Introduction of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) Injectable Contraception at Facility and Community Levels: Pilot Results From 4 Districts of Uganda

George Odwe; Kate Gray; Annet Kyarimpa; Francis Obare; Grace Nagendi

doi:10.9745/GHSP-D-18-00117

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FIGURE 1.
Monthly Trends in the Number of DMPA-SC Units Provided by District, Uganda, April 2016–March 2017
Abbreviation: DMPA-SC, subcutaneous depot medroxyprogesterone acetate.
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During an RHU outreach event in Kabarole district, Uganda, a provider shows women waiting for family planning services what Sayana Press looks like and provides information about the method. © 2016 Irene Kugonza/RHU.
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FIGURE 2.
Percentage Distribution of Family Planning Methods by Service Delivery Channel, 4 Districts of Uganda, April 2016–March 2017
Abbreviations: DMPA-IM, intramuscular depot medroxyprogesterone acetate; DMPA-SC, subcutaneous depot medroxyprogesterone acetate; IUD, intrauterine device; VHT, village health team.
Note: Pills include combined oral contraceptives and progestin-only pills; condoms include male and female condoms; and permanent methods include tubal ligation and vasectomy.

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TABLE 1.

Reproductive Health Indicators for Study Districts, Uganda, 2016

District	Subregion	TFR	Teenage Pregnancy (%)	mCPR (%)	Unmet Need for Family Planning (%)
Mbale	Bugisu	5.6	28.2	43.2	22.1
Kabarole	Toro	5.4	30.3	37.4	41.3
Mbarara	Ankole	4.9	18.9	36.2	44.5
Kabale	Kigezo	4.6	15.5	43.2	NA
National		5.4	24.8	34.8	31.9

Abbreviations: NA, not available (due to small numbers of data); mCPR, modern contraceptive prevalence rate; TFR, total fertility rate.
Source: UBOS and ICF (2018).⁹

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TABLE 2.

Sayana Press Learning Project Activities by Service Delivery Channel, Uganda, April 2016–March 2017

	Service Delivery Channels
	VHTs	Static Clinic		Mobile Outreach
	VHTs	Public Sector	RHU Clinics	Mobile Outreach
Number supported	40 VHTs (40% men, 60% women; 10 VHTs per district selected from existing cadre of active VHTs)	26 clinics with outreach site Kabale (9) Kabarole (4) Mbale (6) Mbarara (7)	4 clinics (1 RHU static clinic per project district)	Mobile outreach conducted in 26 public-sector clinic sites
Service delivery	Comprehensive family planning counseling, information, and awareness raising Short-acting methods (DMPA-IM, DMPA-SC, oral contraceptives, condoms) Referral to mobile outreach teams, RHU clinics, or public-sector clinics for long-acting methods and other SRH services	Comprehensive family planning counseling and information Short-acting methods (DMPA-IM, DMPA-SC, oral contraceptives, condoms) Long-acting methods (implants and IUDs) Permanent methods (tubal ligation and vasectomy) Other SRH services (including HIV and STI testing/treatment and cervical cancer screening)
Trainings	All 40 VHTs received a 7-day training on: Comprehensive counseling on all methods (including DMPA-SC) Provision of DMPA-SC Provision of other short-acting methods Referral processes Project data collection	42 facility-based providers (nurses, midwives, and clinical officers) drawn from public-sector facilities with outreach site and RHU facilities received a 2-day training on: Comprehensive counseling on all methods including DMPA-SC Provision of DMPA-SC Refresher training on all family planning methods
FP supplies and equipment	VHTs obtained FP commodities from RHU clinics in project districts	FP commodities provided through the NMS	All FP commodities (including DMPA-SC) provided through UHMG	All FP commodities and equipment provided by RHU outreach teams
Additional support provided	Monthly supportive supervision provided by RHU clinical staff Comprehensive counseling on all methods including DMPA-SC	NA	NA	NA
Demand creation	1 stakeholders' meeting involving 118 participants (including district health officers and religious and community leaders) drawn from all 4 project districts Educational outreach by RHU providers or VHTs about importance of family planning method through door-to-door mobilization, group information sessions, IEC materials, and media (mainly TV and radio programs)

