Expanding Services for Injectables

CONTENTS

Home (Key Points)

Injectables Today and Tomorrow
Box: Injectables Tomorrow: Subcutaneous DMPA and Home Injection
Web Table 1. Knowledge and Current Use of Injectable Contraceptives Reported by Married Women 15–49, All Surveys 1990–2006
Web Table 2. Knowledge and Current Use of Injectable Contraceptives Reported by Married Women 15–49, Most Recent Surveys 1990–2006
Web Figure. Donor Shipments of Injectables Increasing

Supply Meets Demand With Forecasting and Ingenuity
Web Table 3. Key Resources for Program Managers and Providers

Training to Meet Demand

Box: With Training, a Range of Providers Can Give Contraceptive Injections

Give Injections and Dispose of Waste Safely

Community Programs Can Safely Increase Access to Injectables

Meeting Rising Demand Efficiently

Communication Helps Women Try and Use Injectables

Questions and Answers About Injectables

Box: Women With HIV/AIDS Can Use Injectables

Bibliography

Credits

Coming Soon: "Injectables Toolkit" Web site. Go to http://www.injectablestoolkit.org for job aids and information about injectable contraceptives.

• Table 1: Estimated Worldwide Use of Injectables Among Married Women Ages 15–49, 2006
• Table 2: Formulations, Injection Schedules, and Availability of Injectable Contraceptives
• Table 3: Key Resources for Program Managers and Providers

Tools for Program Managers
• Checklist: Good-Quality Injectables Services
• Checklist: Improving Access to Injectables

Tools for Providers are in the companion INFO Reports. See also Population Reports, "When Contraceptives Change Monthly Bleeding," Series J, No. 54, August 2006.

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See Companion INFO Reports on "Injectable Contraceptives: Tools for Providers"
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Injectables Today and Tomorrow

More and more women are using injectable contraceptives today, and very likely even more will use this method in the future as it becomes increasingly available. Women choose injectables because they are effective, long-lasting, and private. For family planning programs, meeting increasing demand while maintaining good quality will be the key to success with injectables.

Between 1995 and 2005 the number of women worldwide using injectable contraceptives more than doubled. About 12 million married women used injectables in 1995. In 2005 over 32 million were using injectables (108, 163, 194). Injectables are the fourth most popular method worldwide, after female sterilization, the intrauterine device (IUD), and oral contraceptives. In sub-Saharan Africa, injectables are the most popular method, chosen by 38% of women using modern methods (see Table 1). By 2015 worldwide use is projected to reach nearly 40 million—more than triple the 1995 level (163).

Table 1. Estimated Worldwide Use of Injectables Among Married Women Ages 15–49, 2006
	% Currently Using			% of Modern Method Users Using Injectables
Region & Selected Countries	Any Method	Any Modern Method	Injectables
DEVELOPING AREAS	58	52	3	7
Sub-Saharan Africa	21	15	6	38
Kenya 2003	38	31	14	46
Lesotho 2004	36	35	15	42
Malawi 2004	31	28	18	64
Namibia 2000	44	43	19	44
South Africa 2003	60	60	28	47
Near East & North Africa	52	40	2	4
Egypt 2005	62	57	7	12
Asia	63	59	3	5
Bangladesh 2004	53	47	10	21
Cambodia 2005	40	27	8	29
Indonesia 2002–03	60	57	28	49
Nepal 2006	48	44	10	23
Latin America & Caribbean	71	62	4	6
Haiti 2005–06	30	24	11	47
El Salvador 2002-03a	67	61	18	30
Nicaragua 2001	67	66	14	22
DEVELOPED AREAS	68	57	1	1
Europe	74	64	0	0
Eastern Europe & Central Asia	63	42	0	1
North America	75	71	3	4
Other developedb	59	64	0	0
WORLD	59	53	3	6
a Data for women 15–44. b Includes Australia, Israel, Japan, and New Zealand.
Methodology and data sources: Data for the number of married women ages 15–49 for each country were obtained from population projections for 2005 by the World Bank (201). Percentages are weighted by population size—that is, they reflect differences in population among the countries. Usage rates come from the most recent data from the Demographic and Health Surveys and Reproductive Health Surveys and, for countries without these surveys, data from the United Nations, 2005 (194), the U.S. Census Bureau's International Database (191), and other nationally representative surveys, including the U.S. National Surveys of Family Growth (122).

