Elsevier

Contraception

Volume 83, Issue 6, June 2011, Pages 495-503
Contraception

Review article
Provision of DMPA by community health workers: what the evidence shows,☆☆

https://doi.org/10.1016/j.contraception.2010.08.013Get rights and content

Abstract

Background

To reduce a large unmet need for family planning in many developing countries, governments are increasingly looking to community health workers (CHWs) as an effective service delivery option for health care and as a feasible option to increase access to family planning services. This article synthesizes evidence on the feasibility, safety and effectiveness of community-based delivery of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA).

Study Design

Manual and electronic search and systematic review of published and unpublished documents on delivery of contraceptive injectables by CHWs.

Results

Of 600 identified documents, 19 had adequate information on injectables, almost exclusively intramuscular DMPA, provided by CHWs. The data showed that appropriately trained CHW demonstrate competency in screening clients, providing DMPA injections safely and counseling on side effects, although counseling appears equally suboptimal in both clinic and community settings. Clients and CHWs report high rates of satisfaction with community-based provision of DMPA. Provision of DMPA in community-based programs using CHWs expanded access to underserved clients and led to increased uptake of family planning services.

Conclusions

We conclude that DMPA can be provided safely by appropriately trained and supervised CHWs. The benefits of community-based provision of DMPA by CHWs outweigh any potential risks, and past experiences support increasing investments in and expansion of these programs.

Introduction

Unmet need for family planning approaches 40% or higher in some countries and, consequently, many women are at risk of having an unintended pregnancy [1]. The consequences of a pregnancy that is unintended and unwanted can be dire, particularly in developing countries where access to safe abortion is restricted and an unwanted pregnancy is associated with considerable health risks. About 25–35% of maternal deaths, including abortion-related mortality, could be avoided if women who expressed the desire to space or limit births had access to a family planning method [2]. Increasing access to family planning services is a highly effective means of meeting the unmet need for family planning and thereby protecting the health and wellbeing of women and children [3], [4].

A growing number of contraceptive users rely on injectable contraceptives for preventing unintended pregnancy. Injectable use doubled between 1995 and 2005 and is estimated to provide protection for more than 42 million women worldwide every year [1], [5]. The 3-month injectable depot-medroxyprogesterone acetate (DMPA) is the fifth most commonly used contraceptive method worldwide [1], [5]. DMPA is the most popular injectable contraceptive in Sub-Saharan Africa, used by more than one in two users of modern contraceptives and one out of every three users of any contraceptive [1], [5]. In 2006, DMPA was registered for use in 179 countries [6]. The method has been extensively studied and is regarded as a safe and very effective contraceptive for most women [7], [8], [9].

Regulations in many countries allow CHWs to initiate use of combined oral contraceptives (COCs). Prevalence of conditions restricting eligibility for COC use is reported to be low, and effective screening for these conditions does not necessarily require a physician [10], [11]. The medical eligibility for DMPA use is considerably less restrictive than that for COCs [8]; hence screening for eligibility for use of DMPA is a relatively uncomplicated task that can easily be learned and enhanced by use of checklists [8], [12]. DMPA is a safe and highly effective contraceptive [7], [8], [9]. Past controversies [13] surrounding the method have been laid to rest [14], [15]. The effect of DMPA on bone mass was reviewed in 2005 by a World Health Organization (WHO) expert panel [15] and by the American Committee of Obstetricians and Gynecologists (ACOG) in 2008 [14]. The WHO panel and ACOG concluded that women aged 18–45 years should be able to use DMPA without restrictions [14], [15] and that for younger and older women, the “advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk” and that use should be reconsidered over time on an individual basis [15].

Although many countries have observed large increases in use of injectable contraception, currently almost all injectable use is supported through clinic-based provision. Use of injectables is constrained by policies limiting provision of injectables to nurses or physicians. In many countries, health workers with limited medical training are authorized to distribute oral contraceptives and condoms, but must refer clients to clinics for other contraceptive methods, including injectables. Such policies restrict access to injectable contraceptives to women in well-resourced areas with higher concentrations of doctors and nurses [16].

Increasingly, governments are seeking alternative means of delivering health interventions to rural, hard-to-reach and marginalized groups and are looking to community health workers (CHWs) as an effective service delivery option for expanding access to family planning. The definition for community-based worker varies according to context, specific needs and available resources. Generally, CHW receive less training than other professional workers and are members of the communities where they work with links to a clinic-based health system.

Reviews and consultations have been conducted on the experience and impact on different aspects of health of CHW programs [3], [17], [18], [19], [20], but none has looked specifically at delivery of injectable contraception by CHWs. This article synthesizes more than three decades of program and research evidence on the feasibility, safety and effectiveness of community-based delivery of DMPA.

Section snippets

Search strategy and selection criteria

Objectives and outcome measures for the review were developed by an advisory committee [21] consisting of representatives from health, aid and development organizations (World Health Organization, United States Agency for International Development, Family Health International) and technical consultants.

The objectives of the review were to examine evidence on the ability of CHWs to achieve competency in provision of DMPA and meet injection standards related to safety and quality, the

Results

Nearly half of the documents originate from programs implemented in Asia (n=9) although this is heavily weighted with evidence from Bangladesh. Substantial evidence also comes from work conducted in Africa (n=5) and Latin America (n=5).

Discussion

The results of this review provide consistent evidence that appropriately trained CHWs can screen DMPA clients effectively, provide injections safely and counsel on side effects appropriately. Clients of CHWs receiving DMPA had outcomes equivalent to those of clients of clinic-based providers of progestin-only injectables. Clients are satisfied with community-based provision of DMPA, and trained CHWs are comfortable in their ability to provide DMPA. The data also show that provision of DMPA by

Acknowledgments

The authors thank Crystal Dreisbach, Kirsten Krueger, Baker Ndugga Maggwa, Shyam Thapa, and William Finger for all contributions to this work. For valuable advice on unpublished literature, we thank Amanda Abbott, Adrienne Allison, Heather Bergmann, Erinna Bowman, Alice Cartwright, Laura Ehrlich, Jim Foreit, Mia Foreman, Sandy Garcia, Douglas Huber, Jane Hutchings, Neeraj Kak, Dilruba Mahbuba, Noah Marwil, Lesly Michaud, Tanjina Mirza, Winnie Mwebesa, Steve Rubanga, Ruth Simmons, Ricardo

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    The views of the authors do not necessarily represent those of USAID, WHO and FHI. No conflicts of interest are declared.

    ☆☆

    Funding for this study was provided by Family Health International, USID and World Health Organization.

    1

    During the development of this paper she worked as an independent consultant.

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