Abbreviations: DMPA-IM, intramuscular depot medroxyprogesterone acetate; DMPA-SC, subcutaneous depot medroxyprogesterone acetate; FP, family planning; IEC, information, education, and communication; IUD, intrauterine device; NA, not applicable; NMS, National Medical Stores; RHU, Reproductive Health Uganda; SRH, sexual and reproductive health; STI, sexually transmitted infection; UHMG, Uganda Health Marketing Group; VHT, village health team.

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TABLE 3.

Number of DMPA-SC Units Provided by Project District and Service Delivery Channel, Uganda, April 2016–March 2017

District	Service Delivery Channel			Monthly Average No.	Total No.
District	Clinics No. (%)	Outreach No. (%)	VHTs No. (%)	Monthly Average No.	Total No.
Mbale	131 (2.7)	1060 (22.2)	3589 (75.1)	4780	398
Kabarole	110 (3.5)	881 (28.0)	2157 (68.5)	3148	262
Mbarara	87 (4.2)	405 (19.6)	1579 (76.2)	2071	173
Kabale	267 (6.2)	1388 (32.5)	2619 (61.3)	4274	356
Total	595 (4.2)	3734 (26.2)	9944 (69.7)	14,273	1189

Abbreviations: DMPA-SC, subcutaneous depot medroxyprogesterone acetate; VHT, village health team.

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TABLE 4.

Volume of Family Planning Methods Provided Before and During the Intervention by Contraceptive Method, 4 Districts of Uganda

Method	6 Months Before Intervention (Oct 2015–Mar 2016) No. (%)	First 6 Months of Intervention (Apr 2016–Sep 2016) No. (%)	Second 6 Months of Intervention (Oct 2016–Mar 2017) No. (%)	Total No.
Pills^a	2303 (10.8)	3378 (8.4)	3216 (7.6)	8897
DMPA-IM	4292 (20.0)	9115 (22.7)	11,933 (28.3)	25,340
DMPA-SC	—	6470 (16.1)	7803 (18.5)	14,273
Implants	1926 (9.0)	2140 (5.3)	2262 (5.4)	6328
IUD	217 (1.0)	280 (0.7)	254 (0.6)	751
Permanent methods^b	21 (0.1)	94 (0.2)	123 (0.3)	238
Condoms^c	12,662 (59.1)	18,646 (46.5)	16,540 (39.3)	47,848
Total	21,421 (100.0)	40,123 (100.0)	42,131 (100.0)	103,675
Total CYPs	7073	11,491	13,009	31,573

Abbreviations: CYP, couple-years of protection; DMPA-IM, intramuscular depot medroxyprogesterone acetate; DMPA-SC, subcutaneous depot medroxyprogesterone acetate; IUD, intrauterine device.
↵a Includes combined oral contraceptives and progesterone-only pills.
↵b Includes tubal ligation and vasectomy.
↵c Includes both male and female condoms.

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TABLE 5.

Percentage Distribution of Family Planning Clients by Age and Method, 4 Districts of Uganda, April 2016–March 2017

Method	Age Category		Total (N)
Method	<25 Years (%)	≥25 Years (%)	Total (N)
Pills	38.4	61.6	6594
DMPA-IM	36.8	63.2	21,048
DMPA-SC	42.6	57.4	14,273
Implants	21.6	78.4	4402
IUD	16.9	83.1	534
Permanent methods	2.3	97.7	217
Condoms	48.1	51.9	35,186
All methods	42.1	57.9	82,254

Abbreviations: DMPA-IM, intramuscular depot medroxyprogesterone acetate; DMPA-SC, subcutaneous depot medroxyprogesterone acetate; IUD, intrauterine device.
Note: Pills include combined oral contraceptives and progestin-only pills; condoms include male and female condoms; and permanent methods include tubal ligation and vasectomy.