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Increased 1-Year Continuation of DMPA Among Women Randomized to Self-administration: Results From a Randomized Controlled Trial at Planned Parenthood

Consistent use of effective contraception is the most effective way to reduce unintended pregnancy. Approximately 4.5% of US contraceptive users aged 15 to 44 years, an estimated 1.5 million women, relied on injectables as their contraceptive method in 2012. Since 1992, the intramuscular form of depot medroxyprogesterone acetate (DMPA) has been available in the United States. A subcutaneous formulation (DMPA-sc) became available in 2004. This formulation provides the same efficacy at a lower dose and is easier to administer. Patients usually return to a health center for DMPA administration within 12 to 14 weeks of the previous injection. The time and expense of a clinic appointment for some women may outweigh the other advantages of DMPA, leading them to choose less reliable methods of contraception. For these women, self-administration of DMPA-sc outside a clinic setting may be an attractive option. Self-administration of DMPA-sc is a feasible, acceptable, and effective method. The results of a randomized trial published in 2014 showed that women who self-injected DMPA-sc had continuation rates at 12 months of 71% compared with 63% in the clinic administration group (with therapeutic serum concentrations in all women). A recent survey conducted in family planning clinics reported that 40% of DMPA users would be interested in self-administration. The aim of this open-label, randomized, parallel-group trial was to compare 1-year continuation rates of DMPA-sc between women randomized to self-administration versus clinic administration. The study was conducted at 3 Planned Parenthood Health Centers located in Texas and New Jersey. A total of 401 women aged 15 to 44 years requesting DMPA were Health, Inc. All rights reserved. randomized 1:1 to self-administration or clinic administration. Continuation of DMPA and patient satisfaction between groups was compared in follow-up surveys at 6 and 12 months. Participants randomized to self-administration were taught by clinic staff how to self-inject. The first injection was observed by clinic personnel. Those who correctly self-administered received printed instructions and 3 additional doses of DMPA-sc for home use. Women randomized to clinic administration received usual care (no specific intervention). Subcutaneous DMPA was provided at no cost to all participants. Injection reminders were sent to all women via text message or e-mail. Of the 401 patients randomized, 336 (84%) completed the 12-month survey; 316 completed both 6and 12-month surveys (an 80% complete response rate excluding 8 withdrawals). Mean age of participants ranged from 16 to 44 years. One-year DMPA continuous use was higher in the self-administration group than in the clinic group (69% vs 54%); the risk difference was 15%, with a 95% confidence interval of 5% to 26%, P = 0.005. Three self-reported pregnancies occurred during the study period, all in the clinic group; DMPA had been discontinued in all 3 cases, and one of these pregnancies was intended. Ninety-seven percent of participants in the self-administration group reported that it was very or somewhat easy to administer the injection, 87% would recommend self-administration to a friend, and 52% in the clinic group reported interest in self-administration in the future. There was similar satisfaction among groups. There were no serious adverse events. These findings demonstrate that DMPA self-administration improves contraceptive continuation and is a feasible and acceptable option for both adults and adolescents. Self-administration can also improve contraceptive access and autonomy. The authors believe that this option should be made widely available for all women and adolescents.