Greater access largely explains this rapid growth in use. Approval of the progestin-only injectable DMPA (depot medroxyprogesterone acetate) in the United States in 1992 removed a constraint to access and a source of controversy in many countries over providing a drug that was not approved for contraception in the United States. Also, approval in the United States enabled the U.S. Agency for International Development (USAID) to supply DMPA to developing countries. As of 2006 DMPA was registered in 179 countries, an increase from 106 countries in 1995 (83, 99). Several countries, including Ghana, Vietnam, and Zambia are introducing or scaling up DMPA services as part of a package of reproductive or primary health care services (138, 224, 226).

In the next 10 years more family planning programs will offer injectables, and they will offer clients more choices of injectables. Most can be expected to offer a progestin-only injectable—DMPA injected every three months or NET-EN (norethisterone enanthate) injected every two months. Many will offer a combined injectable, probably either medroxyprogesterone acetate (MPA) combined with the estrogen estradiol cypionate (E₂C) or NET-EN combined with the estrogen estradiol valerate (E₂V). Both are injected monthly. Other combined injectables are available in some countries and regions (see Table 2).

	Table 2. Formulations, Injection Schedules, and Availability of Injectable Contraceptives
Common Trade Names	Formulation	Injection Type and Schedule	Registration/Availability in 2006
Progestin-Only Injectables
Depo-Provera®, Megestron®, Contracep®, Depo-Prodasone®	Depot medroxyprogesterone acetate (DMPA) 150 mg	One intramuscular (IM) injection every 3 months	Registered in 179 countries
depo-subQ provera 104® (DMPA-SC)	DMPA 104 mg	One subcutaneous injection every 3 months	Approved in United States and United Kingdom; approval expected soon in other European countries; expected to be available in some developing countries by 2008
Noristerat®, Norigest®, Doryxas®	Norethisterone enanthate (NET-EN) 200 mg	One IM injection every 2 months	Registered in 91 countries
Combined Injectables (progestin + estrogen)1
Cyclofem®, Ciclofeminina®, Lunelle®	Medroxyprogesterone acetate 25 mg + Estradiol cypionate 5 mg (MPA/E2C)	One IM injection every month	Registered in 12 countries2
Mesigyna®, Norigynon®	NET-EN 50 mg + Estradiol valerate 5 mg (NET-EN/E2V)	One IM injection every month	Registered in 33 countries
Deladroxate®, Perlutal®, Topasel®, Patectro®, Deproxone®, Nomagest®	Dihydroxyprogesterone (algestone) acetophenide 150 mg + Estradiol enanthate 10 mg	One IM injection every month	Registered in 14 Latin American countries and Spain
Anafertin®, Yectames®	Dihydroxyprogesterone (algestone) acetophenide 75 mg + Estradiol enanthate 5 mg	One IM injection every month	Registered in 7 Latin American countries
Chinese Injectable No. 1®	17 α-hydroxyprogesterone caproate 250 mg + Estradiol valerate 5 mg	One IM injection every month, except 2 injections in first month	Registered in China
Sources: IPPF 2005 (83), Lande 1995 (99), Liggeri 2006 (103), WHO 1990 (204), WHO 1993 (205) 1 Also called monthly injectables. 2 The U.S. Food and Drug Administration has approved Lunelle, but it is currently not available in the United States.

Women will be able to have injections in more convenient locations (see Checklist for Improving Access to Injectables). More private clinics and providers will offer injectables (144, 152). More pharmacists will provide injectables in many countries, often as a part of social marketing programs (35, 36, 145). More programs will offer injectables in community services, and some women will choose home injection with the new DMPA formulation for subcutaneous injection (under the skin rather than in the muscle) (see Injectables Tomorrow: Subcutaneous DMPA and Home Injection).

