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Reproductive Health

Providing Injectable Contraceptives in Communities

More programs consider community-based distribution.

Family Health Research: 2007, Vol. 1, Issue 2

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Key Points

  • Community health workers can safely and effectively provide injectable contraceptives.
  • Adding injectable contraceptives to an established CBD program can be relatively inexpensive.
  • Strong logistical systems are needed to ensure consistent supplies.

Evidence from a safety and feasibility study in Uganda, along with the increasing availability of safer injection equipment, is generating new interest in improving access to injectable contraceptives through community-based distribution (CBD) programs.

Although community health workers in a number of Asian and Latin American countries have been providing injectable contraceptives to their clients for years, community-based distribution (CBD) of this popular method is rare in sub-Saharan Africa. That is beginning to change, however, as health programs learn about the encouraging results from Uganda.

Improving access

Community-based distribution of contraception clearly has the potential to increase family planning access and convenience, particularly in countries with large rural populations, low contraceptive prevalence, high unmet need for contraception, and critical shortages of trained clinic personnel. CBD programs can increase contraceptive use by making family planning services convenient and by involving trusted community members. Injectable contraceptives are, however, usually provided in clinics. Experience from Asia, Latin America, and now sub-Saharan Africa, shows that the CBD of injectable methods can be safe and effective.

Ensuring effectiveness

Injectable contraceptives are among the most effective contraceptive methods as long as women receive their injections on time. CBD workers must be trained to keep accurate records for scheduled reinjections. Some projects have developed a simple system that helps CBD workers track which clients need reinjections by filing client information cards in the chronological order that the injections were given.

As with any contraceptive method, the consistent availability of DMPA is critical to ensuring its effectiveness. CBD workers usually obtain their supplies from local clinics, so strong relationships between CBD workers and clinic staff are an important link in the contraceptive supply chain.

Adding injectables to CBD programs

The cost of including injectables in a mature CBD program with well-trained, highly motivated workers will be relatively low compared with the cost of adding them to a weaker CBD program, which may have to be strengthened before it can provide injectable contraceptives. Adding injectables may also make CBD programs more cost-effective, because workers may recruit many more new clients by providing local women's preferred method.

A quality-assurance system is essential to ensure that CBD workers use proper screening, counseling, and injection procedures. In some programs, supervisors visit trainees and evaluate their performance three to six months after training.

CBD programs also must develop or strengthen logistical systems for predicting demand and delivering supplies to ensure uninterrupted availability of DMPA, needles, and syringes. In Uganda, for example, the Ministry of Health is working with a logistics advisor hired by the United Nations Population Fund to address persistent stock-outs of DMPA. John Snow, Inc.'s DELIVER Project will conduct a diagnostic study to identify gaps in the contraceptive supply chain, and FHI is training health workers in the three districts that are implementing CBD of DMPA to strengthen their ability to monitor and order supplies.

Experiences with the CBD of DMPA

Bangladesh. A CBD program in three subdistricts more than doubled their region's contraceptive use and increased the percentage of contraceptive users choosing injectable methods from 0.1 percent to 25 percent.

Guatemala. A CBD program that provided DMPA to 750 women in four districts achieved a contraceptive continuation rate of 90 percent. Now all community-based promoters in 22 districts are trained to provide injectable contraceptives.

Afghanistan. The success of a pilot project to test the CBD of injectable contraceptives led to a change in national policy allowing community health workers to administer injectable methods.