pregnancy. Factors that may compromise the ability of CBD workers to maintain reinjection schedules and clients’ decisions to continue DMPA include: • Difficulty obtaining supplies • Difficulty locating clients • Capacity of clients and providers to manage side effects and complications • Uncertainty about how to rule out pregnancy if reinjection outside of the standard injection window is considered Continued availability of supplies As with any contraceptive method, ensuring the consistent availability of DMPA is critical for ensuring its effectiveness. Systems for distributing and storing supplies are needed to prevent stock-outs. Providing CBD workers with strong links to clinics can help ensure that workers always have supplies of DMPA. Ability of providers to locate clients CBD of DMPA requires either that a CBD worker regularly visit clients or that clients regularly visit a CBD worker (at a depot or home) to obtain reinjections. In either case, CBD workers must be trained to keep accurate records for scheduled reinjections. Some projects have developed a simple client card system that helps CBD workers track which clients need reinjections by filing client information cards in the chronological order of injections given. Finding clients to give timely reinjections may pose problems. In the Matlab project in Bangladesh, reinjections often required more frequent visits than expected. Program managers thought that one visit to a village every three months would be sufficient, but as more women chose DMPA, the CBD workers needed to return to the villages once a month. This eventually prompted the government of Bangladesh to increase the number of CBD workers by a third.3 CBD workers who make home visits must be persistent in their efforts to locate and return to clients on time. In communities where clients are expected to visit a CBD worker, the CBD worker must remain available (not leave the community for extended periods) and seek out women who are late for their reinjections. Furthermore, a system for reaching women who migrate away from an area served by a CBD worker may be necessary (unless those women migrate to an urban area where obtaining an injection from a private pharmacist or a health center should be easy). In some cases, the solution has been to provide doses to such women to carry with them, along with instructions for administering the injection.4 With the development of subcutaneous DMPA (Depo-subQ Provera 104 or DMPA-SC) in Uniject devices, self-injection may become an option for women using DMPA, just as self-injection by diabetics has become common. BRIEF 3 Effectiveness of Community-based Distribution of DMPA This brief was produced by the Ministry of Health and its collaborating partners with technical assistance from Family Health International's CRTU program. Financial assistance for the work was provided by the US Agency for International Development (USAID). The contents do not necessarily reflect USAID policy. For more information or additional copies, please contact: Head, Reproductive Health Division, Ministry of Health Uganda Plot 6 Lourdel Rd, Wandegeya P.O. Box 7272 Kampala Uganda Tel: 256-41-340884 Fax: 256-41-340887 E-mail: or Project Director, Family Health International Plot 35, John Babiiha (Acacia) Avenue P.O. Box 4553 Kampala, Uganda Tel: 256-312-244-730 E-mail: January 2007 Full and proper counseling to manage side effects and complications CBD workers must be trained to fully counsel new DMPA users about expected side effects. Women are much more likely to continue use when they understand, for example, that bleeding changes are no cause for alarm. To further ensure continuation, new DMPA users need to know what they can do to alleviate side effects and recognize conditions indicating the need for assistance at a clinic. Follow-up visits for reinjections are also excellent opportunities for CBD workers to ask DMPA users about any concerns or side effects and then, if needed, provide counseling. Capacity of providers to rule out pregnancy if reinjection outside of the standard injection window Because CBD workers often live in or near the communities where their clients reside, they enjoy relatively easy access to these clients and may be better able than clinic-based providers to notify them of their need for reinjection before the end of the two-week grace period. The chance of pregnancy for a woman who is late for her DMPA reinjection by a few weeks is small. However, CBD workers must be trained to know what to do if a woman is late for her DMPA reinjection. A woman can safely receive a DMPA reinjection if a CBD worker can be reasonably sure that the woman is not pregnant. To make that assessment, the CBD worker should first ask the woman if she still has regular menstrual cycles; if so, the worker can use a checklist developed by Family Health International (FHI)5 to rule out pregnancy. If the woman does not have regular menstrual cycles, which is common with DMPA use, the CBD worker should use the following criteria to reasonably ensure that she is not pregnant: • The client has not had sex since two weeks after she should have had her last injection, or • The client has used a backup contraceptive method or emergency contraceptive pills after any unprotected sex since two weeks after she should have had her last injection, or • The client is nearly fully or fully breastfeeding and gave birth less than six months ago and hasn’t had menses. If she fails to meet any of these criteria, then the CBD worker should refer her to a higher level of care to determine whether she is pregnant. Meanwhile, the CBD worker should provide the woman with a back-up method of contraception (usually condoms) to use before she receives her next injection in case she is not pregnant and is at risk of pregnancy. Note: The conventional term “community-based distribution” (CBD) is used throughout these briefs for the sake of consistency. However, the concept of distributing commodities to individuals in communities is gradually being replaced by that of delivering not only commodities, but also services. Thus, the term “community-based services” (CBS), which embraces activities carried out through such vehicles as agricultural extension programs, drug shops, pharmacies, and literacy programs, is increasingly used. Likewise, alternative terms – such as community health workers (CHWs), community reproductive health workers (CRHWs), community health officers (CHOs), or village health workers (VHWs) – have been used to more accurately describe more specific categories of community-based paraprofessionals. 1 Trussell J. Contraceptive efficacy. In Hatcher R, Trussell J, Stewart F, et al., eds. Contraceptive Technology. Eighteenth Revised Edition. New York, NY: Ardent Media, Inc., 2004. 2 World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use, Second Edition. Geneva, Switzerland: WHO, 2004. 3 Phillips JF. A case study of contraceptive introduction: domiciliary DMPA services in rural Bangladesh. The Committee on Population National Academy of Sciences Seminar on the Demographic and Programmatic Consequences of Contraceptive Innovations, Washington, DC, October 6-7, 1988. 4 Fernandez VH, Montufar E, Ottolenghi E, et al. Injectable contraceptive service delivery provided by volunteer community promoters. Unpublished paper. Population Council, 1997. 5 Family Health International (FHI). How to Be Reasonably Sure a Client is Not Pregnant, checklist. Research Triangle Park, NC: FHI, 2006. Available: www.fhi. org/en/RH/Pubs/servdelivery/checklists/pregnancy/index.htm.

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