Demand Accelerates and Suppliers Respond

Since 1995 the percentage of married women who rely on injectables has increased in 40 of 44 developing countries with multiple surveys (see Web Table 1¹). Use increased particularly in Indonesia among married women ages 15–49 from 15% in 1994 to 28% in 2002, after the method was vigorously promoted and more widely distributed. Nearly half of all married Indonesian women using contraception now rely on injectables. Use also has increased sharply in Haiti, Malawi, and Namibia. Between 2005 and 2015 the largest increases in number of users are expected in Indonesia (almost 2 million additional users), Nigeria (almost 1 million more), and Pakistan (over 200,000 more) (163).

Popular in some countries but little used in others. Overall, awareness and use of injectables are increasing, but levels of use vary widely within regions. In sub-Saharan Africa, Asia, and Latin America and the Caribbean, over 40% of married contraceptive users rely on injectables in some countries, while 5%–7% use them in other countries (see Web Table 2¹). Variations within regions can be attributed to a variety of factors, including access to injectables, norms related to contraceptive use, government policies, women's tolerance for side effects, and communication about injectables.

Governments, donors, and manufacturers respond. Where demand is increasing rapidly, governments have responded by placing larger procurement orders for injectables (see Supply Meets Demand With Forecasting and Ingenuity). Major donor agencies have steadily increased shipments of progestin-only injectables to developing countries (see Web Figure²). Between 2003 and 2005 shipments by the United Nations Population Fund (UNFPA), USAID, and the International Planned Parenthood Federation (IPPF) more than doubled, rising from 23 to 48 million doses per year. These donors contribute almost 60% of the total donated contraceptives worldwide. UNFPA, currently the largest supplier of injectables, shipped 27 million doses in 2005, a 35% increase over 2004. Shipments by USAID doubled between 2000 and 2005, rising from 9.3 million to 18.6 million doses, and they are expected to increase to 20 million in 2006 (21, 159). Sales of injectables by social marketing programs more than doubled between 2000 and 2005 (see Some Injectables Users Are Willing to Pay). One manufacturer of DMPA projects annual demand for 150 million doses (enough for 37.5 million users) by 2010 (103).

Effectiveness, Convenience, and Side Effects Influence Use

Many women have chosen injectables as their first modern method, and others have switched to injectables from oral contraceptives or other methods (44, 139). Women are choosing injectables because they offer a variety of advantages:

• Highly effective. Used correctly, injectables are more effective than female sterilization. If women return on time for injections, in the first year on average 3 among every 1,000 women using progestin-only injectables will become pregnant, and 5 among every 10,000 women using combined injectables (190). As injectables are commonly used in the United States, 3 in every 100 women become pregnant in the first year of use. This pregnancy rate is higher than that for IUDs, implants, and male and female sterilization but lower than that for oral contraceptives.
• Long-acting. Users need to remember only to have an injection every two or three months for progestin-only injectables or once a month for combined injectables. Users do not have to remember to do something every day or when about to have sex (20, 54).
• Reversible. Fertility returns after a woman stops using an injectable. Women stopping DMPA to become pregnant, however, take several months longer to conceive on average than women who used other methods (130, 171).
• Private. Women can use injectables without anyone else knowing (20, 109, 126, 138, 186) — particularly if a partner or in-laws object to contraception (19, 31).

Progestin-only injectables offer additional advantages for some women:

• They can be used during breastfeeding starting six weeks after giving birth (212).
• Monthly bleeding stops after a time for many users. Some women see this as an advantage of the method (62).
• Weight gain, common with use of injectables, is welcome for some women (4, 78, 109, 166).

Side effects deter many, but counseling helps. At the same time, many women do not choose injectables or they stop using them mainly because of side effects—particularly bleeding changes, no monthly bleeding, and weight gain (13, 70, 135, 168). In a large multinational World Health Organization (WHO) trial, on average half of women stopped using DMPA and NET-EN within 12 months (202). In the United States more women stop using injectables within 12 months than stop oral contraceptives or the copper IUD (190).

Good counseling, especially about changes in monthly bleeding and other side effects, helps women decide whether injectable contraception will suit them and it helps women continue using injectables (30, 59, 75, 100, 227). Good counseling can be the difference between successful and unsuccessful efforts to expand access to injectables (77, 78, 224). Introducing injectables or any new method is an opportunity to improve counseling and quality of care for all available methods (224).