Despite Illegality, Drug Shops in Uganda Provide Injectable Contraceptives

Potential Exists to Build Capacity and Expand Family Planning Access

In Uganda, informal drug shops are common providers of the injectable contraceptive, depot medroxyprogesterone acetate (DMPA), even though its sale and administration by such shops is illegal, according to a new study by John Stanback of Family Health International et al. Released in the March 2011 issue of International Perspectives on Sexual and Reproductive Health, the study reports on 124 drug shops that provide DMPA in three rural districts of the country. Given Uganda’s low modern contraceptive prevalence rate and shortage of health workers, the authors believe a strong case can be made for building the capacity of drug shop operators to safely provide DMPA, which is the most popular modern contraceptive method in the country.

Stanback et al. found that of the operators surveyed, just 35% reported that their facility was a licensed drug shop, while 9% were licensed private clinics. On average, facilities provided three DMPA injections per week and most operators (96%) administered the injections themselves. All operators surveyed claimed to have some medical qualification: Thirty-three percent identified themselves as nursing aides; 26% as nurses; and the rest as having other nursing, midwifery or medical training. Despite this presence of trained operators, the authors identified safety concerns involving injection methods, contraceptive knowledge and syringe disposal.

One-quarter of providers reported having had at least one needle-stick injury in the past year. And though almost all knew that disposable syringes cannot be sterilized and reused safely, 11% reported having reused a disposable syringe in the past because of lack of supplies. Moreover, although nearly all of the surveyed providers ultimately disposed of syringes in pit latrines or by burning, fewer than half properly disposed of syringes directly after use, and loose syringes were visible in many facilities. Given Uganda’s high rates of HIV and hepatitis B, these findings document practices that could pose a serious health threat.

The study also found that although nearly all providers knew at least one of the common side effects of DMPA, most could name only one or two of the four side effects that would require medical attention. In addition, more than a third could not name any of the health conditions that would make DMPA an inappropriate method for an individual woman.

Despite the problems they identified, the authors believe that drug shops play a valuable role as providers of family planning services, particularly in rural communities. They argue that all operators would benefit from training in safe injection skills and family planning counseling and from having better access to safe sharps disposal. The authors conclude that training operators as community-based providers of contraception (who can legally give injections), along with enforcement of licensing and safety regulations, could make drug shops strong partners in Uganda’s efforts to improve maternal health and achieve its Millennium Development Goals.

The study, "Injected with Controversy: Sales and Administration of Injectable Contraceptives in Uganda," appears in the March 2011 issue of International Perspectives on Sexual and Reproductive Health.

Also in this issue of International Perspectives on Sexual and Reproductive Health:

"Prevalence and Correlates of Sexual Risk Behaviors Among Jamaican Adolescents," Kanako Ishida, Paul Stupp and Olivia McDonald

"What Differentiates Method Stoppers from Switchers? Contraceptive Discontinuation and Switching Among Honduran Women," Janine Barden-O'Fallon and Ilene Speizer

"Associations Between Family Factors and Premarital Heterosexual Relationships Among Female College Students in Tehran," Farideh Khalaj Abadi Farahani, John Cleland and Amir Hooshang Mehryar

Comment, "Postabortion Care: Going to Scale," Saumya RamaRao, John W. Townsend, Nafissatou Diop and Sarah Raifman