Injectable contraceptive continuation and user experiences in Punjab, Pakistan: a non-randomized prospective cohort...

Evidence from multiple pilots and post-introduction scale-up initiatives have demonstrated that self-administered subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) has potential to improve contraceptive continuation rates and expand contraceptive access to populations with limited utilization of facility-based health services. Only a few of these studies have been conducted in South Asian countries, and none where most contraceptive use is of non-hormonal methods that require limited to no contact with the health system, leaving policymakers in countries like Pakistan with limited context-specific evidence to guide decisions on whether, how, and for whom to introduce DMPA-SC.

A prospective cohort study will be conducted in 41 health facilities and surrounding communities in Punjab, Pakistan. The primary objective of the study is to compare the 12-month contraceptive continuation rate for women who receive DMPA-SC with that for women who receive intramuscular depot-medroxyprogesterone acetate (DMPA-IM). The secondary objectives are to compare characteristics and experiences of participants who opt for DMPA-SC with those of women who opt for DMPA-IM, which must be administered by a health worker. Additionally, a sub-study is planned to assess how well women opting for self-injection of DMPA-SC adhere to standards for commodity storage, injection timing, injection technique and waste disposal.

This research offers an opportunity to contribute to global efforts to reduce inequities in access to contraceptive method choices, while generating actionable evidence to inform health sector decision-making in Pakistan. Although study sites are limited to health facilities where a woman's first self-injection of DMPA-SC is supervised by a nurse, midwife, medical officer, Lady Health Visitor, Family Welfare Worker or Family Welfare Councilor, the research protocol and findings will provide a foundation for future studies testing alternative service provision and self-injection support models.

Registered on clinicaltrials.gov as an observational study (NCT05774626).