Comments on: Welcome injectables bloggers

By: John Stanback

John Stanback — Fri, 19 Jan 2007 21:26:14 +0000

Enjoyed the editorial, but you neglected to mention the significant problems faced by clients who present late for re-injections for DMPA (”Depo-Provera”). Not only is the current WHO recommendation for a two-week grace period too short (it should be a month, or even more for at-risk clients), but national, local, and individual practices for late clients vary tremendously. In many places, clients who are more than a week late are not allowed a re-injection and must return when they are bleeding–not easy when Depo has caused long-lasting amenorrhea. Joy Baumgartner here at FHI suspects that a significant proportion of injectable discontinuation is involuntary. Clients want to continue, but aren’t allowed to.

Providers should make every effort to rule out pregnany for clients presenting after the grace period, rather than just sending them home. Where a history doesn’t rule out pregnancy, free pregnancy testing should be available.

By: peggy

peggy — Fri, 26 Jan 2007 19:06:12 +0000

Thanks for the editorial and for the thoughtful comment. I wonder if the authors and John Stanback could expand on two approaches which could help with the problem of clients who don’t return to the clinic within the grace period.

1. Community distribution. The editorial mentions the idea of using community based distributors and a new version of DMPA that is injected under the skin. Could you say more about where this had been tried and what the results were? What are the main impediments to implementing community-based distribution programs?

2. Self injection by the client. How feasible will self-injection ever be for clients in many countries? Is this being done anywhere yet? Could you talk a little more about it?

Thanks,
Peggy D’Adamo

By: Author

Author — Mon, 29 Jan 2007 22:43:06 +0000

Peggy asks about the most recent developments in injectables services. Bangladesh, Ghana, Mexico, and a number of other countries have offered injectables through community distributors. Many women have chosen injectables as their first modern contraceptive method when they are offered in community programs. Injections have been given safely and continuation rates have been high. Counseling and disposal of used equipment, however, have needed improvement in both community and clinic services. Community services will require some governments to change policies that only allow doctors or nurses to give injections. With proper training, a range of health care providers can give injections safely.

Several studies have offered self-injection of the monthly injectable Cyclofem and of the new formulation of DMPA injected subcutaneously. A study in Brazil trained participants to give themselves intramuscular injections of Cyclofem. Almost half of the 102 original participants gave themselves two or three injections. Most of the others declined to give themselves injections even after training, however. In trials of subcutaneous DMPA, 16% gave themselves injections, and 71% in a survey said they would like to give themselves injections at home or in a doctor’s office. For more details, see Population Reports, “Expanding Services for Injectables.”

By: John Stanback

John Stanback — Tue, 06 Feb 2007 23:04:10 +0000

Provision of Depo by community-based reproductive health workers in Uganda was quite successful as a pilot project. Compared to clients who received their injectable contraception from nurses in clinics, CBD clients were just as satisfied, reported similar side effects, recalled just as many counseling messages, and had similar continuation rates. Save the Children is now scaling up the program into two new districts in Uganda. In addition, the MOH in Madagascar is now training its CBD workers to provide Depo injections, and the practice may soon be getting started in a few more places as well.

For CBD programs that are often labelled as too expensive, adding injectable contraception (particularly when programs avail themselves of donated commodities) may be a way to become more cost-effective, by virtue of adding significantly to provider CYPs for a rather modest training cost.

By: admin

admin — Mon, 19 Feb 2007 04:15:34 +0000

A note from Holly Blanchard: I wanted to highlight that the preferred site for intramuscular injection is the ventrogluteal [the side of the hip rather than the upper outer quadrant of the buttock (dorsogluteal)]. Planned Parenthood Federation of America recommended the ventrogluteal site especially for DMPA to all of its affiliates. –Holly Blanchard CNM MS, Technical Advisor for Clinical Service Delivery, ACCESS-FP, JHPIEGO

For further information:

–Donaldson C, Green J. (2005) Using the ventrogluteal site for intramuscular injections. Nursing Times; 101:16,36-38.

–Nicoll L., Hesby A. (2002) Intramuscular injection: An integrative research review and guideline for evidence-based practice. Applied Nursing Research ;16(2):149-162.