Rural Ethiopian women who had received injections of depot medroxyprogesterone acetate (DMPA) from community-based reproductive health agents were less likely than those who had received the shots at health posts to discontinue the method after three months (1% vs. 9%) or between the third and sixth months (2% vs. 4%), according to a prospective community intervention trial.1 Nearly all women in the trial were satisfied with both the injectable and their provider, although those who had used health agents were less likely than women who had gotten their shots at health posts to report side effects at three months. Moreover, at six months they could name more potential side effects than could health post clients.
Community-based distribution of the injectable by trained health agents has been successful in a number of developing countries. In Ethiopia, which has a shortage of skilled health care providers, community-based reproductive health agents (CBRHAs) are allowed to distribute oral contraceptives and condoms, but not the injectable or other methods. The potential benefits of expanding provision by these workers are substantial: Only 11% of rural Ethiopian women use any contraceptive method, even though 36% have an unmet need for family planning. This intervention trial, conducted in 2008–2009, assessed whether CBRHAs could administer the injectable to women in the predominantly rural Tigray region as safely, effectively and acceptably as health extension workers (basic-level providers) at government health posts.
The trial was conducted in four villages in each of the region's two districts. To maximize public support for the trial, community leaders were briefed on the project prior to its initiation. In each village, on average, four CBRHAs and two health extension workers participated in the intervention; all providers attended a 10-day classroom training program on family planning, client screening, injection administration and infection prevention, as well as subsequent clinical training sessions. Women who approached a participating provider for contraceptives and who wished to use DMPA were invited to participate in the study, and self-selected into one of the study arms according to the type of provider they usually saw for family planning needs. After screening women for eligibility, providers administered the injectable without charge. At enrollment, and after receiving their three- and six-month follow-up injections, women completed questionnaires that assessed demographic characteristics, side effects, quality of service and satisfaction with the method and provider. Chi-square and t tests were used to assess differences between the two arms.
At enrollment, 622 women received the injectable from CBRHAs, and 440 from health extension workers. Compared with clients of health extension workers, CBRHA clients were older (mean, 30 vs. 28 years), had more children (4.0 vs. 3.6) and were less likely to be married (88% vs. 92%); they were more likely to have no education (89% vs. 78%) and to be new users of DMPA (58% vs. 46%). Four in 10 women in each group had never used a modern method.
Eighty-four percent of CBRHA clients received their second injection at three months, as did 82% of clients of health extension workers. By this follow-up, only 1% of women in the CBRHA arm had discontinued the method, whereas 9% of those in the other arm had done so. (The remaining women were lost to follow-up.) By six months, 79% of the original CBRHA clients and 62% of the original health extension worker clients had received their third injection, while an additional 2% and 4% of the original samples, respectively, had discontinued use. All of these differences were statistically significant.
At the first follow-up, women who had obtained their injections from CBRHAs were less likely than those who had used health extension workers to report having had side effects, although this difference disappeared by six months. Overall, nearly all women in both arms of the study were satisfied with DMPA and their provider. CBRHA clients were slightly less likely than clients of health extension workers to have received a written appointment reminder (96% vs. 100%), while they were more likely to have been offered condoms in addition to the injectable (80% vs. 73%). At six months, CBRHA clients could recall more potential side effects than could the health extension worker clients, and they were more likely than the latter to be able to cite irregular bleeding (43% vs. 32%) and amenorrhea (42% vs. 20%) as possible side effects. Finally, at six months, CBRHA clients were far more likely than health extension worker clients to want to receive injections at home (84% vs. 52%) or in the home of a health agent (13% vs. 5%), and less likely to want to get them at a health post (2% vs. 43%). The overall preference for home injections, even among women who had opted to receive care from health extension workers, may reflect that almost half of women in the study reported difficulty in traveling to a health facility for family planning.
The researchers believe this study demonstrates that community health workers can safely and effectively provide access to injectables, as well as reach first-time users of the method. They assert that such a community-based approach can not only increase the contraceptive options available to rural women, but also meet the high demand for the injectable in Ethiopia. These findings suggest that the appropriate "combination of social marketing and community-based distribution methods could help defray … the costs of training and monitoring, generate income for community health workers and increase women's access to modern contraceptive methods."—J. Thomas
1. Prata N et al., Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents, Bulletin of the World Health Organization, 2011, 89(8):556–564.