DMPA Self Injection Training

Self injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) lets a patient give her own contraceptive injection at home after training by a health provider. It removes the need to attend a facility every 3 months, improves continuation and gives the patient control over the method. The product is a prefilled single-use injection system containing medroxyprogesterone acetate 104 mg in 0.65 mL, given every 13 weeks.

Who is suitable. Any patient who is eligible for DMPA, chooses it and is willing to learn the technique. Reading ability is not required when picture job aids are used. Patients with no privacy at home, or with an unsafe partner situation, need a discreet plan or a method given at the facility.

Eligibility. The same medical eligibility rules as provider-given DMPA apply, including category 3 for blood pressure of 160/100 mmHg or more and for vascular disease, and category 4 for current breast cancer.

Start timing. Within 7 days of the start of menses with no backup; at any other time when reasonably certain the patient is not pregnant, with backup for 7 days; postpartum breastfeeding patients from 6 weeks.

Preparation for the training visit.

• Counselling on the method, expected bleeding changes, return to fertility and the reinjection schedule.

• Exclusion of pregnancy and consent.

• Supplies: prefilled DMPA-SC units for the first dose and for home use, a puncture-proof sharps container with a lid, soap and water or alcohol swabs, a reinjection calendar, a picture job aid, a follow-up card, and a pinchable skin pad for practice where available.

Teaching approach. Explain each step, demonstrate it, then watch the patient do it (return demonstration). The first self injection is done under supervision at the facility. Use plain language and pictures, and check understanding by asking the patient to describe each step in her own words.

Steps the patient must perform, observed and rated one by one.

• Check the expiry date and that the package is undamaged.

• Wash hands with soap and water and dry them.

• Identify the injection site: front of the thigh or abdomen, keeping at least 5 cm from the navel. The upper arm is used only when someone else gives the injection.

• Clean the site and let it dry.

• Hold the unit and shake it for 30 seconds.

• Activate the unit as shown on the job aid.

• Pinch a fold of skin at the site.

• Insert the needle at a downward angle until the port touches the skin.

• Squeeze the reservoir slowly for 5 to 7 seconds until it is empty.

• Withdraw the needle without recapping it and put the unit straight into the puncture-proof container.

• Record the date of the injection and the date the next dose is due on the card or calendar.

Competency. The patient performs every step correctly without help. If a step is missed, repeat the practice. If she still cannot inject safely, give the injection at the facility and offer training again later.

Late or missed injection.

• Up to 4 weeks late (17 weeks after the last injection): inject at once; no backup is needed.

• More than 4 weeks late: exclude pregnancy by the checklist or a test, give the injection at the facility, and advise backup for 7 days; consider emergency contraception if unprotected sex occurred in the last 5 days.

Technique problems.

• Incomplete dose, leakage or a damaged unit: do not use a damaged unit; return to the facility, where pregnancy is excluded and a repeat dose is decided.

• Injection site pain, redness, a lump or skin dimpling: reassure, rotate sites, and review the technique.

Bleeding changes. Irregular bleeding, spotting or amenorrhoea are common and not harmful. For persistent bleeding exclude pregnancy, infection and pathology, then give ibuprofen 400 mg orally three times daily for 5 days; if unacceptable, change method.

Needle-stick injury to another person. Wash with soap and water, and attend a facility within 72 hours for assessment for post-exposure prophylaxis.

Pregnancy or suspected serious effect. Stop injections and attend for assessment: severe or persistent headache, chest pain, breathlessness, calf pain or swelling, jaundice, severe abdominal pain or heavy bleeding.

Supply. Dispense 4 doses for home self injection at each resupply visit. Collect used units for disposal through the facility.

Reinjection reminders. Give a calendar and follow-up card with the next dates, and suggest a phone alarm. The reinjection window is every 13 weeks, up to 4 weeks late.

Storage at home. Keep the units in a cool, dry place, out of reach of children, and away from heat and moisture.

Disposal. Put each used unit in a puncture-proof container with a well-fitting lid at once, never recap the needle, keep the container safe and out of reach of children, and return it to the facility or a community provider when full. The used packaging can go in household waste.

Follow up. Review technique at each resupply visit. Ask the patient to attend at least once a year for a check, blood pressure and integrated services such as cervical screening and HIV testing. Remind her never to share doses and to return damaged doses.

Dual protection. Advise condoms for STI and HIV protection.

Special groups. Adolescents need a private plan for storage and disposal. People living with HIV can use DMPA-SC. Patients who become uncomfortable with self injection and still prefer an injectable should be given DMPA by a provider.

Referral and escalation. Refer patients with persistent unacceptable bleeding, suspected serious adverse effects, repeated late injections, or who want to stop.